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21 May, 2013

Vaccines for measles, mumps and rubella in children

Vittorio Demicheli^*,
Alessandro Rivetti,
Maria Grazia Debalini,
Carlo Di Pietrantonj

Editorial Group: Cochrane Acute Respiratory Infections Group

Published Online: 15 FEB 2012

Assessed as up-to-date: 12 MAY 2011

DOI: 10.1002/14651858.CD004407.pub3

Full Text

Background

Mumps, measles and rubella (MMR) are serious diseases that can lead to potentially fatal illness, disability and death. However, public debate over the safety of the trivalent MMR vaccine and the resultant drop in vaccination coverage in several countries persists, despite its almost universal use and accepted effectiveness.

Objectives

To assess the effectiveness and adverse effects associated with the MMR vaccine in children up to 15 years of age.

Search methods

For this update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, PubMed (July 2004 to May week 2, 2011) and Embase.com (July 2004 to May 2011).

Selection criteria

We used comparative prospective or retrospective trials assessing the effects of the MMR vaccine compared to placebo, do nothing or a combination of measles, mumps and rubella antigens on healthy individuals up to 15 years of age.

Data collection and analysis

Two review authors independently extracted data and assessed methodological quality of the included studies. One review author arbitrated in case of disagreement.

Main results

We included five randomised controlled trials (RCTs), one controlled clinical trial (CCT), 27 cohort studies, 17 case-control studies, five time-series trials, one case cross-over trial, two ecological studies, six self controlled case series studies involving in all about 14,700,000 children and assessing effectiveness and safety of MMR vaccine. Based on the available evidence, one MMR vaccine dose is at least 95% effective in preventing clinical measles and 92% effective in preventing secondary cases among household contacts.

Effectiveness of at least one dose of MMR in preventing clinical mumps in children is estimated to be between 69% and 81% for the vaccine prepared with Jeryl Lynn mumps strain and between 70% and 75% for the vaccine containing the Urabe strain. Vaccination with MMR containing the Urabe strain has demonstrated to be 73% effective in preventing secondary mumps cases. Effectiveness of Jeryl Lynn containing MMR in preventing laboratory-confirmed mumps cases in children and adolescents was estimated to be between 64% to 66% for one dose and 83% to 88% for two vaccine doses. We did not identify any studies assessing the effectiveness of MMR in preventing rubella.

The highest risk of association with aseptic meningitis was observed within the third week after immunisation with Urabe-containing MMR (risk ratio (RR) 14.28; 95% confidence interval (CI) from 7.93 to 25.71) and within the third (RR 22.5; 95% CI 11.8 to 42.9) or fifth (RR 15.6; 95% CI 10.3 to 24.2) weeks after immunisation with the vaccine prepared with the Leningrad-Zagreb strain. A significant risk of association with febrile seizures and MMR exposure during the two previous weeks (RR 1.10; 95% CI 1.05 to 1.15) was assessed in one large person-time cohort study involving 537,171 children aged between three months and five year of age. Increased risk of febrile seizure has also been observed in children aged between 12 to 23 months (relative incidence (RI) 4.09; 95% CI 3.1 to 5.33) and children aged 12 to 35 months (RI 5.68; 95% CI 2.31 to 13.97) within six to 11 days after exposure to MMR vaccine. An increased risk of thrombocytopenic purpura within six weeks after MMR immunisation in children aged 12 to 23 months was assessed in one case-control study (RR 6.3; 95% CI 1.3 to 30.1) and in one small self controlled case series (incidence rate ratio (IRR) 5.38; 95% CI 2.72 to 10.62). Increased risk of thrombocytopenic purpura within six weeks after MMR exposure was also assessed in one other case-control study involving 2311 children and adolescents between one month and 18 years (odds ratio (OR) 2.4; 95% CI 1.2 to 4.7). Exposure to the MMR vaccine was unlikely to be associated with autism, asthma, leukaemia, hay fever, type 1 diabetes, gait disturbance, Crohn's disease, demyelinating diseases, bacterial or viral infections.

Authors' conclusions

The design and reporting of safety outcomes in MMR vaccine studies, both pre- and post-marketing, are largely inadequate. The evidence of adverse events following immunisation with the MMR vaccine cannot be separated from its role in preventing the target diseases.

Plain language summary

Using the combined vaccine for protection of children against measles, mumps and rubella

Measles, mumps and rubella (MMR) are three very dangerous infectious diseases which cause severe morbidity, disability and death in low-income countries.

Based on the evidence provided by three cohort studies (3104 participants), vaccination with one dose of MMR vaccine is at least 95% effective in preventing clinical measles among preschool children; in schoolchildren and adolescents at least one dose of MMR vaccine was 98% effective in preventing laboratory-confirmed measles cases; one or two MMR doses were respectively 92% and 95% effective in preventing secondary measles cases.

At least one dose of MMR vaccine is effective in preventing clinical mumps among children and adolescents when prepared with Jeryl Lynn strains (vaccine effectiveness = 69% to 81%, one cohort and one case-control study, 1656 participants), as well as when prepared with Urabe strain (vaccine effectiveness = 70% to 75%, one cohort and one case-control study, 1964 participants). Effectiveness against laboratory-confirmed mumps in children and adolescents was estimated to be between 64% to 66% for one and 83% to 88% for two doses of Jeryl Lynn MMR (two case-control studies, 1664 participants) and 87% for Urabe-containing MMR (one cohort study, 48 participants). Vaccination with Urabe MMR confers protection against secondary mumps infection (vaccine effectiveness = 73%, one cohort study, 147 participants).

We identified no studies assessing the effectiveness of MMR vaccine against clinical or laboratory-confirmed rubella.

Results from two very large case series studies involving about 1,500,000 children who were given the MMR vaccine containing Urabe or Leningrad-Zagreb strains show this vaccine to be associated with aseptic meningitis; whereas administration of the vaccine containing Moraten, Jeryl Lynn, Wistar RA, RIT 4385 strains is associated with febrile convulsion in children aged below five years (one person-time cohort study, 537,171 participants; two self controlled case series studies, 1001 participants). The MMR vaccine could also be associated with idiopathic thrombocytopaenic purpura (two case-controls, 2450 participants, one self controlled case series, 63 participants).

We could assess no significant association between MMR immunisation and the following conditions: autism, asthma, leukaemia, hay fever, type 1 diabetes, gait disturbance, Crohn's disease, demyelinating diseases, or bacterial or viral infections. The methodological quality of many of the included studies made it difficult to generalise their results.

The glossary of study designs is available in the full-text review.

Résumé

Vaccins contre la rougeole, les oreillons et la rubéole chez les enfants

Contexte

La rougeole, les oreillons et la rubéole (ROR) sont des maladies graves potentiellement mortelles ou invalidantes. Toutefois, les débats publics concernant la tolérance du vaccin ROR trivalent et la baisse résultante de la couverture de vaccination dans plusieurs pays persistent, malgré son administration quasi universelle et son efficacité reconnue.

Objectifs

Évaluer l'efficacité et les effets indésirables associés au vaccin ROR chez les enfants âgés de moins de 15 ans.

Stratégie de recherche documentaire

Pour cette mise à jour, nous avons effectué des recherches dans le registre Cochrane des essais contrôlés (CENTRAL) (The Cochrane Library 2011, numéro 2), qui contient le registre spécialisé du groupe Cochrane sur les infections respiratoires aiguës, PubMed (de juillet 2004 à la semaine 2 de mai 2011) et Embase.com (de juillet 2004 à mai 2011).

Critères de sélection

Nous avons utilisé des essais prospectifs et rétrospectifs comparatifs évaluant les effets du vaccin ROR par rapport à un placebo, l'absence d'intervention ou une combinaison d'antigènes de la rougeole, des oreillons et de la rubéole sur des enfants de moins de 15 ans en bonne santé.

Recueil et analyse des données

Deux auteurs ont extrait des données et évalué la qualité méthodologique des études incluses, de façon indépendante. Un auteur a servi de médiateur en cas de désaccord.

Résultats Principaux

Nous avons inclus cinq essais contrôlés randomisés (ECR), un essai clinique contrôlé (ECC), 27 études de cohorte, 17 études cas-témoins, cinq essais de séries temporelles, un essai de cas croisés, deux études écologiques, six études de séries de cas auto-contrôlées totalisant environ 14 700 000 enfants et évaluant l'efficacité et la tolérance du vaccin ROR. En fonction des preuves disponibles, une dose de vaccin ROR est efficace à au moins 95 % pour la prévention de la rougeole clinique et à 92 % pour la prévention de cas secondaires dans les foyers.

L'efficacité d'au moins une dose de ROR pour la prévention de la rougeole clinique chez les enfants est estimée entre 69 % et 81 % pour le vaccin préparé avec des souches Jeryl Lynn et entre 70 % et 75 % pour le vaccin contenant la souche Urabe. L'efficacité de la vaccination ROR contenant la souche Urabe a été démontrée à hauteur de 73 % pour la prévention de cas secondaires de rougeole. L'efficacité du vaccin ROR contenant la souche Jeryl Lynn pour la prévention des oreillons confirmés en laboratoire chez les enfants et les adolescents était estimée entre 64 % et 66 % pour une dose et 83 % à 88 % pour deux doses de vaccin. Nous n'avons pas identifié d'études évaluant l'efficacité du vaccin ROR pour la prévention de la rubéole.

Le risque le plus élevé d'association à la méningite aseptique était observé la troisième semaine après l'immunisation effectuée avec un vaccin ROR contenant la souche Urabe (risque relatif (RR) 14,28 ; intervalle de confiance (IC) à 95 % de 7,93 à 25,71) et la troisième (RR 22,5 ; IC à 95 % 11,8 à 42,9) ou cinquième (RR 15,6 ; IC à 95 % 10,3 à 24,2) semaine après l'immunisation pour le vaccin préparé avec la souche Leningrad-Zagreb. Un risque significatif d'association à des convulsions fébriles et à l'exposition ROR les deux semaines précédentes (RR 1,10 ; IC à 95 % 1,05 à 1,15) était évalué dans une étude de cohorte personne-temps réalisée à grande échelle totalisant 537 171 enfants âgés de trois mois à cinq ans. Un risque accru de convulsions fébriles a également été observé chez des enfants âgés de 12 à 23 mois (incidence relative (IR) 4,09 ; IC à 95 % 3,1 à 5,33) et de 12 à 35 mois (IR 5,68 ; IC à 95 % 2,31 à 13,97) au cours des six à onze jours après l'exposition au vaccin ROR. Un risque accru de purpura thrombocytopénique dans les six semaines suivant l'immunisation ROR chez les enfants âgés de 12 à 23 mois était évalué dans une étude cas-témoins (RR 6,3 ; IC à 95 % 1,3 à 30,1) et dans une petite étude de séries de cas auto-contrôlées (rapport des taux d'incidence (RTI) 5,38 ; IC à 95 % 2,72 à 10,62). Un risque accru de purpura thrombocytopénique dans les six semaines suivant l'exposition ROR était également évalué dans une autre étude cas-témoins totalisant 2 311 enfants et adolescents âgés de 1 mois à 18 ans (rapport de cotes (RC) 2,4 ; IC à 95 % 1,2 à 4,7). L'exposition au vaccin ROR avait peu de chances d'être associée à des cas d'autisme, d'asthme, de leucémie, de rhume des foins, de diabète de type 1, de troubles de la marche, de maladie de Crohn, de maladies démyélinisantes, d'infections bactériennes ou virales.

Conclusions des auteurs

La conception et la notification des résultats sur la tolérance dans les études réalisées sur le vaccin ROR, avant et après sa mise sur le marché, sont clairement inadaptées. Les preuves concernant des événements indésirables suite à l'immunisation avec le vaccin ROR ne peuvent pas être séparées de son rôle pour la prévention des maladies ciblées.

Résumé simplifié

Vaccins contre la rougeole, les oreillons et la rubéole chez les enfants

Administration d'un vaccin combiné pour protéger les enfants contre la rougeole, les oreillons et la rubéole

La rougeole, les oreillons et la rubéole (ROR) sont trois maladies infectieuses très dangereuses dont la morbidité, l'invalidité et la mort sont élevées dans les pays à faible revenus.

En fonction des preuves fournies par trois études de cohorte (3 104 participants), la vaccination avec une dose de vaccin ROR est efficace à au moins 95 % pour la prévention de la rougeole clinique chez les enfants d'âge préscolaire ; chez les enfants scolarisés et les adolescents, au moins une dose de vaccin ROR était efficace à 98 % pour la prévention de cas de rougeole confirmés en laboratoire ; une ou deux doses de vaccin ROR étaient respectivement efficaces à 92 % et 95 % pour la prévention de cas secondaires de rougeole.

Au moins une dose de vaccin ROR est efficace pour la prévention des oreillons cliniques chez les enfants et adolescents lorsqu'elle est préparée avec des souches Jeryl Lynn (efficacité du vaccin = 69 % à 81 %, une étude de cohorte et une étude cas-témoins, 1 656 participants), mais aussi lorsqu'elle est préparée avec une souche Urabe (efficacité du vaccin = 70 % à 75 %, une étude de cohorte et une étude cas-témoins, 1 964 participants). L'efficacité évaluée par rapport à des cas d'oreillons confirmés en laboratoire chez des enfants et adolescents était estimée entre 64 % et 66 % pour une dose et entre 83 % et 88 % pour deux doses de vaccin ROR contenant une souche Jeryl Lynn (deux études cas-témoins, 1 664 participants) et 87 % pour un vaccin ROR contenant une souche Urabe (une étude de cohorte, 48 participants). La vaccination ROR avec une souche Urabe assure une protection contre des cas secondaires d'oreillons (efficacité du vaccin = 73 %, une étude de cohorte, 147 participants).

Nous n'avons identifié aucune étude évaluant l'efficacité du vaccin ROR contre la rubéole clinique ou confirmée en laboratoire.

Les résultats issus de deux études de séries de cas réalisées à grande échelle incluant environ 1 500 000 enfants, auxquels le vaccin ROR contenant une souche Urabe ou Leningrad-Zagreb leur a été administré, montrent que ce vaccin peut être associé à la méningite aseptique ; alors que l'administration d'un vaccin contenant les souches Moraten, Jeryl Lynn, Wistar RA, RIT 4385 est associée à des convulsions fébriles chez les enfants de moins de cinq ans (une étude de cohorte personne-temps, 537 171 participants ; deux études de séries de cas auto-contrôlées, 1 001 participants). Le vaccin ROR peut également être associé au purpura thrombocytopénique idiopathique (deux études cas-témoins, 2 450 participants, une étude de séries de cas auto-contrôlée, 63 participants).

Nous avons évalué l'absence d'association significative entre l'immunisation ROR et les affections suivantes : autisme, asthme, leucémie, rhume des foins, diabète de type 1, troubles de la marche, maladie de Crohn, maladies démyélinisantes, infections bactériennes ou virales. La qualité méthodologique de plusieurs des études incluses rend plus difficile la généralisation de leurs résultats.

Le glossaire relatif aux termes de conception des études est disponible dans la revue intégrale.

Notes de traduction

Traduit par: French Cochrane Centre 18th May, 2012
Traduction financée par: Ministère du Travail, de l'Emploi et de la Santé Français

Gout and drinking

People with gout, and their carers, tend to the obsessive when it comes to food, and especially drinking; alcohol and coffee are often banned completely. All of which makes for a bland existence, which is why a frequently asked question is what gout sufferers can drink without exacerbating their condition. A large US survey has reported on coffee, tea, and various forms of alcohol [1,2]. The results will warm the cockles of some hearts.

Studies

A representative sample of the US population was selected and studied between 1988 and 1994. Subjects were interviewed at home, and attended an examination, with blood and urine sample collection. During the interviews, a food frequency questionnaire was used which ascertained the frequency of consumption of coffee, tea, and alcoholic beverages, as well as soft drinks that might contain caffeine. Serum uric acid was measured also.

Results

The survey used data from over 14,000 people aged over 20 years of age. Those with gout, or taking allopurinol or uricosuric agents were excluded.

Coffee, tea, and caffeine

Using a quintile of consumption approach, uric acid levels were identical across quintiles of intake of total caffeine and tea. For coffee (including decaffeinated), drinking more than four cups of coffee a day significantly lowered serum uric acid levels, by about 8% at maximum (Figure 1). The reduction of uric acid by coffee remained after adjusting for a whole range of variables and dietary factors.

Figure 1: Reduction in mean serum uric acid levels according to quintiles of daily intake of coffee

Alcohol

Using the quintile of consumption approach drinking wine did not affect serum uric acid levels at any level of consumption up to one serving per day or more. The consumption of spirits, and especially beer, did increase serum uric acid levels (Figure 2), even after adjusting for a whole range of factors. Beer and spirits drunk daily increased serum uric acid by about 10%; wine did not. The results were similar in men and women, and at lower and higher levels of BMI.

Figure 2: Effect of different daily consumption (quintiles) of different alcoholic beverages on mean serum uric acid levels

Comment

This constitutes useful additional knowledge about what gout suffers might do to avoid increasing their serum uric acid, and perhaps precipitating an attack, or making the pain worse. Drinking beer and spirits are out, but tea and wine have no effect, while coffee actually seems to reduce uric acid levels. We have had some straws in the wind about coffee before, but this adds weight.
More weight comes from a large study of coffee consumption and incident gout in men [3], following 46,000 men with no history of gout at baseline for 12 years. There were 750 cases of incident gout, and the risk was lower with higher coffee consumption, before and after adjustment for a whole host of different possible confounding factors (Figure 3). So increased coffee drinking is linked with both reduced serum uric acid levels and reduced incidence of clinical gout.

Figure 3: Relative risk of incident gout in 12-year follow up of 46,000 men, according to quintiles of daily coffee consumption

We also have information about what we eat and the risk of incident gout [4]. This has been examined in detail on the Bandolier Internet site, but the main results are worth reiterating. Increased consumption of meat was associated with increased risk of gout, but only with beef, pork, and lamb. There was less association with seafood, and none with purine rich vegetables. Increased consumption of dairy food reduced the risk of gout. We find the same now for uric acid [5] where high meat and to a small extent seafood consumption is associated with higher uric acid levels, but dairy food with lower uric acid levels. Much food for thought for those with gout and for healthy eating.

References:

HK Choi, G Curhan. Coffee, tea, and caffeine consumption and serum uric acid level: third National Health and Nutrition Examination Survey. Arthritis & Rheumatism 2007 57: 816-821.
HK Choi, G Curhan. Beer, liquor, and wine consumption and serum uric acid level: third National Health and Nutrition Examination Survey. Arthritis & Rheumatism 2004 51: 1023-1029.
HK Choi et al. Coffee consumption and risk of incident gout in men. Arthritis & Rheumatism 2007 56: 2049-2055.
HK Choi et al. Purine-rich foods, dairy and protein intake, and the risk of gout in men. NEJM 2004 350:1093-1103.
HK Choi et al. Intake of purine-rich foods, protein, and dairy products and relationship to serum levels of uric acid. Arthritis & Rheumatism 2005 52: 283-289.

Uma proposta metodológica para pesquisar as demandas dos pacientes e probabilidades pré-teste através de formulários em papel na atenção primária

GUSSO, G., BENSEñOR, I.. Uma proposta metodológica para pesquisar as demandas dos pacientes e probabilidades pré-teste através de formulários em papel na atenção primária. Revista Brasileira de Medicina de Família e Comunidade, Local de publicação (editar no plugin de tradução o arquivo da citação ABNT), 8, abr. 2013. Disponível em: <http://www.rbmfc.org.br/index.php/rbmfc/article/view/692>. Acesso em: 21 Mai. 2013..

Uma proposta metodológica para pesquisar as demandas dos pacientes e probabilidades pré-teste através de formulários em papel na atenção primária

Gustavo Diniz Ferreira Gusso, Isabela Martins Benseñor

Resumo

Objetivo: O propósito deste estudo é apresentar uma metodologia para avaliar as demandas dos pacientes e calcular probabilidades pré-teste utilizando formulário em papel na atenção primária. Método: A maioria dos países em desenvolvimento não usa registros eletrônicos de saúde (RES) em ambientes de cuidados primários. Isso dificulta o acesso a informações sobre o processo de trabalho dentro do centro de saúde. Existem basicamente duas metodologias para avaliar a demanda do paciente e problemas ou diagnósticos elaborados por médicos. A primeira se fundamenta em “encontro por encontro”, enquanto a segunda, em “episódios de cuidados” de cada problema de uma forma longitudinal. A metodologia desenvolvida neste artigo foi a confrontação do “motivo da consulta” e do “problema registrado” pelos médicos. O formulário de papel que foi desenvolvido teve este conceito como central. Todas as consultas foram codificadas segundo a Classificação Internacional de Atenção Primária (CIAP). Discussão: Mesmo em formulário de papel, o confronto “motivo da consulta” e “problema registrado” pelos médicos é útil para medir as probabilidades pré-teste de cada problema com base em encontros. Essa abordagem pode facilmente ser reproduzida em qualquer centro de saúde e permite um melhor entendimento do perfil da população. A prevalência de muitas enfermidades e doenças não é conhecida em cada realidade e estudos feitos no contexto da atenção secundária e terciária não são adequados para os cuidados de saúde primários. Conclusão: Este artigo oferece uma tecnologia adequada aos trabalhadores de saúde de cuidados primários que tem potencial de transformar cada centro de saúde em um campo de pesquisa, contribuindo diretamente para o atendimento do paciente.

Referências

Starfield B. Primary Care: balancing health needs, services, and technology. New York: Oxford University Press; 1998.
Starfield B. Is primary care essential? Lancet. 1994 Oct 22; 344(8930): 1129-33. http://dx.doi.org/10.1016/S0140-6736(94)90634-3
Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy. 2002; 60(3): 201-18. http://dx.doi.org/10.1016/S0168-8510(01)00208-1
Van Weel C, Rosser WW. Improving health care globally: a critical review of the necessity of family medicine research and recommendations to build research capacity. Ann Fam Med. 2004 May 26; 2 Suppl 2: S5-16. http://dx.doi.org/10.1370/afm.194
Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet. 2011; published online May 9. http://dx.doi.org/10.1016/S0140-6736(11)60054-8
Sampaio LFR. The Brazilian health system: highlighting the primary health care reform. Ital J Public Health. 2010; 7(4): 359-368.
Macinko J, Guanais FC, De Fátima M, De Souza M. An Evaluation of the Impact of the Family Health Program on Infant Mortality in Brazil, 1990-2002. J Epidemiol Community Health. 2006; 60: 13-19. http://dx.doi.org/10.1136/jech.2005.038323
Binns HJ, Lanier D, Pace WD, Galliher JM, Ganiats TG, Grey M, et al. Describing primary care encounters: the Primary Care Network Survey and the National Ambulatory Medical Care Survey. Ann Fam. 2007; 5: 39-47. http://dx.doi.org/10.1370/afm.620
Britt H, Miller GC, Charles J, Henderson J, Bayram C, Harrison C, et al. General practice activity in Australia 1998-99 to 2007-08: 10 year data tabelas. General practice series no. 23. Cat. no. GEP 23. Canberra: Australian Institute of Health and Welfare; 2008.
Soler J-K, Okkes I, Wood M, Lamberts H. The coming of age of ICPC: celebrating the 21st birthday of the International Classification of Primary Care. Fam Pract. 2008 Aug; 25(4): 312-7. http://dx.doi.org/10.1093/fampra/cmn028
Lamberts H, Wood M, editors. International Classification of Primary Care (ICPC). Oxford: Oxford University Press; 1987.
Crombie DL. Diagnostic Process. J Coll Gen Practit. 1963; 6: 579-89.
White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. 1961; 265: 885-892. http://dx.doi.org/10.1056/NEJM196111022651805
Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The Ecology of Medical Care Revisited. New England J. Med. 2001; 2634: 2021-2025. http://dx.doi.org/10.1056/NEJM200106283442611
Bentsen BG. Illness and general practice. A survey of medical care in an island population in South-East Norway. Oslo: Oslo University Press; 1970
Westbury RC.A plan to develop an international classification of disease in family medicine; International Workshop on General Practice Research, 1972. Melbourne; 1972.
Meads S, McLemore T. National Center for Health Statistics: National Ambulatory Medical Care Survey: Symptom classification. Vital and Health Statistics. Series 2-No. 63. DHEW Pub. No. (HRA) 74-1337. Health Resources Administration. Washington: U.S. Government Printing Office; May 1974.
Meads S. The WHO Motivos da consulta Classification. Who Chronicle. 1983; 37(5): 159-162
Lamberts H, Meads S, Wood M. Classification of reasons why persons seek primary care: pilot study of a new system. Public Health Rep. 1984 Nov-Dec; 99(6): 597-605.
Lamberts H, Meads S, Wood M. Results of the international field trial with the Reason for Encounter Classification. Soz Praventivmed. 1985; 30(2): 80-7. http://dx.doi.org/10.1007/BF02083050
Lebrão ML. Classificação internacional de motivos de consulta para assistência primária: testes em algumas áreas brasileiras. Rev Saúde Públ. 1985; 19: 69-78. http://dx.doi.org/10.1590/S0034-89101985000100008
North American Primary Care Research Group. A process code for primary care (NAPCRG-1). International field trial version. Richmond: North American Primary Care Research Group; 1981.
World Organization of National Colleges, Academies – WONCA, Academic Associations of General Practitioners. Family Physicians (WONCA). Classification Committee. International Classification of Health Problemas in Primary Care (ICHPPC-2-Defined). 3nd ed. Oxford: Oxford University Press; 1983
Gusso G. Diagnóstico de demanda em Florianópolis utilizando a Classificação Internacional de Atenção Primária: 2º edição (CIAP-2) [Tese]. São Paulo: Faculdade de Medicina da Universidade de São Paulo; 2009
World Organization of National Colleges, Academies – WONCA, Academic Associations of General Practitioners. Family Physicians Classificação Internacional de Atenção Primária (CIAP 2). Elaborada pelo Comitê Internacional de Classificação da WONCA (Associações Nacionais, Academias e Associações Acadêmicas de Clínicos Gerais/Médicos de Família, mais conhecida como Organização Mundial de Médicos de Família); Consultoria, supervisão e revisão técnica desta edição, Gustavo Diniz Ferreira Gusso. 2. ed. Florianópolis: Sociedade Brasileira de Medicina de Família e Comunidade; 2009.
Sociedade Brasileira de Medicina de Família e Comunidade - SBMFC [homepage on the Internet] [cited 2011 Aug 11]. Disponível em: http://www.sbmfc.org.br/default.asp?site_Acao=MostraPagina&PaginaId=72.
World Organization of National Colleges, Academies – WONCA, Academic Associations of General Practitioners. Family Physicians (WONCA). WONCA International Classification Committee. International Classification of Primary Care (ICPC-2-R). 2nd ed. Revised. Oxford: Oxford University Press; 1998.
Okkes IM, Oskam SK, Van Boven K, Lamberts H. EFP. Episodes of care in Dutch Family Practice. Epidemiological data based on the routine use of the International Classification of Primary Care (ICPC) in the Transition Project of the Academic Medical Center/University of Amsterdam (1985-2003). In: Okkes IM, Oskam SK, Lamberts H. ICPC in the Amsterdam Transition Project. CD-Rom. Amsterdam: Academic Medical Center/University of Amsterdam, Department of Family Medicine; 2005.
Biblioteca Virtual em Saúde. Descritores em Ciências da Saúde [homepage on the Internet]. [cited 2011 Aug 11]. Disponível em: http://decs.bvs.br/cgi-bin/wxis1660.exe/decsserver/?IsisScript=../cgi-bin/decsserver/decsserver.xis&interface_language=p&previous_page=homepage&previous_task=NULL&task=start.
Google. Ferramenta de Idiomas [homepage on the Internet]. [cited 2011 Aug 11]. Disponível em: http://www.google.com.br/language_tools?hl=pt-BR .
Transition Project. TranHis [homepage on the Internet] [cited 2011 Aug 11]. Disponível em: http://www.transitieproject.nl/.
Takeda S. A organização de serviços de Atenção Primária à Saúde. In: Duncan BB, Schmidt MI, Giugliani ERJ. Medicina Ambulatorial: Condutas de Atenção Primária Baseadas em Evidências. Porto Alegre: Artmed Editora; 2004. p. 76-87.
Radaelli SM, Takeda SMP, Gimeno LID, Wagner MB, Kanter FJ, Mello VM, et al. Demanda de serviço de saúde comunitária na periferia de área metropolitana. Rev Saúde Publ. 1990; 24:232-40. http://dx.doi.org/10.1590/S0034-89101990000300010
Faleiros JJ, Martines JC, Piccini RX, AduresTRML, Mota Neto JIS, Silva DB. Motivos de consulta mais freqüentes e utilização em um serviço de atenção primária à saúde. Rev AMRIGS. 1985;29(4):297-300. http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=LILACS&lang=p&nextAction=lnk&exprSearch=64553&indexSearch=ID
Lopes JM, Leite WCL, Stein AT, Ducan BB. Diagnósticos mais comuns no serviço de medicina geral e comunitária, Unidades de Medicina de Família, Hospital Nossa Senhora da Conceição, Porto Alegre, 1983. Rev AMRIGS. 1985; 29: 301-6.
Muller CL, Franco D, Barros LMCA, Somacal LF, Bordin R. Estudo da composição da demanda de uma unidade sanitária da Grande Porto Alegre. Rev Hosp Clin. 1987; 7(2): 77-80.
Takeda SMF, Stein A, Kanter F, Duncan, BB. Estudo dos motivos de consulta em uma vila na periferia de Porto Alegre. Rev AMRIGS. 1985; 29: (3): 231-8. http://bases.bireme.br/cgi-bin/wxislind.exe/iah/online/?IsisScript=iah/iah.xis&src=google&base=ADOLEC&lang=p&nextAction=lnk&exprSearch=34158&indexSearch=ID
Landsberg GA, Savassi LC, De Sousa AB, De Freitas JM, Nascimento JS, Azagra R. [Analysis of demand for family medical care in Brazil using the International Classification of Primary Care]. Cien Saude Colet. 2012 Nov; 17(11): 3025-36. http://dx.doi.org/10.1590/S1413-81232012001100019

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DSM V : el manual de la discordia

Fuente: El Pais

José Luis de la Serna | Madrid

Ya está a la venta en EEUU uno de los libros más esperados en Psiquiatría de los últimos años. Casi 1.500 especialistas han aportado su granito de arena durante la última década para que el llamado DSM-V vea al fin la luz. Se trata de la nueva edición del 'Diagnostic&Statistic of Mental Disorders', un tratado considerado, hasta ahora, como la 'biblia' de la psiquiatría, cuya primera edición se imprimió en los años 50 del siglo pasado. Costará 199 dólares conseguir el texto que clasifica las patologías mentales de una forma que hasta las compañías de seguros al otro lado del Atlántico reembolsan el coste del tratamiento que ofrecen los psiquiatras en función precisamente del tipo de diagnóstico que marca el DSM.
Sin embargo, el manual llega a las librerías sobrado de discordia porque desde hace ya tiempo está siendo muy negativamente criticado por un número alto de especialistas de prestigio probado. El porqué de tanta opinión opuesta tiene que ver con la metodología que se sigue en el texto, que basa los diagnósticos psiquiátricos en los síntomas que describen los pacientes. Al contrario que la mayoría de las patologías orgánicas que sufre el ser humano, en las que se está profundizando hasta en su intimidad molecular para certificar la causa y así su tratamiento, y para las en las que existen además marcadores e imágenes con las que objetivar las manifestaciones que relata un enfermo, en el DSM-V se abunda en datos generales, síntomas, comportamientos, estados de ánimo; sin diferenciar la mayoría de las veces la razón que subyace detrás de tanto síntoma.
De esta forma, algo tan común en el día a día como, por ejemplo, suele ser la depresión o la ansiedad puede ser causado por multitud de patologías en principio distintas. Desde enfermedades cerebrales que puedan observarse con pruebas muy comunes hasta otras patologías más complejas como el trastorno bipolar, la esquizofrenia, el alcoholismo, la drogadicción, las deprivaciones, las pérdidas, la introversión y hasta la timidez o los temperamentos vulnerables.
En manifestaciones escritas estos días de algunos expertos, "muchos síntomas en psiquiatría son el equivalente a lo que es la fiebre en medicina orgánica. Una temperatura elevada puede estar motivada por una enfermedad bacteriana o viral, pero también por crisis de autoinmunidad, cierto tipo de cánceres o hasta por sobre esfuerzo tras un ejercicio intenso que ha provocado inflamación sistémica".
Lejos están los tiempos en los que los problemas de la mente se intentaban justificar acudiendo al inconsciente humano o a los deseos reprimidos de la infancia. Un número elevado de firmas de relieve han insistido estos días pidiendo que se profundice mucho más de lo que se está haciendo en las razones de las psicopatías y que no se intente medicalizar comportamientos individuales que pueden estar incluso en el rango de la normalidad.
Hay expertos que hasta afirman que entre el DSM-V y la abundancia de psicofármacos para casi todo se le está haciendo un flaco favor a las especialidad.
Por otra parte, no se puede ocultar la gran dificultad que tiene investigar la mente de los seres humanos, quizá el área más compleja que existe en Biología. Pero en cualquier caso, el Instituto Nacional de la Salud Mental, en EEUU, ha afirmado que no patrocinará ninguna investigación en Psiquiatría en la que los diagnósticos se basen precisamente en el controvertido texto.

More in English from Hufftington Post

By: Wynne Parry, LiveScience Contributor
Published: 05/20/2013 08:45 AM EDT on LiveScience
With the release of the latest edition of the mental health manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM), LiveScience takes a close look at some of the disorders it defines. This 10-part series asks the fundamental question: What is normal, and what is not?
As of May 22, many mental disorders will never be the same. The full nature of the changes -- some quite controversial --will become apparent with the publication of the latest edition of the mental health manual that classifies these disorders.
This guidebook, the Diagnostic and Statistical Manual of Mental Disorders (DSM), is an influential document. By setting forth the criteria used to diagnose disorders, it draws the line between what is normal and what is not. This diagnostic line can have many implications for people's lives; for instance, a diagnosis based on its criteria can determine whether or not someone qualifies for special education services or disability benefits.
The high stakes, in combination with the complexity and mysteries of the human mind, makes revising this manual a challenging project, to say the least, and likely to generate heated controversy, which it has. [The 10 Most Controversial Psychiatric Disorders]
Keeping up with the times
Work on the latest edition, the fifth, began in 1999. Among the host of changes the new DSM-5 contains, some have sparked considerable discussion before its release at the annual American Psychiatric Association (APA) meeting Saturday (May 18) and subsequent official releaseon May 22.
First published in 1952, the DSM has periodically been reviewed and updated by the APA, with the last major revision completed about 20 years ago.
"Since that time, there has been a wealth of new research about mental disorders," David Kupfer, chairman of the DSM-5 task force and a professor of psychiatry at the University of Pittsburgh School of Medicine, told LiveScience in an email. "Many of the changes in DSM-5 were made to better characterize symptoms and behaviors of groups of people who are currently seeking clinical help but are not well defined by DSM-IV," Kupfer said, referring to the predecessor to DSM-5.
Psychiatric controversies
Before its publication, word of changes in the DSM-5 attracted no shortage of critics.
Among the flashpoints: Asperger's disorder will be folded into autism spectrum disorder; grief will no longer exempt someone from a diagnosis of depression; irritable children who throw frequent temper tantrums can be diagnosed with disruptive mood dysregulation disorder. [Hypersex to Hoarding: 7 New Psychological Disorders]
One prominent critic has been Allen Frances, a professor emeritus of psychiatry at Duke University who chaired the DSM-IV task force.
Frances charges that through a combination of new disorders and lowered thresholds, the DSM-5 is expanding the boundaries of psychiatry to encompass many whom he describes as the "worried well."
Diagnostic inflation?
The problem is that the manual has become too important; the diagnostic criteria carry too much responsibility, creating enormous pressure for expansion, Frances argues. For instance, a diagnosis of autism, or some other disorder, can entitle a student to special services. As a result, there is tremendous pressure to diagnose vague cases, Frances said.
News that the DSM-5 would fold Asperger's disorder into autism spectrum disorders has raised concerns from families and advocates that some people might lose their diagnosis, and as a result, services.
"My contention is this system, without anyone really noticing it, has gotten out of control and it is diagnosing many of the worried well," he told LiveScience, adding that as a result, these new patients are prescribed drugs that have the potential to cause harm.
The architects of the DSM-5 have disputed charges such as Frances'. In a Medscape Psychiatry article published in June, Kupfer called charges that changes in the DSM-5 will lead to more people being diagnosed with mental disorders as "patently wrong."
"We sought to be conservative in our approach to revising DSM-5. Our work was aimed at more accurately defining mental disorders that have a real impact on people's lives," Kupfer told LiveScience in an email, adding that based on field trials and analyses of the changes, the task force does not expect to see more people receiving diagnoses.
He noted that DSM-5 includes approximately the same number of disorders as DSM-IV. (While some new disorders have been added, some have been combined or eliminated. Critics argue the additions will increase the diagnosis of disorders more than the other changes will decrease it.)
Setting the threshold
More than 46 percent of the U.S. population will meet the criteria for at least one DSM-IV diagnosis during their lifetimes, according to research by Ronald Kessler, a professor of health care policy at Harvard Medical School, and colleague Philip Wang published in 2008 in the Annual Review of Public Health.
When told this rate seemed high, Kessler said, "Here's something even more shocking: 99.9 percent of the U.S. population has had a physical health problem in their lives. ...There are all kinds of stuff that count as physical illness. That doesn't mean you're at death's door." (Kessler was not involved in the revisions to the DSM.)
The heaviest burden of mental illness falls on a small proportion of the U.S. population --about 6 percent of people in a given year --whose mental illnesses, such as schizophrenia or major depression, impairs them to the point that they can't hold down a job, become suicidal or become socially isolated, for example, according to other research Kessler has published in the Archives of General Psychiatry in 2003.
Milder, less debilitating cases are more common; however, even these cases are associated with an increased risk of long-term problems compared with people with no diagnosis at all, Kessler and colleagues write in a 2003 paper that argues against the elimination of mild cases from the DSM.
Establishing psychiatric diagnoses is challenging because they rely on symptoms. "It's not like you can look under a microscope," Kessler said.
So, setting a threshold for a diagnosis can be somewhat arbitrary.
"At a certain point, you can say everybody's sick," he said. "The question is, where do you draw the line."
. Original article on LiveScience.com.

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