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      Sobrediagnóstico: "Un mal que daña a nuestros niños" Translated title: First do no harm: overdiagnosis in Pediatrics

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          Abstract

          Pueden cometerse muchos errores en el momento de hacer un diagnóstico: subdiagnosticar, hacer un diagnóstico equivocado y sobrediagnosticar. Mientras que el subdiagnóstico y el diagnóstico equivocado son errores obvios, cuando se sobrediagnostica se descubre una anomalía real, pero la detección no beneficia al paciente. El daño ocurre cuando se continúa evaluando al paciente y se lo trata innecesariamente por una afección que, de no haberse diagnosticado, nunca lo habría afectado. Son varios los fenómenos que apuntan a un posible sobrediagnóstico: que la demora u omisión de un diagnóstico no ocasione daños; que aumente la detección de una enfermedad, pero no haya cambios en los resultados, y que los estudios aleatorizados no muestren ningún beneficio con el diagnóstico.Hay quienes dirían que el saber siempre reporta beneficios, pero los efectos adversos del sobrediagnóstico están bien documentados. Tendremos que adquirir más conocimientos sobre el daño que puede generar el sobrediagnóstico y transmitirlos a nuestros colegas, y deberemos aprender a encontrar el equilibrio entre el posible beneficio de un diagnóstico y el riesgo del sobrediagnóstico.

          Translated abstract

          Many errors can be made in diagnosis: underdiagnosis, misdiagnosis, and overdiagnosis. While underdiagnosis and misdiagnosis are clear errors, in overdiagnosis, a true abnormality is discovered, but detection does not benefit the patient. Harm occurs when patients are further evaluated and treated unnecessarily as a result of making a diagnosis that would never have affected the patient if the diagnosis had not been made. Several phenomena point to potential overdiagnosis: when delayed or missed diagnoses do not result in harm; when there is increased detection of a disease, but no change in the outcome; and when randomized trials show no benefit from the diagnosis. Some might say that there is always benefit in knowing, but the adverse effects of overdiagnosis are well documented. We will need to educate ourselves and our colleagues about the potential for harm from overdiagnosis, and learn how to balance the potential benefit of a diagnosis against the risk of overdiagnosis.

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          Most cited references 17

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          Bronchiolitis-associated hospitalizations among US children, 1980-1996.

          Respiratory syncytial virus (RSV) causes more lower respiratory tract infections, often manifested as bronchiolitis, among young children than any other pathogen. Few national estimates exist of the hospitalizations attributable to RSV, and recent advances in prophylaxis warrant an update of these estimates. To describe rates of bronchiolitis-associated hospitalizations and to estimate current hospitalizations associated with RSV infection. Descriptive analysis of US National Hospital Discharge Survey data from 1980 through 1996. Children younger than 5 years who were hospitalized in short-stay, non-federal hospitals for bronchiolitis. Bronchiolitis-associated hospitalization rates by age and year. During the 17-year study period, an estimated 1.65 million hospitalizations for bronchiolitis occurred among children younger than 5 years, accounting for 7.0 million inpatient days. Fifty-seven percent of these hospitalizations occurred among children younger than 6 months and 81 % among those younger than 1 year. Among children younger than 1 year, annual bronchiolitis hospitalization rates increased 2.4-fold, from 12.9 per 1000 in 1980 to 31.2 per 1000 in 1996. During 1988-1996, infant hospitalization rates for bronchiolitis increased significantly (P for trend <.001), while hospitalization rates for lower respiratory tract diseases excluding bronchiolitis did not vary significantly (P for trend = .20). The proportion of hospitalizations for lower respiratory tract illnesses among children younger than 1 year associated with bronchiolitis increased from 22.2% in 1980 to 47.4% in 1996; among total hospitalizations, this proportion increased from 5.4% to 16.4%. Averaging bronchiolitis hospitalizations during 1994-1996 and assuming that RSV was the etiologic agent in 50% to 80% of November through April hospitalizations, an estimated 51, 240 to 81, 985 annual bronchiolitis hospitalizations among children younger than 1 year were related to RSV infection. During 1980-1996, rates of hospitalization of infants with bronchiolitis increased substantially, as did the proportion of total and lower respiratory tract hospitalizations associated with bronchiolitis. Annual bronchiolitis hospitalizations associated with RSV infection among infants may be greater than previous estimates for RSV bronchiolitis and pneumonia hospitalizations combined.
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            Bronchiolitis-associated mortality and estimates of respiratory syncytial virus-associated deaths among US children, 1979-1997.

            A 1985 estimate that 4500 respiratory syncytial virus (RSV)-associated deaths occur annually among US children has not been updated using nationally representative data. Thus, 1979-1997 multiple cause-of-death records for children <5 years old listing bronchiolitis, pneumonia, or any respiratory tract disease were examined. Deaths among children associated with any respiratory disease declined from 4631 in 1979 to 2502 in 1997. During the 19-year study period, 1806 bronchiolitis-associated deaths occurred (annual mean, 95 deaths; range, 66-127 deaths). Of these deaths, 1435 (79%) occurred among infants <1 year old. Congenital heart disease, lung disease, or prematurity was listed in death records of 179 (9.9%), 99 (5.5%), and 76 (4.2%) children dying with bronchiolitis, respectively. By applying published proportions of children hospitalized for bronchiolitis or pneumonia who were RSV-infected to bronchiolitis and pneumonia deaths, it was estimated that < or =510 RSV-associated deaths occurred annually during the study period, fewer than previously estimated.
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              Antimicrobial prophylaxis for children with vesicoureteral reflux.

              Children with febrile urinary tract infection commonly have vesicoureteral reflux. Because trial results have been limited and inconsistent, the use of antimicrobial prophylaxis to prevent recurrences in children with reflux remains controversial.
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                Author and article information

                Contributors
                Role: ND
                Journal
                aap
                Archivos argentinos de pediatría
                Arch. argent. pediatr.
                Sociedad Argentina de Pediatría (Buenos Aires, , Argentina )
                0325-0075
                1668-3501
                December 2018
                : 116
                : 6
                : 426-429
                Affiliations
                orgnameJunta Estadounidense de Pediatría orgdiv1Vicepresidente, Mantenimiento de la Certificación y Calidad
                Article
                S0325-00752018000600014
                10.5546/aap.2018.426

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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