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Jones JP, Williamson L, Konsoula Z, Anderson R, Reissner KJ, Parker W. Evaluating the Role of Susceptibility Inducing Cofactors and of Acetaminophen in the Etiology of Autism Spectrum Disorder. Life (Basel) 2024; 14:918. [PMID: 39202661 PMCID: PMC11355895 DOI: 10.3390/life14080918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/16/2024] [Accepted: 07/19/2024] [Indexed: 09/03/2024] Open
Abstract
More than 20 previously reported lines of independent evidence from clinical observations, studies in laboratory animal models, pharmacokinetic considerations, and numerous temporal and spatial associations indicate that numerous genetic and environmental factors leading to inflammation and oxidative stress confer vulnerability to the aberrant metabolism of acetaminophen during early development, leading to autism spectrum disorder (ASD). Contrary to this conclusion, multivariate analyses of cohort data adjusting for inflammation-associated factors have tended to show little to no risk of acetaminophen use for neurodevelopment. To resolve this discrepancy, here we use in silico methods to create an ideal (virtual) population of 120,000 individuals in which 50% of all cases of virtual ASD are induced by oxidative stress-associated cofactors and acetaminophen use. We demonstrate that Cox regression analysis of this ideal dataset shows little to no risk of acetaminophen use if the cofactors that create aberrant metabolism of acetaminophen are adjusted for in the analysis. Further, under-reporting of acetaminophen use is shown to be a considerable problem for this analysis, leading to large and erroneously low calculated risks of acetaminophen use. In addition, we argue that factors that impart susceptibility to acetaminophen-induced injury, and propensity for acetaminophen use itself, can be shared between the prepartum, peripartum, and postpartum periods, creating additional difficulty in the analysis of existing datasets to determine risks of acetaminophen exposure for neurodevelopment during a specific time frame. It is concluded that risks of acetaminophen use for neurodevelopment obtained from multivariate analysis of cohort data depend on underlying assumptions in the analyses, and that other evidence, both abundant and robust, demonstrate the critical role of acetaminophen in the etiology of ASD.
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Affiliation(s)
- John P. Jones
- WPLab, Inc., Durham, NC 27707, USA; (J.P.J.III); (Z.K.); (R.A.)
| | - Lauren Williamson
- Department of Biological Sciences, Northern Kentucky University, Highland Heights, KY 41099, USA;
| | | | - Rachel Anderson
- WPLab, Inc., Durham, NC 27707, USA; (J.P.J.III); (Z.K.); (R.A.)
| | - Kathryn J. Reissner
- Department of Psychology and Neuroscience, University of North Carolina, Chapel Hill, NC 27599, USA;
| | - William Parker
- WPLab, Inc., Durham, NC 27707, USA; (J.P.J.III); (Z.K.); (R.A.)
- Department of Psychology and Neuroscience, University of North Carolina, Chapel Hill, NC 27599, USA;
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Zhao L, Jones III JP, Anderson LG, Konsoula Z, Nevison CD, Reissner KJ, Parker W. Acetaminophen causes neurodevelopmental injury in susceptible babies and children: no valid rationale for controversy. Clin Exp Pediatr 2024; 67:126-139. [PMID: 37321575 PMCID: PMC10915458 DOI: 10.3345/cep.2022.01319] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/10/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
Despite the worldwide acceptance of acetaminophen (APAP) as a necessary medicine in pediatrics, evidence that early exposure to APAP causes neurodevelopmental injury in susceptible babies and children has been mounting for over a decade. The evidence is diverse and includes extensive work with laboratory animals, otherwise unexplained associations, factors associated with APAP metabolism, and limited studies in humans. Although the evidence has reached an overwhelming level and was recently reviewed in detail, controversy persists. This narrative review evaluates some of that controversy. Evidence from the pre- and postpartum periods was considered to avoid controversy raised by consideration of only limited evidence of risks during the prepartum period. Among other issues, the association between APAP use and the prevalence of neurodevelopmental disorders was considered. A systematic review revealed that the use of APAP in the pediatric population was never tracked carefully; however, historical events that affected its use were documented and are sufficient to establish apparent correlations with changes in the prevalence of neurodevelopmental disorders. Moreover, problems with the exclusive reliance on results of meta-analyses of large datasets with limited time frames of drug exposure were reviewed. Furthermore, the evidence of why some children are susceptible to APAPinduced neurodevelopmental injuries was examined. We concluded that available evidence demonstrates that early exposure to APAP causes neurodevelopmental injury in susceptible babies and small children.
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Affiliation(s)
| | | | | | | | - Cynthia D. Nevison
- Institute for Arctic and Alpine Research, University of Colorado Boulder, Boulder, CO, USA
| | - Kathryn J. Reissner
- Department of Psychology and Neuroscience, University of North Carolina, Chapel Hill, NC, USA
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Parker W, Anderson LG, Jones JP, Anderson R, Williamson L, Bono-Lunn D, Konsoula Z. The Dangers of Acetaminophen for Neurodevelopment Outweigh Scant Evidence for Long-Term Benefits. CHILDREN (BASEL, SWITZERLAND) 2023; 11:44. [PMID: 38255358 PMCID: PMC10814214 DOI: 10.3390/children11010044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024]
Abstract
Based on available data that include approximately 20 lines of evidence from studies in laboratory animal models, observations in humans, correlations in time, and pharmacological/toxicological considerations, it has been concluded without reasonable doubt and with no evidence to the contrary that exposure of susceptible babies and children to acetaminophen (paracetamol) induces many, if not most, cases of autism spectrum disorder (ASD). However, the relative number of cases of ASD that might be induced by acetaminophen has not yet been estimated. Here, we examine a variety of evidence, including the acetaminophen-induced reduction of social awareness in adults, the prevalence of ASD through time, and crude estimates of the relative number of ASD cases induced by acetaminophen during various periods of neurodevelopment. We conclude that the very early postpartum period poses the greatest risk for acetaminophen-induced ASD, and that nearly ubiquitous use of acetaminophen during early development could conceivably be responsible for the induction in the vast majority, perhaps 90% or more, of all cases of ASD. Despite over a decade of accumulating evidence that acetaminophen is harmful for neurodevelopment, numerous studies demonstrate that acetaminophen is frequently administered to children in excess of currently approved amounts and under conditions in which it provides no benefit. Further, studies have failed to demonstrate long-term benefits of acetaminophen for the pediatric population, leaving no valid rationale for continued use of the drug in that population given its risks to neurodevelopment.
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Affiliation(s)
- William Parker
- Department of Psychology and Neuroscience, University of North Carolina, Chapel Hill, NC 27599, USA
- WPLab, Inc., Durham, NC 27707, USA
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | | | | | | | - Lauren Williamson
- Department of Biological Sciences, Northern Kentucky University, Highland Heights, KY 41099, USA;
| | - Dillan Bono-Lunn
- Department of Public Policy, University of North Carolina, Chapel Hill, NC 27599, USA;
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4
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Patel E, Jones Iii JP, Bono-Lunn D, Kuchibhatla M, Palkar A, Cendejas Hernandez J, Sarafian JT, Lawton VG, Anderson LG, Konsoula Z, Reissner KJ, Parker W. The safety of pediatric use of paracetamol (acetaminophen): a narrative review of direct and indirect evidence. Minerva Pediatr (Torino) 2022; 74:774-788. [PMID: 35822581 DOI: 10.23736/s2724-5276.22.06932-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Paracetamol (acetaminophen) use during pregnancy and early childhood was accepted as safe in the 1970s, but is now a subject of considerable concern. Careful analysis shows that initial acceptance of the drug was based on the false assumption that drug interactions in babies and adults are the same, and on a complete absence of knowledge regarding the impact of the drug on brain development. At least fourteen epidemiological studies now indicate that prenatal exposure to paracetamol is associated with neurodevelopmental problems. Based on these studies, it can be concluded that prenatal exposure to paracetamol causes statistically significant risks of developmental delays, attention deficit hyperactivity disorder, and a subtype of autism spectrum disorder (ASD) associated with hyperkinetic behavior. In contrast, data regarding postnatal exposure to paracetamol are limited, and several factors impede a classic multivariate analysis of epidemiologic data to resolve the issue. However, circumstantial evidence regarding postnatal exposure to the drug is abundant, and includes at least three otherwise unexplained temporal relationships, data from laboratory animal studies, several miscellaneous and otherwise unexplained correlations, and a lack of alternative suspects that fit the evidence-derived profile. Based on this evidence, it can be concluded without any reasonable doubt that oxidative stress puts some babies and children at risk of paracetamol-induced neurodevelopmental injury, and that postnatal exposure to paracetamol in those susceptible babies and children is responsible for many if not most cases of ASD.
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Affiliation(s)
| | - John P Jones Iii
- WPLab, Inc. Durham, NC, USA.,Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dillan Bono-Lunn
- Departments of Public Policy, University of North Carolina, Chapel Hill, NC, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - Antara Palkar
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Joshua T Sarafian
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Victoria G Lawton
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Lauren G Anderson
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Kathryn J Reissner
- Department of Psychology, University of North Carolina, Chapel Hill, NC, USA.,Department of Neuroscience, University of North Carolina, Chapel Hill, NC, USA
| | - William Parker
- WPLab, Inc. Durham, NC, USA - .,Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Uberoi M, Abdulcadir J, Ohl DA, Santiago JE, Rana GK, Anderson FWJ. Potentially under-recognized late-stage physical and psychosexual complications of non-therapeutic neonatal penile circumcision: a qualitative and quantitative analysis of self-reports from an online community forum. Int J Impot Res 2022; 35:234-241. [PMID: 36274189 DOI: 10.1038/s41443-022-00619-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 07/28/2022] [Accepted: 09/12/2022] [Indexed: 11/09/2022]
Abstract
The removal of non-pathogenic foreskin from the penis of healthy neonates and infants for non-religious reasons is routinely practiced in many parts of the world. High level data from well-designed randomized controlled trials of circumcision in neonates and infants does not guide clinical practice. Reliable counts of immediate and short term circumcision complications are difficult to estimate. Emerging evidence suggests routine neonatal circumcision could lead to long term psychological, physical, and sexual complications in some men. The stigma associated with discussing circumcision complications creates a prevalence paradox where the presence of significant circumcision complications is higher than reported. Prior to the Internet, there were very few forums for men from diverse communities, who were troubled about their circumcision status, to discuss and compare stories. To investigate the long term consequences of circumcision, we reviewed 135 posts from 109 individual users participating in a circumcision grief subsection of Reddit, an internet discussion board. We identified three major categories of complications: physical such as pain during erections and lost sensitivity, psychological such as anxiety and violation of autonomy, and sexual such as feeling that the sexual experience was negatively altered or being unable to complete a sexual experience. We also identified a "discovery process" where some men described coming into awareness of their circumcision status. These findings suggest that neonatal circumcision can have significant adverse consequences for adult men. The removal of normal foreskin tissue should be limited to adult men who choose the procedure for cosmetic reasons or when medically indicated.
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Morris BJ, Moreton S, Krieger JN, Klausner JD. Infant Circumcision for Sexually Transmitted Infection Risk Reduction Globally. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00811. [PMID: 36041835 PMCID: PMC9426975 DOI: 10.9745/ghsp-d-21-00811] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/21/2022] [Indexed: 12/26/2022]
Abstract
Population-based studies in high-income countries have failed to find that male circumcision protects against sexually transmitted infections. Using evidence from several sources, we show that male circumcision does protect against HIV during insertive intercourse for men who have sex with men.
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences, University of Sydney, Sydney, Australia.
| | | | - John N Krieger
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
| | - Jeffrey D Klausner
- Department of Medicine, Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Morris BJ, Moreton S, Bailis SA, Cox G, Krieger JN. Critical evaluation of contrasting evidence on whether male circumcision has adverse psychological effects: A systematic review. J Evid Based Med 2022; 15:123-135. [PMID: 35785439 PMCID: PMC9540570 DOI: 10.1111/jebm.12482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 06/16/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To conduct the first systematic review critically examining evidence on whether early male circumcision has short- and long-term adverse psychological effects. METHODS We searched PubMed, EMBASE, SCOPUS, Cochrane Library, and Google Scholar. RESULTS Twenty-four studies with original data met the inclusion criteria. These comprised 11,173 total males, 4340 circumcised in infancy and 6908 uncircumcised. Nineteen were rated 1+, 2++ or 2+, and 5 were rated 2- by SIGN criteria. Neonatal circumcision, particularly without anesthetic, increased vaccination pain response, but had little effect on breastfeeding or cognitive ability. Studies reporting associations with sudden infant death syndrome, autism, alexithymia and impaired sexual function and pleasure had design flaws and were rated 2-. Sexual arousal, touch, pain, and warmth thresholds measured by quantitative sensory testing were not diminished in neonatally circumcised men. Neonatal circumcision was not associated with empathy in men, contradicting the hypothesis that procedural pain causes central nervous system changes. After correcting all associations with socioaffective processing parameters for multiple testing only higher sociosexual desire, dyadic sexual libido/drive, and stress remained significant. The relatively greater sexual activity found in circumcised men might reflect reduced sexual activity in uncircumcised men overall owing to pain and psychological aversion in those with foreskin-related medical conditions (reverse causality). Most studies employed case-control designs with limited follow-up. Studies beyond childhood were prone to confounding. CONCLUSION The highest quality evidence suggest that neonatal and later circumcision has limited or no short-term or long-term adverse psychological effects.
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Affiliation(s)
- Brian J. Morris
- Faculty of Medicine and HealthSchool of Medical SciencesUniversity of SydneySydneyNew South WalesAustralia
| | | | | | - Guy Cox
- School of AerospaceMechanical & Mechatronic EngineeringUniversity of SydneySydneyAustralia
- Australian Centre for Microscopy and MicroanalysisUniversity of SydneySydneyAustralia
| | - John N. Krieger
- Department of UrologyUniversity of Washington School of MedicineSeattle
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Morris BJ, Katelaris A, Blumenthal NJ, Hajoona M, Sheen AC, Schrieber L, Lumbers ER, Wodak AD, Katelaris P. Evidence-based circumcision policy for Australia. JOURNAL OF MEN'S HEALTH 2022; 18:132. [PMID: 36034719 PMCID: PMC9409339 DOI: 10.31083/j.jomh1806132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The aim was (1) to perform an up-to-date systematic review of the male circumcision (MC) literature and (2) to determine the number of adverse medical conditions prevented by early MC in Australia. Searches of PubMed using "circumcision" with 39 keywords and bibliography searches yielded 278 publications meeting our inclusion criteria. Early MC provides immediate and lifetime benefits, including protection against: urinary tract infections, phimosis, inflammatory skin conditions, inferior penile hygiene, candidiasis, various STIs, and penile and prostate cancer. In female partners MC reduces risk of STIs and cervical cancer. A risk-benefit analysis found benefits exceeded procedural risks, which are predominantly minor, by approximately 200 to 1. It was estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. An increase in early MC in Australia to mid-1950s prevalence of 85% from the current level of 18.75% would avoid 77,000 cases of infections and other adverse medical conditions over the lifetime for each annual birth cohort. Survey data, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation indicate that MC has no detrimental effect on sexual function, sensitivity or pleasure. US studies found that early infant MC is cost saving. Evidence-based reviews by the AAP and CDC support early MC as a desirable public health measure. Although MC can be performed at any age, early MC maximizes benefits and minimises procedural risks. Parents should routinely be provided with accurate, up-to-date evidence-based information in an unbiased manner early in a pregnancy so that they have time to weigh benefits and risks of early MC and make an informed decision should they have a son. Parental choice should be respected. A well-trained competent practitioner is essential and local anaesthesia should be routinely used. Third party coverage of costs is advocated.
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Affiliation(s)
- Brian J. Morris
- School of Medical Sciences, University of Sydney, Sydney, NSW 2006, Australia
| | - Athos Katelaris
- Department of Urology, St George Hospital, Sydney, NSW 2217, Australia
| | - Norman J. Blumenthal
- Department of Obstetrics and Gynaecology, SAN Clinic, Wahroonga, NSW 2076, Australia
| | - Mohamed Hajoona
- Victoria Circumcision Clinic, The Regent Medical Group, Preston, VIC 3072, Australia
| | | | - Leslie Schrieber
- Department of Medicine, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Eugenie R. Lumbers
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Pregnancy and Reproduction Program, Hunter Medical Research Institute, New Lambton Heights; Priority Research Centre for Reproductive Sciences, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Alex D. Wodak
- St Vincent’s Hospital, Australian Tobacco Harm Reduction Association and Australia21, Darlinghurst, NSW 2010, Australia
| | - Phillip Katelaris
- Katelaris Urology, North Shore Private Hospital, St Leonards, NSW 2065, Australia
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Cendejas-Hernandez J, Sarafian JT, Lawton VG, Palkar A, Anderson LG, Larivière V, Parker W. Paracetamol (acetaminophen) use in infants and children was never shown to be safe for neurodevelopment: a systematic review with citation tracking. Eur J Pediatr 2022; 181:1835-1857. [PMID: 35175416 PMCID: PMC9056471 DOI: 10.1007/s00431-022-04407-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/26/2022]
Abstract
Although widely believed by pediatricians and parents to be safe for use in infants and children when used as directed, increasing evidence indicates that early life exposure to paracetamol (acetaminophen) may cause long-term neurodevelopmental problems. Furthermore, recent studies in animal models demonstrate that cognitive development is exquisitely sensitive to paracetamol exposure during early development. In this study, evidence for the claim that paracetamol is safe was evaluated using a systematic literature search. Publications on PubMed between 1974 and 2017 that contained the keywords "infant" and either "paracetamol" or "acetaminophen" were considered. Of those initial 3096 papers, 218 were identified that made claims that paracetamol was safe for use with infants or children. From these 218, a total of 103 papers were identified as sources of authority for the safety claim. Conclusion: A total of 52 papers contained actual experiments designed to test safety, and had a median follow-up time of 48 h. None monitored neurodevelopment. Furthermore, no trial considered total exposure to drug since birth, eliminating the possibility that the effects of drug exposure on long-term neurodevelopment could be accurately assessed. On the other hand, abundant and sufficient evidence was found to conclude that paracetamol does not induce acute liver damage in babies or children when used as directed. What is Known: • Paracetamol (acetaminophen) is widely thought by pediatricians and parents to be safe when used as directed in the pediatric population, and is the most widely used drug in that population, with more than 90% of children exposed to the drug in some reports. • Paracetamol is known to cause liver damage in adults under conditions of oxidative stress or when used in excess, but increasing evidence from studies in humans and in laboratory animals indicates that the target organ for paracetamol toxicity during early development is the brain, not the liver. What is New: • This study finds hundreds of published reports in the medical literature asserting that paracetamol is safe when used as directed, providing a foundation for the widespread belief that the drug is safe. • This study shows that paracetamol was proven to be safe by approximately 50 short-term studies demonstrating the drug's safety for the pediatric liver, but the drug was never shown to be safe for neurodevelopment. Paracetamol is widely believed to be safe for infants and children when used as directed, despite mounting evidence in humans and in laboratory animals indicating that the drug is not safe for neurodevelopment. An exhaustive search of published work cited for safe use of paracetamol in the pediatric population revealed 52 experimental studies pointing toward safety, but the median follow-up time was only 48 h, and neurodevelopment was never assessed.
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Affiliation(s)
- Jasmine Cendejas-Hernandez
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
- WPLab, Inc, 1023 Wells St, Durham, NC 27707 USA
| | - Joshua T. Sarafian
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Victoria G. Lawton
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Antara Palkar
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Lauren G. Anderson
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Vincent Larivière
- École de Bibliothéconomie Et Des Sciences de L’information, Université de Montréal, Montreal, Canada
| | - William Parker
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
- WPLab, Inc, 1023 Wells St, Durham, NC 27707 USA
- Duke Global Health Institute, Duke University and Duke University Medical Center, Durham, NC 27710 USA
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10
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Wester T, Gunnarsdottir A, Skoglund C, Svenningsson A. Attention deficit hyperactivity and autism spectrum disorders in patients with anorectal malformations. Acta Paediatr 2021; 110:3131-3136. [PMID: 34498328 DOI: 10.1111/apa.16100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022]
Abstract
AIM To assess the risk of neurodevelopmental disorders in patients with anorectal malformations compared to controls. METHODS This was a population-based cohort study including all patients born in Sweden 1997-2012 with anorectal malformation in the Swedish National Patient Register and five matched controls per patient. Anorectal malformation was the exposure. All individuals were evaluated for the outcomes, attention deficit hyperactivity disorder or autism spectrum disorder in the National Patient Register. Data on drugs for attention deficit hyperactivity disorder were retrieved from the Swedish Prescribed Drug Register and used as proxy for attention deficit hyperactivity disorder. Conditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (95% CI). Analyses were adjusted for confounders. RESULTS Five hundred and fifteen patients with anorectal malformations and 2560 controls were included. Patients with anorectal malformation had a higher risk of attention deficit hyperactivity disorder (OR 3.01 (95% CI, 1.83-4.95)) and autism spectrum disorders (OR 3.07 (95% CI, 1.62-5.79)) compared to the controls. Significantly more patients with anorectal malformation had been prescribed medication for attention deficit hyperactivity disorder compared to controls (OR 2.26 (95% CI 1.33-3.85)). CONCLUSION Patients with anorectal malformations have a higher risk of attention deficit hyperactivity disorder and autism spectrum disorders than controls.
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Affiliation(s)
- Tomas Wester
- Department of Pediatric Surgery Karolinska University Hospital Stockholm Sweden
- Pediatric Surgery Research Unit Department of Women’s and Children’s Health Karolinska Institute Stockholm Sweden
| | - Anna Gunnarsdottir
- Department of Pediatric Surgery Karolinska University Hospital Stockholm Sweden
- Pediatric Surgery Research Unit Department of Women’s and Children’s Health Karolinska Institute Stockholm Sweden
| | | | - Anna Svenningsson
- Department of Pediatric Surgery Karolinska University Hospital Stockholm Sweden
- Pediatric Surgery Research Unit Department of Women’s and Children’s Health Karolinska Institute Stockholm Sweden
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11
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Frisch M, Simonsen J. Non-therapeutic male circumcision in infancy or childhood and risk of human immunodeficiency virus and other sexually transmitted infections: national cohort study in Denmark. Eur J Epidemiol 2021; 37:251-259. [PMID: 34564796 PMCID: PMC9110485 DOI: 10.1007/s10654-021-00809-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 09/12/2021] [Indexed: 12/14/2022]
Abstract
Whether male circumcision in infancy or childhood provides protection against the acquisition of human immunodeficiency virus (HIV) or other sexually transmitted infections (STIs) in adulthood remains to be established. In the first national cohort study to address this issue, we identified 810,719 non-Muslim males born in Denmark between 1977 and 2003 and followed them over the age span 0–36 years between 1977 and 2013. We obtained information about cohort members’ non-therapeutic circumcisions, HIV diagnoses and other STI outcomes from national health registers and used Cox proportional hazards regression analyses to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) associated with foreskin status (i.e., circumcised v. genitally intact). During a mean of 22 years of follow-up, amounting to a total observation period of 17.7 million person-years, 3375 cohort members (0.42%) underwent non-therapeutic circumcision, and 8531 (1.05%) received hospital care for HIV or other STIs. Compared with genitally intact males, rates among circumcised males were not statistically significantly reduced for any specific STI. Indeed, circumcised males had a 53% higher rate of STIs overall (HR = 1.53, 95% CI: 1.24–1.89), and rates were statistically significantly increased for anogenital warts (74 cases in circumcised males v. 7151 cases in intact males, HR = 1.51; 95% CI: 1.20–1.90) and syphilis (four cases in circumcised males v. 197 cases in intact males, HR = 3.32; 95% CI: 1.23–8.95). In this national cohort study spanning more than three decades of observation, non-therapeutic circumcision in infancy or childhood did not appear to provide protection against HIV or other STIs in males up to the age of 36 years. Rather, non-therapeutic circumcision was associated with higher STI rates overall, particularly for anogenital warts and syphilis.
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Affiliation(s)
- Morten Frisch
- Department of Epidemiology Research, Statens Serum Institut, 2300, Copenhagen S, Denmark. .,Department of Clinical Medicine, Center for Sexology Research, Aalborg University, 9000, Aalborg, Denmark.
| | - Jacob Simonsen
- Department of Epidemiology Research, Statens Serum Institut, 2300, Copenhagen S, Denmark
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12
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Miani A, Di Bernardo GA, Højgaard AD, Earp BD, Zak PJ, Landau AM, Hoppe J, Winterdahl M. Neonatal male circumcision is associated with altered adult socio-affective processing. Heliyon 2020; 6:e05566. [PMID: 33299934 PMCID: PMC7702013 DOI: 10.1016/j.heliyon.2020.e05566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/21/2020] [Accepted: 11/17/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Neonatal male circumcision is a painful skin-breaking procedure that may affect infant physiological and behavioral stress responses as well as mother-infant interaction. Due to the plasticity of the developing nociceptive system, neonatal pain might carry long-term consequences on adult behavior. In this study, we examined whether infant male circumcision is associated with long-term psychological effects on adult socio-affective processing. METHODS We recruited 408 men circumcised within the first month of life and 211 non-circumcised men and measured socio-affective behaviors and stress via a battery of validated psychometric scales. RESULTS Early-circumcised men reported lower attachment security and lower emotional stability while no differences in empathy or trust were found. Early circumcision was also associated with stronger sexual drive and less restricted socio-sexuality along with higher perceived stress and sensation seeking. LIMITATIONS This is a cross-sectional study relying on self-reported measures from a US population. CONCLUSIONS Our findings resonate with the existing literature suggesting links between altered emotional processing in circumcised men and neonatal stress. Consistent with longitudinal studies on infant attachment, early circumcision might have an impact on adult socio-affective traits or behavior.
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Affiliation(s)
- Alessandro Miani
- Department of Nuclear Medicine and PET, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Institute of Work and Organizational Psychology, University of Neuchâtel, Switzerland
| | - Gian Antonio Di Bernardo
- Department of Education and Human Sciences, University of Modena and Reggio Emilia, Reggio Emiilia, Italy
| | | | - Brian D. Earp
- Departments of Philosophy and Psychology, Yale University, New Haven, CT, USA
| | - Paul J. Zak
- Center for Neuroeconomics Studies, Claremont Graduate University, Claremont, CA, USA
| | - Anne M. Landau
- Department of Nuclear Medicine and PET, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Translational Neuropsychiatry Unit, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jørgen Hoppe
- Department of Nuclear Medicine and PET, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Michael Winterdahl
- Department of Nuclear Medicine and PET, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Postnatal Acetaminophen and Potential Risk of Autism Spectrum Disorder among Males. Behav Sci (Basel) 2020; 10:bs10010026. [PMID: 31906400 PMCID: PMC7017213 DOI: 10.3390/bs10010026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/30/2019] [Accepted: 12/30/2019] [Indexed: 12/13/2022] Open
Abstract
Some evidence from the literature suggests that postnatal acetaminophen exposure may be associated with increased risk of autism spectrum disorder (ASD). Using a data set obtained from a previous study that was derived from an Internet-based survey among parents on 1515 children from the US, an adjusted odds ratio (aOR) and gender-specific aORs for doses of postnatal acetaminophen provided before age two were calculated against the outcome of ASD. Separately, parental uncertainty on the number of doses of acetaminophen provided was analyzed. A population attributable fraction (PAF) associated with postnatal acetaminophen exposure before age two for ASD among males was also estimated. Postnatal acetaminophen exposure, measured in doses before age two, was found to be associated with ASD among male children (aOR 1.023, CI 1.005–1.043, p = 0.020*), and parental uncertainty on the number of doses of acetaminophen provided before age two was also found to be associated with ASD. Using this data set, the PAF associated with postnatal acetaminophen was estimated to be about 40% of the risk of ASD among male children in the US. These results suggest the possibility that postnatal acetaminophen may be a significant contributor to the risk of ASD among males in the US.
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14
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Morris BJ, Moreton S, Krieger JN. Critical evaluation of arguments opposing male circumcision: A systematic review. J Evid Based Med 2019; 12:263-290. [PMID: 31496128 PMCID: PMC6899915 DOI: 10.1111/jebm.12361] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/03/2019] [Accepted: 05/12/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To systematically evaluate evidence against male circumcision (MC). METHODS We searched PubMed, Google Scholar, EMBASE and Cochrane databases. RESULTS Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems. CONCLUSIONS Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.
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Affiliation(s)
- Brian J Morris
- School of Medical SciencesUniversity of SydneySydneyNew South WalesAustralia
| | | | - John N Krieger
- Department of UrologyUniversity of Washington School of MedicineSeattleWashington
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15
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Van Howe RS, Frisch M, Adler PW, Svoboda JS. Circumcision registry promotes precise research and fosters informed parental decisions. BMC Med Ethics 2019; 20:6. [PMID: 30626392 PMCID: PMC6327488 DOI: 10.1186/s12910-018-0337-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2017 Ploug and Holm argued that anonymizing individuals in the Danish circumcision registry was insufficient to protect these individuals from what they regard as the potential harms of being in the registry (overreaching social pressure, stigmatization, medicalization of a religious practice, discrimination and promoting polarized research). DISCUSSION We argue that Ploug and Holm's fears in each of the areas are misguided, not supported by the evidence, and could interfere with the gathering of accurate data. The extent of the risks and harms associated with ritual circumcision is not well known. The anonymized personal health data supplemented with the circumcision registry will enable more precise research into the medical consequences of ritual circumcision, and allow parents to make more fully informed decisions about circumcision with minimal, if any, adverse consequences.
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Affiliation(s)
- Robert S Van Howe
- Department of Paediatrics, Central Michigan University College, 413 E. Ohio Street, Marquette, MI, 49855, USA.
| | - Morten Frisch
- Department of Clinical Medicine, Center for Sexology Research, Aalborg University, DK-9000, Aalborg, Denmark
| | - Peter W Adler
- University of Massachusetts (Lowell), Lowell, MA, USA
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16
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Earp BD, Allareddy V, Allareddy V, Rotta AT. Factors Associated With Early Deaths Following Neonatal Male Circumcision in the United States, 2001 to 2010. Clin Pediatr (Phila) 2018; 57:1532-1540. [PMID: 30066572 DOI: 10.1177/0009922818790060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We sought to quantify early deaths following neonatal circumcision (same hospital admission) and to identify factors associated with such mortality. We performed a retrospective analysis of all infants who underwent circumcision in an inpatient hospital setting during the first 30 days of life from 2001 to 2010 using the National Inpatient Sample. Over 10 years, 200 early deaths were recorded among 9 833 110 subjects (1 death per 49 166 circumcisions). Note: this figure should not be interpreted as causal but correlational as it may include both undercounting and overcounting of deaths attributable to circumcision. Compared with survivors, subjects who died following newborn circumcision were more likely to have associated comorbid conditions, such as cardiac disease (odds ratio [OR] = 697.8 [378.5-1286.6]; P < .001), coagulopathy (OR = 159.6 [95.6-266.2]; P < .001), fluid and electrolyte disorders (OR = 68.2 [49.1-94.6]; P < .001), or pulmonary circulatory disorders (OR = 169.5 [69.7-412.5]; P < .001). Recognizing these factors could inform clinical and parental decisions, potentially reducing associated risks.
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Affiliation(s)
- Brian D Earp
- 1 Yale University, New Haven, CT, USA.,2 The Hastings Center, Garrison, NY, USA
| | - Veerajalandhar Allareddy
- 3 Stead Family Children's Hospital, Iowa City, IA, USA.,4 University of Iowa, Iowa City, IA, USA
| | | | - Alexandre T Rotta
- 6 UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA.,7 Case Western Reserve University, Cleveland, OH, USA
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17
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Bauer AZ, Kriebel D, Herbert MR, Bornehag CG, Swan SH. Prenatal paracetamol exposure and child neurodevelopment: A review. Horm Behav 2018; 101:125-147. [PMID: 29341895 DOI: 10.1016/j.yhbeh.2018.01.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/09/2017] [Accepted: 01/03/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The non-prescription medication paracetamol (acetaminophen, APAP) is currently recommended as a safe pain and fever treatment during pregnancy. However, recent studies suggest a possible association between APAP use in pregnancy and offspring neurodevelopment. OBJECTIVES To conduct a review of publications reporting associations between prenatal APAP use and offspring neurodevelopmental outcomes. METHODS Relevant sources were identified through a key word search of multiple databases (Medline, CINAHL, OVID and TOXNET) in September 2016. All English language observational studies of pregnancy APAP and three classes of neurodevelopmental outcomes (autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), and intelligence quotient (IQ)) were included. One reviewer (AZB) independently screened all titles and abstracts, extracted and analyzed the data. RESULTS 64 studies were retrieved and 55 were ineligible. Nine prospective cohort studies fulfilled all inclusion criteria. Data pooling was not appropriate due to heterogeneity in outcomes. All included studies suggested an association between prenatal APAP exposure and the neurodevelopmental outcomes; ADHD, ASD, or lower IQ. Longer duration of APAP use was associated with increased risk. Associations were strongest for hyperactivity and attention-related outcomes. Little modification of associations by indication for use was reported. CONCLUSIONS Together, these nine studies suggest an increased risk of adverse neurodevelopmental outcomes following prenatal APAP exposure. Further studies are urgently needed with; precise indication of use and exposure assessment of use both in utero and in early life. Given the current findings, pregnant women should be cautioned against indiscriminate use of APAP. These results have substantial public health implications.
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Affiliation(s)
- Ann Z Bauer
- Department of Public Health, University of Massachusetts, 1 University Avenue, Lowell, MA, 01854, USA.
| | - David Kriebel
- Department of Public Health, University of Massachusetts, 1 University Avenue, Lowell, MA, 01854, USA.
| | - Martha R Herbert
- Department of Neurology, MGH, Harvard Medical School, A.A. Martinos Centre for Biomedical Imaging, MGH/MIT/Harvard 149 Thirteenth Street, Charlestown, MA 02129, USA
| | - Carl-Gustaf Bornehag
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA; Department of Health Sciences, Karlstad University, Karlstad, Sweden.
| | - Shanna H Swan
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA.
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18
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19
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Holm S, Ploug T. Big Data and Health Research-The Governance Challenges in a Mixed Data Economy. JOURNAL OF BIOETHICAL INQUIRY 2017; 14:515-525. [PMID: 28980135 DOI: 10.1007/s11673-017-9810-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 08/16/2017] [Indexed: 06/07/2023]
Abstract
Denmark is a society that has already moved towards Big Data and a Learning Health Care System. Data from routine healthcare has been registered centrally for years, there is a nationwide tissue bank, and there are numerous other available registries about education, employment, housing, pollution, etcetera. This has allowed Danish researchers to study the link between exposures, genetics and diseases in a large population. This use of public registries for scientific research has been relatively uncontroversial and has been supported by facilitative regulation that allows data to be used without the consent of data subjects. However, in the future much of the data will not be held by public authorities but by private companies. What are the implications of this shift for the governance of the research use of the data? This paper will argue that increased involvement of Research Ethics Committees and better training of researchers are necessary; and that some form of consent will have to be re-introduced. Four different consent models will be discussed: Opt-Out, Broad/Blanket consent, Dynamic consent, and Meta consent. It will be argued that a governance model including a possibility for citizens to make meta-choices strikes the best balance between individual and public interests.
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Affiliation(s)
- Søren Holm
- Centre for Social Ethics and Policy, School of Law, Williamson Building, University of Manchester, Manchester, M13 9PL, UK.
| | - Thomas Ploug
- Centre for Applied Ethics and Philosophy of Science, Aalborg University Copenhagen, AC Meyers Vænge 15, S 2450, København, Denmark
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20
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Ploug T, Holm S. Informed consent and registry-based research - the case of the Danish circumcision registry. BMC Med Ethics 2017; 18:53. [PMID: 28915865 PMCID: PMC5602924 DOI: 10.1186/s12910-017-0212-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 09/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research into personal health data holds great potential not only for improved treatment but also for economic growth. In these years many countries are developing policies aimed at facilitating such research often under the banner of 'big data'. A central point of debate is whether the secondary use of health data requires informed consent if the data is anonymised. In 2013 the Danish Minister of Health established a new register collecting data about all ritual male childhood circumcisions in Denmark. The main purpose of the register was to enable future research into the consequences of ritual circumcision. DISCUSSION This article is a study into the case of the Danish Circumcision Registry. We show that such a registry may lead to various forms of harm such as 1) overreaching social pressure, 2) stigmatization, 3) medicalization of a religious practice, 4) discrimination, and 5) polarised research, and that a person may therefore have a strong and legitimate interest in deciding whether or not such data should be collected and/or used in research. This casts doubt on the claim that the requirement of informed consent could and should be waived for all types of secondary research into registries. We finally sketch a new model of informed consent - Meta consent - aimed at striking a balance between the interests in promoting research and at the same time protecting the individual. Research participants may have a strong and legitimate interest in deciding whether or not their data should be collected and used for registry-based research whether or not their data is anonymised.
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Affiliation(s)
- Thomas Ploug
- Centre for Applied Ethics and Philosophy of Science, Department of Communication, Aalborg University Copenhagen, A C Meyers Vænge, 2450 København SV, Denmark
| | - Søren Holm
- University of Manchester, Centre for Social Ethics and Policy, School of Law, Manchester, M13 9PL UK
- Center for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway
- Centre for Applied Ethics, Aalborg University, Aalborg, Denmark
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21
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Morris BJ, Krieger JN, Klausner JD. CDC's Male Circumcision Recommendations Represent a Key Public Health Measure. GLOBAL HEALTH, SCIENCE AND PRACTICE 2017; 5:15-27. [PMID: 28351877 PMCID: PMC5478224 DOI: 10.9745/ghsp-d-16-00390] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 01/31/2017] [Indexed: 12/20/2022]
Abstract
Frisch and Earp, opponents of male circumcision, have criticized draft recommendations from the CDC that advocate counseling men and parents of newborn boys in the United States about the benefits and risks of male circumcision. We provide a rebuttal to Frisch and Earp's criticisms and contend that the recommendations are entirely appropriate and merit consideration for policy development.
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, New South Wales, Australia.
| | - John N Krieger
- University of Washington School of Medicine and VA Puget Sound Health Care System, Section of Urology, Seattle, WA, USA
| | - Jeffrey D Klausner
- Department of Epidemiology, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA, USA
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22
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Parker W, Hornik CD, Bilbo S, Holzknecht ZE, Gentry L, Rao R, Lin SS, Herbert MR, Nevison CD. The role of oxidative stress, inflammation and acetaminophen exposure from birth to early childhood in the induction of autism. J Int Med Res 2017; 45:407-438. [PMID: 28415925 PMCID: PMC5536672 DOI: 10.1177/0300060517693423] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The wide range of factors associated with the induction of autism is invariably linked with either inflammation or oxidative stress, and sometimes both. The use of acetaminophen in babies and young children may be much more strongly associated with autism than its use during pregnancy, perhaps because of well-known deficiencies in the metabolic breakdown of pharmaceuticals during early development. Thus, one explanation for the increased prevalence of autism is that increased exposure to acetaminophen, exacerbated by inflammation and oxidative stress, is neurotoxic in babies and small children. This view mandates extreme urgency in probing the long-term effects of acetaminophen use in babies and the possibility that many cases of infantile autism may actually be induced by acetaminophen exposure shortly after birth.
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Affiliation(s)
- William Parker
- 1 Departments of Surgery, Duke University Medical Center, Durham, NC USA
| | - Chi Dang Hornik
- 2 Departments of Pediatrics, Duke University Medical Center, Durham, NC USA
| | - Staci Bilbo
- 3 Departments of Pediatrics, Harvard Medical School, Charlestown, MA, USA
| | - Zoie E Holzknecht
- 1 Departments of Surgery, Duke University Medical Center, Durham, NC USA
| | - Lauren Gentry
- 1 Departments of Surgery, Duke University Medical Center, Durham, NC USA
| | - Rasika Rao
- 1 Departments of Surgery, Duke University Medical Center, Durham, NC USA
| | - Shu S Lin
- 1 Departments of Surgery, Duke University Medical Center, Durham, NC USA
| | - Martha R Herbert
- 4 Departments of Neurology, Harvard Medical School, Charlestown, MA, USA
| | - Cynthia D Nevison
- 5 Institute for Arctic and Alpine Research, University of Colorado, Boulder, Boulder, CO, USA
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Circumcision does not alter long-term glucocorticoids accumulation or psychological effects associated with trauma- and stressor-related disorders. Transl Psychiatry 2017; 7:e1063. [PMID: 28291263 PMCID: PMC5416669 DOI: 10.1038/tp.2017.23] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 01/09/2017] [Accepted: 01/12/2017] [Indexed: 01/17/2023] Open
Abstract
Male infants and boys through early adolescence can undergo circumcision either for the sake of upholding religious traditions or for medical reasons. According to both, Jewish as well as Islamic tenets, circumcision is a religious rite symbolizing the bond with God. The World Health Organization (WHO), the United Nations Council (UNC) as well as the American Academy of Pediatrics (AAP), and the Centers for Disease Control and Prevention (CDC) strongly recommend circumcision to promote hygiene and prevent disease. This procedure has frequently been criticized by various communities claiming that circumcision in infancy and early adolescence were psychologically traumatizing with medical implications up into old age. Due to the lack of evidence concerning an alleged increase in vulnerability, we measured objective and subjective stress and trauma markers, including glucocorticoids from hair samples, in circumcised and non-circumcised males. We found no differences in long-term limbic-hypothalamic-pituitary-adrenal axis activity, subjective stress perception, anxiety, depressiveness, physical complaints, sense of coherence and resilience. Rather, an increase in the glucocorticoid levels indicated a healthy lifestyle and appropriate functioning. Thus, our findings provide evidence that male circumcision does not promote psychological trauma. Moreover, a qualitative approach, the ambivalence construct, was used for the discussion, aiming at a discourse devoid of biases.
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Frisch M, Simonsen J. Cultural background, non-therapeutic circumcision and the risk of meatal stenosis and other urethral stricture disease: Two nationwide register-based cohort studies in Denmark 1977-2013. Surgeon 2016; 16:107-118. [PMID: 28017691 DOI: 10.1016/j.surge.2016.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/04/2016] [Accepted: 11/30/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Meatal stenosis is markedly more common in circumcised than genitally intact males, affecting 5-20 per cent of circumcised boys. However, no population-based study has estimated the relative risk of meatal stenosis and other urethral stricture diseases (USDs) or the population attributable fraction (AFp) associated with non-therapeutic circumcision. METHODS In two nationwide cohort studies (comprising 4.0 million males of all ages and 810 719 non-Muslim males aged 0-36 years, respectively), we compared hospital contact rates for USD during 1977-2013 between circumcised and intact Danish males. Hazard ratios (HRs) were obtained using Cox proportional hazards regression, and the AFp estimated the proportion of USD cases in <10 year-old boys that is due to non-therapeutic circumcision. RESULTS Muslim males had higher rates of meatal stenosis than ethnic Danish males, particularly in <10 year-old boys (HR 3.44, 95 per cent confidence interval 2.42-4.88). HRs linking circumcision to meatal stenosis (10.3, 4.53-23.4) or other USDs (5.14, 3.48-7.60) were high, and attempts to reduce potential misclassification and confounding further strengthened the association, particularly in <10 year-old boys (meatal stenosis: 26.3, 9.37-73.9; other USDs: 14.0, 6.86-28.6). Conservative calculations revealed that at least 18, 41, 78, and 81 per cent of USD cases in <10 year-old boys from countries with circumcision prevalences as in Denmark, the United Kingdom, the United States and Israel, respectively, may be attributable to non-therapeutic circumcision. CONCLUSION Our study provides population-based epidemiological evidence that circumcision removes the natural protection against meatal stenosis and, possibly, other USDs as well.
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Affiliation(s)
- Morten Frisch
- Statens Serum Institut, Department of Epidemiology Research, DK-2300 Copenhagen S, Denmark; Aalborg University, Department of Clinical Medicine, Center for Sexology Research, DK-9000 Aalborg, Denmark.
| | - Jacob Simonsen
- Statens Serum Institut, Department of Epidemiology Research, DK-2300 Copenhagen S, Denmark
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25
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Carmack A, Notini L, Earp BD. Should Surgery for Hypospadias Be Performed Before An Age of Consent? JOURNAL OF SEX RESEARCH 2016; 53:1047-1058. [PMID: 26479354 DOI: 10.1080/00224499.2015.1066745] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Hypospadias is a relatively common genital condition in which the urethral opening forms on the underside of the penis, as opposed to at the tip of the glans. Patients with hypospadias are typically referred for surgery during infancy or early childhood. Recent evidence, however, indicates that many individuals with hypospadias do not experience the functional or psychosocial difficulties commonly attributed to the condition, and that surgical intervention for hypospadias carries substantial risk of adverse outcomes. In this article, we review published outcomes data and conduct an in-depth analysis of the typical rationales for hypospadias surgery, taking into consideration both the potential benefits and harms of the procedure, as well as the existence of nonsurgical alternatives. We argue, first, that most childhood surgeries for hypospadias are performed for anticipated future problems concerning function and cosmesis, rather than extant physical and/or psychosocial problems that are adversely affecting the child's well-being. Second, we contend that the surgery can be safely performed after an age of consent without increasing the absolute risk of surgical complications to an ethically meaningful degree. We conclude, therefore, that surgery for hypospadias should be performed only if requested by the affected individual, under conditions of informed consent.
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Affiliation(s)
| | - Lauren Notini
- b Doctoral Candidate in Bioethics, Centre for Health Equity, Melbourne School of Population and Global Health and Department of Paediatrics , University of Melbourne
| | - Brian D Earp
- c Research Associate, Oxford Uehiro Centre for Practical Ethics, University of Oxford
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26
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Eckert K, Janssen N, Franz M, Liedgens P. Die nicht-retrahierbare Vorhaut bei beschwerdefreien Jungen. Urologe A 2016; 56:351-357. [DOI: 10.1007/s00120-016-0232-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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27
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Smits A, van den Anker JN, Allegaert K. Clinical pharmacology of analgosedatives in neonates: ways to improve their safe and effective use. ACTA ACUST UNITED AC 2016; 69:350-360. [PMID: 27364566 DOI: 10.1111/jphp.12599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/11/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To propose approaches tailored to the specific needs of neonates, such as structured product development programmes, with the ultimate goal to improve the safe and effective use of analgosedatives in these fragile patients. KEY FINDINGS The feasibility and relevance of a structured product development programme in neonates (optimal study design based on preliminary data; model development; internal, external and prospective evaluation; an individualized dosing regimen; long-term safety; pharmacogenetics) are illustrated for the use of morphine. Based on changes in clinical practices, similar development plans are in progress for short-acting analgosedatives such as propofol, but are in need of tailored pharmacodynamic tools to assess and quantify effects. Furthermore, for drugs like paracetamol where there is already sufficient clinical pharmacology knowledge, attention needs to be given to long-term safety aspects. Finally, new covariates such as pharmacogenetics might further improve neonatal pain management, but clearly need to be integrated with other well-established covariates like age or weight. SUMMARY Product development programmes for analgosedatives in neonates are needed. These programmes should be tailored to their specific needs (short-acting sedation, pain relief), should include long-term safety and should incorporate the exploration of newer covariates like pharmacogenetics.
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Affiliation(s)
- Anne Smits
- Neonatal Intensive Care Unit, VU Medical Center, Amsterdam, The Netherlands.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - John N van den Anker
- Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland.,Division of Pediatric Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA.,Departments of Pediatrics, Integrative Systems Biology, Pharmacology & Physiology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Karel Allegaert
- Intensive Care and Department of Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Abstract
OBJECTIVE As a consequence of the discussion on whether the health benefits of newborn male circumcision outweigh the risks and the discrepancies in reported figures of complications, we evaluated the incidence and morbidity of foreskin surgery due to medical indications in boys from the Capital Region of Denmark in 2014. METHODS Medical records from all boys operated on the foreskin due to medical reasons in the Capital Region in 2014 were reviewed. Patients with hypospadias, ritual circumcision, and redo-surgery because of complications to nontherapeutic circumcision were excluded. RESULTS A total of 181 patients were included. The cumulative risk of undergoing foreskin operation before 18 years of age was 1.7%. Forty patients had histologic verified balanitis xerotica obliterans (BXO) corresponding to a total risk of 0.37% of developing BXO. Mean age at surgery was 10.1 years (range 1-17). Phimosis was the most frequently reported indication (95.0%). The remaining 5.0% underwent surgery because of frenulum breve causing problems during erection. Before surgery, 27.1% had foreskin-related voiding problems and 17.1% had at least 1 episode of balanitis. Circumcision was initially performed in 44 cases. The remaining 137 patients had a foreskin-preserving operation performed. Nine boys had secondary circumcision after initially having foreskin-preserving operation. Fifty patients initially had preputial histology performed. BXO was verified in 37 patients. Of the 9 patients with redo-surgery due to recurrent phimosis, a further 3 had histologically verified BXO. CONCLUSIONS Childhood foreskin-related problems in a region with no tradition of newborn male circumcision should not be neglected.
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Affiliation(s)
- Ida Sneppen
- Department of Pediatric Surgery, Surgical Clinic C, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark; and
| | - Jørgen Thorup
- Department of Pediatric Surgery, Surgical Clinic C, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark; and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Chaudhry FA, Knutsen L, Kohn LA, Kirschner R. [Re: Circumcision of boys]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:106. [PMID: 26813812 DOI: 10.4045/tidsskr.15.1367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
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Frisch M, Simonsen J. Circumcision-autism link needs thorough evaluation: Response to Morris and Wiswell. J R Soc Med 2015; 108:297-8. [PMID: 26268917 DOI: 10.1177/0141076815593048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Morten Frisch
- Department of Epidemiology Research, Division of National Health Surveillance and Research, Statens Serum Institut, DK-2300 Copenhagen S, Denmark and Department of Clinical Medicine, Center for Sexology Research, Aalborg University, DK-9000 Aalborg, Denmark
| | - Jacob Simonsen
- Department of Epidemiology Research, Division of National Health Surveillance and Research, Statens Serum Institut, DK-2300 Copenhagen S, Denmark
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Earp BD. Do the Benefits of Male Circumcision Outweigh the Risks? A Critique of the Proposed CDC Guidelines. Front Pediatr 2015; 3:18. [PMID: 25853108 PMCID: PMC4364150 DOI: 10.3389/fped.2015.00018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 02/21/2015] [Indexed: 01/12/2023] Open
Abstract
The Centers for Disease Control and Prevention (CDC) have announced a set of provisional guidelines concerning male circumcision, in which they suggest that the benefits of the surgery outweigh the risks. I offer a critique of the CDC position. Among other concerns, I suggest that the CDC relies more heavily than is warranted on studies from Sub-Saharan Africa that neither translate well to North American populations nor to circumcisions performed before an age of sexual debut; that it employs an inadequate conception of risk in its benefit vs. risk analysis; that it fails to consider the anatomy and functions of the penile prepuce (i.e., the part of the penis that is removed by circumcision); that it underestimates the adverse consequences associated with circumcision by focusing on short-term surgical complications rather than long-term harms; that it portrays both the risks and benefits of circumcision in a misleading manner, thereby undermining the possibility of obtaining informed consent; that it evinces a superficial and selective analysis of the literature on sexual outcomes associated with circumcision; and that it gives less attention than is desirable to ethical issues surrounding autonomy and bodily integrity. I conclude that circumcision before an age of consent is not an appropriate health-promotion strategy.
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Affiliation(s)
- Brian D Earp
- Uehiro Centre for Practical Ethics, University of Oxford , Oxford , UK
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