Application Of Diagnostic Criteria Research Articles

Applicability of Diagnostic Criteria and High Prevalence of Familial Dysbetalipoproteinemia in Russia: A Pilot Study.

Familial dysbetalipoproteinemia (FD) is a highly atherogenic genetically based lipid disorder with an underestimated actual prevalence. In recent years, several biochemical algorithms have been developed to diagnose FD using available laboratory tests. The practical applicability of FD diagnostic criteria and the prevalence of FD in Russia have not been previously assessed. We demonstrated that the diagnostic algorithms of FD, including the diagnostic apoB levels, require correction, taking into account the distribution of apoB levels in the population. At the same time, a triglycerides cutoff ≥ 1.5 mmol/L may be a useful tool in identifying subjects with FD. In this study, a high prevalence of FD was detected: 0.67% (one in 150) based on the ε2ε2 haplotype and triglycerides levels ≥ 1.5 mmol/L. We also analyzed the presence and pathogenicity of APOE variants associated with autosomal dominant FD in a large research sample.

Case Report: Painless obstructive jaundice caused by IgG4 autoimmune pancreatitis; the role of endoscopic ultrasound in diagnosis

We report the case of a 60-year-old woman, presenting with painless obstructive jaundice of unknown etiology, who was finally found to suffer from type I autoimmune pancreatitis (AIP). This case emphasizes AIP as a rare cause in the differential diagnosis of obstructive jaundice and the role of endoscopic ultrasound (EUS) in final diagnosis, which is difficult to establish. According to diagnostic criteria, we combined the results from serologic, imaging and histological features (specifically lgG4 levels, computed tomography, magnetic resonance imaging/magnetic resonance cholangiopancreatography and EUS) with cytological results, leading to a final diagnosis. Our patient’s response to corticosteroids was impressive, confirming the diagnosis, leading to complete remission of the disease. Whilst diagnosis of AIP is challenging, the application of diagnostic criteria can lead to correct diagnosis. Therapy is corticosteroid based, with very satisfying outcomes.

Malnutrition In older people - Screening And Assessment

Malnutrition is widespread in older people and if not treated leads to numerous negative clinical consequences, such as functional decline and in-hospital complications as well as increased health care costs. Prerequisites for a successful prevention and therapy of malnutrition are the early identification of persons at risk or those affected and a detailed assessment of their nutritional situation. Based on the current literature, this article provides an overview of important aspects considered in the screening and assessment of malnutrition in older people, such as the use of malnutrition screening tools, the application of diagnostic criteria, the quantification of energy and protein deficiencies, the identification of potential causes of malnutrition and the determination of individual preferences and resources.

Diagnosis of Attention Deficit Hyperactivity Disorder in Intellectual Disability: Diagnostic and Statistical Manual of Mental Disorder V versus clinical impression.

Diagnosing Attention Deficit Hyperactivity Disorder (ADHD) in people with intellectual disability (ID) remains challenging. The Diagnostic and Statistical Manual of Mental Disorder V (DSM V) classification system is often used to diagnose ADHD in the general population; however, the presence of ID and other associated conditions such as autism and communication difficulties can make it difficult to apply the DSM V criteria in people with ID. Therefore, diagnosing ADHD in people with ID is often made using clinical judgement and/or the application of diagnostic criteria. There are no studies comparing the diagnostic accuracy of clinical judgement and the use of DSM V criteria in people with ID and ADHD. The aims of the study were to compare the accuracy of the diagnosis of ADHD in people with ID according to the DSM V criteria versus clinical judgement and to determine which criteria are more reliable. A questionnaire was developed using five fictional case scenarios of people with ID. Questionnaires were presented to practising psychiatrists chosen as a convenience sample in the United Kingdom over a period of 12 months. Case scenarios were developed and agreed to be positive or negative for ADHD by the study authors prior to rating by clinicians. The clinicians were asked to read the scenarios and to make a judgement on the cases regarding the symptoms of ADHD. They were then presented with the 18 DSM V criteria of ADHD and asked to select the criteria they considered were present in each scenario. Sensitivity, specificity, likelihood ratios and predictive values for both the DSM V criteria and clinical opinions were calculated for correctly identifying the exemplar cases. The data showed strong sensitivity [0.82 95% confidence interval (CI) 0.74-0.89] and high specificity (1.00 95% CI 0.95-1.00) for the raters' clinical opinion. In contrast, the DSM V criteria alone, as assessed by the raters, did not reliably provide ADHD diagnoses, with a sensitivity of only 0.23 (95% CI 0.15-0.31). This difference in sensitivity between the two was statistically significant at P < 0.001. The study results suggest that clinical opinion is the 'gold standard' at present in diagnosing ADHD in adults with ID in the absence of a validated diagnostic tool in this group. Further studies are needed to understand how symptoms of ADHD can be presented differently in people with ID. DSM V criteria for ADHD may need to be adapted according to the severity of ID and other neurodevelopmental disorders.

Agreement Analysis: What He Said, She Said Versus You Said.

Correlation and agreement are 2 concepts that are widely applied in the medical literature and clinical practice to assess for the presence and strength of an association. However, because correlation and agreement are conceptually distinct, they require the use of different statistics. Agreement is a concept that is closely related to but fundamentally different from and often confused with correlation. The idea of agreement refers to the notion of reproducibility of clinical evaluations or biomedical measurements. The intraclass correlation coefficient is a commonly applied measure of agreement for continuous data. The intraclass correlation coefficient can be validly applied specifically to assess intrarater reliability and interrater reliability. As its name implies, the Lin concordance correlation coefficient is another measure of agreement or concordance. In undertaking a comparison of a new measurement technique with an established one, it is necessary to determine whether they agree sufficiently for the new to replace the old. Bland and Altman demonstrated that using a correlation coefficient is not appropriate for assessing the interchangeability of 2 such measurement methods. They in turn described an alternative approach, the since widely applied graphical Bland-Altman Plot, which is based on a simple estimation of the mean and standard deviation of differences between measurements by the 2 methods. In reading a medical journal article that includes the interpretation of diagnostic tests and application of diagnostic criteria, attention is conventionally focused on aspects like sensitivity, specificity, predictive values, and likelihood ratios. However, if the clinicians who interpret the test cannot agree on its interpretation and resulting typically dichotomous or binary diagnosis, the test results will be of little practical use. Such agreement between observers (interobserver agreement) about a dichotomous or binary variable is often reported as the kappa statistic. Assessing the interrater agreement between observers, in the case of ordinal variables and data, also has important biomedical applicability. Typically, this situation calls for use of the Cohen weighted kappa. Questionnaires, psychometric scales, and diagnostic tests are widespread and increasingly used by not only researchers but also clinicians in their daily practice. It is essential that these questionnaires, scales, and diagnostic tests have a high degree of agreement between observers. It is therefore vital that biomedical researchers and clinicians apply the appropriate statistical measures of agreement to assess the reproducibility and quality of these measurement instruments and decision-making processes.

Acute Myopericardial Syndromes.

Acute myopericardial syndromes are common but can be challenging to manage and potentially have life-threatening complications. Careful clinical history, physical examination, electrocardiogram interpretation, and application of diagnostic criteria are needed to make an accurate diagnosis, exclude concomitant disease, and properly treat patients. Therapy for acute pericarditis should be guided per the underlying cause. For the most common causes, nonsteroidal antiinflammatory drugs or aspirin with the addition of colchicine remains the mainstay of therapy. Patients with hemodynamic compromise who are resistant to therapy or display high-risk features should prompt hospitalization and initiation of more aggressive and/or invasive therapy.

Knowledge and Practices Regarding Polycystic Ovary Syndrome among Physicians in Europe, North America, and Internationally: An Online Questionnaire-Based Study.

To inform knowledge translation by identifying evidence-practice gaps in polycystic ovary syndrome (PCOS) care and variations between disciplines and across world regions via an online, anonymous, devised questionnaire distributed via professional societies and completed by 1,495 physicians (2015-2016). Multivariable logistic regression analyses generated adjusted odds ratios (OR) and 95% confidence intervals (CI) for associations between outcome measures and world region, specialty, annual patients with PCOS, age, and sex. Features corresponding to Rotterdam diagnostic criteria were well recognized (e.g., irregular menstrual cycles by 99% of physicians), but psychological implications were recognized only by 29 to 64%. Reproductive endocrinologists were more likely to use Rotterdam diagnostic criteria (OR: 3.1; 95% CI: 2.3-4.3; p < 0.007) than obstetrician-gynecologists. Reproductive (OR: 2.0; 95% CI: 1.5-2.8; p < 0.007) and medical endocrinologists (OR: 3.1; 95% CI: 1.7-5.7; p < 0.007) were more likely to recommend lifestyle management than obstetrician-gynecologists. Physicians in Europe (OR: 4.7; 95% CI: 3.5-6.1; p < 0.007) and other regions (OR: 4.0; 95% CI: 2.8-5.9; p < 0.007) were more likely to use Rotterdam diagnostic criteria than physicians in North America. Knowledge gaps in PCOS care to be addressed internationally include physician awareness of the breadth of PCOS features, application of diagnostic criteria, and recommending lifestyle management effectively.

Overinterpretation is common in pathological diagnosis of appendix cancer during patient referral for oncologic care.

ContextLow-grade appendiceal mucinous neoplasm (LAMN) and appendiceal adenocarcinoma are known to cause the majority of pseudomyxoma peritonei (PMP, i.e. mucinous ascites); however, recognition and proper classification of these neoplasms can be difficult despite established diagnostic criteria.ObjectiveTo determine the pathological diagnostic concordance for appendix neoplasia and related lesions during patient referral to an academic medical center specialized in treating patients with PMP.DesignThe anatomic pathology laboratory information system was searched to identify cases over a two-year period containing appendix specimens with mucinous neoplasia evaluated by an outside pathology group and by in-house slide review at a single large academic medical center during patient referral.Results161 cases containing appendix specimens were identified over this period. Forty-six of 161 cases (28.6%) contained appendiceal primary neoplasia or lesions. Of these, the originating pathologist diagnosed 23 cases (50%) as adenocarcinoma and 23 cases (50%) as LAMN; however, the reference pathologist diagnosed 29 cases (63.0%) as LAMN, 13 cases (28.3%) as adenocarcinoma, and 4 cases (8.7%) as ruptured simple mucocele. Importantly, for cases in which the originating pathologist rendered a diagnosis of adenocarcinoma, the reference pathologist rendered a diagnosis of adenocarcinoma (56.5%, 13 of 23), LAMN (39.1%, 9 of 23), or simple mucocele (4.3%, 1 of 23). The overall diagnostic concordance rate for these major classifications was 71.7% (33 of 46) with an unweighted observed kappa value of 0.48 (95% CI, 0.27–0.69), consistent with moderate interobserver agreement. All of the observed discordance (28.3%) for major classifications could be attributed to over-interpretation. In addition, the majority of LAMN cases (65.5%) had potential diagnostic deficiencies including over-interpretation as adenocarcinoma and lacking or discordant risk stratification (i.e. documentation of extra-appendiceal neoplastic epithelium).ConclusionsAppendiceal mucinous lesions remain a difficult area for appropriate pathological classification with substantial discordance due to over-interpretation in this study. The findings highlight the critical need for recognition and application of diagnostic criteria regarding these tumors. Recently published consensus guidelines and a checklist provided herein may help facilitate improvement of diagnostic concordance and thereby reduce over-interpretation and potential overtreatment. Further studies are needed to determine the extent of this phenomenon and its potential clinical impact.

The WHO ICD-11 classification and diagnosis of mental disorder in people with disorders of intellectual development (PWDID): An international study on clinical utility

IntroductionConstituting 2% of the population, PWDID are a vulnerable group with a higher prevalence of mental disorders than the general population. ICD diagnostic criteria often rely on adequate cognitive functioning and hence diagnosis of mental disorders in PWDID can be difficult, consequently leading to inequity of treatment, prognosis and stigma. Our study critically analysed the available evidence base and explored the feasibility of applying modified diagnostic criteria within the context of cumulative iterative iteration. We present the outcome using diagnosis of DID and anxiety disorder as examples.AimsAddress current shortcomings in ICD classification regarding PWDID by contributing effectively to the WHO ICD-11 consultation process in collaboration with international stakeholders.ObjectivesFacilitate accessibility of ICD-11 criteria for diagnosis of mental disorders capable of engendering robust evidence based epidemiological data and healthcare in PWDID.MethodsWe evaluated current evidence via a systematic literature search utilising PRISMA guidelines and developed pragmatic guidelines to adapt ICD diagnostic criteria in PWDID. A brief screener [Glasgow Level of Ability and Development Scale (GLADs)] for detecting DID was also studied internationally within the context of clinical utility (n = 136).ResultsThe evidence base relating to mental disorders in PWDID is poor, significantly hampered by difficulties in applicability of diagnostic criteria. The GLADs appears to be a promising screening tool with good clinical utility for detecting disorders of intellectual development (DID) particularly where resources are scarce.ConclusionsPragmatic modifications to ICD-11 diagnostic criteria and the GLADS tool facilitates its clinical utility for PWDID and contributes significantly to enhancing research based evidence, and, ultimately their health access and well-being.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Early-Onset Dementia: Frequency, Diagnostic Procedures, and Quality Indicators in Three European Tertiary Referral Centers.

Early-onset dementia (EOD) is a rare condition, with an often atypical clinical presentation, and it may therefore be challenging to diagnose. Specialized memory clinics vary in the type of patients seen, diagnostic procedures applied, and the pharmacological treatment given. The aim of this study was to investigate quality-of-care indicators in subjects with EOD from 3 tertiary memory clinics in 3 European countries. We included 1325 newly diagnosed EOD patients, ages 65 years or younger, between January 1, 2007 and December 31, 2013, from the Danish Dementia Registry (Rigshospitalet, Copenhagen), the Swedish Dementia Registry ("SveDem", Karolinska University Hospital, Stockholm), and the Amsterdam Dementia Cohort (VU University Medical Center). The frequency of EOD among all dementia patients was significantly lower in Copenhagen (410, 20%) and Stockholm (284, 21%) compared with Amsterdam (631, 48%). Not all quality indicator targets were met, such as the time to diagnosis, the mini-mental state examination score available, and the prescription of cholinesterase inhibitors. Cerebrospinal fluid sampling, registered in 2 sites, was performed in over 80% of the subjects. In tertiary referral centers in Copenhagen, Stockholm, and Amsterdam, quality indicators were not always met for patients with EOD. Results partly reflect differences in referral pattern, the application of diagnostic criteria, and local best practices. Standardized international procedures for patients with EOD may reduce this variability.

Cystic Fibrosis Diagnostic Challenges over 4 Decades: Historical Perspectives and Lessons Learned

Because cystic fibrosis (CF) can be difficult to diagnose, and because information about the genetic complexities and pathologic basis of the disease has grown so rapidly over the decades, several consensus conferences have been held by the US CF Foundation, and a variety of other efforts to improve diagnostic practices have been organized by the European CF Society. Despite these efforts, the application of diagnostic criteria has been variable and caused confusion. To improve diagnosis and achieve standardization in terms and definitions worldwide, the CF Foundation in 2015 convened a committee of 32 experts in the diagnosis of CF from 9 countries. As part of the process, all previous consensus-seeking exercises sponsored by the CF Foundation, along with the important efforts of the European CF Society, were comprehensively and critically reviewed. The goal was to better understand why consensus conferences and their publications have not led to the desired results. Lessons learned from previous diagnosis consensus processes and products were identified. It was decided that participation in developing a consensus was generally not inclusive enough for global impact. It was also found that many efforts to address sweat test issues were valuable but did not always improve clinical practices as CF diagnostic testing evolved. It also became clear from this review that premature applications of potential diagnostic tests such as nasal potential difference and intestinal current measurement should be avoided until validation and standardization occur. Finally, we have learned that due to the significant and growing number of cases that are challenging to diagnose, an associated continuing medical education program is both desirable and necessary. It is necessary but not sufficient to organize and publish CF diagnosis consensus processes. Follow-up implementation efforts and monitoring practices seem essential.

Schnitzler syndrome: validation and applicability of diagnostic criteria in real-life patients.

Schnitzler syndrome is characterized by an urticarial rash, a monoclonal gammopathy, and clinical, histological, and biological signs of neutrophil-mediated inflammation. The aim of this study was to assess the applicability and validity of the existing diagnostic criteria in real-life patients. This multicentric study was conducted between 2009 and 2014 in 14 hospitals in which patients with Schnitzler syndrome or controls with related disorders were followed up. We compared the sensitivities and specificities and calculated the positive and negative predictive values of the Lipsker and of the Strasbourg criteria for the patients with Schnitzler syndrome and for the controls. We included 42 patients with Schnitzler syndrome, 12 with adult-onset Still's disease, 7 with cryopyrin-associated periodic disease, 9 with Waldenström disease, and 10 with chronic spontaneous urticaria. All patients with Schnitzler syndrome met the Lipsker criteria. According to the Strasbourg criteria, 34 patients had definite Schnitzler syndrome, five had probable Schnitzler syndrome, and three did not meet the criteria. One control met the Lipsker criteria and had probable Schnitzler syndrome according to the Strasbourg criteria. Sensitivity and specificity of the Lipsker criteria were 100% and 97%, respectively. For the Strasbourg criteria, sensitivity for definite and probable diagnosis was 81% and 93%, respectively, with a corresponding specificity of 100% and 97%. Diagnostic criteria currently in use to diagnose Schnitzler syndrome are reliable. More investigations must be done to attest their efficiency in patients with recent-onset manifestations.

Temporomandibular disorder and generalized joint hypermobility: application of diagnostic criteria

AbstractGeneralized joint hypermobility (GJH) has been considered a predisposing factor for the development of temporomandibular disorder (TMD). AimTo evaluate clinical and psychosocial aspects in individuals diagnosed with TMD with or without GJH. Materials and methodsClinical and experimental study, which enrolled 34 women, from 18 to 35 years of age with TMD diagnosed by RDC/TMD. The GJH was assessed by the Beighton score and volunteers were broken down into 2 groups: with GJH (n = 22) and without GJH (n = 12). ResultsWe found a high percentage of GJH (64.71%). All participants had myofascial pain; 79.41% had arthralgia and 41% had disk displacement. There was a correlation between higher GJH scores and higher passive mouth opening amplitude (p=0.0034), with pain (p=0.0029) and without pain (p=0.0081). Greater mandibular range of motion was observed in the group with GJH, except for protrusion. Painful mouth opening was statistically higher in the GJH group (p=0.0279). ConclusionsIndividuals with TMD associated or not to GJH do not differ significantly regarding clinical and psychosocial aspects, except in the mandibular opening range of motion, which if kept at physiological levels can lead to a late diagnosis of TMD in these individuals.

Variation in Risk and Mortality of Acute Kidney Injury in Critically Ill Patients: A Multicenter Study

Background: Despite standardized definitions of acute kidney injury (AKI), there is wide variation in the reported rates of AKI and hospital mortality for patients with AKI. Variation could be due to actual differences in disease incidence, clinical course, or a function of data ascertainment and application of diagnostic criteria. Using standard criteria may help determine and compare the risk and outcomes of AKI across centers. Methods: In this cohort study of critically ill patients admitted to the intensive care units at six hospitals in four countries, we used KDIGO criteria to define AKI. The main outcomes were the occurrence of AKI and hospital mortality. Results: Of the 15,132 critically ill patients, 32% developed AKI based on serum creatinine criteria. After adjusting for differences in age, sex, and severity of illness, the odds ratio for AKI continued to vary across centers (odds ratio (OR), 2.57-6.04, p < 0.001). The overall, crude hospital mortality of patients with AKI was 27%, which also varied across centers after adjusting for KDIGO stage, differences in age, sex, and severity of illness (OR, 1.13-2.20, p < 0.001). The severity of AKI was associated with incremental mortality risk across centers. Conclusions: In this study, the absolute and severity-adjusted rates of AKI and hospital mortality rates for AKI varied across centers. Future studies should examine whether variation in the risk of AKI among centers is due to differences in clinical practice or process of care or residual confounding due to unmeasured factors.

Intellectual disability and the ICD-11: towards clinical utility?

Purpose – The 11th revision of the International Classification of diseases which sets global standards for defining, reporting and managing health conditions is under way. The International Classification of Diseases (ICD) underpinning principle of clinical utility is currently poor for persons with Disorders of Intellectual Development (DID) and mental disorders. This impedes access to healthcare resources; services and social inclusion thereby further aggravating their vulnerability. The purpose of this paper is to present a critical overview and evidence informed recommendations within the context of an international collaborative programme, undertaken by the Faculty of Psychiatry of Intellectual Disability, Royal College of Psychiatrists, UK with support from the World Health Organisation (WHO). Design/methodology/approach – The authors carried out: first, a systematic review (SR) of literature, using PRISMA guidelines regarding the reliability, validity and utility of the ICD-10/Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria in people with DID (PWDID); second, a national and international consultation exercise with partners, stakeholders and experts; third, a multicentric survey of problem behaviours in PWDID; and finally, information dissemination/dialogues including presentations and workshops at key scientific events, consultation networking, data gathering and consensus building. Findings – The SR revealed a dearth of robust studies – most consisting of weak research methodologies. Significant difficulties were highlighted regarding the application of diagnostic criteria in the current classificatory systems – particularly in people with severe/moderate DID. Recommendations supported the introduction WHERE APPROPRIATE of modifications based on observed phenomena (signs) in PWDID in lieu of reported symptoms to facilitate DIAGNOSIS AND better access to healthcare and the community. Heterogeneity precluded quantitative pooling and meta-analysis. The consensus building exercise globally revealed that problem behaviours were the commonest reasons for referral to healthcare services with significant numbers without a diagnosed mental disorder being prescribed psychoactive medication. Research limitations/implications – The consensus gathering exercise WAS SELECTIVE AND did not cover all of the 194 member states of WHO due to resource and time constraints and this constitutes the main limitation of our study. Based on the SR and expert consensus, the authors submitted evidence informed pragmatic proposals to the WHO aimed at addressing the shortcomings of the ICD-10. The key recommendations focused on improving clinical utility within the context of epistemic iteration which would consolidate and strengthen the future evidence base. It was also recommended that self-injurious behaviour should form a standalone sub category in view of its relevance for healthcare services and resources which underpin clinical utility. Practical implications – The ICD-11 is a global, multidisciplinary and multilingual development for public health benefit with 70 per cent of the world's health expenditures assigned using this system for resource allocation. Currently mental disorders in PWDID can be misinterpreted, unrecognised and under reported resulting in barriers to access to treatment and healthcare resources. Conversely disorders may be over diagnosed when the inherent discrepancies between the chronological age and the developmental level of functioning are not considered. Conclusions and recommendations from this study will result in better diagnosis of mental disorders and healthcare resources in this population. Social implications – PWDID are a vulnerable sector of the population with an increased prevalence of mental health problems who are marginalised and discriminated by society. Early detection, treatment and management of these conditions will prevent further decompensation and stigmatisation. Originality/value – To the best of the authors knowledge this is the first comprehensive, large-scale study which evaluates the ICD classificatory system within the context of clinical utility for PWDID, including experts and stakeholders from both lower/middle- and high-income countries. The international consultation/consensus building process culminating in the formulation of evidence informed recommendations, aimed at improving the clinical utility of the ICD-11 for this population, has the potential to improve access to appropriate healthcare and treatment and consequent enhancement of their quality of life.

The Australian experience with the Bethesda classification system for thyroid fine needle aspiration biopsies

Fine needle aspiration biopsy (FNAB) is the initial investigation of choice for thyroid nodules. The Bethesda system, which classifies thyroid FNABs into different categories each linked to a risk of malignancy, has been widely adopted. However, the risk of malignancy implied by each Bethesda category is likely to vary due to population characteristics and inconsistency in the application of diagnostic criteria.We present our experience of the Bethesda system in 2076 thyroid nodules from 1410 patients. Categories were as follows: 266 (12.8%) were category 1 (B1) non-diagnostic, 1551 (74.7%) category 2 (B2) benign, 97 (4.7%) category 3 (B3) atypia of uncertain significance, 98 (4.7%) category 4 (B4) suspicious for follicular neoplasm, 16 (0.8%) category 5 (B5) suspicious for malignancy and 48 (2.3%) category 6 (B6) malignant.Surgery was performed on 425 nodules from 315 patients. Malignancy rates in the target nodules were B1 4.2%, B2 0.26%, B3 9.3%, B4 15.3%, B5 79% and B6 100%. Twelve patients with B3 nodules underwent repeat FNAB, with eight reclassified as B2, one as B3, one as B1 and two as B4. An incidental microcarcinoma separate to the target nodule was identified in 11.1%.As applied in our institution, and despite very sparing use of B3 and B5 categories, our audit has demonstrated risks of malignancy broadly in keeping with that predicted. Of note, the risk of malignancy in the clinically indeterminate categories of B1, B3 and B4 were all at the lower ranges of those predicted in the Bethesda atlas and mostly lower than those reported by other studies.

Posttraumatic Symptom Structure Across Age Groups

The applicability of diagnostic criteria of Posttraumatic Stress Disorder to the pediatric population has been a focus of much debate (e.g., Carrion, Weems, Ray, & Reiss, 2002), informing changes in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5). The current study examined the factor structure of posttraumatic distress among adult versus pediatric samples using confirmatory factor analysis. The analysis was performed on the DSM–IV-adherent Posttraumatic Diagnostic Scale (Foa, Cashman, Jaycox, & Perry, 1997) and Child Posttraumatic Symptom Scale (Foa, Johnson, Feeny, & Treadwell, 2001). The sample included 378 adult and 204 child and adolescent victims of diverse single-event traumas. A series of models based on previous findings and DSM–IV specification were evaluated. A 4-factor model (Intrusions, Avoidance, Dysphoria, and Hyperarousal), similar to the DSM–5 model, best fit the data among adults, and a different 4-factor model (Intrusion, Avodiance, Numbing, and Hyperarousal) best fit the data among children and adolescents. Despite some similarity, the posttraumatic symptom profiles of pediatric and adult samples may differ. These differences are not fully incorporated into the DSM–5, and warrant further examination.

The costs and benefits of diagnosis of ADHD: commentary on Holden et al.

In this journal, Holden, Jenkins-Jones, Poole, Morgan, Coghill and Currie , CAPMH 7:34, 2013, report on the prevalence and financial costs of treating people with attention deficit hyperactivity disorder (ADHD) in the UK over the last ten years. We commend the authors on their thorough cost analysis, and discuss differences in prevalence estimates of diagnosed ADHD, that is the proportion of the child population with an ADHD diagnosis, which varies dramatically between studies. We also discuss the reasons for this. Regional variation in application of diagnostic criteria and clinical subjectivity are likely partial explanations.

Hepatite autoimune: os critérios simplificados são menos sensíveis?

IntroductionAutoimmune hepatitis (AIH) has variable clinical presentation and recognition can be difficult. The diagnostic criteria of the International AIH Group initially proposed for scientific purposes, are complex in clinical practice. In 2008, Henes et al. proposed simplified diagnostic criteria (SDC), with positive and negative predictive values of about 90%, but they need further confirmation. ObjectiveTo compare classic and simplified criteria in patients with AIH. MethodsRetrospective analysis of clinical records and application of diagnostic criteria. ResultsIncluded 42 patients (40 females/2 males), with mean age of 38 years old (9-78). Chronic hepatitis was the form of presentation in 66.7%, acute hepatitis in 23.8% and fulminant hepatitis in 9,5%. The majority (91%) had type I HAI and 24% were asymptomatic. Asthenia (64%), jaundice (50%), anorexia (47%), weight loss (31%), arthralgia (29%), hepatomegaly (24%), nausea and vomit (24%) were the most frequent clinical findings; 21% had another autoimmune disease. Patients were treated with prednisolone and azathioprine (45.2%), prednisolone (35.7%) or deflazacort (2,4%); the evolution was favorable in 86% patients, 14% died. In pre-treatment, classic diagnostic criteria classified 25 patients (60%) as definite AIH and 17 (40%) as probable; applying SDC, there was agreement with classic criteria in only19 patients (45%); AIH changed from definite to probable in 14 (33%) and from probable to definite in 3 (7%); in 14% the score was inferior to 6 (definite AIH in 3 and probable in 3, in classic criteria). ConclusionsIn our patients, type I AIH (91%) and chronic hepatitis presentation form (66, 7%), were the most frequent. The majority had remission with treatment. Comparison between the diagnostic criteria revealed concordance in 45% of the cases; in 14% the SDC didn’t allow classification as HAI. In practice, faced with suspected HAI, SDC are an initial option, but classical criteria should also be used, particularly in atypical cases.

Headache in patients with idiopathic intracranial hypertension: a pilot study to assess applicability of ICHD-2 diagnostic criteria

Headache is one of the most common symptoms of idiopathic intracranial hypertension (IIH). The aim of this study was to investigate the applicability of the diagnostic criteria for "Headache attributed to IIH" included in the current classification of headache disorders, particularly as far as the main headache features. A consecutive clinical series of IIH patients with demonstration of increased intracranial pressure by lumbar puncture in the recumbent position were enrolled. Among a total of 22 patients, headache was reported by 14. The proportion of patients reporting the main headache features required by diagnostic criteria were: 93 % for daily or nearly-daily occurrence; 71.5 % for diffuse/non-pulsating pain; 57 % for aggravation by coughing/straining. Thus, these three headache features, at least one of which is required for diagnosis of headache attributed to IIH, were present in the vast majority of our sample, suggesting that their inclusion should be regarded as appropriate. The analysis of our results may suggest possible changes in the current ICDH-2 criteria for headache attributed to IIH, based on the following considerations: the existence of remarkable differences as far as the relative frequency of each headache feature; the fact that diffuse and non-pulsating pain-included in the current classification as a single requirement-were not always found together; the high frequency of migrainous associated symptoms (nausea or photophobia-phonophobia were present in 71.5 % cases).