Application Of Diagnostic Criteria Research Articles

Instrumental investigations and migraine diagnosis

Migraine diagnosis is based on clinical parameters. Before reaching a correct diagnosis, patients usually consult a large number of specialists and perform unhelpful exams. This represents a significant problem for an optimization of healthy resources. Our aim in this study was to evaluate the relationship between time interval from symptoms' onset to a correct diagnosis and number and type of clinical and instrumental investigations. We considered 180 consecutive patients referred to our Headache Center who obtained the first diagnosis of migraine without aura. Most patients were referred to our center by general practitioners (80%). Previously, about half of patients consulted a specialist not involved in migraine management. In 68% of cases, patients performed radiological and/or laboratory exams. Time from symptom onset to a correct diagnosis of migraine was less than 1 year in only 16.7% of the cases. In 83.3% of patients, the time delay overcame 1 year. In 53.3%, it reached 5 or more years. The time interval to obtain a correct diagnosis significantly influenced the number of specialists consulted and the number of radiological and laboratory investigations performed. Our findings confirm the presence of problems in migraine management. In particular, expensive and unnecessary visits and exams are very often prescribed. This inappropriate procedure could be easily counteracted by a correct application of diagnostic criteria for migraine.

Presentation and management of ICU myopathy and neuropathy

Critical illness myopathy and neuropathy are common complications in the ICU, causing limb and respiratory muscle weakness. We review the most recent data concerning their presentation, diagnosis and treatment. Limb muscle strength can be reliably assessed by using the Medical Research Council scale or handgrip dynamometry. A Medical Research Council sum score below 48 or mean Medical Research Council score below 4 (antigravity strength) across all testable muscle groups, and a force value of less than 11 kg-force for men and less than 7 kg-force for women at dominant-hand dynamometry identify ICU-acquired weakness in previously healthy individuals admitted to an ICU for nonneuromuscular disorder. Clinical signs, together with measurements of the maximal inspiratory and expiratory pressures and vital capacity, are important to timely diagnose respiratory muscle weakness. Electrophysiological testing is usefully implemented in unconscious patients or in awake patients who do not improve despite appropriate treatments. Early physiotherapy in the ICU can increase the proportion of patients reaching an independent functional status following their ICU stay. Critical illness myopathy and neuropathy may occur outside the ICU; however, exact estimates are lacking. Systematic application of diagnostic criteria and early physiotherapy may help clinicians to timely diagnose critical illness myopathy and neuropathy and to reduce the associated morbidity.

10. Outcomes following cytological prediction of possible LSIL

Background Under the 1994 management guidelines for screen-detected cervical abnormalities, women with nonspecific minor changes were directed to annual cytology until smears returned to normal. The new 2006 guidelines recommend the same management strategy for possible low-grade squamous intraepithelial lesions (LSIL) as for definite LSIL – those with persistent ‘possible LSIL’ or worse at the 12 month repeat to be referred for colposcopy and immediate colposcopy or repeat smear at 6 months for women aged over 30 years and without a history of negative cytology in the preceding 36 months. Over-referral for colposcopy is of concern in terms of costs and patient anxiety. Aims To examine the outcome for women with cytological prediction of possible LSIL during 2006–2008 and determine if any differences in outcome exist between age groups 30 years old. Methods All cases diagnosed at VCS over the period January 2006 to December 2008 for which the index smear was ‘possible LSIL’ and the results of follow-up cervical histology available were collated according to age group at time of index smear. The groups were statistically compared regarding the diagnostic frequency of dysplasia on follow-up cervical biopsy. Results A total of 4054 patients diagnosed with ‘possible LSIL’ had follow-up histology results available. Of the 1771 women aged 30 years, biopsy was negative in 1646 (72.1%), a result significantly higher than the Conclusions Women aged 430 years are significantly more likely to have only benign changes on biopsy following an index smear of ‘possible LSIL’. The critical application of diagnostic criteria in this age group is important to avoid potentially unnecessary colposcopy. HPV testing may have a triage application in this setting.

CVD risk in South Asians: the importance of defining adiposity and influence of dietary polyunsaturated fat

The prevalence of the metabolic syndrome (MetS), CVD and type 2 diabetes (T2D) is known to be higher in populations from the Indian subcontinent compared with the general UK population. While identification of this increased risk is crucial to allow for effective treatment, there is controversy over the applicability of diagnostic criteria, and particularly measures of adiposity in ethnic minorities. Diagnostic cut-offs for BMI and waist circumference have been largely derived from predominantly white Caucasian populations and, therefore, have been inappropriate and not transferable to Asian groups. Many Asian populations, particularly South Asians, have a higher total and central adiposity for a similar body weight compared with matched Caucasians and greater CVD risk associated with a lower BMI. Although the causes of CVD and T2D are multi-factorial, diet is thought to make a substantial contribution to the development of these diseases. Low dietary intakes and tissue levels of long-chain (LC) n-3 PUFA in South Asian populations have been linked to high-risk abnormalities in the MetS. Conversely, increasing the dietary intake of LC n-3 PUFA in South Asians has proved an effective strategy for correcting such abnormalities as dyslipidaemia in the MetS. Appropriate diagnostic criteria that include a modified definition of adiposity must be in place to facilitate the early detection and thus targeted treatment of increased risk in ethnic minorities.

Mood disorders in children and adolescents

This article reviews our current understanding of depressive and bipolar disorders in children and adolescents. It highlights issues related to causality, assessment and treatment. Early onset depression arises as a consequence of interrelated predisposing and precipitating factors, which together lead to alterations to biological and psychological functioning and result in depression. Assessment needs to be carefully and thoroughly undertaken by a clinician with experience in child and adolescent psychiatric disorders. Following a brief psychoeducational intervention, further treatment should be initially with psychotherapeutic approaches. Cognitive and interpersonal therapies are supported by the best evidence. Pharmacological treatments may be associated with increases in suicidal ideation and behaviours and should be initiated only by those with specialist training and experience in child and adolescent mental health problems. Early onset bipolar disorder remains a controversial area of practice, with uncertainty over the application of diagnostic criteria, validity of the disorder and its relationship with other disorders such as ADHD. For those adolescents and, rarely, children with true bipolar disorder, the longer-term outcome for early-onset bipolar disorder appears to be similar to that for adults, although younger sufferers are more likely to have a more rapid cycling clinical picture than adults. There is very little research evidence investigating response to medication, although there is some evidence for the efficacy of lithium, valproic acid and carbamazepine in the treatment of early-onset mania. Major advances relate to the pharmacological treatment of depression in this age-group. Data on the adverse events found with SSRIs have been re-analysed and have resulted in warnings about the appearance of suicidal behaviour in the early stages of treatment. This has in turn resulted in regulatory authorities suggesting that extreme care should be taken when treating early onset depression with medication in this age group.

Mood disorders in teenage girls

This article reviews our current understanding of depressive and bipolar disorders in teenage girls. It highlights issues related to causality, assessment and treatment. Early onset depression arises as a consequence of inter-related predisposing and precipitating factors which together lead to alterations to biological and psychological functioning and result in depression. Assessment needs to be carefully and thoroughly undertaken by a clinician with experience in child and adolescent mental health problems. Following a brief psychoeducational intervention, further treatment should be initially with psychotherapeutic approaches. Cognitive and interpersonal therapies are supported by the best evidence. Pharmacological treatments may be associated with increased suicidal ideation and behaviour and should only be initiated by those with specialist training and experience in child and adolescent mental health problems. Early onset bipolar disorder remains a controversial area of practice, with uncertainty over the application of diagnostic criteria, validity of the disorder and its relationship with other disorders such as ADHD. For those adolescents and, rarely, children with true bipolar disorder, the longer-term outcome for early-onset bipolar disorder appears to be similar to that for adults, although younger sufferers are more likely to have a more rapidly cycling clinical picture than adults. There is very little research evidence investigating response to medication although there is some evidence for the efficacy of lithium, valproic acid and carbamazepine in the treatment of early-onset mania.

The Epidemiology of Chronic Venous Insufficiency and Varicose Veins

Chronic venous disease is a common condition presenting to physicians in Western Europe and the United States. This article provides a comprehensive review of the published literature in the English language, from 1942 to the present, and focuses on the prevalence of chronic venous insufficiency and varicose veins, as well as the involved risk factors. Prevalence estimates vary widely by geographic location, with the highest reported rates in Western countries. Reports of prevalence of chronic venous insufficiency vary from < 1% to 40% in females and from < 1% to 17% in males. Prevalence estimates for varicose veins are higher, <1% to 73% in females and 2% to 56% in males. The reported ranges in prevalence estimations presumably reflect differences in the population distribution of risk factors, accuracy in application of diagnostic criteria, and the quality and availability of medical diagnostic and treatment resources. Established risk factors include older age, female gender, pregnancy, family history of venous disease, obesity, and occupations associated with orthostasis. Yet, there are several factors that are not well documented, such as diet, physical activity and exogenous hormone use, which may be important in the development of chronic venous disease and its clinical manifestations.

Démarche diagnostique devant un syndrome démentiel

Purpose. – The high prevalence of dementia, particularly of Alzheimer’s disease, the increase of their incidence with age, and the population aging make this group of diseases a major problem for public health. Nevertheless, diagnosis is difficult because it depends on evolution of disturbances that patients often cannot precisely relate, on complex neuropsychological explorations, and on pathological examination difficult to obtain. Today in France, geriatricians are fully implicated in the diagnosis of dementia and all the physicians who give care to elderly, should lead easily a diagnosis of dementia. Current knowledge and key points. – In February 2000 ANAES (French governmental agency for accreditation and evaluation of health system) published recommendations called “practical recommendations for the diagnosis of Alzheimer’s disease”. These recommendations allow physicians to standardize their practices and consist of a rigorous clinical history and examination, a neuropsychological analysis, standard investigations and application of diagnostic criteria already widely diffused and used. Future prospects and projects. – Deepening of knowledge, in particular in the domains of neuropsychology and functional cerebral imagery, should allow physicians to diagnose early dementia. These early diagnosis should allow to initiate a multidisciplinary, preventive and effective care for patients. Specific drugs, that will be available, will be intended mostly for patients with early diagnosis, ideally at a pre-dementia state.

Male Rett syndrome variant: application of diagnostic criteria

Classic Rett syndrome (RS) has been described in females only. Although an X chromosome origin is probable, it has not been substantiated. It is possible, therefore, that RS could occur in males. The authors describe a male with RS and review all the reported cases involving male patients. The authors compare their patient to the other patients and examine the applicability of the classic RS diagnostic criteria to this variant. To date, nine male patients with RS have been reported. The authors describe an additional male who met seven of nine necessary criteria and six of eight supportive criteria as defined by the RS Diagnostic Criteria Work Group. When the authors applied these criteria to the other nine reported patients, many necessary inclusion criteria were not met despite the absence of exclusion criteria. The supportive criteria were even more variable and limited in many patients. In conclusion, males with RS appear to represent a heterogeneous phenotype, with clinical features that may meet many but not all of the necessary diagnostic criteria of classic RS. Less restrictive criteria are needed to include this variant, which should be considered when evaluating males with idiopathic developmental regression, autistic features, and loss of hand function.

ADVERSITY, VULNERABILITY AND DEPRESSION

Progress in the methods of assessment of adverse experience, together with developments in measures of the longitudinal course of diagnosable psychiatric disorder, have provided an increasingly firm foundation for enabling a clearer understanding of the relationship between social stress and mental health and for identifying factors that influence that relationship. This article addresses two substantive issues within this research area that have benefited from these advances in longitudinal methodology: firstly, the investigation of the specificity of psychiatric response to adverse experience, and secondly, the extent to which long-term vulnerability or resilience to the recurrence of major affective disorder appears to be conferred through individual difference attributes. These issues will be informed by the results from two studies that included detailed clinical course assessments based upon the Longitudinal Interval Follow-up Evaluation in association with the formal application of diagnostic criteria. For the first study, two groups of women were studied through their common adverse experience of either their husband's non-fatal myocardial infarction (MI) or their husband's death. Interviews were completed with 64 bereaved women and 143 women shortly following their partner's MI. Follow-up interviews were completed about 3 months following the initial interview. Results will be presented concerning the mental health of the women during the study and the nature of that response. The second study was based upon a 12-year longitudinal follow-up of 80 patients with a primary depressive disorder, originally selected from a consecutive series seeking care at a hospital in Scotland. Preliminary results will be presented concerning the relationship between a measure of self-appraisal, completed on recovery from their inception episode, and the subsequent recurrence of affective disorder. The significance of the results for a psychosocial model of depression will be discussed.

Validity of diagnoses of chronic diseases in general practice: The application of diagnostic criteria

Certainty of a diagnosis is not only important for the patient but also for morbidity studies. In the absence of a gold standard, agreement with diagnostic criteria is often the best approach in measuring the certainty of a diagnosis. The agreement with diagnostic criteria has been studied for 5 chronic diseases (hypertension, chronic ischemic heart disease, diabetes mellitus, chronic nonspecific lung disease and osteoarthritis) in 7 general practices with a total practice population of 23,534 persons. Agreement with diagnostic criteria is operationalized into 3 categories. For each chronic disease a diagnostic quality measure per general practitioner is computed. Retrospective data have been collected in the practices on 2295 diseases in 1989 patients. Two-thirds of the diagnoses were made in general practice. The agreement with the diagnostic criteria for the cases diagnosed in general practice is high, ranging from 96% true positive cases in diabetes mellitus to 58% in chronic nonspecific lung disease. The highest rate of false positive cases is 4%. On the level of general practitioners diagnostic qualities vary from 62 to 96% true positive cases for the different diseases. The variation in diagnostic quality between general practitioners is substantial. The prevalence rates for the 5 chronic diseases are lower after adjustment by only including true positive cases. Diagnoses of the 5 chronic diseases recorded in general practice are generally valid with low numbers of false positive cases.

Application of diagnostic criteria in the diagnosis of myocardial infarction.

A random sample of all patients with a registered diagnosis of acute myocardial infarction (AMI) was selected from the hospitalisation register of Stockholm County in 1973. The sample consisted of 269 patients. The medical records of these patients were scrutinized concerning the fulfilment of criteria of a diagnosis of AMI. The criteria of AMI chosen were those established in a Sweden cooperative study (6). 33 patients did not fulfil the diagnosis of AMI, corresponding to an estimated proportion of 10%. In 4% this was due to more technical reasons such as the use of incorrect code numbers, and in 6% the diagnosis had been made without the criteria being fulfilled.