Changes In Classification Systems Research Articles

Shifts in Alcohol-Related Diagnoses After the Introduction of International Classification of Diseases, Tenth Revision, Clinical Modification Coding in U.S. Hospitals: Implications for Epidemiologic Research.

In October 2015, the United States transitioned healthcare diagnosis codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), to the Tenth Revision (ICD-10-CM). Trend analyses of alcohol-related stays could show discontinuities solely from the change in classification systems. This study examined the impact of the ICD-10-CM coding system on estimates of hospital stays involving alcohol-related diagnoses. This analysis used 2014 to 2017 administrative data from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project State Inpatient Databases for 17 states. Quarterly ICD-9-CM data from second quarter 2014 through third quarter 2015 were concatenated with ICD-10-CM data from fourth quarter 2015 through first quarter 2017. Quarterly counts of alcohol-related stays were examined overall and then by 6 diagnostic subgroups: withdrawal, abuse, dependence, alcohol-induced mental disorders (AIMD), nonpsychiatric alcohol-induced disease, and intoxication or toxic effects. Within each group, we calculated the difference in the average number of stays between ICD-9-CM and ICD-10-CM coding periods. On average, the number of stays involving any alcohol-related diagnosis in the 6 quarters before and after the ICD-10-CM transition was stable. However, substantial shifts in stays occurred for alcohol abuse, AIMD, and intoxication or toxic effects. For example, the average quarterly number of stays involving AIMD was 170.7% higher in the ICD-10-CM period than in the ICD-9-CM period. This increase was driven in large part by 1 ICD-10-CM code, Alcohol use, unspecified with unspecified alcohol-induced disorder. Researchers conducting trend analyses of inpatient stays involving alcohol-related diagnoses should consider how ongoing modifications in the ICD-10-CM code system and coding guidelines might affect their work. An advisable approach for trend analyses across the ICD-10-CM transition is to aggregate diagnosis codes into broader, clinically meaningful groups-including a single global group that encompasses all alcohol-related stays-and then to select diagnostic groupings that minimize discontinuities between the 2 coding systems while providing useful information on this important indicator of population health.

Social and ethical implications of psychiatric classification for low- and middle-income countries

<p>With the publication of the <em>Diagnostic and Statistical Manual</em>, 5th edition, and the ongoing revision of the <em>International Classification of Diseases</em>, currently 10th edition, it is timely to consider the wider societal implications of evolving psychiatric classification, especially within low- and middle-income countries (LMICs). </p><p>The author reviewed developments in psychiatric classification, especially the move from categorical to dimensional approaches based on biobehavioural phenotypes. While research supports this move, there are several important associated ethical challenges. Dimensional classification runs the risk of ‘medicalising’ a range of normality; the broadening of some definitions and the introduction of new disorders means more people are likely to attract psychiatric diagnoses. Many LMICs do not have the political, social, legal and economic systems to protect individuals in society from the excesses of medicalisation, thus potentially rendering more citizens vulnerable to forms of stigma, exploitation and abuse, conducted in the name of medicine and psychiatry. Excessive medicalisation within such contexts is also likely to worsen existing disparities in healthcare and widen the treatment gap, as inappropriate diagnosis and treatment of mildly ill or essentially normal people has an impact on health budgets and resources, leading to relative neglect of those with genuine, severe psychiatric disorders.<strong> </strong></p><p>In an era of evolving psychiatric classification, those concerned for, and involved in, global mental health should be critically self-reflective of all aspects of the modern psychiatric paradigm, especially changes in classification systems, and should alert the global profession to the sociopolitical, economic and cultural implications of changing nosology for LMIC regions of the world.</p>

Social and ethical implications of psychiatric classification for low- and middle-income countries

With the publication of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, and the ongoing revision of the International Classification of Diseases, currently 10th edition, it is timely to consider the wider societal implications of evolving psychiatric classification, especially within low- and middle-income countries (LMICs). The author reviewed developments in psychiatric classification, especially the move from categorical to dimensional approaches based on biobehavioural phenotypes. While research supports this move, there are several important associated ethical challenges. Dimensional classification runs the risk of ‘medicalising’ a range of normality; the broadening of some definitions and the introduction of new disorders means more people are likely to attract psychiatric diagnoses. Many LMICs do not have the political, social, legal and economic systems to protect individuals in society from the excesses of medicalisation, thus potentially rendering more citizens vulnerable to forms of stigma, exploitation and abuse, conducted in the name of medicine and psychiatry. Excessive medicalisation within such contexts is also likely to worsen existing disparities in healthcare and widen the treatment gap, as inappropriate diagnosis and treatment of mildly ill or essentially normal people has an impact on health budgets and resources, leading to relative neglect of those with genuine, severe psychiatric disorders. In an era of evolving psychiatric classification, those concerned for, and involved in, global mental health should be critically self-reflective of all aspects of the modern psychiatric paradigm, especially changes in classification systems, and should alert the global profession to the sociopolitical, economic and cultural implications of changing nosology for LMIC regions of the world.

Towards the DSM‐5 Criteria for Autism: Clinical, Cultural, and Research Implications

The new edition of the DSM is proposing significant changes to current diagnostic definitions of autism and related conditions. In this article, we will discuss the clinical, research, and cultural implications of these changes. We conclude that the new criteria appear to better reflect current understanding of the autism spectrum disorder than the current DSM‐IV criteria. As expected with any major change in classification systems, there are also significant risks, which will have to be carefully monitored and addressed by both policy makers and the scientific community to ensure that best clinical practice and research are facilitated and advanced.

Non-Hodgkin Lymphoma in Early Life

Non-Hodgkin Lymphoma in Early Life

Vascular and Perivascular Lesions of Skin and Soft Tissues in Children and Adolescents

Vascular anomalies in children and adolescents are the most common soft tissue lesions and include reactive, malformative, and neoplastic tumefactions, with a full spectrum of benign, intermediate, and malignant neoplasms. These lesions are diagnostically challenging because of morphologic complexity and recent changes in classification systems, some of which are based on clinical features and others on pathologic findings. In recent decades, there have been significant advances in clinical diagnosis, development of new therapies, and a better understanding of the genetic aspects of vascular biology and syndromes that include unusual vascular proliferations. Most vascular lesions in children and adolescents are benign, although the intermediate locally aggressive and intermediate rarely metastasizing neoplasms are important to distinguish from benign and malignant mimics. Morphologic recognition of a vasoproliferative lesion is straightforward in most instances, and conventional morphology remains the cornerstone for a specific diagnosis. However, pathologic examination is enhanced by adjunctive techniques, especially immunohistochemistry to characterize the type of vessels involved. Multifocality may cause some uncertainty regarding the assignment of "benign" or "malignant." However, increased interest in vascular anomalies, clinical expertise, and imaging technology have contributed greatly to our understanding of these disorders to the extent that in most vascular malformations and in many tumors, a diagnosis is made clinically and biopsy is not required for diagnosis. The importance of close collaboration between the clinical team and the pathologist cannot be overemphasized. For some lesions, a diagnosis is not possible from evaluation of histopathology alone, and in a subset of these, a specific diagnosis may not be possible even after all assembled data have been reviewed. In such instances, a consensus diagnosis in conjunction with clinical colleagues guides therapy. The purpose of this review is to delineate the clinicopathologic features of vascular lesions in children and adolescents with an emphasis on their unique aspects, use of diagnostic adjuncts, and differential diagnosis.

Time trends in pharyngeal cancer incidence in Norway 1981–2005: a subsite analysis based on a reabstraction and recoding of registered cases

Incidence rates of oropharyngeal squamous cell carcinoma (SCC) have been reported to be increasing in several countries in recent decades, contrasting with trends of SCCs diagnosed in neighboring anatomical sites. We investigated whether changes in classification systems and/or coding/registration practices might explain the trends in Norway, focusing on changes in oropharyngeal cancer. Trends in cancers of the oropharynx, base of tongue, nasopharynx, hypopharynx were graphically presented for the period 1981-2005, before and after recoding. Age-period-cohort and future prediction models were fitted to oropharyngeal SCC incidence. A total of 85 (3.7%) of the 2315 pharyngeal cancers required recoding. Rates of oropharyngeal cancer in Norway were consistently two to three times higher in men, with rapid increases in both men (5% per annum) and women (4.2% per annum). Assuming generational effects, male cohorts born 1915-1950 were at increasingly higher risk of the disease. The number of oropharyngeal cancer cases is expected to double in Norway by 2020. The trends were not considered materially biased by potential artefacts. The increasingly higher proportion of oropharyngeal SCC cancers is more likely explained by other factors, including an increasing high-risk HPV prevalence among recent cohorts. These results will likely have consequences on treatment and health care provision in the near future.

Translocations Involving 8q24 in Burkitt Lymphoma and Other Malignant Lymphomas: A Historical Review of Cytogenetics in the Light of Todays Knowledge

Burkitt lymphoma (BL) has a characteristic clinical presentation, morphology, immunophenotype and primary chromosomal aberration, i.e. the translocation t(8;14) (q24;q32) or its variants. However, diagnostic dilemmas may arise in daily practice due to overlap of BL with subsets of other aggressive, mature B cell lymphomas such as a small subset of diffuse large B cell lymphomas (DLBCL). Recently, two gene expression studies have described a distinct molecular profile for BL, but also showed the persistence of some cases intermediate between BL and DLBCL. An alternative approach to define BL is to consider (cyto)genetic data, in particular chromosomal abnormalities other than the t(8;14) or its variants. In this study the “Mitelman Database of Chromosome Aberrations in Cancer”, harboring the majority of all published neoplasia related karyotypes, was explored to define a cytogenetic profile of “true” BL. To that end a core subset of BL was defined bya histologic diagnosis of BL,the presence of a t(8;14), t(2;8) or t(8;22) indicating a MYC/IG breakpoint, andthe absence of a 3q27/BCL6, 18q21/BCL2 or 11q13/CCND1 breakpoint additional to the 8q24/MYC breakpoint.These core BL (N=481) showed a very low complexity of chromosomal changes, with 40% of the cases having the IG-MYC fusion as the sole abnormality; in the remaining cases additional recurrent and partially exclusive abnormalities included gains at chromosomes 1q, 7 and 12, and losses of 6q, 13q32-34 and 17p. No differences were found between pediatric (N=205) and adult patients (N=215). Moreover, no differences were found between such core BL cases published before (N= 280) and after 1994 (N=201) indicating that historical changes in classification systems had no major impact on this profile.The genetic profiles and age distribution of the core subset were significantly different from BL with an 8q24 breakpoint not affecting one of the three IG loci (N=13), lymphomas that were diagnosed as BL but had a translocation involving 18q21/BCL2, 3q27/BCL6 or 11q13/BCL1 additional to a breakpoint at 8q24/MYC (“double hit BL”; N=44), and from other morphological types of lymphomas with an 8q24/MYC breakpoint (N=327; 256/327 cases had an IG-MYC breakpoint). These groups showed an other age distribution and a higher cytogenetic complexity than the core subset of BL. BL without a detectable 8q24/MYC breakpoint (N=108) might have been heterogeneous and deserves further studies. We suggest that, concordant with the WHO classification to be published in 2008, the diagnosis of BL should be restricted to cases with expression of CD10 and BCL6, absence or very weak expression of BCL2 protein, a homogeneously very high proliferation index, and a proven IG-MYC translocation without evidence of a chromosomal translocation typical for other lymphoma entities. Additionally, a high number of non-specific cytogenetic abnormalities should suggest need for a critical review of the diagnosis of BL. Finally, the steady increase in age of lymphomas that mimic BL strongly emphasizes that there is no distinct age at which a pathologist can safely make a diagnosis of BL without any ancillary cytogenetic or molecular studies.

Extranodal lymphoma: a reappraisal

Approximately one-third of non-Hodgkin lymphomas (NHLs) arise primarily from sites other than lymph nodes, spleen or the bone marrow and even from sites which normally contain no native lymphoid tissue [1, 2]. Indeed, extranodal lymphomas can arise in almost every organ [1, 2]. However most of the presentations appears to be clustered in a few sites: skin, stomach, brain, small intestine and—when included in the reports—the Waldeyer’s ring [3, 4]. The extranodal lymphomas represent a challenge in routine lymphoma diagnosis, due to the variety of histological types, molecular abnormalities and clinical pictures that can be present. Correct diagnosis and appropriate treatment of extranodal lymphoma are also complicated by the relative rarity of many of these tumours. Moreover, in comparison with nodal presentation, Band T-cell lymphomas diagnosed at extranodal sites may have quite different outcomes and may frequently require different therapeutic approaches due to specific organ-related problems. The definition of primary extranodal lymphoma is controversial, particularly in the presence of both nodal and extranodal disease. Strict criteria were first proposed in 1961 by Dawson, who defined primary gastric lymphoma as presentation with main disease manifestation in stomach, with or without involvement of regional lymph nodes. Later these criteria were extended to allow for contiguous involvement of other organs (e.g. liver, spleen) and for distant nodal disease providing that the extranodal lesion was the presenting site and, after routine staging procedures, constituted the predominant disease bulk, to which primary treatment must be directed [3]. The inclusion among primary extranodal lymphomas of cases presenting with stage III and IV is also questionable and several authors consider only stage I and II presentation as primary extranodal disease. Since many extranodal lymphomas have the potential to disseminate, this approach may, however, lead to an imperfect representation. On the other hand, extranodal involvement in a disseminated disease may represent a secondary spread. Any chosen definition inevitably introduces a selection bias; in a recent Dutch study the frequency of extranodal NHL fluctuated from 20% to 34% depending on the definition criteria adopted [5]. The incidence of extranodal NHL in Western countries has increased substantially in the last 40 years [4, 6]. This may in part be due to improved diagnostic procedures (particularly in brain and gastrointestinal lymphomas) and changes in classification systems, but much of the change is real and the AIDS epidemic in the 1980s does not completely explain this rise [4]. The aetiology of extranodal lymphomas appears to be multifactorial and includes immune suppression, infections, both viral and bacterial, and exposure to pesticides and other environmental agents. Nevertheless, despite the considerable progress made in the understanding of MALT lymphoma and its relationship to bacterial infections [7], the precise cause of most lymphoid neoplasms remains unknown [1–3]. The proportion of NHL presenting at extranodal sites comprises 25–50% of new lymphoma cases with important geographic variations that may be explained by the variability of the reporting criteria (variable definitions of primary extranodal disease) as well as by different types of data source (referral cancer centres versus tumour registry). True geographic differences are, however, present, for example, the incidence of Epstein–Barr virus and human T-cell lymphotropic virus 1-associated T-cell lymphomas is higher in Asia than in Europe and North America. The histological spectrum of extranodal lymphomas somehow differs from that of nodal lymphomas. Nearly half of the extranodal cases are of diffuse large cell histology. Aggressive subtypes, mainly diffuse large B-cell lymphomas (DLBCLs) are predominant in NHL of central nervous system (CNS), testis, bone and liver while in the gastrointestinal tract a large spectrum of histological disease entities can be seen, comprising DLBCL, MALT lymphoma (including the immunoproliferative small intestinal disease), Burkitt’s lymphoma, enteropathy-associated T-cell lymphoma, mantle cell lymphoma and follicular lymphoma. Although extranodal lymphomas are not rare, the frequency of involvement of any particular site is not high enough for a single institution to answer the major question about their natural history and proper therapy. Attempting to overcome these difficulties, in the late 1990s, the International Extranodal Lymphoma Study Group (IELSG) was created to provide an adequate network to study the extranodal lymphomas. This international collaboration has originated a number of retrospective and prospective trials aimed to clarify the management issues distinct to extranodal presentations (http://www.ielsg.org). Whether or not extranodal lymphomas as a whole have a worse overall survival in comparison with that of nodal cases The author reports no relationships with companies whose products or services are mentioned in this manuscript.

The non-Hodgkin lymphomas: A review of the epidemiologic literature

The non-Hodgkin lymphomas (NHL) are a heterogeneous group of B-cell and T-cell neoplasms that arise primarily in the lymph nodes. NHL incidence rates in the US doubled between about 1970 and 1990, and stabilized during the 1990s. NHL accounts for approximately 3.4% of cancer deaths in the US. Although some of the observed patterns in NHL have been related to HIV/AIDS, these conditions cannot fully explain the magnitude of the changes; neither do changes in classification systems nor improved diagnostic capabilities. Studies of occupational and environmental exposures (e.g., pesticides, solvents) have produced no consistent pattern of significant positive associations. Inverse associations with ultraviolet radiation exposure and alcohol and fish intake, and positive associations with meat and saturated fat intake have been reported in several studies; additional studies are needed to confirm or refute these associations. Family history of NHL or other hematolympho-proliferative cancers and personal history of several autoimmune disorders are associated with increased risk of NHL, but are not likely to account for a large proportion of cases. HIV and other infectious agents, such as human herpesvirus 8 and Epstein-Barr, appear to be associated with differing types of NHL, such as some B-cell lymphomas. Future epidemiologic studies should evaluate associations by NHL type, enhance exposure information collected, and elucidate factors that may identify susceptible (or resistant) subpopulations because of genetic, immunologic or other characteristics. The extent to which the etiology of NHL types may differ is important to resolve in ongoing and future studies.

Attention-deficit hyperactivity disorder in adults: validity unknown1

Attention-deficit hyperactivity disorder (ADHD) is a commonly diagnosed childhood psychiatric disorder. Debate over its diagnostic validity, aetiology, presentation and treatment has extended from the clinical to the public domain. As children with ADHD diagnoses reach adulthood there is increasing interest in ‘adult ADHD’. Cohorts followed up show poorer outcomes as adults than do controls. Self-referred adults, sometimes relatives of children with ADHD, are also of interest regarding adult ADHD. Innovative work is being done examining issues of aetiology, treatment, outcomes and comorbidity in these groups, but heterogeneity among those diagnosed with ADHD and changes in classification systems and diagnostic criteria over time complicate comparison of research findings. The diagnostic validity of adult ADHD remains uncertain and needs further study.

General hospitals and the severely mentally ill: changing patterns of diagnosis

The author's goal is to determine whether there has been a recent change in the number and proportion of severely ill psychiatric patients treated in general hospitals. He analyzed the discharge data from the National Hospital Discharge Survey for the years between 1970 and 1987, focusing particularly on the discharges of patients with psychiatric versus nonpsychiatric diagnoses. The number and proportion of discharges of patients with psychiatric diagnoses in four major diagnostic groups (depression, bipolar spectrum disorders, schizophrenia, and other psychoses) were determined. Between 1970 and 1987, discharges of patients with psychiatric diagnoses from general hospitals increased by a factor of 0.8. The percentage of discharges of patients with the diagnoses of depression (18.0%-22.7%), schizophrenia (9.4%-13.6%), and paranoid or other nonorganic psychoses (3.1%-4.0%) remained relatively constant. The percentage of discharges of patients with the diagnosis of nondepressed bipolar disorder increased from 0.6% in 1970 to 3.2% in 1987. Although there has been a recent absolute increase in the number of general hospital patients with severe psychiatric diagnoses, the increase has been tempered by a concomitant increase in the number of patients with nonsevere diagnoses. Changes in classification systems (DSM-II or ICDA-8 to DSM-III or ICD-9-CM) and questions regarding the rigor with which the nosologic changes have been incorporated into practice complicate the interpretation of these findings.