Current World Health Organization Criteria Research Articles

Acute neurological events associated with influenza vaccination: Are the WHO criteria for assessing causality adequate?

We identified neurological admissions temporally associated with influenza vaccine to determine the likelihood of causality using World Health Organization (WHO) criteria. Although all cases were categorized as possibly related to the vaccine, most had a compelling alternative explanation. This observation suggests that the current WHO criteria may not be sufficient in determining if an adverse event is truly vaccine related.

Improving Case Definitions for Severe Malaria

The lack of a gold standard definition for severe malaria has been a longstanding problem for both clinicians and researchers. The definitions currently used comprise a set of clinical and laboratory parameters associated with an increased risk of death combined with the presence of Plasmodium falciparum parasitemia. In young children these criteria are predominantly altered consciousness severe anemia and respiratory distress; a broader range of criteria is applicable to adolescents and adults. While these criteria are sensitive in diagnosing severe malaria they are also present in other serious illnesses. Since asymptomatic parasitemia is common in malaria-endemic areas patients fulfilling current World Health Organization (WHO) criteria for severe malaria often have disease attributable to another cause such as bacterial sepsis with incidental parasitemia thereby limiting the specificity of this definition. For a treating clinician a sensitive but less specific definition of severe malaria is entirely appropriate. However for research purposes a sensitive clinical definition may not necessarily be appropriate and the case definition should depend on the research question. (excerpt)

High frequency of rapid immunological progression in African infants infected in the era of perinatal HIV prophylaxis

To determine the natural history of HIV infection following peripartum single-dose nevirapine (sd-NVP) prophylaxis in a resource-limited country, and to assess implications for antiretroviral therapy (ART) roll-out programmes. Infants of HIV-infected mothers in KwaZulu-Natal, South Africa, were tested on days 1 and 28 to detect intrauterine (IU) and intrapartum (IP) infection. Infant follow-up included monthly viral load and CD4 cell measurement. ART was initiated at infant CD4 cell% < or = 20%. In 740 infants born to 719 HIV-infected women, mother-to-child transmission (MTCT) was 10.3% (69% IU, 31% IP). Median viral load was higher in mothers of infants infected IP than IU (279 000 versus 86 600 copies/ml; P = 0.039) and lower in mothers of uninfected infants (median 26 750 copies/ml; P < 0.001). Peak viraemia was higher in infants infected IP than IU (5 160 000 versus 984 000 copies/ml; P < 0.001). Median viral load at birth in IU-infected infants (155 000 copies/ml) fell 1.4 log to 6510 copies/ml by day 5 and was beneath the detection limit using dried blood spot analysis in 38% of infants. CD4 cell% declined rapidly, to < or = 20% in 70% and < or = 25% in 85% [current World Health Organization (WHO) criteria for initiating ART] of infants by 6 months. MTCT was reduced by sd-NVP through an effect on IP transmission. Where MTCT occurred despite NVP, two-thirds of transmissions arose IU; IP-infected babies were born to mothers with very high viral load. Disease progression was particularly rapid, 85% infants meeting WHO criteria for ART within 6 months. These findings argue for more effective MTCT-prevention programmes in resource-limited countries.

Rare mutation of PIK3CA in meningiomas

The phosphoinositide 3-kinase (PI3K)/AKT signaling pathway plays a pivotal role in diverse cellular processes, such as proliferation, survival, and cytoskeletal rearrangement [reviewed in 9]. Anomalous activation of this pathway has been implicated in the development and progression of a wide variety of human cancers. For instance, inactivation of PTEN, an antagonist of PI3K, is frequently detected in glioblastomas, whereas activation of AKT2, a downstream effector of PI3K, is reported in breast and ovarian tumors. The PI3K/AKT pathway can also be activated by gene amplification and/or overexpression of PIK3CA, which encodes the p110a catalytic subunit of the class IA PI3K [2, 6]. Recently, Samuels et al. reported that somatic mutation is an alternative mechanism for PIK3CA activation and such genetic aberration has been detected in colorectal, gastric, breast, and lung tumors and glioblastomas [8]. About 80% of the base alterations are found clustered in the helical (exon 9) and kinase (exon 20) domains of PIK3CA. In this study, we investigated whether somatic mutation of PIK3CA was involved in meningiomas. Using direct sequencing, we screened for base alterations at the mutational hotspots of PIK3CA, exons 9 and 20, as well as on exon 1, where somatic mutation has been reported in brain tumor [1]. A series of 78 meningiomas (26 grade I, 33 grade II, and 19 grade III), classified according to the current World Health Organization criteria, were examined. Five of these tumors (one grade I, three grade II, and one grade III) were recurrences. Our mutation analysis identified one base substitution, A3140G, with a predicted amino acid change from histidine to arginine at codon 1047 (H1047R) of exon 20 in a primary grade III meningioma (Fig. 1). Such base change was not observed in patient’s peripheral lymphocytes, indicating that it was a somatic alteration. The patient was a 71-year-old female, presented with expressive dysphasia and cognitive dysfunction. Histologic examination of the tumor revealed frank brain invasion, numerous mitoses, and high MIB1 labeling index. The tumor, located in the left temporal lobe, was debulked. The patient died 10 months after initial diagnosis. In addition, our previous methylation analysis indicated that this malignant tumor also had promoter hypermethylation of RB1 [5]. No base alteration on either exon 1 or exon 9 of PIK3CA was detected in the series examined. The H1047R mutation maps to the kinase domain of PIK3CA and the amino acid residue involved is highly conserved through evolution. Previous studies showed that the H1047R mutant protein had elevated kinase activity in vitro [4, 8]. Forced expression of the mutant gene in chicken embryo fibroblasts led to cellular transformation with high efficiency [4]. Moreover, treatment of breast tumor cell lines carrying various PIK3CA mutations, including H1047R, with PI3K inhibitor resulted in decreased proliferation and increased apoptosis [10]. Together these results strongly suggest that the H1047R mutation of PIK3CA is oncogenic. Mawrin et al. recently demonstrated higher levels of activated, phosphorylated Akt in atypical and malignant meningiomas compared with benign tumors [7]. Their results suggest that activation of the PI3K/AKT signaling contributes to the aggressive behavior of malignant meningiomas. Another component of the PI3K/ AKT pathway reported altered in meningiomas is This study was supported by the Research Grant Council of Hong Kong, Hong Kong, China

Loss of Heterozygosity Analysis of Benign, Atypical, and Anaplastic Meningiomas

Up to 70% of typical meningiomas demonstrate allelic loss at chromosome 22q. Allelic loss at additional chromosomal loci is associated with atypia and anaplasia in meningiomas. The pattern of allelic loss or loss of heterozygosity (LOH) follows a nonrandom, multistep pattern. All surgical meningioma samples obtained from 1991 to 1992 at the University of Pittsburgh Medical Center were analyzed according to current World Health Organization criteria. Samples without constitutional deoxyribonucleic acid (DNA) were excluded from this analysis. Individual hematoxylin and eosin slides from 43 patients were microdissected, and the DNA was harvested and amplified in the presence of 24 pairs of polymerase chain reaction primers, representing 24 microsatellite loci. The polymerase chain reaction products were subjected to capillary gel electrophoresis and a fluorescence-based DNA analysis system. LOH was defined as ratios of allelic peak heights falling within a conservative threshold of less than 0.5 or more than 2.0. Fisher's exact test and receiver operator characteristic curves were used to test the relationship between benign versus atypical and malignant pathological features and LOH at specific loci or combinations of loci. On review by two independent pathologists, 34 benign meningiomas, 6 atypical meningiomas, and 3 anaplastic meningiomas were identified. The mean number of alleles with LOH was 1.5 +/- 1.2 for benign meningiomas, 6.7 +/- 2.7 for atypical meningiomas, and 8.3 +/- 2.3 for anaplastic meningiomas (P < 0.001). The most important individual loci to predict malignancy were D1S407 (P = 0.006), L-myc (P < 0.001), D10S520 (P = 0.003), D10S1173 (P = 0.042), D11S1920 (P < 0.001), D14S555 (P = 0.041), D17S1289 (P < 0.001), D22S417 (P = 0.001), D22S431 (P = 0.019), and D22S532 (P = 0.028). Combining the LOH data across loci, the area under the receiver operator characteristic curve was 0.993, corresponding to virtually perfect prediction of pathological characteristics. Microsatellite marker analysis of allelic loss is a useful method of predicting atypia and anaplasia in meningiomas. More regions of allelic loss are seen in anaplastic and atypical meningiomas as compared with benign meningiomas. This study confirms previously reported chromosomal regions of allelic loss in atypical and anaplastic meningiomas and suggests additional chromosomal regions that may represent heretofore uncharacterized deletions within meningiomas. This type of genetic fingerprint ultimately may serve both a diagnostic and therapeutic role.

The mitosis-specific antibody anti-phosphohistone-H3 (PHH3) facilitates rapid reliable grading of meningiomas according to WHO 2000 criteria.

Mitotic figure (MF) counting is the most objective criterion for grading of meningiomas according to the 2000 World Health Organization (WHO) classification. However, the search for the area(s) of highest mitotic activity is tedious, and there is high interobserver variability in differentiating MF from apoptotic cells. We tested the utility of the mitosis-specific marker phosphohistone-H3 (PHH3) to enhance rapid recognition of MFs and quick reliable grading of meningioma. Fifty-four archival meningiomas (26 benign, 20 atypical, 8 anaplastic) were reclassified according to current WHO criteria. PHH3-immunostained MFs were counted the same way as in hematoxylin and eosin-stained sections. Anti-PHH3-labeled MFs were easily seen and permitted quick identification of the area(s) of highest mitotic activity. Count results (mean) show a strong correlation between both methods: benign, hematoxylin and eosin 1.4, PHH3 2.2; atypical, hematoxylin and eosin 9.0, PHH3 15.9; anaplastic, hematoxylin and eosin 22.4, PHH3 34.1. PHH3 counting yielded greater sensitivity and in 12 cases (22.2%) suggested a change in grade (increased 9; lowered 3). All cases in which PHH3 lowered the grade were from older blocks, suggesting a loss of antigen preservation. PHH3 immunostaining facilitates the rapid reliable grading of meningiomas by focusing attention on the most mitotically active areas and by allowing easy and objective differentiation of MFs from apoptotic nuclei.

MANIFESTATION AND OUTCOME OF SEVERE MALARIA IN CHILDREN IN NORTHERN GHANA

The symptoms of severe malaria and their contribution to mortality were assessed in 290 children in northern Ghana. Common symptoms were severe anemia (55%), prostration (33%), respiratory distress (23%), convulsions (20%), and impaired consciousness (19%). Age influenced this pattern. The fatality rate was 11.2%. In multivariate analysis, circulatory collapse, impaired consciousness, hypoglycemia, and malnutrition independently predicted death. Children with severe malaria by the current World Health Organization (WHO) classification, but not by the previous one (1990), showed relatively mild clinical manifestations and a low case fatality rate (3.2%). In hospitalized children with severe malaria in northern Ghana, severe anemia is the leading manifestation, but itself does not contribute to mortality. In this region, malnutrition and circulatory collapse were important predictors of fatal malaria. The current WHO criteria serve well in identifying life-threatening disease, but also include rather mild cases that may complicate the allocation of immediate care in settings with limited resources.

Molecular classification of human diffuse gliomas by multidimensional scaling analysis of gene expression profiles parallels morphology-based classification, correlates with survival, and reveals clinically-relevant novel glioma subsets.

There are several currently employed classification systems for diffuse gliomas that sort tumors based on histological features. Contemporary molecular techniques, however, offer the promise of improved tumor classification and resultant patient stratification for treatment and prognosis. In particular, gene expression profiling has shown exceptional promise for providing an alternative and more objective molecular approach to glioma classification. In this study, we used cDNA array technology to profile the gene expression of 30 primary human glioma tissue samples comprising 4 different glioma subtypes as defined by current World Health Organization (WHO 2000) criteria: glioblastoma (GM, WHO grade IV), anaplastic astrocytoma (AA, WHO grade III), anaplastic oligodendroglioma (AO, WHO grade III), and oligodendroglioma (OL, WHO grade II). Gene expression data alone were used to group the tumors using multidimensional scaling, which is an unsupervised statistical method. Results show that impressive separation of the 4 glioma subtypes can be achieved solely on the basis of molecular data. In addition, a subcluster of 3 glioblastomas was identified as distinct from other GMs and from the oligodendroglial tumors. These 3 patients have shown extended survival compared to other GMs in the study. Survival analysis of the full data set revealed a good correlation with the molecular classification. Results of this proof-of-principle study demonstrate that molecular profiling alone can recapitulate conventional histologic classification and grading with high fidelity. In addition, results show that the molecular approach to tumor classification can generate clinically meaningful patient stratification, and, more importantly, is an efficient class-discovery tool for human gliomas, permitting the identification of previously unrecognized, clinically relevant tumor subsets.

Typical and Atypical Pulmonary Carcinoids: Outcome in Patients Presenting With Regional Lymph Node Involvement

Typical pulmonary carcinoid tumors are well-differentiated neuroendocrine tumors that are associated with good patient survival rates, while atypical carcinoid tumors are more aggressive and have worse patient survival rates. Because these tumors rarely involve the thoracic lymph nodes at presentation, it is currently unknown to what extent the presence of thoracic lymph node metastases at the time of diagnosis influences patient survival. A computerized search of the medical records for pulmonary carcinoid tumor at the Mayo Clinic from 1976 to 1997 revealed 517 patients, from which we identified 36 patients with pulmonary carcinoid tumors involving regional thoracic lymph nodes but without distant disease. For each patient, we reviewed the tumor histology, stage, and outcome. In addition, because the histologic criteria for the diagnosis of carcinoid tumors had changed significantly during the time of the study, we reexamined all of the histologic specimens using the current World Health Organization (WHO) criteria for classifying pulmonary neuroendocrine tumors. After reclassification with the WHO criteria for neuroendocrine tumors, 23 patients had typical carcinoid tumors with thoracic lymph node involvement. At the last follow-up, 19 patients had no evidence of disease (NED), 2 patients had developed systemic metastases (SM) and are still alive, and 2 patients had died. Eleven patients had atypical carcinoid tumors with thoracic lymph node involvement. At the last follow-up, four patients had NED, seven patients had developed SM within a median time of 17 months, and six patients with SM died shortly thereafter (median survival time, 25.5 months), while one is still alive. Two patients had been reclassified with large cell neuroendocrine carcinoma at the time of this review; both of these patients had developed SM (at 4 months and 21 months after diagnosis) and had died (at 15 months and 21 months after diagnosis, respectively). These data suggest that patients with atypical pulmonary carcinoid tumors with regional lymph node metastases have a high likelihood of developing recurrent disease if treated with surgical resection alone and have significantly worse outcome (p < 0.001) compared to those patients with typical carcinoid tumors with thoracic lymph node involvement.

New ADA criteria in the Korean population: fasting blood glucose is not enough for diagnosis of mild diabetes especially in the elderly.

BackgroundTo compare the 1997 American Diabetes Association (ADA) criteria with the 1985 World Health Organization (WHO) criteria in categorization of the diabetes diagnostic status of Koreans and to define clinical characteristics of subjects diagnosed differently by the two criteria.MethodsIn 810 Korean subjects, we analyzed blood glucose and insulin response during 75 g oral glucose tolerance test (OGTT). According to current WHO criteria, the cutoff values of FPG which distinguish normal and IGT from diabetes were determined. Then the subjects were categorized according to both WHO and ADA criteria. The clinical characteristics of the subjects with different diagnostic categories by the two criteria were defined.ResultsThe FPG cut point distinguishing diabetes from IGT was 117 mg/dl, and from normal was 110 mg/dl. The overall agreement between the ADA criteria and the WHO criteria was moderate, as reflected in the κof 0.45. 141 of subjects categorized diabetes by WHO criteria were not diagnosed with ADA criteria. These discordant subjects were older in age and showed blunted early insulin response than concordant normal subjects.ConclusionThese results suggest that mild diabetes by the WHO criteria, especially in the elderly, would not be diagnosed as diabetes by the ADA FPG criteria only. Thus, in a group at high risk for developing diabetes or in a relatively older age group, we should continue using the OGTT.

The Performance of the Revised Criterion for Diagnosis of Diabetes Mellitus in Jordan

The Performance of the Revised Criterion for Diagnosis of Diabetes Mellitus in Jordan

Reduced prevalence of diabetes according to 1997 American Diabetes Association criteria.

We examined the prevalence of diabetes and investigated the characteristics of subjects diagnosed by the American Diabetes Association and the World Health Organization criteria. A total of 1235 Japanese-Americans living in Hawaii and Los Angeles was studied. Of the subjects 114 were classified as previously diagnosed as having diabetes. A 75-g glucose tolerance test was given to the rest of the subjects. When abnormal glucose tolerance was diagnosed by the American Diabetes Association criteria, it was possible to identify only 40 % of diabetic subjects who had not been previously diagnosed compared with the current World Health Organization criteria based on a glucose tolerance test. In addition, the subjects identified by the American Diabetes Association criteria had higher glucose concentrations and had less insulin secretory capacity and they were in need of intensive treatment for diabetes. On the other hand, the subjects not diagnosed by the American Diabetes Association criteria alone were those whose glucose tolerance would be more likely to improve with lifestyle modification. It might be better to use the fasting plasma glucose criterion advocated by the American Diabetes Association in combination with a glucose tolerance test after taking a detailed medical history. To reduce the number of subjects requiring the glucose tolerance test, priority should be given to subjects with impaired fasting glucose (6.1 </= fasting plasma glucose < 7.0 mmol/l). [Diabetologia (1999) 42: 1168-1170]

Usefulness of revised fasting plasma glucose criterion and characteristics of the insulin response to an oral glucose load in newly diagnosed Japanese diabetic subjects.

To examine the usefulness of the revised criterion for fasting plasma glucose (FPG) in the diagnosis of diabetes recommended by the American Diabetic Association (ADA) (126 mg/dl, 7 mmol/l), and to characterize insulin response during the 75-g oral glucose tolerance test (OGTT) in newly diagnosed Japanese diabetic subjects. A series of 2,121 Japanese subjects underwent a 75-g OGTT (0-3 h) and were divided into three groups (normal glucose tolerance [NGT], impaired glucose tolerance [IGT], and diabetes mellitus [DM] according to the current World Health Organization criteria. After the cutoff values of FPG that distinguish NGT and IGT from diabetes were analyzed, the usefulness of the ADA criterion for FPG was examined by comparing diagnostic parameters (sensitivity, specificity, and accuracy) with those for the cutoff value of 140 mg/dl. To assess insulin response, both the insulinogenic index (IsIx), a marker of early secretion, and the area under the insulin response curve (AUCins), a marker of total secretion, were compared between the DM, NGT, and IGT groups. First, the FPG cutoff value distinguishing NGT from diabetes was 109 mg/dl. An FPG of 126 mg/dl showed a higher sensitivity (0.52 vs. 0.31), the same specificity (1.00), and a higher accuracy (0.82 vs. 0.74) than an FPG of 140 mg/dl, and it had a higher specificity (1.00 vs. 0.86) with a slightly lower accuracy (0.82 vs. 0.85) than an FPG of 109 mg/dl. Second, the FPG cutoff value differentiating IGT from diabetes was 113 mg/dl. An FPG of 126 mg/dl showed a higher sensitivity (0.52 vs. 0.31) and accuracy (0.80 vs. 0.74) and a similar specificity (0.97 vs. 1.00) compared with an FPG of 140 mg/dl, and it had a higher specificity (0.97 vs. 0.82) with the same accuracy (0.80) as an FPG of 113 mg/dl. Third, the DM group showed the lowest IsIx among the three groups at all FPG values. The AUCIns in the DM group increased along with FPG, reached the maximum level at an FPG of 110 mg/dl, and declined thereafter. AUCIns was higher in the DM group than in the NGT group at FPG values > or = 100 mg/dl. The revised ADA criterion for FPG of 126 mg/dl may improve diagnostic sensitivity without loss of specificity in Japanese diabetic subjects when compared with an FPG criterion of 140 mg/dl. Although early insulin secretion was impaired, total insulin secretion did not seem to be reduced in newly diagnosed Japanese diabetic subjects.

Proton magnetic resonance spectroscopy in patients with glial tumors: a multicenter study

The authors represent a cooperative group of 15 institutions that examined the feasibility of using metabolic features observed in vivo with 1H-magnetic resonance (MR) spectroscopy to characterize brain tumors of the glial type. The institutions provided blinded, centralized MR spectroscopy data processing long with independent central review of MR spectroscopy voxel placement, composition and contamination by brain, histopathological typing using current World Health Organization criteria, and clinical data. Proton 1H-MR spectroscopy was performed using a spin-echo technique to obtain spectra from 8-cc voxels in the tumor and when feasible in the contralateral brain. Eighty-six cases were assessable, 41 of which had contralateral brain spectra. Glial tumors had significantly elevated intensities of choline signals, decreased intensities of creatine signals, and decreased intensities of N-acetylaspartate compared to brain. Choline signal intensities were highest in astrocytomas and anaplastic astrocytomas, and creatine signal intensities were lowest in glioblastomas. However, whether expressed relative to brain or as intratumoral ratios, these metabolic characteristics exhibited large variations within each subtype of glial tumor. The resulting overlaps precluded diagnostic accuracy in the distinction of low-and high-grade tumors. Although the extent of contamination of the 1H-MR spectroscopy voxel by brain had a marked effect on metabolite concentrations and ratios, selection of cases with minimal contamination did not reduce these overlaps. Thus, each type and grade of tumor is a metabolically hetero-geneous group. Lactate occurred infrequently and in all grades. Mobile lipids, on the other hand, occurred in 41% of high-grade tumors with higher mean amounts found in glioblastomas. This result, coupled with the recent demonstration that intratumoral mobile lipids correlate with microscopic tumor cell necrosis, leads to the hypothesis that mobile lipids observed in vivo in 1H-MR spectroscopy may correlate independently with prognosis of individual patients.

Indicators of life-threatening malaria in African children.

About 90 percent of the deaths from malaria are in African children, but criteria to guide the recognition and management of severe malaria have not been validated in them. We conducted a prospective study of all children admitted to the pediatric ward of a Kenyan district hospital with a primary diagnosis of malaria. We calculated the frequency and mortality rate for each of the clinical and laboratory criteria in the current World Health Organization (WHO) definition of severe malaria, and then used logistic-regression analysis to identify the variables with the greatest prognostic value. We studied 1844 children (mean age, 26.4 months) with a primary diagnosis of malaria. Not included were 18 children who died on arrival and 4 who died of other causes. The mortality rate was 3.5 percent (95 percent confidence interval, 2.7 to 4.3 percent), and 84 percent of the deaths occurred within 24 hours of admission. Logistic-regression analysis identified four key prognostic indicators: impaired consciousness (relative risk, 3.3; 95 percent confidence interval, 1.6 to 7.0), respiratory distress (relative risk, 3.9; 95 percent confidence interval, 2.0 to 7.7), hypoglycemia (relative risk, 3.3; 95 percent confidence interval, 1.6 to 6.7), and jaundice (relative risk, 2.6; 95 percent confidence interval, 1.1 to 6.3). Of the 64 children who died, 54 were among those with impaired consciousness (n = 336; case fatality rate, 11.9 percent) or respiratory distress (n = 251; case fatality rate, 13.9 percent), or both. Hence, this simple bedside index identified 84.4 percent of the fatal cases, as compared with the 79.7 percent identified by the current WHO criteria. In African children with malaria, the presence of impaired consciousness or respiratory distress can identify those at high risk for death.

Limitations of the WHO/CDC clinical case definition for AIDS in Africa.

The authors screened 268 patients over the period July-September 1990 selected by systematic sample from those attending the sexually transmitted diseases section of the adult filter clinic at the University Teaching Hospital in Lusaka Zambia. Clinical findings were recorded to establish whether each patient fulfilled the World Health Organization (WHO) clinical case definition for AIDS. For pragmatic reasons the presence of oral candida any episode of herpes simplex and any episode of herpes zoster were considered positive criteria. Participants were also examined for the presence of palpable epitrochlear lymph nodes enlarged to one centimeter or more. Blood was drawn for analysis for HIV-1 antibody using HIVCHEK and for syphilis using Syfacard-R. 158 participants were found to be HIV-1 seropositive. It was also determined that current WHO criteria for the clinical case definition of AIDS offers only low positive predictive value and sensitivity. The authors therefore urge that caution be taken in interpreting that case definition and that serological testing for HIV be used in conjunction with the clinical case definition whenever possible. HIVCHEK can be routinely used in areas where there is no serological evidence of HIV-2. Furthermore epitrochlear adenopathy is a simple clinical finding which has in this study a positive predictive value for HIV infection of 77%; a similar study in Zambia showed a positive predictive value of 89%. Further studies are needed to validate this finding in other settings but the presence of the nodes may provide an additional clinical criterion for predicting HIV seropositivity in the absence of other known causes of epitrochlear lymphadenopathy.

Case definitions for paediatric AIDS: the Zambian experience.

For the purpose of surveillance of the acquired immunodeficiency syndrome (AIDS) in developing countries, the World Health Organization (WHO) has recommended criteria for the clinical case definition of AIDS in adults and children. In a preliminary examination of children in Zambia a number of patients with obvious AIDS did not fit the published WHO case definition for paediatric AIDS. Based on this the Zambia National AIDS Surveillance Committee designed local criteria for the clinical case definition of paediatric AIDS. We compared the Zambian criteria with the WHO criteria for the diagnosis of paediatric AIDS by studying 134 consecutively admitted children to one of the paediatric wards at the University Teaching Hospital in Lusaka. Twenty-nine of the patients were HIV-1 seropositive and 105 were HIV-1 seronegative. Among the 29 HIV-seropositive patients, the Zambian criteria identified 23, and the WHO criteria identified 20 children as having AIDS. The 105 HIV-seronegative children were classified as having AIDS in 9 cases by the Zambian criteria and in 38 cases by the WHO criteria. These results give the Zambian criteria for the diagnosis of AIDS a sensitivity of 79.3%, a specificity of 91.4% and a positive predictive value of 86.8% compared to a sensitivity of 69%, specificity of 64% and a positive predictive value of 38% for the WHO criteria. The current WHO criteria are inadequate for the diagnosis of paediatric AIDS. The need to refine the WHO criteria for the diagnosis of paediatric AIDS is discussed.

New criteria for interpretation of the 75 g oral glucose tolerance test in pregnancy

A 75 g oral glucose tolerance test (OGTT) was performed on 135 high-risk pregnant patients. When the current World Health Organization (WHO) criteria for the diagnosis of gestational-glucose tolerance were applied, 88 patients were considered normal, 11 had gestational diabetes, and 36 patients had impaired-glucose tolerance, respectively. The plasma glucose, insulin, and C-peptide levels during the OGTT were further studied in the 88 patients (who had normal results). Two metabolically distinct groups were identified; a group (n = 53) with a 2-hour plasma glucose ≤6.6 mmol/L (118.8 mg/dL), had a normal insulin and C-peptide pattern, and a second group (n = 35) who had 2-hour plasma glucose >6.6 mmol/L displayed a glycemic, insulin, and C-peptide pattern similar to that of patients with gestational diabetes mellitus. The risks of macrosomic babies and operative delivery were significantly greater in the latter group. These results suggest that in our pregnant population, a group of patients with impaired glucose tolerance will be under-diagnosed using the current WHO criteria. Based on our results new criteria for gestational glucose intolerance are suggested for our population.

Validation of coronary heart disease hospital discharge data.

Data from a 1983 Auckland coronary heart disease register applying current World Health Organization criteria have been used to validate routine hospital discharge data. The register contained 905 patients under 65 years admitted to hospital and 858 of these patients were matched with hospital discharge records. Of the registered definite myocardial infarction cases 86% received the International Classification of Diseases code 410 (acute myocardial infarction); 9% of these cases received a code 411-414 (other forms of coronary heart disease or angina) and 5% received other codes. Only 405 of the 604 cases (67%) coded 410 in the hospital discharge data were true definite myocardial infarctions according to the World Health Organization criteria. The routine hospital International Classification of Diseases data do not provide diagnostic groups sufficiently close to World Health Organization categories for them to be used alone to monitor trends in coronary heart disease morbidity rates.