New classification and diagnostic criteria for diabetes mellitus

There has been an explosive growth in knowledge about diabetes mellitus since the National Diabetes Data Group promulgated diagnostic criteria and a classification system in 1979 that was largely adopted by the World Health Organization. However, recent findings regarding the levels of glucose associated with development of retinopathy, and growing confusion caused by a system of classification of diabetes based largely on the treatment used have led to a new assessment of the diagnosis and classification of diabetes mellitus. Using new data from population-based studies, and placing emphasis on a pathophysiology-based system of classification, in 1997, the Expert Committee of the American Diabetes Association released its recommendations for the classification and diagnosis of diabetes. The major changes from the 1979 report include: (a) the preferred use of the terms "type 1" and "type 2" instead of "insulin-dependent" and "non-insulin-dependent" to designate the two major types of diabetes mellitus; (b) a simplification of the diagnostic test to two fasting plasma glucose (FPG) determinations; and (c) a lower cutoff for FPG (126 mg/dL) to diagnose diabetes (this level of FPG having been found equivalent to the 200-mg/dL value in the oral glucose tolerance test for diagnosis). These changes provide an easier and more reliable means of diagnosing persons at risk of complications of hyperglycemia. Even though the fasting criterion was lowered, the total number of persons who will be diagnosed with diabetes by exclusive reliance on FPG will actually be somewhat less than with the old criteria. Moreover, epidemiologic data support the recommendation that screening for diabetes should start at age 45 and be repeated every 3 years in persons without risk factors, and earlier and more often in those with risk factors.     

Nephrotic syndrome: pathophysiology, classification and diagnostic criteria

The nephrotic syndrome is defined by heavy proteinuria due to abnormal increase of glomerular permeability and following hypoalbuminemia, hyperlipidemia and edema. Disorders of size selective barrier, charge selective barrier, slit diaphragm and circulating permeability factors are thought to be the causes of proteinuria. Most patients with nephrotic edema have primary salt retention. Overproduction and impaired catabolism of lipoproteins are the causes of hyperlipidemia. Abnormality of coagulation factors is also associated with nephrotic syndrome. Nephrotic syndrome may be primary or secondary to systemic disorders. Once diagnosed, the cause for the nephrotic syndrome must be examined.     

Pathogenesis, classification, diagnostic criteria for depression

There is the concern that adaptation range of depression is enlarged, because operation diagnosis methods of ICD-10 and DSM-IV-TR spread in a clinic of psychiatry. On the other hand, clinical condition of depressive state may diversify. This is a review of the pathogenesis, classification and diagnostic criteria of depression. In the pathogenesis, we discussed about the biological origin (a neurotransmitter-related model, a neuroendocrine model et al) and the psychosocial origin with focus on a historic flow and recent knowledge of the pathogenetic theory. In the classification and diagnostic criteria, we mainly explained the points to notice and the problems on ICD-10 and DSM-IV-TR. It is necessity to arise the problem such as clinical symptoms are inconsistent with the classification and diagnostic criteria of ICD-10 and DSM-IV-TR, because all the pathogenesis is not elucidated now. A development of the classification and criteria of depression is expected in future by scientific elucidation advancing.     

Outline of revision of classification and diagnostic criteria of diabetes mellitus in Japan

Japan Diabetes Society organized a committee for the revision of diagnostic criteria of diabetes mellitus in 1995. Like ADA and WHO reports, this committee adopts a classification based on etiologies, and presents a two-dimensional figure with etiologies and the state of insulin deficiency on different axis. The words IDDM and NIDDM will be retained as terms representing the different degree of insulin deficiency. On the basis of glycemia, diabetic type is defined when fasting plasma glucose exceeded 126 mg/dl and/or 2-hour plasma glucose by 75 g GTT exceeded 200 mg/dl. The diagnosis of diabetes in an individual can be made by confirming sustained diabetic type on repeated tests or co-existance of characteristic clinical features of diabetes. Normal type is defined by FPG < 110 mg/dl and 2hPG < 140 mg/dl. The borderline type, defined as neither normal nor diabetic types, corresponds to IFG plus IGT according to ADA and WHO reports. The application of HbA1c for diagnosis of diabetes and the criteria for gestational diabetes mellitus are also discussed.     

The classification of chronic daily headache in adolescents--a comparison between the second edition of the international classification of headache disorders and alternative diagnostic criteria

OBJECTIVES: To compare the second edition of the International Classification of Headache Disorders (ICHD-2) and the Silberstein-Lipton (S-L) criteria in the classification of adolescents with chronic daily headache (CDH). METHODS: We reviewed the clinical records and the headache diaries of 170 adolescents (13 to 17 years) seen between 1998 and 2003 at a headache center. Relevant information was transferred to a standardized form that included operational criteria for the ICHD-2. CDH subtypes were classified according the criteria proposed by S-L into transformed migraine (TM) with (TM+) and without medication overuse (TM-), chronic tension-type headache (CTTH), new daily persistent headache (NDPH), and hemicrania continua (HC). RESULTS: From the 69 patients with TM- according the S-L criteria, most (71%) could be classified as chronic migraine (CM), while a minority of patients required a combination of diagnosis, mainly migraine and CTTH (14.4%). Of the patients with TM+, just 39.6% met the criteria for probable CM (PCM) with probable medication overuse (PMO). If instead of 15 migraine days per month, we considered 15 or more days of migraine or probable migraine, 84% of the subjects with TM- and 68.7% of those with TM+ could be classified. Of the 27 subjects classified as NDPH without medication overuse according to the S-L system, the majority (51.2%) were also classified as NDPH according the ICHD-2. Interestingly, three (11.1% of the subjects with NDPH without medication overuse) were classified as CM in the ICHD-2 because these patients had an abrupt onset of 15 or more days of migraine per month. All patients with NDPH with medication overuse according to the S-L criteria required a combination of diagnoses in the ICHD-2. All subjects with CTTH received a single diagnosis in both classification systems. CONCLUSIONS: (i) Among adolescents with TM, the majority (58.1%) could be classified as CM, according to the ICHD-2. These results were driven by TM without medication overuse. (ii) If the ICHD-2 criteria for CM are revised to require 15 days of migraine or probable migraine, the proportion of patients with TM- who meet the criteria for CM increases from 71% to 84%; for TM+, the proportion with probable chronic migraine and PMO increases from 30% to 68%. (iii) About half of the patients with NDPH according to the S-L criteria have too many migraine features to meet ICHD-2 criteria for NDPH.     

Fulfillment of diagnostic criteria in Kawasaki disease

BACKGROUND: The diagnosis of Kawasaki disease (KD) is made by fulfillment of clinical criteria. The dramatic effectiveness of intravenous immune globulin in this disease might lead to treatment of cases that do not meet those criteria. METHODS: A retrospective review was conducted of all cases of KD treated at Kosair Children's Hospital between January 1993 and July 1997. RESULTS: Fifty-six patients were identified. Demographic features were similar to reports from other regions of the country. Forty-eight children fulfilled criteria for typical or atypical KD and 8 (14%) did not. The latter children were not distinguished from those meeting criteria by standard laboratory test results. Echocardiographic abnormalities were found in 17 cases, including 3 with coronary artery aneurysms, but all abnormalities eventually resolved. CONCLUSIONS: The treatment of 14% of patients despite incomplete diagnostic criteria illustrates the tendency to be liberal in treatment decisions regarding KD. Whether this proportion of patients has a forme fruste of the illness that warrants treatment will await definitive biological markers for the syndrome.     

BMW diagnostic criteria for IBS

Rome I diagnostic criteria for IBS was published in 1992 and it became a global diagnostic criteria. However, the criteria was not practical and somewhat complicated. Moreover, its symptomatic duration was too long (defined as more than 3 months) to be introduced in clinical practice. Therefore, Japanese member of BMW(Bowel Motility Workshop) tried to develop a new diagnostic criteria for IBS and it was established in 1995 by way of the Delphi method. The criteria was named as BMW diagnostic criteria and it was shown below: BMW diagnostic criteria for IBS (1995) At least one month or more of repetitive symptoms of the following 1) and 2) and no evidence of organic disease that likely to explain the symptoms. 1) Existence of abdominal pain, abdominal discomfort or abdominal distension 2) Existence of abnormal bowel movement (diarrhea, constipation) Abnormal bowel movement includes at least one of the below; (1) Abnormal stool frequency (2) Abnormal stool form (lumpy/hard or loose/wartery stool) Moreover, the following test should be performed as a rule to exclude organic diseases. (1) Urinalysis, fecal occult blood testing, CBC, chemistry (2) Barium enema or colonofiberscopic examination The other diagnostic criteria for IBS was also reviewed and their characteristics were compared with BMW diagnostic criteria.     

关于误诊判定标准和分级分类的几点建议

目前误诊研究中急需解决的课题是确定误诊判定标准及分类分级,从理论上与医疗事故区别开来,为处理医疗纠纷提供科学依据。作者认为,判定误诊不以离开疾病的自然史这个重要的时间概念,误诊与否应该在疾病的结局期,以出院诊断作为判定误诊的标准,对产生误诊的原因和误诊产生的后果,应按不同类型、不同程度,进行分类、分级,藉此规范误诊研究,引导社会舆论,提高学术评论的权威性。