Operational criteria application does not change clinicians' opinion on the diagnosis of mental disorder: a pre- and post-intervention validity study.

Objective: Our objective was to check if the ICD-10 operational criteria application changes non-operational, prototype-based diagnoses obtained in a real-life scenario. Methods: Psychiatry residents applied the diagnostic criteria of the ICD-10 as a "diagnostic test" to five outpatient patients they were already following who had a prototype-based diagnosis. Tests were used to ascertain whether changes in opinion were significant and if any of the diagnostic groups were more prone to change than others. The present paper is part of the study with UTN U1111-1260-1212. Results: Seventeen residents reviewed their last five case files, retrieving 85 diagnostic pairs of non-operational-based vs. operational-based diagnoses. The Stuart-Maxwell test did not indicate a significant opinion change (χ2 = 5.25, p = 0.39; power = 0.94) besides 30% of diagnostic changes. Despite not being statistically significant, 20.2% of all evaluations resulted in a change that would affect treatment choices. Using ICD-10 operational criteria slightly increased the number of observed diagnoses, but probably without clinical relevance. None of the non-operational diagnoses have a higher tendency to change with operational criteria application (χ2 = 11.6, p = 0.07). The female gender was associated with a higher diagnostic change tendency. Conclusion: Applying ICD-10 operational criteria as a diagnostic test does not induce a statistically significant diagnostic opinion change in residents and no diagnostic group seems more sensible to diagnostic change. Gender-related differences in diagnostic opinion changes might be evidence of sunk cost bias. Although not statistically significant, using operational criteria after diagnostic elaboration might help to deal with subjects without adequate treatment response.

Translation, adaptation, and clinical validation of the Premature Ejaculation Diagnostic Tool in Spanish (Colombia).

Background: Premature ejaculation is the most prevalent form of sexual dysfunction in men. The Premature Ejaculation Diagnostic Tool (PEDT) is an instrument used to evaluate premature ejaculation. It offers adequate psychometric properties and good reliability. Aim: To adapt and validate a Colombian version of the PEDT in Colombian clinical and nonclinical samples. Methods: Two samples were used in this study. The first was made up of 1110 men who were recruited to evaluate validity and reliability. Their ages ranged from 19 to 65 years (mean ± SD, 39.71 ± 12.53). The second sample included 123 men (66.7%) who did not meet diagnostic criteria for premature ejaculation per the International Statistical Classification of Diseases and Related Health Problems (ICD-10), while 33.3% met ICD-10 criteria for this dysfunction. Their ages ranged from 18 to 65 years (34.19 ± 12.65). Scores were used to calculate the cutoff. Outcomes: A translated and adapted version of the PEDT was developed specifically for Colombia. All participants completed the Colombian version of the PEDT, a sociodemographic questionnaire, the Colombian version of the Massachusetts General Hospital-Sexual Functioning Questionnaire, and a semistructured interview based on the ICD-10. Results: The results showed adequate psychometric properties and satisfactory internal consistency and confirmed the 1-dimensional factorization of the scale. According to ICD-10 criteria, the study also confirmed significant differences between participants who self-reported premature ejaculation and those who did not. In addition, it showed adequate evidence of convergent validity, with a moderate correlation with sexual functioning scores. As a result, the cutoff point was set to 10.5, with an area under the curve of 96.8%. Therefore, a score ≥11 points suggested the presence of premature ejaculation. Clinical Translation: The current Colombian version of the PEDT is a useful instrument that determines the presence of premature ejaculation that is compatible with ICD-10 criteria. Strengths and Limitations: The Colombian version of the PEDT presents evidence of reliability and validity, a confirmed 1-dimensional factorization, and a cutoff point for Hispanic populations. More in-depth evaluation of the diagnosis of premature ejaculation is required, and further research among other Spanish-speaking countries and sexual minorities is recommended. Conclusion: The Colombian version of the PEDT is a psychometric adequacy tool for evaluating and diagnosing premature ejaculation, following the ICD-10 criteria.

Meteorological parameters and hospitalizations of patients with sickle cell anemia: a 20-year retrospective study in Campinas, São Paulo, Brazil.

To investigate the influence of climate on hospitalizations of sickle cell anemia (SCA) adults and children, we analyzed the health and meteorological parameters from a metropolis (1999-2018). 1462 hospitalizations were coded for SCA patients in crisis (M:F = 715:747) and 1354 hospitalizations for SCA patients without crisis (M:F = 698:656) [age = 22.9 vs 15.2 years and duration of hospitalization (DoH) = 5.7 vs 4.4 days, respectively,]. More hospitalizations were for adults than children in crisis, and for children than adults without crisis. More children and adults were hospitalized in winter andspring than in summer and autumn Hospitalizations correlated positively with humidity (lag -5), maximum pressure (lag -2), mean pressure (lag -2), and thermal amplitude (lag -2), and negatively with maximum temperature (lag -3). DoH positively correlated with minimum temperature (lag -4). Understanding these complex associations would induce attitudinal/behavioral modifications among patients and their caregivers.

Estado de la salud materna un análisis global a puertas de la endemia de la covid-19 / State of maternal health a global analysis on the point of the covid-19 endemia

Dentro de los cambios endémicos por la infección del SARSCoV-2, con efectos en el perfil epidemiológico de la mortalidad materna a nivel global, este articulo refleja los contraste en la accesibilidad a los servicios de salud, más evidente en países de ingresos bajos a medianos, con debilidades en los sistemas de vigilancia epidemiológica que se ven influenciados por la superposición de datos relevantes en la atención prenatal , el parto y atención al recién nacido, el puerperio, y el acceso a la planificación familiar. Siendo necesario identificar las tendencias de mortalidad y morbilidad materna, para reducir el impacto sobre todo en grupos prioritarios.

Within the endemic changes due to SARS-CoV-2 infection, with effects on the epidemiological profile of maternal mortality globally, this article reflects the contrasts in accessibility to health services, more evident in low-income countries. to medium, with weaknesses in the epidemiological surveillance systems that are influenced by the overlapping of relevant data in prenatal care, delivery and newborn care, the postpartum period, and access to family planning. It is necessary to identify trends of maternal mortality and morbidity, to reduce the impact, especially in priority groups

A Retrospective Study of Mucopolysaccharidosis Type II in Brazil - Data from Brazilian Health System (DATASUS)

Abstract Data on Mucopolysaccharidosis type II (MPS II) in Latin America are scarce. This retrospective database study, using data from the Informatics Department of the Brazilian Health System (DATASUS), aimed to estimate the prevalence of MPSII in Brazil from 2008 to 2020 and to describe demographic and clinical profiles from patients under treatment. The study population was derived from DATASUS records of MPS II (ICD-10 E76.1) diagnosed in Brazil. Initially 455 patients were found, but only 181 patients who were receiving idursulfase treatment were included in this study. Among these cases, as expected in a X-linked disease, all were males and 40% of the cases were recorded in the Southeast region, and another 34% in the Northeast region. The biggest proportion of patients (39%) were diagnosed when they were 10-19 years old. There are 212 clinical conditions associated with MPS II, although the main comorbidities related to MPSII include: abdominal/inguinal hernia, respiratory complications, and carpal tunnel syndrome. Respiratory disorders were the fifth most frequent comorbidity recorded in these patients. The healthcare professionals in Brazil more involved in the diagnosis of MPS II were radiologists, followed by geneticists and cardiologists. Despite some limitations, DATASUS is a relevant database to provide information on rare diseases such as MPS II. Most cases were reported in southeast and northeast regions, respectively. This information is crucial to help design targeted public policies.

Impact of COVID-19 mitigation strategies on asthma hospitalizations in Brazil.

Background: In 2020, a unique social experience was provided by the pandemic of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2. Interventions to tackle the pandemic may affect the burden of other respiratory diseases. Objective: This study aims to assess the impact of the COVID-19 mitigation strategies on hospitalizations for asthma in children aged between 1 and 14 years, adults aged between 20 and 59 years, and elderly older than 60 years. Methods: Data from hospital admissions for asthma were obtained from the Department of Informatics of Brazilian Public Health System database in the period between January 2016 and December 2020 and analyzed by age groups. To evaluate the effect of containment measures on the incidence of asthma and respiratory system diseases (total), the absolute reduction and relative reduction were calculated by analyzing the subsets from 2016 to 2019 versus 2020. Results: There was a significant reduction in the average incidence of hospitalizations in 2020, with numbers ranging from -59% (incidence rate ratio, 0.41 [0.37-0.45]) for age 1 to 14 years (prepandemic 1,393.2/100,000 vs pandemic 574.9/100.000), -37% (incidence rate ratio, 0.63 [0.49-0.80]) for age 20 to 59 years (prepandemic 160.2/100,000 vs pandemic 101.1/100,000), and -60% (incidence rate ratio, 0.40 [0.33-0.47]) for older than 60 years (prepandemic 460.6/100,000 vs pandemic 185.3/100,000). Conclusions: Ashtma hospitalizations decreased in 2020, especially in the pediatric group and the older group during the COVID-19 pandemic, which may be associated with the reduction in the incidence of many respiratory viral infections.

Age, sex, and contemporary outcomes in surgical repair of type A aortic dissection: Insights from the National Inpatient Sample.

Objective: Acute type A aortic dissection (ATAAD) is a surgical emergency with significant morbidity and mortality, as well as significant center-level variation in outcomes. Our study aims to leverage a nationally representative database to assess contemporary in-hospital outcomes in surgical repair of ATAAD, as well as the association of age and sex with outcomes. Methods: The National Inpatient Sample was queried to identify hospital discharge records of patients aged ≥18 years who underwent urgent surgical repair of ATAAD between 2017 and 2018. Patients with a diagnosis of thoracic aortic dissection, who underwent surgical intervention of the ascending aorta, were identified. Patient demographics were assessed, and predictors of in-hospital mortality were identified. Results: We identified 7805 weighted cases of surgically repaired ATAAD nationally, with an overall mortality of 15.3%. Mean age was 60.0 ± 13.6 years. There was a male predominance, although female subjects made up a larger proportion of older age groups-female subjects up 18.4% of patients younger than 40 years with ATAAD but 53.6% of patients older than 80 years. In multivariable analysis controlling for sex, race, comorbidities, and malperfusion, age was a significant predictor of mortality. Patients aged 71 to 80 years had a 5.3-fold increased risk of mortality compared with patients ≤40 years old (P < .001), and patients aged >80 years had a 6.8-fold increased risk of mortality (P < .001). Sex was not significantly associated with mortality. Conclusions: Surgical repair of ATAAD continues to carry high risk of morbidity and mortality, with outcomes impacted significantly by patient age, regardless of patient comorbidity burden.

Musculoskeletal Conditions in Older Men and Women: An Emergency Room Study.

OBJECTIVE: To study the utilization of emergency room (ER) services for health complaints of the musculoskeletal (MSK) system in older men and women. METHODS: Data from all medical encounters at the ER of a teaching hospital for calendar years 2016-2020 were extracted from an electronic database. MSK encounters were defined as those with ICD 10-CM M and S codes in the primary diagnosis field of the database. Frequency distributions were calculated by year, sex, and age group for MSK and all encounters. The most frequent codes used by sex and age groups were assessed. RESULTS: The number of unique patients with medical encounters at the ER during the five-year period was 94,346. There was a total of 220,153 encounters (median:1 encounter per patient; interquartile range:1-3). A 33.2% reduction in the number of encounters occurred in 2020 compared to 2019. The total number of unique patients in the 60 yr. and older group was 24,412 (25.9% of all unique patients). The total number of encounters in the group 60 yr. and older was 56,294 (25.6% of all encounters). Women accounted for 31,488 (56%) encounters in this age group. A total of 12,744 encounters (22.6%) in older adults involved the MSK system and this proportion decreased with increasing age. The most common MSK conditions included low back pain, pain in joints, and femoral fractures. CONCLUSION: Older adults with MSK health conditions represent a substantial portion of ER patients. Many MSK health conditions could be evaluated and treated in other health care settings.

Intra-rater Kappa Accuracy of Prototype and ICD-10 Operational Criteria-Based Diagnoses for Mental Disorders: A Brief Report of a Cross-Sectional Study in an Outpatient Setting.

Background and Objectives: The use of "operational criteria" is a solution for low reliability, contrasting with a prototypical classification that is used in clinics. We aim to measure the reliability of prototypical and ICD-10 diagnoses. Methods: This is a retrospective study, with a convenience sample of subjects treated in a university clinic. Residents reviewed their diagnosis using ICD-10 criteria, and Cohen's kappa statistic was performed on operational and prototype diagnoses. Results: Three out of 30 residents participated, reviewing 146 subjects under their care. Diagnoses were grouped in eight classes: organic (diagnoses from F00 to F09), substance disorders (F10-F19), schizophrenia spectrum disorders (F20-F29), bipolar affective disorder (F30, F31, F34.0, F38.1), depression (F32, F33), anxiety-related disorders (F40-F49), personality disorders (F60-F69), and neurodevelopmental disorders (F70-F99). Overall, agreement was high [K = 0.77, 95% confidence interval (CI) = 0.69-0.85], with a lower agreement related to personality disorders (K = 0.58, 95% CI = 0.38-0.76) and higher with schizophrenia spectrum disorders (K = 0.91, 95% CI = 0.82-0.99). Discussion: Use of ICD-10 criteria did not significantly increase the number of diagnoses. It changed few diagnoses, implying that operational criteria were irrelevant to clinical opinion. This suggests that reliability among interviewers is more related to information gathering than diagnostic definitions. Also, it suggests an incorporation of diagnostic criteria according to training, which then became part of the clinician's prototypes. Residents should be trained in the use of diagnostic categories, but presence/absence checking is not needed to achieve operational compatible diagnoses.

Temporal trends in the epidemiology of inflammatory bowel diseases in the public healthcare system in Brazil: A large population-based study.

Background: Population-based data on epidemiology of Inflammatory Bowel Diseases (IBD) in Brazil are scarce. This study aims to define temporal trends of incidence and prevalence rates of Crohn's disease (CD) and ulcerative colitis (UC) in Brazil. Methods: All IBD patients from the public healthcare national system were included from January 2012 to December 2020. Average Annual Percent Change (AAPC) and 95% confidence intervals (CI) were calculated using log-linear regression for incidence and binomial regression for prevalence. Moran's I autocorrelation index was used to analyse clustering of cities by level of prevalence. Findings: A total of 212,026 IBD patients were included. Incidence of IBD rose from 9.4 in 2012 to 9.6 per 100,000 in 2020 (AAPC=0.8%; 95% CI -0.37, 1.99); for UC, incidence increased from 5.7 to 6.9 per 100,000 (AAPC=3.0%; 95% CI 1.51, 4.58) and for CD incidence decreased from 3.7 to 2.7 per 100,000 (AAPC=-3.2%; 95% CI -4.45, -2.02). Prevalence of IBD increased from 30.0 in 2012 to 100.1 per 100,000 in 2020 (AAPC=14.8%; CI 14.78-14.95); for UC, from 15.7 to 56.5 per 100,000 (AAPC=16.0%; CI 15.94, 16.17); for CD from 12.6 to 33.7 per 100,000 (AAPC=12.1% CI 11.95, 12.02). A south-north gradient was observed in 2020 prevalence rates of IBD [I=0.40 (p<0.0001)], CD [I=0.22 (p<0.0001)] and UC [I=0.42 (p<0.0001)]. Interpretation: Incidence of CD is decreasing whereas of UC is increasing, leading to stabilization in the incidence of IBD from 2012 to 2020 in Brazil. Prevalence of IBD has been climbing with 0.1% of Brazilians living with IBD in 2020. Funding: None.

Health expenditures and causa mortis: an investigation on municipalities of the State of Paraná, Brazil / Gastos com saúde e causa mortis: uma investigação dos municípios do Estado do Paraná, Brasil / Gastos en salud y causa mortis: una investigación para los municipios del Estado de Paraná, Brasil

The Brazilian government shares the responsibility of financing public health among federal, state, and municipal levels. Health expenditures are thus uneven across the country and cannot contribute equally to health outcomes across disease categories. This study aims to identify how the health expenditures of municipalities affect the mortality rate in the state of Paraná by causa mortis. We considered years of life lost for each municipality, the chapters of the International Classification of Diseases (10th revision), and the elasticity of this measure in relation to public health expenditure. Considering the possibility of endogeneity, this study follows the instrumental variable approach in a panel of generalized method of moments - instrumental variable (GMM-IV) with fixed effects. Our results show that a 1% increase in health expenditure could decrease the average number of years lost specifically for some causes from 0.176% to 1.56% at the municipal level. These findings could elucidate policy perspective within state finance.

O financiamento da saúde pública é uma responsabilidade compartilhada entre as três esferas governamentais brasileiras, i.e., a federal, estadual e municipal. Logo, gastos divergem pelo território e não se poderia esperar que contribuíssem de forma homogênea para os desfechos de saúde em todos os tipos de doença. Este artigo busca identificar como gastos municipais afetam a taxa de mortalidade no Estado do Paraná dado sua causa mortis. Consideramos anos de vida perdidos para cada município, os capítulos da Classificação Internacional de Doenças (10ª revisão) e estimamos a elasticidade dessa medida em relação aos gastos públicos em saúde. Considerando uma possível endogeneidade, este artigo segue a abordagem variável instrumental em um painel de método generalizado de momentos (GMM-IV) com efeitos fixos. Nossos resultados mostram que um aumento de 1% nos gastos municipais com saúde pode diminuir o número médio de anos perdidos entre 0,176% e 1,56% para algumas causas especificas de mortalidade. Nosso estudo pode lançar alguma luz sobre a perspectiva política das finanças dos estados.

La financiación de la salud pública es una responsabilidad compartida entre las tres esferas del gobierno brasileño, a nivel federal, estatal y municipal. En este sentido, los gastos son desiguales en el territorio, y no se puede esperar que contribuyan de forma homogénea a los resultados de salud en las distintas categorías de enfermedades. La función de este trabajo es identificar cómo los gastos de los municipios afectan a la tasa de mortalidad en el Estado de Paraná, por causa mortis. Se consideraron los años de vida perdidos para cada municipio, los capítulos de la Clasificación Internacional de Enfermedades (10ª revisión), y se estimó la elasticidad de esta medida en relación con el gasto sanitario público. Teniendo en cuenta la posibilidad de endogeneidad, este trabajo sigue el enfoque de variables instrumentales en un panel de los método generalizado de momentos (GMM-IV) con efectos fijos. Nuestros resultados muestran que un aumento del 1% en el gasto sanitario puede disminuir el número medio de años perdidos específicamente por algunas causas del 0,176% al 1,56%, a nivel municipal. Esto puede arrojar algo de luz sobre la perspectiva política dentro de las finanzas de los estados.

Musculoskeletal Conditions in the Emergency Room: A Teaching Opportunity for Medical Students and Residents.

OBJECTIVE: Assess the potential value of an emergency room (ER) for the teaching of musculoskeletal (MSK) medicine to medical students and residents in training. METHODS: Data from all encounters to the ER of a teaching hospital for calendar years 2016-2019 were extracted from an electronic database. Encounters with ICD-10-CM M codes (MSK system) and S codes (injury) were selected (MSK encounters). Frequency distributions were calculated by year, sex, and age group for all encounters and MSK encounters. Annual distributions of encounters involving the shoulder, hip, knee, and ankle joints were assessed. RESULTS: The number of unique patients seen during the four-year period was 84,094, and the number of encounters was 187,829 (Median: 1 encounter; interquartile range: 1-2). The mean number of encounters per year was 46,957 (range: 45,311- 48,382). There was no seasonal variation. Most patients were women (45,868; 54.6%) and young (20 29 yr.) adults (15,012; 17.8%), and these groups generated the largest numbers of encounters (women: 108,799; 57.9%; young adults: 35,969; 19.1%). A total of 41,353 encounters (22.0% of all encounters) involved the MSK system. The shoulder, hip, knee, and ankle were involved in 2,768 (1.5%), 1,592 (0.8%), 3,082 (1.6%), and 1,718 (0.9%) encounters, respectively. The most common conditions for each joint were shoulder pain, femoral fracture, knee contusion, and ankle sprain. CONCLUSION: Our findings suggest that ER physicians should have broad knowledge of MSK conditions and injuries. An ER is an excellent location for the teaching of MSK medicine to medical students and residents of other training programs.

A supervised clustering MCMC methodology for large categorical feature spaces.

There is a well-established tradition within the statistics literature that explores different techniques for reducing the dimensionality of large feature spaces. The problem is central to machine learning and it has been largely explored under the unsupervised learning paradigm. We introduce a supervised clustering methodology that capitalizes on a Metropolis Hastings algorithm to optimize the partition structure of a large categorical feature space tailored towards minimizing the test error of a learning algorithm. This is a general methodology that can be applied to any supervised learning problem with a large categorical feature space. We show the benefits of the algorithm by applying this methodology to the problem of risk adjustment in competitive health insurance markets. We use a large claims data set that records ICD-10 codes, a large categorical feature space. We aim at improving risk adjustment by clustering diagnostic codes into risk groups suitable for health expenditure prediction. We test the performance of our methodology against common alternatives using panel data from a representative sample of twenty three million citizens in Colombian Healthcare System. Our results outperform common alternatives and suggest that it has potential to improve risk adjustment.

Prevalence of clinically-evident congenital anomalies in the Western highlands of Guatemala.

BACKGROUND: Congenital anomalies are a significant cause of death and disability for infants, especially in low and middle-income countries (LMIC), where 95% of all deaths due to anomalies occur. Limited data on the prevalence and survival of infants with congenital anomalies are available from Central America. Estimates have indicated that 53 of every 10,000 live births in Guatemala are associated with a congenital anomaly. We aim to report on the incidence and survival of infants with congenital anomalies from a population-based registry and classify the anomalies according to the International Classification of Disease, Tenth Revision (ICD-10). METHODS: We conducted a planned secondary analysis of data from the Maternal Newborn Health Registry (MNHR), a prospective, population-based study carried out by the Global Network for Women's and Children's Health Research in seven research sites. We included all deliveries between 2014 and 2018 in urban and rural settings in Chimaltenango, in the Western Highlands of Guatemala. These cases of clinically evident anomalies were reported by field staff and reviewed by medically trained staff, who classified them according to ICD - 10 categories. The incidence of congenital anomalies and associated stillbirth, neonatal mortality, and survival rates were determined for up to 42 days. RESULTS: Out of 60,142 births, 384 infants were found to have a clinically evident congenital anomaly (63.8 per 10,000 births). The most common were anomalies of the nervous system (28.8 per 10,000), malformations and deformations of the musculoskeletal system (10.8 per 10,000), and cleft lip and palate (10.0 per 10,000). Infants born with nervous system anomalies had the highest stillbirth and neonatal mortality rates (14.6 and 9.0 per 10,000, respectively). CONCLUSIONS: This is the first population-based report on congenital anomalies in Guatemala. The rates we found of overall anomalies are higher than previously reported estimates. These data will be useful to increase the focus on congenital anomalies and hopefully increase the use of interventions of proven benefit. TRIAL REGISTRATION: ClinalTrial.gov ID: NCT01073475 .

Risk Factors for Unnecessary Antibiotic Prescribing for Acute Respiratory Tract Infections in Primary Care.

OBJECTIVE: To determine independent risk factors for inappropriate antibiotic prescribing for acute respiratory tract infections (ARIs) in internal medicine (IM) residency-based primary care offices. PATIENTS AND METHODS: A retrospective study was conducted to measure antibiotic prescribing rates, and multivariable analysis was utilized to identify predictors of inappropriate prescribing among patients presenting to IM residency-based primary care office practices. Patients with an office visit at either of 2 IM residency-based primary care office practices from January 1, 2016, through December 31, 2016, with a primary encounter diagnosis of ARI were included. RESULTS: During the study period, 911 unique patient encounters were included with 518 for conditions for which antibiotics were considered always inappropriate. Antibiotics were not indicated in 85.8% (782 of 911) of encounters. However, antibiotics were prescribed in 28.4% (222 of 782) of these encounters. Inappropriate antibiotic prescribing occurred in 111 of 518 (21.4%) encounters for conditions for which antibiotics are always inappropriate. Using multivariable logistic regression analysis to assess for independent risk factors when adjusted for other potential risk factors for office visits at which antibiotics were not indicated, IM resident-associated visits (odds ratio, 0.25; 95% CI, 0.18-0.36) was the only variable independently associated with lower risk of inappropriate antibiotic prescribing. CONCLUSION: For ARI visits at which antibiotics were not indicated, IM resident comanagement was associated with lower rates of inappropriate prescribing.

Legal and Policy Implications in Mexico of Changes in ICD-11 Paraphilic Disorders.

INTRODUCTION: The World Health Organization (WHO) has made substantial changes to the classification of paraphilic disorders for the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11), recently approved by the World Health Assembly. The most important is to limit paraphilic disorders primarily to persistent and intense patterns of atypical sexual arousal involving non-consenting individuals, manifested through persistent sexual thoughts, fantasies, urges, or behaviors, that have resulted in action or significant distress. AIM: To analyze the legal, regulatory, and policy implications of the changes in the ICD-11 classification of paraphilic disorders for forensic practice, health systems, adjudication of sex offenders, and the provision of treatment in Mexico. METHODS: An expert Mexican advisory group was appointed to conduct this evaluation following an assessment guide provided by the WHO. MAIN OUTCOME MEASURES: The WHO assessment guide covered (i) laws related to sexual behaviors; (ii) the relationship between legal and clinical issues for non-forensic health professionals; (iii) implications of mental disorder classification for forensic practice; (iv) other implications of ICD-11 paraphilic disorders proposals; and (v) contextual issues. RESULTS: A variety of factors in Mexico make it highly unlikely that appropriate, evidence-based treatments for paraphilic disorders will be provided to those who need them, even if they seek treatment voluntarily and have not committed a crime. Mexican law focuses on the punishment of specific sexual behaviors rather than on underlying disorders. A paraphilic disorder would not be considered sufficient grounds for exemption from criminal responsibility. The application and scope of mental health evaluations in Mexican legal proceedings are quite limited, and individuals who commit sexual crimes almost never undergo forensic evaluations to establish the presence of paraphilic disorders. Psychiatric services may be mandated for sex offenders in highly specific circumstances but cannot exceed the duration of the criminal sentence. CLINICAL IMPLICATIONS: Evaluation and treatment guidelines should be developed based on international evidence and standards and promulgated for use with individuals with paraphilic disorders in forensic and non-forensic poopulations. The much greater specificity and operationalization of the ICD-11 guidelines as compared with the ICD-10 guidelines provide a better basis for identification and case formulation. STRENGTHS & LIMITATIONS: Major strengths of this analyses were that it was conducted to facilitate international comparability across several participating countries and the fact that it was conducted by a diverse multidisciplinary group representing various relevant legal, forensic and and clinical sectors. A limitation was that it was only possible to examine relevant federal laws and those of Mexico City rather than those of all 32 Mexican states. CONCLUSION: The descriptions of paraphilic disorders in the ICD-11 could support substantial improvements in the treatment of individuals with paraphilic disorders and the adjudication of sex offenders in Mexico, but specific changes in Mexican law would be required. Martínez-López JNI, Robles R, Fresán A, et al. Legal and Policy Implications in Mexico of Changes in ICD-11 Paraphilic Disorders. J Sex Med 2019;16:1623-1637.

ICD-10 impact on ascertainment and accuracy of oral cleft cases as recorded by the Brazilian national live birth information system.

We compared Brazilian oral cleft (OC) frequencies between the population-based Brazilian System of Live Birth (SINASC) and the hospital-based Latin American Collaborative Study of Congenital Malformations (ECLAMC), trying to understand the paucity of cleft of lip and palate (CLP) in the first system. SINASC uses the International Classification of Disease version 10 (ICD-10) for congenital defects coding, ECLAMC uses ICD-8 with modifications. In SINASC, the CLP frequency was 1.7 per 10,000 (95% confidence limits 1.7-1.8), cleft lip (CL) 1.6 (1.5-1.7), and cleft palate (CP) 2.0 (1.9-2.1). In ECLAMC, the CLP frequency was 10.4 per 10,000 (9.0-12.1), CL 5.5 (4.5-6.7), and CP 4.4. (4.5-6.7). In SINASC, only 33% of the oral clefts were CLP, versus 51% in ECLAMC. Part of this discrepancy may have been due to the relative excess of CP and CL cases. Although congenital defect frequencies are usually lower in population than in hospital-based registries, differences in the proportion of the main OC categories are not expected and are probably due to ICD-10 coding issues, such as lumping of unilateral CL and CL without other specifications. ICD-10 codes, whose deficiency for oral clefts is fully explained in the literature, lack modifiers for severity, or clinical subtypes. This paper shows the practical aspect of the ICD-10 system deficiency in capturing cleft lip and palate (CLP) subtypes, as demonstrated in SINASC covering three million births per year. Such errors are expected to occur in any registry that uses the ICD-10 coding system, and must be adjusted, given its relevance worldwide.

La histeria clásica y moderna: una visión sinóptica Parte II Diagnóstico / Classic and modern hysteria: a synoptic view. Part II Diagnosis

Todo diagnóstico de un problema descubierto lleva implícito un proceso de análisis y síntesis. Todavía no se ha logrado encontrar una clara definición de la histeria, precisamente por su "psicoplasticidad", es decir, por la infinidad de expresiones clínicas en que se puede presentar. Además su eliminación de los códigos diagnósticos la fragmentó en diversos síndromes o conjuntos sintomáticos. El psicoanálisis, asociado al concepto, fue desperfilado por la psiquiatría americana con el advenimiento de la investigación biológica sobre trastornos mentales y nuevos descubrimientos como los sistemas de neurotransmisores. Quedaron atrás los criterios de Feighner, que abarcaban los diagnósticos de neurosis de ansiedad, neurosis obsesivo-compulsiva, neurosis fóbica, histeria. Se analiza clasificaciones CIE y DSM, en las que se puede rastrear la histeria. Palabras claves: histeria, neurosis, diagnóstico, CIE-10.

Every diagnosis of a discovered problem implies a process of analysis and synthesis. A clear definition of hysteria has not yet been found, precisely because of its "psychoplasticity", that is, by the infinity of clinical expressions in which it can be presented. In addition its elimination of the diagnostic codes fragmented it in diverse syndromes or symptomatic sets. Psychoanalysis, associated with the concept, was unburied by American psychiatry with the advent of biological research on mental disorders and new discoveries such as neurotransmitter systems. Feighner's criteria, which included diagnoses of anxiety neurosis, obsessive-compulsive neurosis, phobic neurosis and hysteria, were left behind. We analyze CIE and DSM classifications, in which hysteria can be traced.

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

OBJECTIVE: 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. STUDY DESIGN: 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. 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. CONCLUSIONS: It is necessary but not sufficient to organize and publish CF diagnosis consensus processes. Follow-up implementation efforts and monitoring practices seem essential.

Effect of Antimicrobial Stewardship Program Guidance on the Management of Uncomplicated Skin and Soft Tissue Infections in Hospitalized Adults.

OBJECTIVE: To assess the effect of an antimicrobial stewardship program (ASP)-bundled initiative on the appropriate use of antibiotics for uncomplicated skin and soft tissue infections (uSSTIs) at 2 academic medical centers in Pittsburgh, Pennsylvania. PATIENTS AND METHODS: A retrospective preintervention and postintervention study was conducted to compare management of patients admitted with uSSTIs before and after the implementation of the bundled initiative. The preintervention period was from August 1, 2014, through March 31, 2015, and the postintervention period was from August 1, 2015, through March 31, 2016. RESULTS: A total of 160 patients were included in the preintervention cohort, and 163 were included in the postintervention cohort. Compared with the preintervention group, the mean duration of therapy decreased (12.5 days vs 8.8 days; P<.001) and an appropriate duration of less than 10 days increased in more patients (20.6% [33 of 160] vs 68.7% [112 of 163]; P<.001) in the postintervention period. Fewer patients were exposed to antimicrobials with extended gram-negative (44.4% [71 of 160] vs 9.2% [15 of 163]; P<.001), anaerobic (39.4% [63 of 160] vs 9.8% [16 of 163]; P<.001), and antipseudomonal (16.3% [26 of 160] vs 1.8% [3 of 163]; P<.001) coverage. The mean length of stay decreased from 3.6 to 2.2 days (P<.001) without an increase in 30-day readmissions (6.3% [10 of 160] vs 4.9% [8 of 163]; P=.64). The ASP made recommendations for 125 patients, and 96% were accepted. CONCLUSION: Implementation of an ASP-bundled approach aimed at optimizing antibiotic therapy in the management of uSSTIs led to shorter durations of narrow-spectrum therapy as well as shorter hospital length of stay without adversely affecting hospital readmissions.