Expanding Diabetes Screening to Identify Undiagnosed Cases Among Emergency Department Patients.

Introduction: Diabetes screening traditionally occurs in primary care settings, but many who are at high risk face barriers to accessing care and therefore delays in diagnosis and treatment. These same high-risk patients do frequently visit emergency departments (ED) and, therefore, might benefit from screening at that time. Our objective in this study was to analyze one year of results from a multisite, ED-based diabetes screening program. Methods: We assessed the demographics of patients screened, identified differences in rates of newly diagnosed diabetes by clinical site, and the geographic distribution of high and low hemoglobin A1c (HbA1c) results. Results: We performed diabetes screening (HbA1c) among 4,211 ED patients 40-70 years old, with a body mass index ≥25, and no prior history of diabetes. Of these patients screened for diabetes, 9% had a HbA1c result consistent with undiagnosed diabetes, and nearly half of these patients had a HbA1c ≥9.0%. Rates of newly diagnosed diabetes were notably higher at EDs located in neighborhoods of lower socioeconomic status. Conclusion: Emergency department-based diabetes screening may be a practical and scalable solution to screen high-risk patients and reduce health disparities experienced in specific neighborhoods and demographic groups.

Reporte de caso: intoxicación por ácido valproico y hallazgos neuropsiquiátricos / Case report: valproic acid intoxication and neuropsychiatric findings

PEl Ácido Valproico (AVP), fármaco ampliamente conocido por sus propiedades antiepilépticas para el manejo de la epilepsias parciales y simples. Es también utilizado dentro de la Psiquiatría como estabilizador del humor y apoyo en el tratamiento de episodios de manía donde el uso del litio está contraindicado. Presentamos el caso de un hombre de 53 años con trastorno esquizoafectivo no especifico y mala adherencia al tratamiento, quien al iniciar manejo con AVP desarrolló una intoxicación por este fármaco, independiente a los niveles en suero de este, revolviéndose con líquidos intravenosos y reajuste de dosis.

Valproic Acid (VA), a widely known medication being used in partial and simple epilepsy treatment because of its antiepileptic properties. It's also used within Psychiatry as a mood stabilizer and the support in the treatment for manic episodes on which lithium its contraindicated. We present the case of a 53-year-old man with nonspecified schizoaffective disorder and poor adherence to treatment, when initiated treatment with VA developed drug toxicity that was independent of VA serum levels, resolving with intravenous fluids and dose readjustment.

Multi-center European evaluation of HIV testing on serum and saliva samples.

OBJECTIVE: to evaluate the reliability of HIV antibody testing on saliva. DESIGN: matched serum and saliva samples were collected from both seronegative (n = 344) and seropositive (n = 125) individuals in five European countries. Duplicate saliva samples collected with Omni-Sal devices provided by Saliva Diagnostic System (SDS) were pooled before analysis. METHODS: all samples were analyzed by Recombinant HIV1 EIA Cambridge Bioscience and 2nd generation Abbott HIV 1&2 1A80. EIA procedures were adapted for saliva testing by modification of sample dilution and/or cut-off calculation. All saliva recording positive and/or doubtful EIA results were further analyzed by Western blot as a confirmatory method. RESULTS: EIA results obtained from sera analysis from both seropositives and seronegatives allowed for calculation of the tests' sensitivity (HIV1 Biotech: 99.2%-100%; Abbott: 100%) and specificity (both tests 100%). In the series of 125 saliva samples collected from seropositives, the EIA results were as follows: with Biotech (3 negative, 3 in the grey-zone and 119 reactive) and with Abbott (1 negative, 1 in the grey-zone and 123 reactive). One saliva sample found negative by both EIA tests, although fulfilling HIV1 WB criteria of positivity, was collected from an HIV2 infected person. Out of 125 saliva samples collected from seropositives, 121 produced positive Western Blot profiles, 4 were indeterminate and 1 was found negative whereas 125/125 sera were found positive. CONCLUSION: the reliability of HIV testing of saliva is dependent on the sensitivity of EIA tests and on the criteria used for the interpretation of Western blot tests as well. Although saliva testing offers numerous advantages for epidemiological purposes, it should not be recommended for diagnosis.

Purification of a galactosyl-alpha 1-4-galactose-binding adhesin from the gram-positive meningitis-associated bacterium Streptococcus suis.

Streptococcus suis causes meningitis, sepsis, and other serious infections in newborn and young pigs and in adult humans. The Gal alpha 1-4Gal-binding adhesin of S. suis was purified to homogeneity by ultrasonic treatment, fractional ammonium sulfate precipitation, and preparative polyacrylamide gel electrophoresis. Pigeon ovomucoid, a glycoprotein with Gal alpha 1-4Gal terminals, was used to detect the adhesin by blotting. The purified adhesin appeared as single band of an apparent size of 18 kDa and of a pI of 6.4; no disulfide bridges were present. The amount of adhesin as revealed by pigeon ovomucoid binding correlated with the hemagglutination activity of different S. suis strains. The purified adhesin bound to latex particles induced hemagglutination which was specifically inhibited with the same inhibitors as hemagglutination by the intact bacteria, thus demonstrating that the purified protein was the Gal alpha 1-4Gal-recognizing adhesin of S. suis. Two adhesin variants (PN and PO) with differing Gal alpha 1-4Gal binding specificity had the similar electrophoretic mobilities and the same N-terminal peptide sequences, indicating that they were closely related. This represents the first isolation of an adhesin with well-defined cell surface carbohydrate binding activity from Gram-positive bacteria associated with meningitis.

Characterization of a novel bacterial adhesion specificity of Streptococcus suis recognizing blood group P receptor oligosaccharides.

Streptococcus suis causes sepsis, meningitis, and other serious infections in piglets, and meningitis in humans. Hemagglutination inhibition experiments with mono- and oligosaccharides and glycoproteins indicated that galactose-binding strains of S. suis recognized the Gal alpha 1-4Gal sequence present in the P1 and Pk blood group antigen structures. In thin-layer chromatography overlay assays the bacteria bound to trihexosylceramide (GbO3) but not to globoside (GbO4) or Forssman glycolipid (GbO5), in contrast to P-fimbriated Escherichia coli, which bound only to the latter two. The S. suis adhesin also differed from that of E. coli in that some of the hydrogen bonds formed with the receptor, as determined with chemically modified receptor analogues, were different. In agreement with the binding specificity, the S. suis bacteria agglutinated best among P blood group erythrocytes those of the P1k and P2k type, and from different animal erythrocytes those from rabbit, which express GbO3 as the predominant glycolipid. Binding to frozen sections of pig pharyngeal tissue was decreased by the free GbO3 oligosaccharide and its protein conjugate, which indicated that the corresponding glycolipid may function as receptor for galactose-binding strains of S. suis in pig pharyngeal epithelium.

Production of stable human-mouse hybridomas secreting monoclonal antibodies against Rh D and c antigens.

Peripheral blood lymphocytes from donors immunized against Rh antigens were fused with mouse myelomas and heteromyelomas in order to obtain human-mouse hybridomas secreting antibodies specific for these antigens. Three cell lines secreting anti-D IgG and two secreting anti-c IgM were stabilized and produced immunoglobulins for several months. These human monoclonal antibodies were evaluated as reagents for Rh phenotyping. Their complementary activity towards weak D and partial D antigens is examined.

Influence of affinity of antibodies upon their detection by liquid phase radiobinding assay and solid phase enzyme linked immunosorbent assay. Demonstration using monoclonal antibodies raised against rDNA human proinsulin.

Hybridomas producing proinsulin antibodies were cloned by limiting dilution of cell cultures obtained by fusion of splenocytes of immunized mice with immortal myeloma cells. Some proinsulin monoclonal antibodies crossreacted with labelled insulin but none did with labelled C-peptide indicating that the involved epitopes were at one of the insulin/C-peptide junctions or included in the insulin moiety. Hybridoma supernatants were assayed for IgG concentration by a solid phase assay and for ligand binding by a radiobinding assay and an enzyme linked immunosorbent assay. The half-life of immune complexes formed with radioligand was measured and, as expected, correlated with affinity as measured by the method of Scatchard. Antibody titres determined by enzyme linked immunosorbent assay did not correlate to those measured by radiobinding assay. IgG concentration correlated to enzyme linked immunosorbent assay titres but not to radiobinding assay titres. Finally, a significant correlation was found between radiobinding assay titre and the product of enzyme linked immunosorbent assay titre by the period of immune complexes. It is concluded that, except for very low affinity antibodies, enzyme linked immunosorbent assay is a capacity assay whereas radiobinding assay is influenced by both antibody concentration and affinity. The former assay is thus best suited to detecting low affinity antibodies whereas the latter is more efficient in the presence of low levels of high affinity antibodies.

Clonally restricted insulin autoantibodies in a cohort of 2200 healthy blood donors.

Serum samples of 2200 blood donors were screened for anti-insulin IgG by enzyme-linked immunosorbent assay. Specificity of detected antibodies was verified by competition with an excess of insulin and observation that saturated anti-insulin IgG were no longer measurable. The upper limit of measured signal in the population was defined as the mean plus three SD. In the direct assay, 32 sera were positive. Among these, 22 (1%) contained saturable insulin antibodies (true positive) and 10 were non-saturable and considered as non-insulin-specific. The positive blood donors were requested to answer a questionnaire and according to their answers, none had ever received insulin, was a first degree relative of a Type 1 (insulin-dependent) diabetic patient or had experienced a hypoglycaemic episode. None of the 22 true positive sera detected by enzyme-immunosorbent assay bound 125-I-insulin to any significant extent. The nine sera yielding the highest signal were further characterized with regard to heavy and light chains as well as species specificity of ligand. Anti-insulin IgG from healthy blood donors contained only one heavy (gamma 1 2/9;gamma 3 7/9) and one light (kappa 8/9); lambda 1/9) chain. Three sera were human insulin specific; two were non-species-specific; the other four bound insulin in the order human = porcine greater than bovine. These results indicate that low affinity clonally restricted antibodies against insulin are present in unselected blood donors with a prevalence of 1%.

Detection of p30 antigen in sexual assault case material.

A sandwich enzyme immunoassay for the detection of p30 prostate specific antigen was applied in 52 forensic cases. In each case, immunoassay results were compared with those of the search for spermatozoa and prostatic acid phosphatase analysis. The results indicate that the p30 assay gave no false positive and fewer false negative reactions than the acid phosphatase test. The sensitivities compared to the search for spermatozoa as a reference method were 94.8% for the p30 assay and 84.4% for the acid phosphatase test; the specificities were 95.6% and 90.0% respectively.

An enzyme immunoassay for prostate-specific p30 antigen detection in the postcoital vaginal tract.

A sandwich enzyme immunoassay test utilising a mouse monoclonal antibody has been adapted for the sensitive detection of the p30 prostatic antigen in semen and in postcoital vaginal swabs. In liquid semen, p30 was still detectable at a 1/1,000,000 dilution, and it could still be detected on vaginal swabs 24 h postcoitus.

Characterization of a neuraminidase from Corynebacterium aquaticum responsible for Th polyagglutination.

Th polyagglutinability is characterized by the agglutination of the red blood cells (RBC) by Arachis hypogaea, Medicago disciformis, Vicia cretica but, in contrast to the T phenomenon, not by Glycine max (Glycine soja). Because Th transformation of RBC has been obtained in vitro, the mechanism of Th polyagglutinability expression has been studied and reproduced experimentally. An enzyme with neuraminidase specificity has been isolated from the culture supernatant of Corynebacterium aquaticum, and further characterized (MW = 55,600 kDa, pH = 5.5, Km = 0.138 microM, Kcat = 0.22 micrograms). Reversely, Th transformation of RBC could be obtained by using other neuraminidases but in very mild conditions of hydrolysis. From our results, it can be concluded that by the release of less than 20 micrograms of sialic acid per 10(10) RBC, Th reactivity can be induced whereas hydrolysis of greater amounts of sialic acid (greater than 20 micrograms/10(10) RBC) give the classical T polyagglutinability.

Elucidation of non-parallel EIA curves.

Quantitative determinations by EIA can be only obtained by reverse regression when linear portions of sample and standard curves are parallel. However, analysis of complex biological fluids often yields sigmoid curves displaying lower slopes, thus invalidating any quantitative interpretation. We hypothesized that this phenomenon was due to a competition effect between the target (for example an antigen) and related molecules for the binding sites (for example a capture antibody) immobilized onto the solid phase. This has been confirmed experimentally using various target-to-competitor ratios and formulated as a mathematical model. The slope decrease in target detection was related to the proportion of competitor, not in a linear, but in an exponential manner. This mathematical model has been computerized and can be used to correct aberrant sample curves provided the relevant parameters have been previously determined in the same systems.

Characterization of a murine monoclonal antibody specific for the human P1 blood group antigen.

Four monoclonal antibodies (MAbs) directed against the P1 blood group antigen were produced by hybridomas obtained from mouse immunized with turtle-dove avomucoid. One of the MAb (154 IX B6) selected as a blood typing reagent agglutinated native P1 and Pk1 red cells with a high titer but was inactive against native P2, Pk2 and p erythrocytes. After papain treatment the reactivity towards P1 and Pk1 erythrocytes was enhanced whereas p erythrocytes remained unreactive. A weak cross-reactivity of the MAb with the Pk antigen was suspected since enzyme-treated Pk2 erythrocytes became significantly agglutinated. Further analysis of the antibody specificity was established by binding studies using neutral glycolipids prepared from P1 and P2 erythrocytes, affinity immunoabsorbents carrying known oligosaccharide structures and hapten inhibition with synthetic oligosaccharides. The MAb bound weakly to the Gal alpha 1-4Gal structure common to P1 and Pk antigens but had a marked preference for the P1 determinant (Gal alpha 1-4 Gal beta 1-4 GlcNAc) and the binding was abolished by prior treatment of oligosaccharide antigens by alpha(not beta)-galactosidase, which supports evidence that a terminal alpha-galactose residue is involved in the blood group P1 and Pk specificities. The MAb has a slightly broader specificity than the human anti-P1 counterpart but can be used safely for routine blood typing.

An enzyme-linked immunosorbent assay utilizing monoclonal antibodies for the characterization of immunoglobulin classes and subclasses of anti-red cell antibodies.

The destruction of transfused red cells results from both humoral and cellular immune mechanisms. Numerous factors are likely to affect this destruction. Among them, the class and subclass of antibody-carrying immunoglobulins are of great importance. Compatibility testing routinely realized in vitro in Blood Group Laboratories is not always very helpful in predicting the in vivo significance of alloantibodies. In this sense, we have investigated an enzyme immunoassay that makes it possible to identify the isotype profile of any auto- or alloantibody. This solid-phase immunoassay utilizes mouse monoclonal antibodies specific for individual human IgG subclasses in a double-sandwich test, in which the sample to be analyzed is an eluate obtained by classical absorption-elution methods.

A potential new procedure for removing anti-factor VIII antibodies from hemophilic plasma.

A new approach for removing the anti-factor VIII antibodies in hemophilic patients by immunoadsorption is proposed. The method is based on the fact that the anti-factor VIII antibodies were predominantly of the IgG4 subclass; anti-human IgG4 antibodies were covalently linked to agarose and large amounts of anti-factor VIII antibodies can be eliminated. A study of 21 blood samples from hemophilic patients with anti-factor VIII antibodies allows us to confirm the large predominance of IgG4 in the anti-factor VIII population. In some samples, the presence of IgG3 related anti-VIII:C was checked by adsorption on an anti-IgG3 column. In a majority of cases, after IgG4 (or IgG4 + IgG3) immunoadsorption, the substitution therapy becomes possible or easier.