Novel paradigm enables accurate monthly gestational screening to prevent congenital toxoplasmosis and more.

Background: Congenital toxoplasmosis is a treatable, preventable disease, but untreated causes death, prematurity, loss of sight, cognition and motor function, and substantial costs worldwide. Methods/Findings: In our ongoing USA feasibility/efficacy clinical trial, data collated with other ongoing and earlier published results proved high performance of an Immunochromatographic-test(ICT) that enables accurate, rapid diagnosis/treatment, establishing new paradigms for care. Overall results from patient blood and/or serum samples tested with ICT compared with gold-standard-predicate-test results found ICT performance for 4606 sera/1876 blood, 99.3%/97.5% sensitive and 98.9%/99.7% specific. However, in the clinical trial the FDA-cleared-predicate test initially caused practical, costly problems due to false-positive-IgM results. For 58 persons, 3/43 seronegative and 2/15 chronically infected persons had false positive IgM predicate tests. This caused substantial anxiety, concerns, and required costly, delayed confirmation in reference centers. Absence of false positive ICT results contributes to solutions: Lyon and Paris France and USA Reference laboratories frequently receive sera with erroneously positive local laboratory IgM results impeding patient care. Therefore, thirty-two such sera referred to Lyon's Reference laboratory were ICT-tested. We collated these with other earlier/ongoing results: 132 of 137 USA or French persons had false positive local laboratory IgM results identified correctly as negative by ICT. Five false positive ICT results in Tunisia and Marseille, France, emphasize need to confirm positive ICT results with Sabin-Feldman-Dye-test or western blot. Separate studies demonstrated high performance in detecting acute infections, meeting FDA, CLIA, WHO ASSURED, CEMark criteria and patient and physician satisfaction with monthly-gestational-ICT-screening. Conclusions/Significance: This novel paradigm using ICT identifies likely false positives or raises suspicion that a result is truly positive, rapidly needing prompt follow up and treatment. Thus, ICT enables well-accepted gestational screening programs that facilitate rapid treatment saving lives, sight, cognition and motor function. This reduces anxiety, delays, work, and cost at point-of-care and clinical laboratories. Author's Summary: Toxoplasmosis is a major health burden for developed and developing countries, causing damage to eyes and brain, loss of life and substantial societal costs. Prompt diagnosis in gestational screening programs enables treatment, thereby relieving suffering, and leading to > 14-fold cost savings for care. Herein, we demonstrate that using an ICT that meets WHO ASSURED-criteria identifying persons with/without antibody to Toxoplasma gondii in sera and whole blood with high sensitivity and specificity, is feasible to use in USA clinical practice. We find this new approach can help to obviate the problem of detection of false positive anti- T.gondii IgM results for those without IgG antibodies to T.gondii when this occurs in present, standard of care, predicate USA FDA cleared available assays. Thus, this accurate test facilitates gestational screening programs and a global initiative to diagnose and thereby prevent and treat T.gondii infection. This minimizes likelihood of false positives (IgG and/or IgM) while maintaining maximum sensitivity. When isolated IgM antibodies are detected, it is necessary to confirm and when indicated continue follow up testing in ∼2 weeks to establish seroconversion. Presence of a positive ICT makes it likely that IgM is truly positive and a negative ICT makes it likely that IgM will be a false positive without infection. These results create a new, enthusiastically-accepted, precise paradigm for rapid diagnosis and validation of results with a second-line test. This helps eliminate alarm and anxiety about false-positive results, while expediting needed treatment for true positive results and providing back up distinguishing false positive tests.

Determination of U-236 in sediment samples by accelerator mass spectrometry.

236U is produced only by neutron irradiation of uranium and therefore is potentially useful as a marker for anthropogenic uranium in the environment. Accelerator mass spectrometry (AMS) provides a technique for the determination of very low concentrations of actinide nuclides, and has now been applied to the determination of 236U:235U ratios in an intertidal sediment core collected from the North Irish Sea. Combining measurements of the 238U mass concentrations calculated from alpha spectrometry with 238U:235U ratios from ICP-MS and 236U:235U ratios from AMS has allowed the estimation of the mass concentrations of 236U in the sediments. 236U mass concentrations are in the range 10(-8) to 10(-9) g kg-1, and 236U:238U atom ratios in the range from 10(-5) to 10(-6), well above natural baseline levels. Uncertainties based on propagation of measurement errors were less than +/- 10% although +/- 15% is perhaps a more realistic estimate of overall uncertainty.

The changing face of publicly funded employment services.

The federal-state vocational rehabilitation (VR) program has been a significant stream of funding for individuals with traumatic brain injury (TBI). However, the success of this traditional rehabilitation approach with people with brain injuries remains limited. Recently, the use of specialized employment services, such as Supported Employment, has proven to be far more effective, but funding for this population remains limited. In addition, even individuals who receive specialized employment services often require more intensive, ongoing supports to remain employed. In response, many states have developed innovative services and approaches that are improving the placement and retention rates of individuals with TBI. In this article, the authors provide an overview of selected federal funding initiatives related to the provision of employment services to people with brain injuries, including recent amendments to the Rehabilitation Act. The article also highlights progressive state employment policies and makes suggestions for creative use of government employment monies.

The legal and risk management conundrum of telemedicine.

A store-and-forward teledermatology service was established between two general practices and the department of plastic surgery at Derriford Hospital in Plymouth. An academic lawyer and an expert in risk management made an assessment of the service. They looked at the following issues: medicolegal problems; security; confidentiality; and risk. None of them was considered insoluble and there is no reason why such issues should prevent the National Health Service from developing telemedicine services. All organizations considering telemedicine need to ensure that the proposed telemedicine service satisfies the issues raised in this study.

Survey of case manager training needs in traumatic brain injury.

The results of 138 surveys assessing the training needs of case managers in the area of traumatic brain injury were analysed. Sixty-six per cent of the respondents were case managers working primarily with adults in a variety of work settings. Respondents rated working with families, vocational rehabilitation, and community re-entry as the top three areas for training. Mild traumatic brain injury, paediatric traumatic brain injury, neuropsychological assessment, and medicolegal aspects received the highest rankings by case managers with more than 8 years experience. The need for certification of case managers in specialty areas was supported by 83% of all respondents.

The pathology of "sheep-associated" malignant catarrhal fever in the hamster.

Lesions induced in hamsters by inoculation with the "sheep-associated" agents of malignant catarrhal fever (SA-MCF) isolated from a red deer (Cervus elaphus), designated D/1 and of bovine origin (C/2), are described. Clinical signs in hamsters inoculated with the D/1 isolate occurred as early as 13 days after infection although the mean incubation period in animals that developed signs was 27 days. Increased numbers of polymorphonuclear leucocytes were present in the blood of clinically affected hamsters. Gross lesions included erosions of epithelium in the buccal cavity, haemorrhage of the forestomach, dilated fluid-filled intestines and enlargement of the mesenteric lymph node. Microscopic lesions were widespread throughout the body but had a predilection for epithelial surfaces. They consisted of hyperplasia of certain lymph nodes, vasculitis and interstitial accumulations of mononuclear cells of lymphoid appearance in non-lymphoid tissues. Cytolysis was also seen. Lesions produced by the C/2 isolate were similar and both isolates produced disease comparable with that seen in naturally occurring cases in cattle and deer. It is suggested that disease might arise through a dysfunction of the immune system following infection of host large granular lymphocytes by the SA-MCF agent, in a way similar to that suggested for the rabbit.

Assessment of catheter-associated infection risk with the Hickman right atrial catheter.

One hundred fifty Hickman right atrial catheters were inserted into 143 patients and were followed prospectively until removal. Primary indications for their use were: cancer chemotherapy (45), parenteral nutrition (35), antibiotic therapy (63), and miscellaneous (7). The overall catheter-associated infection rate was 12.0%. Since the mean duration of catheterization was 125 days, the infection/duration rate was 1.0/1,000 days of use. The risk of infection differed significantly according to the primary indication for catheterization: parenteral nutrition greater than antibiotic therapy greater than cancer chemotherapy. The increased risk of catheter-associated infection attributable to duration of catheterization was additive, and the per day risk of such infections remained constant regardless of duration. Nearly two-thirds of patients were discharged home with catheters in place, without adversely affecting infection risk.

The consequences and effectiveness of intubation in the palliation of dysphagia due to benign and malignant strictures affecting the oesophagus.

In a study of 66 patients intubated to relieve dysphagia, 52 (79 per cent) survived the procedure and were discharged home. Of these, 23 (44 per cent) developed further dysphagia due to tube dysfunction, and 19 patients (37 per cent) were readmitted for further procedures to restore swallowing. With early intervention, the periods of dysphagia were short and the palliation so achieved was effective. Overall, intubation proved to be an effective method of relieving dysphagia in patients unsuitable for curative treatment.

Lung biopsy in immunocompromised hosts.

Ninety-five lung biopsy procedures in 78 immunocompromised patients yielded treatable diagnoses in 35 per cent of the needle aspirates, 46 per cent of the cutting needle biopsies and 65 per cent of the open thoracotomies. Complication rates of bleeding or pneumothorax were comparable to those previously described in nonimmunocompromised patients. In patients with coagulation defects, the risk of having bleeding complications was high. Among 44 patients with primary lymphoma, 22 (50 per cent) had a lymphomatous infiltrate in the lung. Twenty-two patients with severe hypoxemia were studied and their mortality, although significantly greater than in the patients without hypoxemia, was marginally improved when a treatable lung lesion was found. The over-all recovery rate was 70 per cent when a treatable diagnosis was made in contrast to 25 per cent when there was no specific diagnosis. Hence lung biopsy, particularly by thoracotomy, appears to be a valuable procedure in immunocompromised patients who have otherwise undiagnosable lung lesions.

Fever in acute myelogenous leukemia.

Implications and course of fever were evaluated during hospitalization of 24 patients with acute myelogenous leukemia. Forty-five febrile episodes were identified. Fever present at admission was usually associated with a diagnosable and treatable infection; fever shortly after induction was self-limited; and fever during granulocytopenia was more likely to be associated with bacteremia. Bacteremia and pneumonia were the most common types of infection. Only Gram-negative bacteria and Candida were identified as causes of infection during life, with Pseudomonas and Klebsiella the most frequently isolated pathogens. Invasive candidiasis was a major postmortem finding. A delay in initiation of empirical treatment beyond the third day of fever was associated with an increase in mortality as was continuation of treatment for longer than 14 days.