Nonreactive Test Research Articles

Blissful Ignorance When Managing Pregnant Women With Syphilis and Nonreactive Nontreponemal Tests?

Blissful Ignorance When Managing Pregnant Women With Syphilis and Nonreactive Nontreponemal Tests?

Index of Suspicion in the Nursery

A 1-day-old boy presents to the NICU with the mouth deviating to right side while crying, inability to close the left eye, absence of wrinkles on the left side of the forehead, and a normal appearing face when in repose. This infant was born at 38-weeks’ 5 days of gestation via cesarean delivery to a 28-year-old primi-gravida woman with a significant history of chronic hypertension, for which she took labetalol throughout her pregnancy. She was admitted for induction of labor for nonreactive stress test and an amniotic fluid index less than 5. She had a prolonged second stage of labor. She pushed for more than 3 hours after complete dilation of the cervix but without success. She was taken for cesarean delivery for failure to progress. A low transverse cesarean delivery was performed. No forceps or vacuum were used to deliver the infant. Birthweight was 3,840 g. The infant was born limp, cyanotic, with heart rate below 100 per minute, and with no respiratory effort. Bag-mask ventilation and chest compressions were started. The infant responded well to resuscitation. Apgar scores were 1 and 8 at 1 and 5 minutes, respectively. The infant was transferred to the NICU for further management. On physical examination, the infant is noted to have caput succedaneum located over the left temporo-parieto-occipital region. The infant’s face significantly deviates to the right side, whereas the left eye stays open; he is noted to have absent wrinkles on the left side of the forehead while crying, and there is flattening of the left sided naso-labial fold, as noted in Fig 1. The remainder of the physical examination is considered to be normal except for a 1.0 × 1.0 cm superficial lesion over the left mastoid region, just behind the left ear, as noted in Fig 2. …

Clinical Features and Follow-up of Congenital Syphilis

The aim of this study was to investigate clinical features and outcomes of children treated for congenital syphilis (CS). Infants born alive in the public sector of São Lucas Hospital, Porto Alegre, Brazil, 1997 to 2004, whose mothers had syphilis and neonates with CS born in other facilities and admitted during this period were included. Follow-up was performed from birth up to 5 years. Among 24,920 live births, 379 (1.5%) met the criteria for CS. A further 19 infants born in other hospitals were included, for a total of 398 with CS. We compared infants with CS with 120 infants whose mothers received adequate treatment of syphilis before delivery (total sample, 518 infants). Congenital syphilis was associated with delivery before 34 weeks, low birth weight, and small for gestational age. During the study period, 37 stillbirths with CS were detected. Result from the serum venereal disease research laboratory test was negative at birth in 17.5% of the neonates with CS, and in 4 infants, it became positive after the second day. Thirty percent of the infants with CS were reevaluated between 8 and 60 months, and most had a good outcome when managed according to standard guidelines. Sixteen infants (13.3%) had sequelae. Of these, 8 were symptomatic in the neonatal period, and 13 (81%) of 16 had laboratory/x-ray findings. All asymptomatic and 78% of symptomatic infants had nonreactive fluorescent treponemal antibody absorption test after 12 months of age. Congenital syphilis remains an impacting disease that causes fetal and neonatal deaths, prematurity, low birth weight, and severe and irreversible sequelae in some children. This study confirms the value of standard guidelines for its management.

Acetone Droplet Behavior in Reacting and Non Reacting Turbulent Flow

Acetone droplet characteristics in reacting and non-reacting turbulent flow are predicted and compared to experimental data. Investigations are conducted to study the effects of surrounding environment properties on the velocities, dispersion, and evaporation of a relatively volatile spray fuel that featured a wide range of Stokes numbers. The simulations are performed in the framework of Reynolds Averaged Navier Stokes equations along with the Eulerian-Lagrangian approach in which 12 different classes of the dispersed phase. The phase transition is modeled by the Langmuir-Knudsen law that accounts for non equilibrium effects based on a consistent determination of the molar mass fraction on the droplet surfaces. For the droplet dispersion, the Markov sequence model is improved by adding a correction drift term to the fluid fluctuation velocity at the parcel position along the droplet trajectory. This correction term aimed at accounting for the non-homogeneity effects in the turbulent flow. The combustion is captured using the Bray-Moss-Libby model that is extended to account for the partially premixed spray combustion. The chemistry is described with the flamelet model using a recent detailed reaction mechanism that involves 84 species and 409 reactions for which the Lewis number is not set to the unity. Mean droplet velocities for reacting and non-reacting test cases are compared with experimental data. Good agreement is observed. The spray is interacting with the nozzle edge developing new classes and relatively dense region. Hence the RMS-velocities close to the nozzle exit plan demonstrate discrepancies. The droplets group combustion effect is found to be important in the modeling of the burning velocity which influences the flame propagation. Reasonable agreements between the numerical and the experimental results are also observed in the spray flux and temperature profiles.

Letter: recommendations for the management of latent tuberculosis infection in IBD patients may not be applicable in all settings – author's reply

et al., where the conversion and reversion rates of screening tests for latent tuberculosis (LTB) of patients under antitumour necrosis factor-alpha (TNF-a) therapy were tested. In this context, we present a case report of a Caucasian, 26-year-old woman, with no travelling history to endemic areas for tuberculosis, nor close contact with tuberculosis patients. She had Crohn’s disease diagnosed in 2009, with a nonreactive tuberculin skin test (TST) at the time. In January 2011, azathioprine was started, but interrupted due to acute pancreatitis. Five months later, another TST was performed and repeated 14 days later, according to national standards of care. 3 Both were nonreactive. The chest radiograph remained unchanged. Infliximab was then initiated, but the third infusion was not performed because of fever, dry cough and asthaenia. The TST had a 27-mm induration and the interferon gamma release assay (IGRA) was positive. CT chest, the histology of supraclavicular adenopathy and Ziehl-Neelsen were compatible with disseminated tuberculosis, and polymerase chain reaction was positive for Mycobacterium tuberculosis. The patient began tuberculosis treatment and was afebrile at the 2nd day of therapy. We question the role of the negativity of TST even in the absence of immunosuppression, and support the Austrian guidelines on LTB screening that omit TST as a screening test. According to these recommendations, only 42% of the originally treated patients would have received chemoprophylaxis with isoniazid. 5 Perhaps the patient described in this letter could belong to the remaining 58% and could have been saved from disseminated tuberculosis if IGRA had been performed prior to TNF-a therapy.

Characterization of sera with discordant results from reverse sequence screening for syphilis.

Reverse sequence screening for syphilis (RSSS) (screening with treponemal tests, followed by confirmation with nontreponemal tests) has been increasingly adopted. CDC recommends confirmation of discordant results (reactive EIA/CIA and nonreactive nontreponemal test) with Treponema pallidum particle agglutination assay (TP-PA). We characterized sera with discordant results from RSSS with Architect Syphilis TP CIA. Among 15,713 screening tests using Architect Syphilis TP at Seoul National University Gangnam Center between October 2010 and May 2011, 260 (1.7%) showed reactive results. Rapid plasma reagin (RPR) and TP-PA were performed on 153 available sera among them. On sera with discordant results between Architect Syphilis TP and TP-PA, INNO-LIA Syphilis Score and FTA-ABS were performed. Among 153 sera, RPR was nonreactive in 126 (82.4%). Among them, TP-PA was positive in 103 (81.7%), indeterminate (±) in 7 (5.6%), and negative in 16 (12.7%). Out of 16 CIA(+)/RPR(−)/TP-PA(−) sera, INNO-LIA Syphilis Score and/or FTA-ABS were negative on 14 sera. Out of 7 CIA(+)/RPR(−)/TP-PA(±) sera, INNO-LIA Syphilis Score and FTA-ABS were positive/reactive in 6 sera. RSSS with confirmation by TP-PA on sera with discordant results between Architect Syphilis TP and RPR effectively delineated those discordant results and could be successfully adopted for routine checkup for syphilis.

Factors Associated with False-Positive Results from Fingerstick OraQuick ADVANCE Rapid HIV 1/2 Antibody Test

Identify factors associated with false-positive rapid HIV antibody tests. This retrospective cohort study with nested case-controls involved patients tested for HIV by Boston Medical Center (BMC) affiliates. Cases had a reactive fingerstick OraQuick ADVANCE rapid HIV 1/2 antibody test and a negative Western blot. Controls had nonreactive rapid tests. We compared the prevalence of HIV risk factors between cases and the total nonreactive population and the prevalence of other clinical factors between cases and controls. Of the 15 094 tests, 14 937 (98.9%) were negative and 11 (0.07%) were false positives (specificity of 99.9%). Cases were more likely to have had an HIV-infected sex partner and to be tested at certain sites compared to true negatives. More cases than controls had O-negative blood type. O-negative blood type and sex with an HIV-infected person may increase false-positive HIV fingerstick results. More targeted studies should examine these risk factors.

A computationally efficient, physics-based model for simulating heat loss during compression and the delay period in RCM experiments

A computationally efficient, physics-based model is developed to account for the heat loss that occurs during the compression process and delay period in rapid compression machine (RCM) experiments. The model is formulated using multiple zones (MZs) and accounts for conductive losses in the main reaction chamber as well as convective losses in the piston crevice and ringpack regions. Blowby past the piston ringpack is also considered. The loss terms can be incorporated into the widely-utilized ‘adiabatic core’ model in order to perform ‘volumetric expansion’ calculations during chemical kinetic simulations that correct for pressure and temperature reductions resulting from these energy losses. An advantage of this approach over existing models and ‘ad-hoc’, or empirical methods is that the MZM constants are only a function of the machine geometry and therefore do not vary from experiment to experiment. As such, fewer experiments need to be conducted (e.g., non-reacting tests+reacting tests at each condition), while existing literature data can be more reliably utilized for kinetic model validation and improvement. This formulation also has the potential to account for effects of multi-stage ignition, as well as phase change that can occur during experiments with involatile, transportation-relevant fuels. The performance of the new MZM is validated here via comparisons with multi-dimensional RCM simulations as well as experiments employing non-reacting and reacting mixtures. Excellent agreement is demonstrated for the overall pressure decay experienced in the reaction chamber during the delay period, as well as the computed gas temperature and velocity behavior within the crevice. Predicted thermal stratification within the reaction chamber also agrees well when high pressure, low viscosity conditions are utilized, i.e., when no vorticular motion is present. Computed ignition delay times for H2/O2/diluent mixtures using the new model agree favorably with the reactive CFD simulations and experimental measurements.

Treponemal Tests for Neurosyphilis—Less Accurate Than What We Thought?

Treponema pallidum subsp. pallidum (hereafter termed T. pallidum) is the bacterium that causes syphilis. Neuroinvasion by T. pallidum occurs early in the course of disease (1-3) and can lead to asymptomatic meningitis that, untreated, can progress to symptomatic neurosyphilis. Early forms of symptomatic neurosyphilis include meningitis, hearing loss, vision loss, and stroke. Late forms include dementia (general paresis) and sensory ataxia (tabes dorsalis). Cerebrospinal fluid (CSF) analysis is crucial for diagnosis of asymptomatic and symptomatic neurosyphilis, but there is no perfect “gold standard” diagnostic test. Typical CSF abnormalities include mild mononuclear pleocytosis and elevated protein concentration. The CSF-Venereal Disease Research Laboratory (VDRL) test is specific but not sensitive, and particularly in early neurosyphilis, may be nonreactive. The “party line” has been that CSF treponemal antibody tests, while lacking the specificity of the CSF-VDRL, are diagnostically sensitive and can be used to rule out the diagnosis of neurosyphilis in equivocal cases. A systematic review by Harding and Ghanem (4) published in this issue of Sexually Transmitted Diseases challenges this tenet. In their review, the authors assessed studies that described the performance of CSF treponemal tests. They focused on the negative predictive value of these tests and restricted the analysis to studies in which controls were individuals who had syphilis but not neurosyphilis, an approach that is most relevant to clinical practice. Perhaps not surprisingly for a disease that lacks a gold standard diagnostic test, the authors found that the sensitivity of the CSF treponemal tests varied with how neurosyphilis was defined. If CSF-VDRL reactivity was used to establish the diagnosis, the sensitivity of the CSF treponemal antibody tests consistently approached 100%, but if broader criteria were used, particularly including clinical manifestations, the sensitivity was lower and more variable (22.2%-100%). Treponemal antibodies are directed against T. pallidum proteins, as detected by the fluorescent treponemal antibody absorbed (FTA-ABS) test, the T. pallidum particle agglutination (TPPA) test, the T. pallidum hemagglutination (TPHA) test or various enzyme immunassays (EIAs). Another treponemal test included in the analysis, the microhemagglutination-T. pallidum (MHA-TP), is no longer commercially available. The FTA-ABS, TPPA and TPHA tests measure IgG and IgM antibodies to native T. pallidum antigens, while the EIA assays detect IgG and IgM antibodies to recombinant treponemal proteins, usually TpN15, TpN17, and TpN47. For the FTA-ABS, TPPA and TPHA tests, the patient's serum or CSF is mixed with sorbent to remove cross-reactive antibodies to non-pathogenic treponemes. CSF samples that are nonreactive by FTA-ABS test are often reactive when the absorption step is omitted (5). Because EIA does not require the pre-absorption step, it could potentially be a more accurate test. However, there are no currently published studies using EIA on CSF to test this hypothesis. In the studies analyzed by Harding and Ghanem, it is difficult to determine whether the treponemal antibodies measured in the CSF were made intrathecally or in the periphery. Some investigators have argued that CSF:serum treponemal antibody ratios or indicies corrected for CSF and serum albumin or IgG concentrations can differentiate between intrathecal and peripheral antibody production and thus distinguish true CNS infection from passive diffusion of antibody from the peripheral blood (6-8). Sera from patients with reactive CSF FTA-ABS and CSF-TPPA tend to have higher treponemal antibody titers than sera from those with non-reactive tests, suggesting that a reactive CSF FTA-ABS or CSF-TPPA may simply be a surrogate for higher antibody concentration in sera (6, 9, 10). A study of the diagnostic utility of the CSF-TPHA suggested that a CSF titer >1:320 was as good as an elevated antibody index for neurosyphilis diagnosis (8), suggesting that there may be a CSF treponemal antibody concentration above which intrathecal antibody production is more likely. Distinguishing the source of CSF treponemal antibodies is important in assessing the accuracy of CSF treponemal tests. However, Harding and Ghanem did not include studies using such indices in their review. Syphilis and HIV co-infection occurs commonly worldwide (11, 12). Diagnosing neurosyphilis in HIV-infected patients continues to be a challenge because HIV infection itself can cause CSF pleocytosis and elevated protein concentration. Only four of the studies (1, 3, 7, 13) assessed by the authors included HIV-infected patients, and one of the four studies had very small patient numbers (7), making it difficult for the authors to assess the accuracy of CSF treponemal tests in this patient population. This article highlights the challenges clinicians caring for patients with syphilis continue to face – imperfect tests for neurosyphilis that are neither very sensitive nor specific. As the authors point out, while a positive CSF-VDRL “rules in” neurosyphilis, a negative CSF FTA-ABS does not necessarily “rule out” the diagnosis, especially when patients have neurological symptoms or signs. As the incidence of syphilis continues to increase, especially among HIV-infected patients, further work to develop better neurosyphilis diagnostic tests is sorely needed.

Predictive factors for repetition of the tuberculin test after a nonreactive test in patients with HIV/AIDS

The outcome of interest was repetition of the tuberculin skin test (TST) and the objectives were to estimate the rate of TST repetition, the probability of no TST repetition after 1 year, and the probability of no TST repetition at the end of the follow-up period in patients whose initial test was nonreactive. The study also set out to analyze factors associated with the time until TST repetition at two HIV/AIDS referral services that carry out the TST on a routine basis in Recife, Pernambuco, Brazil. A cohort of HIV-positive patients who initially tested nonreactive on the TST were followed from November 2007 to February 2010. The Kaplan-Meier method was used to estimate the probability of not repeating the TST, and Cox's regression analysis was used to analyze the factors associated with time until repeating the TST. Cox's multivariate analysis was stratified according to each hospital where patients were followed, because this variable did not respect the principle of proportionality of risk. The probability of not repeating the TST for 1 year was 80.0% and at the end of the follow-up period it was 42.0%. The variables that remained associated with TST repetition in the final Cox multivariate model were an age of 40 years or older, body mass index between 18.0 and 24.9, being female, and years of schooling. This study encountered a very low TST repetition rate after 1 year of follow-up and identified groups of individuals who should be the target of interventions aimed at repeating the TST.

Advances in upper airway diseases and allergen immunotherapy in 2011

The purpose of this review is to highlight recently published important articles on upper airway diseases and allergen immunotherapy. We review articles on rhinitis, sinusitis, conjunctivitis, and immunotherapy. New insights into epidemiology, pathophysiology, diagnosis, and therapy are described for each of the above diseases.

Serodiagnosis of Syphilis in the Recombinant Era: Reversal of Fortune

Serodiagnosis of Syphilis in the Recombinant Era: Reversal of Fortune

Detection of bacterial contamination in prestorage culture‐negative apheresis platelets on day of issue with the Pan Genera Detection test

Bacterial contamination is currently the most important infectious risk associated with transfusion of platelet (PLT) products. Prestorage culture has reduced but not eliminated this problem. Eighteen hospitals studied the Pan Genera Detection (PGD) test, a rapid, lateral-flow immunoassay for the detection of Gram-positive and Gram-negative bacteria. The PGD test was performed on day of issue on apheresis PLTs released by collection centers as culture negative. Confirmatory bacterial culture was performed when PGD tests were repeatedly reactive, with three sites performing culture on all doses studied. PGD tests on nine of 27,620 (1:3069, 95% confidence interval [CI] 1:6711 to 1:1617; or 326 per million, 95% CI 149-618 per million) apheresis PLT doses were repeatedly reactive and verified as bacterially contaminated by confirmatory culture. Bacterial species isolated included coagulase-negative staphylococci (n = 6), Bacillus sp. (n = 2), and Enterococcus faecalis (n = 1). The ages of these contaminated doses were Day 3 (n = 4), Day 4 (n = 2), and Day 5 (n = 3). Two contaminated doses with nonreactive PGD tests were detected among 10,424 doses at hospitals where concurrent culture was performed, and one other was identified via a transfusion reaction investigation. There were 142 PGD false positives (0.51%). The PGD test detected bacterial contamination in 1:3069 (9 of 27,620) doses released as negative by prestorage culture in PLTs as young as 3 days old. Three contaminated doses, two clinically insignificant, had nonreactive PGD tests, while 0.51% of tests were false positives. Application of this test on day of issue can interdict contaminated units and prevent transfusion reactions.

Hepatitis C virus infection and biological falsepositive syphilis test: a single-center experience

Rapid plasma regain positive and/or treponema pallidum hemagglutination negative [RPR(+)/TPHA(-)] results were designated as biologic false-positive (BFP). There are limited data about BFP reactions against syphilis in patients with hepatitis C virus (HCV) infection. This study aimed to determine the prevalence of BFP reactions for syphilis in patients with HCV infection in a large sample and assess the relationship between BFP reactions and HCV infection. A total of 2656 patients with positive anti-HCV and 5600 healthy control subjects were enrolled in this study. Hepatitis C serology was determined by a second generation ELISA test for HCV antibody. Syphilis serology was determined by the RPR test. Those subjects with reactive RPR positive underwent the TPHA test. Demographics and laboratory data were collected by trained clinicians. Among 2656 patients, 111 (4.2%) had a reactive RPR test. Of the 111 patients who were subjected to reactive RPR test, 30 (27.0%) showed HCV(+)/RPR(+). Of 5600 healthy controls, 80 (1.4%) had a reactive RPR test. Fourteen (17.5%) controls with HCV(-)/RPR(+) had a non-reactive TPHA test. These represented 1.1% of all HCV-positive and 0.3% of all HCV-negative subjects (P<0.001). A significantly increased prevalence shown by false-positive tests for syphilis was observed in elderly HCV-seropositive patients. BFP-HCV positive group had a higher prevalence of eosinophilia. The eosinophil abnormality was compared between the patients and controls (66.7% vs 21.4%, P=0.0043). No significant results were observed in antinuclear antibodies, antiphospholipid and complement (C3, C4) (P>0.05). The data of this study demonstrate that HCV infection is associated with a false-positive RPR test. In this study BFPs were significantly more common in HCV positive patients compared to HCV-negative ones. Eosinophil abnormality can be considered as a predictor for BFP. Excessive BFPs must be considered in assessing the frequency of syphilis in a HCV-positive population and the importance of the treponemal specific serologic test should be emphasized for a diagnosis of syphilis in such population.

P2-495 Predictive factors for non-repetition of the tuberculin test in patients with HIV/AIDS: a survival analysis

IntroductionPeriodic repetition of the tuberculin skin (TST) test in individuals with HIV/AIDS with an initially non-reactive test should be carried out to identify those who should be treated for latent...

Towards targeted screening for acute HIV infections in British Columbia.

BackgroundOur objective was to describe the characteristics of acute and established HIV infections diagnosed in the Canadian province of British Columbia. Province-wide HIV testing and surveillance data were analyzed to inform recommendations for targeted use of screening algorithms to detect acute HIV infections.MethodsAcute HIV infection was defined as a confirmed reactive HIV p24 antigen test (or HIV nucleic acid test), a non-reactive or reactive HIV EIA screening test and a non-reactive or indeterminate Western Blot. Characteristics of unique individuals were identified from the British Columbia HIV/AIDS Surveillance System. Primary drug resistance and HIV subtypes were identified by analyzing HIV pol sequences from residual sera from newly infected individuals.ResultsFrom February 2006 to October 2008, 61 individuals met the acute HIV infection case definition, representing 6.2% of the 987 newly diagnosed HIV infections during the analysis period. Acute HIV infection cases were more likely to be men who have sex with men (crude OR 1.71; 95% CI 1.01-2.89], to have had a documented previous negative HIV test result (crude OR 2.89; 95% CI 1.52-5.51), and to have reported a reason for testing due to suspected seroconversion symptoms (crude OR 5.16; 95% CI 2.88-9.23). HIV subtypes and rates of transmitted drug resistance across all classes of drugs were similar in persons with both acute and established HIV infections.ConclusionsTargeted screening to detect acute HIV infection is a logical public health response to the HIV epidemic. Our findings suggest that acute HIV infection screening strategies, in our setting, are helpful for early diagnosis in men who have sex with men, in persons with seroconversion symptoms and in previously negative repeat testers.

Conventional Linear Criteria with Sample Entropy in the Interpretation of Reactive Antepartum Fetal Heart Rate Tracings

Objective: To compare the test duration times and rate of nonreactive results between the conventional linear reactive criteria (CLRC) and the modified nonlinear reactive criteria (MNRC) in electronic fetal heart rate (FHR) monitoring. The MNRC are the CLRC with the addition of approximate entropy or sample entropy. Methods: One thousand women with singleton pregnancies between 30 and 37 weeks’ gestation were selected. They visited Hanyang University Hospital for non-stress tests (NSTs). In these patients, FHR tracings were recorded for 50 min including the first and second 20 min of NST and 10 min of vibroacoustic stimulation test. All patients had a reactive NST with CLRC in these antepartum FHR tests. The rate of nonreactive tests and test duration times of these linear and nonlinear criteria were calculated and compared. Results: The rate of nonreactive tests within a 20- and 40-min period with the MNRC (6.8 and 1.2%) was significantly lower than with the CLRC (35.2 and 10.5%, respectively; p < 0.001). To meet the reactive criteria, the mean durations of the MNRC and the CLRC were 11.47 (95% CI, 11.11–11.84) and 18.45 (95% CI, 17.79–19.12) min, respectively (p < 0.001). The MNRC led to a significant reduction in testing time of 37.8% compared to the CLRC. The rate of reactive tests using only sample entropy (0.20), calculated over 5-min segments of FHR tracings, was 88.3% (95% CI, 88.0–88.7). It was close to the results using the MNRC (93.2%) in the 20-min time window. Conclusion:The use of the MNRC significantly reduced the test duration times and decreased the rate of nonreactive tests when compared to the CLRC. It may be useful in providing more rapid and accurate assessment of the fetus in electronic FHR monitoring.

Natural History of Syphilitic Aortitis

No large studies of cardiovascular syphilis at necropsy have been reported since 1964. We examined at necropsy 90 patients who had characteristic morphologic findings of syphilitic aortitis. None had ever undergone cardiovascular surgery. With the exception of 2 cases seen more recently, the hearts and aortas of the 90 patients were examined and categorized by one of us (W.C.R.) from 1966 to 1990. All 90 had extensive involvement of the tubular portion of the ascending aorta by the syphilitic process, which spared the sinuses of Valsalva in all but 4 patients. The aortic arch was also involved in 49 (91%) of 54 patients and the descending thoracic aorta in 47 (90%) of 52 patients. Syphilis was the cause of death in 23 (26%) of the 90 patients. It was secondary to rupture of the ascending or descending thoracic aorta in 12, severe aortic regurgitation leading to heart failure in 10, and severe narrowing of the aortic ostium of the right coronary artery in 1 patient. Of the 40 patients who had undergone serologic testing for syphilis, 28 (70%) had a positive (reactive) finding. Those patients with a negative or nonreactive test or who did not undergo a serologic test for syphilis had morphologic and histologic findings in the aorta at necropsy similar to the findings of those patients who had had a positive serologic test for syphilis. In conclusion, cardiovascular syphilis has not disappeared. In patients with dilated ascending aortas, with or without aortic regurgitation, a serologic test for syphilis is recommended. If the findings are positive or if characteristic morphologic features of cardiovascular syphilis are suspected, irrespective of the results of the serologic tests, antibiotic therapy appears desirable.

Admission test as precursor of perinatal outcome: a prospective study

To test the reliability of the admission test to identify the compromised fetus and thus reduce the neonatal morbidity and mortality by early intervention. A prospective analysis over a period of 1 year from December 2007 to December 2008 included 100 antepartum patients and were evaluated for perinatal outcome in two groups. In both low and high risk groups the incidence of meconium staining was 25 and 37.5% in patients with nonreactive traces as compared to 8.6 and 9.5%, respectively, in reactive traces with specificity of 90.9%. Clinically detected fetal distress was more common in patients with nonreactive test. Operative interference for fetal distress was more in patients with nonreactive test. Occurence of low Apgar score was more in patients with nonreactive test. Admission to neonatal unit was more in nonreactive than reactive traces. Incidence of neonatal death was more in nonreactive test. Incidence of low birth weight was more in nonreactive trace group and more so in high risk group than in low risk group. Admission test may be best recommended in all patients irrespective whether they are in low or high risk as incidence of neonatal morbidity is high 33.3% babies required NICU admission and 33% babies expired in nonreactive tracing, in centers where advance facilities are not available. Whenever there is a nonreactive tracing further test should be carried out.

Another look at Emergency Department HIV screening in practice: no need to revise expectations

BackgroundA recent study reported a lower than expected specificity and positive predictive value of the rapid oral HIV test in the setting of routine emergency department (ED) screening. These results appeared inconsistent with the findings in another urban Emergency Department during the same time period.ObjectiveTo compare the specificity and positive predictive vale (PPV) of an oral rapid HIV test used in an ED screening program in Washington DC with that performed in the USHER clinical trial.DesignPeriod cross-sectional analysis of rapid oral HIV testing conducted in an ongoing HIV screening program emergency department patients.SettingThe George Washington University Emergency Department (Washington DC) from 7 February to 1 October 2007.Patients1,560 adults seen in the ED for non-HIV-related presenting complaints, who participated in the HIV screening program.InterventionRapid HIV testing with the OraQuick ADVANCE Rapid HIV-1/2 Antibody Test (OraSure Technologies, Bethlehem, Pennsylvania). Patients with reactive rapid test results were offered Western blot testing for confirmation.MeasurementsSpecificity and positive predictive value for the program were determined. Findings were compared to those found in the USHER trial.ResultsOf 1,560 patients screened for HIV, 13 [0.8%, 95% CI 0.38% to 1.28%] had a reactive HIV screening test, and all were confirmed to be positive by Western Blot. The specificity was 100% (95% CI 99.6%-100%).LimitationSince non-reactive tests were not confirmed, the test sensitivity cannot be determined.ConclusionReview of our data conflict with findings from the USHER study surrounding false positive OraQuick HIV screening. Our data suggest that rapid HIV screening protocols implemented in EDs outside of the clinical trial paradigm perform effectively without an excess of false positive results. Compared with other screening tests, HIV rapid screening should remain an essential component of ED practice.