Le test post coïtal à l’heure de l’AMP

The recent development of assisted reproductive technologies has greatly modified treatment and evaluation of infertility. In view of the high pregnancy rates obtained, the value of conventional diagnostic tests, especially the post-coital test, has become controversial. Apart from differences in terms of standardization, the confusion concerning the diagnostic and prognostic value is largely due to the interpretation and the purpose of the test. According to the World Health Organization guidelines, the post-coital test remains a reliable tool for the diagnosis of cervical infertility and sperm dysfunction, which is a possible cause of unexplained infertility. Over the last two cases, most other conventional tests have become inoperative and the results of the post-coital test may indicate the need for further investigations and may positively influence the treatment strategy.     

Diagnostic accuracy and role of immediate interpretation of fine needle aspiration biopsy specimens from various sites

A statistical analysis of the accuracy of the immediate interpretation of 425 fine needle aspiration (FNA) biopsies from various sites was performed. Preliminary interpretation of Diff-Quik-stained smears was rendered within a few minutes after performing the FNA biopsy, using diagnostic terminology similar to that of a surgical pathology report. The immediate assessment was documented in the formal cytology report and compared to the final diagnosis. For the entire series, the immediate interpretation had a sensitivity of 96%, a specificity of 97%, a positive predictive value (PV) of 98%, a negative PV of 95% and an efficiency of the test of 96%. There were 14 false-negative or falsely insufficient immediate interpretations and one false-positive immediate diagnosis. The diagnostic accuracy of the immediate interpretation of FNA biopsies from specific sites was also calculated; FNA biopsies of the pancreas were the least accurate procedure, having a sensitivity of 60% but a specificity of 100%. The role of the immediate interpretation of FNA biopsies is similar to the use of frozen sections in surgical pathology. An immediate assessment can (1) determine whether an adequate specimen is present, (2) render a specific preliminary diagnosis, (3) guide further clinical investigations or treatment, and (4) determine whether ancillary studies are needed to make a more accurate or specific diagnosis from the FNA specimen. Our results indicate that the immediate interpretation of FNA biopsies is an accurate procedure that should be routinely employed.     

Ethical considerations in prenatal diagnosis.

Prenatal diagnostic testing raises a number of important ethical issues, some related to diagnostic testing in general and others related to the special circumstances of pregnancy. These issues are most effectively addressed in the context of a broader understanding of the goals of prenatal diagnosis. Our dual obligations--to the pregnant woman and to the fetus--have an important influence on the goals of testing. Testing seldom leads to treatment beneficial to the fetus, but more often can be beneficial to the pregnant woman, particularly if the information provided enhances her ability to make sound decisions about reproductive matters. The process of prenatal diagnostic testing can, however, limit a woman''s sense of control over the decisions made about her pregnancy. It can also provide an opportunity for third parties to become involved in what are usually considered private matters. It is therefore important that the process of testing include adequate counseling and follow-up and that the patient''s confidence be respected. As prenatal diagnostic technology expands, both in terms of patients to be tested and diagnoses to be sought, society will face difficult questions concerning access to testing and the justification for its use.     

When to refer an infertile mare to a theriogenologist

Most equine infertility cases can be solved with a methodical, thorough physical and reproductive examination and appropriate diagnostic laboratory aids. Repeated examinations may be needed in some cases to identify subtle anatomical abnormalities or irregularities between hormonal and physiological relationships of the reproductive tract. For pregnancy to occur, hormonal signaling must be exquisitely synchronized with physical changes of the reproductive tract and deposition of fertile semen in the uterus. Asynchrony of these events, infection, inflammation, previous trauma to the reproductive tract or "stress" can interfere with conception or maintenance of pregnancy. Infertile mares are presented for three common problems: (1) accumulation of intra-uterine fluid during or immediately after estrus; (2) long standing infection and/or chronic inflammation; or (3) irregular or no estrous cycles. By defining the problem, diagnostics can be chosen to determine the cause. Treatment protocols should be designed around the diagnosis and antibiotics, ecbolics or steroids should not be used indiscriminately. In all cases of mare infertility, semen quality needs to be determined to be satisfactory as a subfertile stallion bred to a subfertile mare greatly decreases the likelihood of pregnancy.     

FRACTURES AND DISLOCATIONS OF THE CARPUS

Although one-eighth to one-tenth of all fractures of the wrist are carpal fractures, they may be overlooked, unless attention is directed particularly to them in diagnostic examination. Symptoms may be slight or lacking, but diagnosis is important because such injuries may give rise to pain or disability later. There are certain guides and procedures in physical and roentgenographic examination which make diagnosis easier and more certain. Treatment depends upon the nature of the lesion. It must be based on all the knowledge obtainable by examination, mental review of the anatomy and pathologic changes, inquiry into the cause of injury, and the interpretation of roentgenologic findings.     

Realities of diagnosing Helicobacter pylori infection in clinical practice: a case for non-invasive indirect methodologies.

BACKGROUND: The current, arbitrarily defined gold standard for the diagnosis of H. pylori infection requires histologic examination of two specially stained antral biopsy specimens. However, routine histology is potentially limited in general clinical practice by both sampling and observer error. The current study was designed to examine the diagnostic performance of invasive and non-invasive H. pylori detection methods that would likely be available in general clinical practice. METHODS: The diagnostic performance of rotating clinical pathology faculty using thiazine staining was compared with that of an expert gastrointestinal pathologist in 38 patients. In situ hybridization stains of adjacent biopsy cuts were also examined by the expert pathologist for further comparison. Receiver operator characteristic (ROC) analysis was performed to evaluate whether the diagnostic performance of the expert pathologist differed depending upon the histologic method employed. A similar analysis was made to evaluate the diagnostic performance of pathology trainees relative to the expert. In the absence of an established invasive gold standard, non-invasive testing methods (rapid serum antibodies, formal Elisa antibodies and carbon-14 urea breath testing) were evaluated in 74 patients by comparison with a gold standard defined using a combination of diagnostic tests. RESULTS: Using either rapid urease testing of biopsy specimens or urea breath testing as the gold standard for comparison, the diagnostic performance of the rotating clinical pathology faculty was inferior to that of the expert gastrointestinal pathologist especially with regard to specificity (e.g., 69 percent for the former versus 88 percent, with the latter relative to rapid urease testing). Although interpretation of in situ hybridization staining by the expert appeared to have an even higher specificity, ROC analysis failed to show a difference. The mean ROC areas for thiazine and in situ hybridization staining for trainee pathologists relative to the expert were 0.88 and 0.94, respectively. In untreated patients, urea breath testing had a sensitivity and specificity of 100 percent as compared with thiazine staining with a sensitivity of 83 percent and a specificity of 97 percent. Post-therapy, breath testing had a sensitivity of 100 percent but a specificity of only 86 percent as compared with invasive testing with a sensitivity and specificity of 100 percent. Rapid serum antibody testing and formal Elisa antibody testing agreed in 93 percent of cases (Kappa 0.78) with the rapid test being correct in three of the four disagreements. CONCLUSIONS: The current study illustrates a number of realities regarding H. pylori diagnosis. There is no diagnostic gold standard in general clinical practice. Accurate interpretation of specially stained slides is a learned activity with a tendency towards overdiagnosis early on. Urea breath testing is likely to be the diagnostic method of choice for untreated patients in general clinical practice although antibody testing is almost as accurate. Rapid antibody tests are at least as accurate as formal Elisa antibody tests. Urea breath testing is useful for confirming cure after therapy, but false-positive results may occur in some patients.     

Non–Culture-Based Methods for the Diagnosis of Invasive Candidiasis

Given the limitations of current fungal diagnostics, the use of non–culture-based methods for the diagnosis of invasive candidiasis (IC) is highly warranted. The implementation of molecular diagnostic strategies could permit the timely onset of appropriate therapy and may be expected to pave the way for improved clinical outcome of IC. Polymerase chain reaction (PCR) may have higher sensitivity for the diagnosis of IC than conventional blood cultures. The detection of fungal antigens generally requires a large fungal burden, and the presence of fungus-specific antibodies may not correlate with the underlying diseases. Therefore, the combined mannan and anti-mannan antibody testing is recommended. No single test has been shown convincingly to compensate for all the limitations of culture. Real-time PCR coupled with fungal culture and/or antigen detection will likely be required to significantly ameliorate the diagnostic problems in IC.     

DIAGNOSTIC SELF‐TESTING: AUTONOMOUS CHOICES AND RELATIONAL RESPONSIBILITIES

Diagnostic self‐testing devices are being developed for many illnesses, chronic diseases and infections. These will be used in hospitals, at point‐of‐care facilities and at home. Designed to allow earlier detection of diseases, self‐testing diagnostic devices may improve disease prevention, slow the progression of disease and facilitate better treatment outcomes. These devices have the potential to benefit both the individual and society by enabling individuals to take a more proactive role in the maintenance of their health and by helping society improve health and reduce health costs. However, the full implications of future home‐based diagnostic technology for individuals and society remain unclear due to their novelty. We argue that the development of diagnostic tools, especially for home use, will heighten a number of ethical challenges. This paper will explore some of the ethical implications of home‐based self‐testing diagnostic devices for the autonomous and relational dimensions of the person. This will be facilitated by examining the impact of diagnostic devices for individual autonomy, for the delivery of accurate diagnosis and for the personal significance of the information for the user. The latter will be examined using Charles Taylor's view of personhood and his emphasis on human agency and interpretation. While the ethical issues are not necessarily new, the development of home‐based self‐testing diagnostic devices will make issues regarding autonomy, accuracy of information and personal significance more and more demanding. This will be the case particularly when an individual's autonomous choices come into conflict with the person's relational responsibilities.     

Simple and inexpensive immunoassay-based diagnostic tests

Simple and inexpensive yet sensitive and robust diagnostic tests are critically needed for resource-poor settings to enable timely diagnosis and effective use of limited health care resources. Current tests are often too expensive, too slow, or have compromised clinical performance, and they often require health care professional to perform the test. In addition, most assays are not intended to be used in extreme environmental conditions, but their performance may be affected by high temperatures and humidity often encountered in resource-poor settings. This review provides an overview of current immunoassay technologies and their advantages and limitations with respect to their feasibility to resource-poor settings. Future trends of immunoassay development for decentralized testing are also discussed. Homogeneous assays as such are out of the scope of this article because they are generally not yet sensitive enough or otherwise less feasible for inexpensive rapid diagnostic tests.     

Traditional and innovative diagnostic tools: when and why they should be applied

The development of new technological methods surely improves the quality of the Diagnostic Services in Parasitology offered to the National Sanitary Service, however, cost and simplicity have not to be neglected, even when the prime consideration is efficiency. Moreover, the mere fact that something can be done by one of these new approaches does not mean that it should be done that way or that it is most cost-effective to do it that way. A review of diagnostic tools in Parasitology is proposed, to evaluate when and why each of them should be applied. Traditional procedures for the diagnosis of parasitosis are only based on the "direct" recovery and recognition of the parasite, with the microscope as main tool and few other instruments as co-operator. The innovative procedures, recently adjusted on the basis of new scientific knowledge and made possible by the development of the laboratory instrument weapons, can evidence the parasites both directly and indirectly. If it is obvious that the direct identification of a pathogen is more reliable than that indirect, is not so evident what is the most useful direct method, and when it would be better to use indirect diagnostic tools. Advantages and disadvantages of each procedure, cost as well as the purpose of the test (diagnosis, post-treatment, research), and the general condition in which the test have to been applied must be taken into account when we are choosing. In general, we can say that the rationale for their use can be summarised as follows: 1) The macroscopic/microscopic analysis of samples is always recommended (with the exception of samples coming from tissues that need surgery). This "old" procedure allows the identification in 20 minutes of all the parasites present in mixed infections, and the evaluation of the parasite load. It is a cost-effective method which relies ultimately on the skill of the observer to detect and identify parasite stages; 2) Parasite antigen detection is an innovative and expensive immunological diagnostic, which can suffer of sensitivity and specificity. It could be useful to directly diagnose "occult" infections; 3) Parasite DNA/RNA direct detection is an innovative, sensitive and specific procedure, which can also identify sibling species. It is expensive, therefore its use is restricted to reference laboratories; 4) Host antibody detection is an innovative indirect tool to evaluate the presence of a parasite by means the evaluation of the host response to infection. It can suffer of sensitivity and specificity, and the interpretation of the test results may be difficult. It could be applied as first step to evaluate the presence of tissue parasites, whose direct diagnosis would require surgery. Some tests can be performed in well-equipped laboratories; other tests are available through research laboratories. The specimens, appropriately collected and preserved, have always to be processed in security for potential risk of infection hazard, and submitted to tests appropriate to the laboratory's goals, where, therefore, field and research diagnostic tools shouldn't be applied. The test selected for routine use has to be chosen taking into account value and limitations of each method. Reduction in excessive and often unnecessary testing is mandatory, and therefore it is critical for the clinical Parasitology to perform relevant testing while maintaining appropriate quality. To date, the microscopic analysis of samples is the only direct method that allows all identifications in short times, at a reduced cost, independently from geographical origin and peculiar status of the patient. It has to be regarded as the first step in diagnostic procedures for all laboratories. Some molecular techniques have greater sensitivity than traditional methods, but at least at the present time, their costs may well preclude their routine use. It is difficult to know, exactly, where diagnostic Parasitology will be moving in the next few years, although many soothsayers feel very strongly that the area of molecular diagnostics will replace more traditional means. It is also possible that immunological or perhaps cytometric procedures will replace our more standard diagnostic approach; nevertheless they will continue to remain oddities on the outside of the general practice and be confined to a few reference laboratories. As far as semi-automated or automated instruments and robotics-based techniques, they are useful when large numbers of the same test are performed. Supposing that they will enter in our laboratory, that will happen in central facility rather than in each local facility. So, the great interest in using new technological methods to solve old problems probably will have to be seen in the right perspective.     

Physical diagnosis versus modern technology. A review.

The role of physical diagnosis in an age of modern diagnostic technology has been evaluated by investigators assessing specific techniques in a number of areas, though there has been no systematic comprehensive study of the sensitivity, specificity, cost-benefit ratio, and reliability of physical diagnosis relative to technologic diagnostic tools. In a review of published studies comparing physical with nonphysical diagnostic techniques, the startling accuracy of physical diagnosticians in some areas contrasts sharply with the extremely poor correlation of physical findings with autopsy or imaging studies in others. In a time of constricting financial resources, physicians-and those who teach or judge physicians'' skills-must begin to compare physical and nonphysical diagnostic techniques rigorously so that the best, safest, and least expensive diagnostic test is chosen in each clinical situation.     

Trace elements in buried human bones and their value. A review

Since more than a decade, the trace element content of archaeological human bones is analyzed by physical anthropologists. Some of these elements give clues to the diets of ancient populations, others serve in estimating weaning age and the length of the active reproductive time span in human females. Therefore, trace element analysis becomes very important for palaeodemography and palaeoecology. On the other hand, a lot of basic research still has to be carried out, especially concerning the alteration of trace element concentrations in ancient bones either by soil processes or by microorganisms. The lack of reference series is obvious. Recommendations for the techniques to be applied are given, the parameters which may bias the interpretation of the data are discussed and the diagnostic potential of trace element analysis is demonstrated.     

Quantitative multiplexed strategies for human Lyme disease serological testing

Lyme disease, which is primarily caused by infection with the bacterium Borrelia burgdorferi in the United States or other Borrelia species internationally, presents an ongoing challenge for diagnostics. Serological testing is the primary means of diagnosis but testing approaches differ widely, with varying degrees of sensitivity and specificity. Moreover, there is currently no reliable test to determine disease resolution following treatment. A distinct challenge in Lyme disease diagnostics is the variable patterns of human immune response to a plurality of antigens presented by Borrelia spp. during the infection. Thus, multiplexed testing approaches that capture these patterns and detect serological response against multiple antigens may be the key to prompt, accurate Lyme disease diagnosis. In this review, current state-of-the-art multiplexed diagnostic approaches are presented and compared with respect to their diagnostic accuracy and their potential for monitoring response to treatment.     

Partial AUC estimation and regression

Accurate diagnosis of disease is a critical part of health care. New diagnostic and screening tests must be evaluated based on their abilities to discriminate diseased from nondiseased states. The partial area under the receiver operating characteristic (ROC) curve is a measure of diagnostic test accuracy. We present an interpretation of the partial area under the curve (AUC), which gives rise to a nonparametric estimator. This estimator is more robust than existing estimators, which make parametric assumptions. We show that the robustness is gained with only a moderate loss in efficiency. We describe a regression modeling framework for making inference about covariate effects on the partial AUC. Such models can refine knowledge about test accuracy. Model parameters can be estimated using binary regression methods. We use the regression framework to compare two prostate-specific antigen biomarkers and to evaluate the dependence of biomarker accuracy on the time prior to clinical diagnosis of prostate cancer.     

Association of EBV infection with lymphomas

The diagnostic reliability of the IgA immunoblot test in the diagnosis of EBV associated lymphomas was examined. Serum samples from patients with clinically diagnosed lymphomas were tested for the presence of EBV specific IgG and IgA antibodies and based on test results the EBV association with lymphoma was estimated. Obtained results indicated that EBV IgA testing may be helpful in diagnosis of EBV association with lymphomas.     

Review: Diagnosis and treatment of dementia: 2. Diagnosis

Background

Dementia can now be accurately diagnosed through clinical evaluation, cognitive screening, basic laboratory evaluation and structural imaging. A large number of ancillary techniques are also available to aid in diagnosis, but their role in the armamentarium of family physicians remains controversial. In this article, we provide physicians with practical guidance on the diagnosis of dementia based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, held in March 2006.

Methods

We developed evidence-based guidelines using systematic literature searches, with specific criteria for study selection and quality assessment, and a clear and transparent decision-making process. We selected studies published from January 1996 to December 2005 that pertained to key diagnostic issues in dementia. We graded the strength of evidence using the criteria of the Canadian Task Force on Preventive Health Care.

Results

Of the 1591 articles we identified on all aspects of dementia diagnosis, 1095 met our inclusion criteria; 620 were deemed to be of good or fair quality. From a synthesis of the evidence in these studies, we made 32 recommendations related to the diagnosis of dementia. There are clinical criteria for diagnosing most forms of dementia. A standard diagnostic evaluation can be performd by family physicians over multiple visits. It involves a clinical history (from patient and caregiver), a physical examination and brief cognitive testing. A list of core laboratory tests is recommended. Structural imaging with computed tomography or magnetic resonance imaging is recommended in selected cases to rule out treatable causes of dementia or to rule in cerebrovascular disease. There is insufficient evidence to recommend routine functional imaging, measurement of biomarkers or neuropsychologic testing.

Interpretation

The diagnosis of dementia remains clinically integrative based on history, physical examination and brief cognitive testing. A number of core laboratory tests are also recommended. Structural neuroimaging is advised in selected cases. Other diagnostic approaches, including functional neuroimaging, neuropsychological testing and measurement of biomarkers, have shown promise but are not yet recommended for routine use by family physicians.     

Variability in the reproductive performance of beneficial insects in standard laboratory toxicity assays - Implications for hazard classification of pesticides

Nowadays the development of pesticides is not only directed to design compounds with sufficient efficacy against resistant and non-resistant strains of pests as well as with a high margin of safety for man and the environment, but also to allow their potential use in IPM (Integrated Pest Management) programmes. For identification of IPM suitable pesticides, a whole battery of standardised laboratory and semi-field test protocols have been developed. Based on the observed lethal and sublethal effects in those tests, compounds are categorised into different hazard groups which should advise farmers on their suitability for IPM. For a valid classification of compounds on the basis of laboratory test results, threshold values for lethal and sublethal effects have to be developed which reliably differentiate between harmful and safe compounds without bearing the risk of erroneous labelling and/or too frequent requests for higher tier testing. As an evaluation criterion for sublethal effects of pesticides, the reproductive performance of beneficial insects is frequently considered in standard laboratory assays. A preliminary analysis of available data on the reproductive performance of several standard test species elaborated during regulatory testing indicates that this evaluation criterion is subject to high variability. As expected, individual test species differed in their reproductive performance. Aleochara bilineata (Coleop-tera: Staphylinidae) and Orius insidiosus (Heteroptera: Anthocoridae) showed a fairly homogeneous reproductive performance within test series. Based on the observed variability of the reproductive performance in control groups, the average probability of an erroneous labelling of pesticides for these two species was only 4% and 6% (maximum probability: 13% and 19%), respectively, when an adverse effect threshold value of 30% (= actual value of the EU (European Union)) was applied. In contrast, Coccinella septempunctata (Coleoptera: Coccinellidae), Chryso-perla carnea (Neuroptera: Chrysopidae), Aphidius rhopalosiphi (Hymenoptera: Aphidiidae) and Trichogramma cacoeciae (Hymenoptera: Trichogrammatidae) exhibited a high variability in their reproductive performance, giving a mean probability between 25% and 35% (maximum probability: 36–64%) to label a pesticide either false positive or false negative. Besides species-inherent variability, there was an indication that test-inherent factors including parent sex ratio and parent breeding density may have had an influence on the reproductive performance of these insect species. Seasonal influences on the reproductive performance of the beneficial insects in laboratory testing were not evident. Based on our data analyses, there is a significant risk of erroneous classification of pesticides when the reproductive performance is quantitatively assessed following the currently established test protocols and an adverse effects threshold value of 30% is applied. We propose therefore that either the testing procedure for assessing the reproductive performance, or the effect threshold value for this evaluation criterion is reconsidered in the light of the high “species-inherent” variability in the reproductive performance of some beneficial insects.     

Screening and diagnosis for the fragile X syndrome among the mentally retarded: an epidemiological and psychological survey. Collaborative Fragile X Study Group.

The fragile X syndrome is an X-linked mental retardation disorder caused by an expanded CGG repeat in the first exon of the fragile X mental retardation (FMR1) gene. Its frequency, X-linked inheritance, and consequences for relatives all prompt for diagnosis of this disorder on a large scale in all affected individuals. A screening for the fragile X syndrome has been conducted in a representative sample of 3,352 individuals in schools and institutes for the mentally retarded in the southwestern Netherlands, by use of a brief physical examination and the DNA test. The attitudes and reactions of (non)consenting parents/guardians were studied by (pre- and posttest) questionnaires. A total of 2,189 individuals (65%) were eligible for testing, since they had no valid diagnosis, cerebral palsy, or a previous test for the FMR1 gene mutation. Seventy percent (1,531/2,189) of the parents/guardians consented to testing. Besides 32 previously diagnosed fragile X patients, 11 new patients (9 males and 2 females) were diagnosed. Scoring of physical features was effective in preselection, especially for males (sensitivity .91 and specificity .92). Major motives to participate in the screening were the wish to obtain a diagnosis (82%), the hereditary implications (80%), and the support of research into mental retardation (81%). Thirty-four percent of the parents/guardians will seek additional diagnostic workup after exclusion of the fragile X syndrome. The prevalence of the fragile X syndrome was estimated at 1/ 6,045 for males (95% confidence interval 1/9,981-1/ 3,851). On the basis of the actual number of diagnosed cases in the Netherlands, it is estimated that >50% of the fragile X cases are undiagnosed at present.     

Experience in managing a large-scale rescreening of Papanicolaou smears and the pros and cons of measuring proficiency with visual and written examinations

Experiences in a large-scale interlaboratory rescreening of Papanicolaou smears are detailed, and the pros and cons of measuring proficiency in cytology are discussed. Despite the additional work of the rescreening project and some psychological and technical problems, it proved to be a useful measure of the laboratory's performance as a whole. One problem to be avoided in future similar studies is the creation of too many diagnostic categories. Individual testing and certification have been shown to be accurate predictors of proficiency. For cytology, such tests require a strong visual component to test interpretation and judgment skills, such as by the use of glass slides or photomicrographs. The potential of interactive videodisc technology for facilitating cytopathologic teaching and assessment is discussed.