Myelin basic protein, oligoclonal bands, and IgG in cerebrospinal fluid as indicators of multiple sclerosis

There currently are three clinical laboratory procedures for use with cerebrospinal fluid that assist in the diagnosis of multiple sclerosis: measurement of myelin basic protein and IgG, and demonstration of an oligoclonal band. We compared characteristics of these procedures, using CSF samples from 166 patients identified as having (54 patients) or not having (112 patients) multiple sclerosis. We find that oligoclonal band demonstration is the most useful single test in helping to establish the presence of multiple sclerosis; IgG quantitation is the least helpful. Myelin basic protein should be quantitated for following the activity of multiple sclerosis; it may be applied only selectively in the context of screening. The incidence of false-positive results reinforces the view that the diagnosis of multiple sclerosis must be made in clinical context. These laboratory procedures are not suitable for use as screening tests.     

Carbon monoxide poisoning. An occult epidemic.

Carbon monoxide poisoning is a significant health threat in the United States. Smoke inhalation from fires is the most common source. History of carbon monoxide exposure and elevated carboxyhemoglobin levels should alert physicians to the diagnosis of acute poisoning. When there is no history of exposure, carbon monoxide poisoning must be considered when two or more patients are similarly or simultaneously sick. The diagnosis must be excluded by a directed history and physical examination. If suspicion remains, carboxyhemoglobin levels should be determined and oxygen therapy should be started empirically while laboratory results are pending. Prompt administration of hyperbaric oxygen may reduce the risk of death. If carbon monoxide poisoning is confirmed, the source must be identified and recommendations for correction or avoidance should be made.     

Differential diagnosis of midline facial granulomas.

The list of differential diagnoses in the case of midline facial granulomatous lesions is long. Intensive investigation into the true origin of disease must be done before definitive treatment can be begun. Extensive and repeated biopsies are necessary. The diagnosis may narrow down to the nonspecific midline lethal granuloma. Evidence in the literature coupled with our experience strongly indicates that this disease does not exist as a pathologic entity but merely as a clinical syndrome which upon further evaluation will reveal either Wegener's granulomatosis or a reticulum cell neoplasm. Treatment of the syndrome consists of corticosteroid drugs, irradiation, and chemotherapy until a definitive diagnosis is made. Midline granulomas have been and will continue to be a challenging diagnostic and therapeutic problem for the otolaryngologist.     

Is it Lyme disease? How to interpret results of laboratory testing.

Although laboratory testing is likely to have a greater role in diagnosis and monitoring of treatment of Lyme disease in the future, at present physicians must rely on a combination of history taking, clinical manifestations, and laboratory results. Unwarranted antibiotic therapy is to be avoided. Asymptomatic persons with positive serologic results who live in an endemic area present a challenge, and borderline serologic results in patients with manifestations of late Lyme disease are also troubling. All relevant clinical information must be considered before treatment is undertaken, until more specific and sensitive tests are available.     

Bioterrorism: What? Why? and Who?

The former Secretary of the Department of Health and Human Services, Donna Shalala, indicated in an address in 1999 that complacency needs to be replaced with a sense of urgency in order for us to deal successfully with the threats of bioterrorism. The attack on September 11, 2001 and the anthrax threats have made our vulnerability clear. We are now living in a new and frightening world. Our complacency is gone. The victims and the survivors shall remain forever in our minds. Dr. Jeffery Koplan, Director, Centers for Disease Control and Prevention in his broadcast, Building Infrastruture to Protect the Public Health said we must look at preparedness in a new way. We need to: build a solid public health infrastructure with grant monies; rapidly address the problem of inadequately trained staff; and address the capacity of a laboratory to produce timely and accurate results for the diagnosis of agents in the investigation of outbreaks. We must take action to prepare the healthcare system to rapidly meet any challenge, overt or covert, that may emerge.     

Prenatal diagnosis of fetal lymphatic system abnormalities by ultrasound.

Antenatal ultrasound diagnoses of gross lymphatic system abnormalities were made in three fetuses. Although the diagnosis was made in only 1 fetus at a stage early enough in pregnancy to allow selective termination, knowledge of the abnormality in the remaining 2 fetuses proved to be valuable for subsequent management of those pregnancies. It is stressed that the extent of the abnormality must be carefully assessed because of the possibility of corrective surgery should the lesion be small and that the parents must be given detailed counseling before any definitive measures are taken.     

Infektiöse Spondylitis als Differenzialdiagnose persistierender Rückenschmerzen

PATIENTS: Between 1/1994 and 12/1998 40 patients with a vertebral osteomyelitis were treated at the Orthopedic University Hospital of Witten/Herdecke. All data of 15 female and 25 male patients with an mean age of 61 years (25-87 years) were analyzed in a retrospective study. Diagnosis of vertebral osteomyelitis was made between 1 and 84 weeks after onset of symptoms. Before admissions in our hospital up to 4 hospitalizations without proper diagnosis were reported. TREATMENT: The treatment consisted bed-rest in an individual orthesis and percutaneous discovertebral biopsy before systemic administration of antibiotics. In 11 from a total of 21 biopsies we could prove bacteria as follows: 6 times Staphylococcus aureus, 2 times E. coli and 3 times Mycobacterium tuberculosis. Radiological diagnosis was made by conventional x-ray in 2 dimensions and nuclear magnetic resonance. Together with radiological, histological, microbiological and laboratory investigation we found 11 patients with a specific tuberculosis of the spine, 25 patients with a pyogenic vertebral osteomyelitis and 4 patients with a post-nucleotomy osteomyelitis. 14 patients underwent operative treatment. All patients were mobilized in an individual brace after CRP and ESR indicated remission of inflammation. DURATION OF HOSPITAL TREATMENT: Duration of the hospital treatment lasted between 33 and 137 days. At follow-up 12 months after demission 35 patients were free of symptoms, two patients had still signs of osteomyelitis, two patients, one of them with recurrence of spondylitis, were reoperated because of dislocation of the implants, and one patient died after surgery suffering from severe peritonitis and multi-organ-failure. DISCUSSION: We report pathogenesis and the current diagnostic and therapeutic concept of treatment of the vertebral osteomyelitis. Despite modern diagnostic possibilities, diagnosis of vertebral osteomyelitis is often made very late. Vertebral osteomyelitis is an important differential diagnosis for persistent back pain and needs to be considered more often.     

Reduction of the rate of false-positive cultures of Mycobacterium tuberculosis in a laboratory with a high culture positivity rate.

Our laboratory, engaged in a prospective study of adult pulmonary tuberculosis, processed on average 1186 sputum samples per year for the detection of Mycobacterium tuberculosis (M. tuberculosis). Approximately 55% of all sputum samples were culture-positive. The study protocol required that all patients had their M. tuberculosis isolates DNA fingerprinted at diagnosis, and at subsequent time points if the patients either failed treatment or presented again with tuberculosis. Over a 22-month period, there were 14 apparent treatment failures from 109 patients who had completed 6 months of therapy. Only two of these were true treatment failures, while the other 12 had DNA fingerprints that were different from those obtained at diagnosis. It was concluded that these 12 cultures represented episodes of laboratory cross-contamination. Retrospective DNA fingerprinting of patient isolates was done so that each patient had at least two independent isolates fingerprinted. This survey revealed that 7.3% of DNA fingerprints were discordant. False-positive cultures with discordant DNA fingerprints generally arose late in chemotherapy and the isolates were usually co-processed with other strongly smear-positive sputum samples. Simple modifications of laboratory procedures were made, and over a following 10.5-month period the false-positive rate was reduced to 2.1%. These modifications did not increase the workload or the cost of processing samples and can thus be used successfully by any laboratory, and particularly by those in resource-poor settings.     

介绍一种诊断明确时定性检测方法的性能评估方案

目的建立一种诊断明确时定性检测方法的性能评估方案。方法采用比较分析的方法，分别将新方法和原方法的检测结果与明确诊断结果进行比较。结果以实例的方式将新方法、原方法的检测结果和诊断结果进行比较，得出性能较好的定性检测方法。结论定性检测是临床实验室一种很重要的检测方法，其检测性能如何直接决定患者的检测结果，该评估方法的提出为临床实验室引入一种新的检测方法提供了指南。     

Cross matching

Donor blood should be selected properly before transfusion. Cross-matching has to be done in the laboratory by at least two established techniques. The importance of the bedside test and the controlled blood transfusion is pointed out.     

Cerebral malaria versus bacterial meningitis in children with impaired consciousness.

Cerebral malaria (CM) and acute bacterial meningitis (ABM) are the two common causes of impaired consciousness in children presenting to hospital in sub-Sahara Africa. Since the clinical features of the two diseases may be very similar, treatment is often guided by the initial laboratory findings. However, no detailed studies have examined the extent to which the laboratory findings in these two diseases may overlap. We reviewed data from 555 children with impaired consciousness admitted to Kilifi District Hospital, Kenya. Strictly defined groups were established based on the malaria slide, cerebrospinal fluid (CSF) leucocyte count and the results of blood and CSF culture and CSF bacterial antigen testing. Our data suggests significant overlap in the initial CSF findings between CM and ABM. The absolute minimum proportions of children with impaired consciousness and malaria parasitaemia who also had definite bacterial meningitis were 4% of all children and 14% of children under 1 year of age. The estimated maximum proportion of all children with impaired consciousness and malaria parasitaemia in whom the diagnosis was dual or unclear was at least 13%. The finding of malaria parasites in the blood of an unconscious child in sub-Saharan Africa is not sufficient to establish a diagnosis of cerebral malaria, and acute bacterial meningitis must be actively excluded in all cases.     

The late Greco-Roman and Byzantine contribution to the evolution of laboratory examinations of bodily excrement. Part 1: Urine, sperm, menses and stools.

It is a common belief that laboratory investigation processes were developed after the 16th century and that before that time no attempts were made to attain a diagnosis by investigating material coming from the human body. In this paper we present data extracted from Byzantine codices that support the following thesis: The idea of examining human excrement for diagnostic purposes has its roots in the Roman and Byzantine eras. The lack of technological means was no obstacle for the doctor to create an "examinational" mind, i.e., to try to correlate the macroscopic findings in the excrement with the pathophysiological mechanism that induced it, using only the human senses.     

Laboratory safety and the WHO World Alliance for Patient Safety

Laboratory medicine has been a pioneer in the field of patient safety; indeed, the College of American Pathology first called attention to the issue in 1946. Delivering reliable laboratory results has long been considered a priority, as the data produced in laboratory medicine have the potential to critically influence individual patients' diagnosis and management. Until recently, most attention on laboratory safety has focused on the analytic stage of laboratory medicine. Addressing this stage has led to significant and impressive improvements in the areas over which laboratories have direct control. However, recent data demonstrate that pre- and post-analytical phases are at least as vulnerable to errors; to further improve patient safety in laboratory medicine, attention must now be focused on the pre- and post-analytic phases, and the concept of patient safety as a multi-disciplinary, multi-stage and multi-system concept better understood. The World Alliance for Patient Safety (WAPS) supports improvement of patient safety globally and provides a potential framework for considering the total testing process.     

Headache resembling tension-type headache as the single manifestation of Lyme neuroborreliosis

We present two patients with monosymptomatic headache resembling chronic tension-type headache as the first manifestation of Lyme neuroborreliosis. The headache developed over a few days in both cases and lasted for three months in the first case and for two and a half years in the second case before the diagnosis of Lyme neuroborreliosis was made. Neuroimaging and many laboratory investigations did not lead to the diagnosis, which was only established after lumbar puncture. The CSF in both cases showed high protein, lymphocytic pleocytosis and Borrelia burgdorferi-specific intrathecal antibody synthesis. The headache disappeared completely after treatment with penicillin G. In patients suffering from daily headaches which have developed subacutely, Lyme neuroborreliosis should be considered even in the absence of signs of meningeal irritation. A lumbar puncture should be performed more often than is presently customary and the CSF should be examined for pleocytosis as well as Borrelia burgdorferi -specific intrathecal antibody synthesis.     

"Falling snowflakes," an ultrasound sign of hydatid sand

It has been claimed that the distinction between a simple cyst and a simple noncomplicated hydatid cyst cannot be made by ultrasound examination. It is very important to make this distinction before attempting a diagnostic or therapeutic puncture of a cyst, at least in geographic areas where echinococcosis is endemic. The authors report an ultrasound sign that makes this differential diagnosis possible.     

Colonoscopy in inflammatory bowel disease

This article discusses the important role endoscopy plays in the diagnosis and management of inflammatory bowel disease and how the procedure adds crucial information to the constellation of history, physical examination, radiographic findings, and laboratory values. Differentiation between Crohn's disease and ulcerative colitis has important ramifications for medical therapy, surgical options, and prognosis. This distinction can be accurately made in at least 85% of patients.     

Role of testing for anticytoplasmic autoantibodies in the differential diagnosis of scleritis and orbital pseudotumor

Wegener's granulomatosis is a multisystem disease often with protean manifestations. Eye signs and symptoms can be prominent and may be the patient's initial complaint. For a definitive diagnosis of Wegener's granulomatosis, a tissue biopsy specimen must show vasculitis and necrotizing granuloma. The presence of anticytoplasmic autoantibodies in the serum of patients has been found to be highly specific for Wegener's granulomatosis and can considerably facilitate early diagnosis and be used to monitor disease activity. In two illustrative cases, the utility of this laboratory test in the differential diagnosis of scleritis and orbital pseudotumor is demonstrated.     

Laboratory request appropriateness in emergency: impact on hospital organization.

Within the activities of the Risk Management Unit of the Bari Polyclinic Hospital Corporation, an anomalous trend was found, with excessive requests for urgent laboratory tests being made in the time period between 05:00 and 07:45 h. In addition to slowing down laboratory operations, this anomaly suggested the possibility of inappropriate testing, at least in terms of the request mode, if not in absolute terms. An audit was implemented within the facility to check the grounds of this suspicion and to identify any errors and/or critical points. The results gathered are extremely interesting, as they show deficiencies at both the organizational and clinical level. The final objective of the investigation is to draft a common corporate procedure.     

Diagnostic aspects of ischemic abdominal visceropathy

The clinical picture and results of instrumental and laboratory investigation of 60 patients suffering from atherosclerosis of unpaired branches of the abdominal aorta with the involvement of the digestive system (ischemic abdominal visceropathy) were analyzed. A scheme of combined clinico-instrumental diagnosis of abdominal atherosclerosis to be made in a hospital was developed.     

Evolution in indications for blood component transfusion.

Indications for blood components are changing but continue to be based on a combination of clinical assessment and laboratory data. In the perioperative setting, some decisions must be made before laboratory data are available. To prevent the inappropriate usage of blood components, prophylactic or expectant treatment should be limited. In red cell transfusion, physiologic indices of oxygen utilization may soon supplement hemoglobin/hematocrit levels in clinical decision making. Less progress has been made in transfusion for hemostasis. Well-designed clinical studies are needed to answer remaining questions; in the interim, nationally accepted guidelines are available to assist clinicians in their decisions.