Top PDF Direct nitrate reductase assay versus microscopic observation drug susceptibility test for rapid detection of MDR-TB in Uganda.

Direct nitrate reductase assay versus microscopic observation drug susceptibility test for rapid detection of MDR-TB in Uganda.

Direct nitrate reductase assay versus microscopic observation drug susceptibility test for rapid detection of MDR-TB in Uganda.

The most common method for detection of drug resistant (DR) TB in resource-limited settings (RLSs) is indirect susceptibility testing on Lowenstein-Jensen medium (LJ) which is very time consuming with results available only after 2– 3 months. Effective therapy of DR TB is therefore markedly delayed and patients can transmit resistant strains. Rapid and accurate tests suitable for RLSs in the diagnosis of DR TB are thus highly needed. In this study we compared two direct techniques - Nitrate Reductase Assay (NRA) and Microscopic Observation Drug Susceptibility (MODS) for rapid detection of MDR-TB in a high burden RLS. The sensitivity, specificity, and proportion of interpretable results were studied. Smear positive sputum was collected from 245 consecutive re-treatment TB patients attending a TB clinic in Kampala, Uganda. Samples were processed at the national reference laboratory and tested for susceptibility to rifampicin and isoniazid with direct NRA, direct MODS and the indirect LJ proportion method as reference. A total of 229 specimens were confirmed as M. tuberculosis, of these interpretable results were obtained in 217 (95%) with either the NRA or MODS. Sensitivity, specificity and kappa agreement for MDR-TB diagnosis was 97%, 98% and 0.93 with the NRA; and 87%, 95% and 0.78 with the MODS, respectively. The median time to results was 10, 7 and 64 days with NRA, MODS and the reference technique, respectively. The cost of laboratory supplies per sample was low, around 5 USD, for the rapid tests. The direct NRA and MODS offered rapid detection of resistance almost eight weeks earlier than with the reference method. In the study settings, the direct NRA was highly sensitive and specific. We consider it to have a strong potential for timely detection of MDR-TB in RLS.
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Evaluation of rapid alternative methods for drug susceptibility testing in clinical isolates of Mycobacterium tuberculosis

Evaluation of rapid alternative methods for drug susceptibility testing in clinical isolates of Mycobacterium tuberculosis

A study was carried out to compare the performance of a commercial method (MGIT) and four inexpensive drug susceptibility methods: nitrate reductase assay (NRA), microscopic observation drug susceptibility (MODS) assay, MTT test, and broth microdilution method (BMM). A total of 64 clinical isolates of Mycobacterium tuberculosis were studied. The Lowenstein-Jensen proportion method (PM) was used as gold standard. MGIT, NRA, MODS, and MTT results were available on an average of less than 10 days, whereas BMM results could be reported in about 20 days. Most of the evaluated tests showed excellent performance for isoniazid and rifampicin, with sensitivity and specificity values > 90%. With most of the assays, sensitivity for ethambutol was low (62-87%) whereas for strepto- mycin, sensitivity values ranged from 84 to 100%; NRA-discrepancies were associated with cultures with a low proportion of EMB-resistant organisms while most discrepancies with quantitative tests (MMT and BMM) were seen with isolates whose minimal inhibitory concentrations fell close the cutoff. MGIT is reliable but still expensive. NRA is the most inexpensive and easiest method to perform without changing the organization of the routine PM laboratory performance. While MODS, MTT, and BMM, have the disadvantage from the point of view of biosafety, they offer the possibility of detecting partial resistant strains. This study shows a very good level of agreement of the four low-cost methods compared to the PM for rapid detection of isoniazid, rifampicin and streptomycin resistance (Kappa values > 0.8); more standardization is needed for ethambutol.
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COMPARATIVE EVALUATION OF THE NITRATE REDUCTASE ASSAY AND THE RESAZURIN MICROTITRE ASSAY FOR DRUG SUSCEPTIBILITY TESTING OF MYCOBACTERIUM TUBERCULOSIS AGAINST FIRST LINE ANTI-TUBERCULOSIS DRUGS

COMPARATIVE EVALUATION OF THE NITRATE REDUCTASE ASSAY AND THE RESAZURIN MICROTITRE ASSAY FOR DRUG SUSCEPTIBILITY TESTING OF MYCOBACTERIUM TUBERCULOSIS AGAINST FIRST LINE ANTI-TUBERCULOSIS DRUGS

NRA-7H9 and REMA were used to determine the susceptibility of 57 clinical isolates. Three isolates were resistant to INH by REMA and susceptible by NRA-7H9. One isolate was resistant to INH and to RMP by both methods. This MDR isolate was obtained from the sputum of a TB patient diagnosed in 2004 and previously treated for TB, but failed to complete the treatment, which is in agreement with studies that show that previous treatments are risk factors for the selection of resistant strains (3,6). The identification of a MDR strain highlights the need for implementation of susceptibility tests in the routine tuberculosis diagnose. The NRA-7H9 assay presented advantages to rapid and inexpensive determination of susceptibility profiles in clinical isolates. Detection of color change in the NRA is faster (immediately after addition of the reagents) than redox methods and more cost-effective for developing countries. Moreover, as nitrate reductase activity is used as one of the discriminatory tests for the identification of M. tuberculosis, this method provides specificity to the test unlike the general metabolic activity detected by other dyes. NRA might represent an inexpensive and alternative assay for rapid detection of resistance in low-income countries.
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PROPEC-Programa de Pós Graduação em Engenharia Cívil :: APPROACHES FOR AUTOMATED DAMAGE DETECTION IN STRUCTURAL HEALTH MONITORING

PROPEC-Programa de Pós Graduação em Engenharia Cívil :: APPROACHES FOR AUTOMATED DAMAGE DETECTION IN STRUCTURAL HEALTH MONITORING

Over the last decades, several techniques have been developed in the context of Structural Health Monitoring (SHM) programs. However, when it comes to novelty (or damage) detection, these methods are inevitably based on human decisions. Moreover, most of the strategies already published in this topic mainly focus on modal identification procedures and tracking their outputs i.e., structural modal parameters. Such approaches usually lead to high computational costs and can still be insensitive to minor changes in structural behavior, thus missing crucial damage scenarios in their initial manifestations. To circumvent these drawbacks, recent researches showed that the use of symbolic representations derived directly from raw time-domain data (e.g. acceleration measurements) could provide more damage- sensitive responses with lower computational effort. Indeed, good results have been achieved by representing raw measurements in terms of their statistical distributions over time. Nevertheless, the lack of information regarding the frequency spectrum represents a decisive drawback. Therefore, this paper presents a novel symbolic object, which considers both time and frequency responses of structural dynamic measurements. Then, the proposed methodology employs a k-medoids clustering over such objects within a moving time- window framework and uses a single-valued index to indicate whether a novelty is present in the acquired data. Two practical studies – a 3D frame tested in laboratory and a motorway bridge – show that the proposed approach provide an unsupervised and adaptive scheme for SHM applications.
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Predictors of multidrug- and extensively drug-resistant tuberculosis in a high HIV prevalence community.

Predictors of multidrug- and extensively drug-resistant tuberculosis in a high HIV prevalence community.

Recent global data have shown rising rates of drug-resistant TB in sub-Saharan Africa, the region also suffering from the world’s highest burden of HIV/AIDS [23]. This is the first study of clinical predictors of MDR and XDR TB in a high HIV prevalence setting and provides important insights into the clinical charac- teristics of patients with drug-resistant TB. We found that three readily available pieces of clinical data – hospitalization history, TB treatment history and HIV status – were strong independent predictors for MDR or XDR TB. Using these data, clinicians practicing in high HIV prevalence settings may be able to cohort high-risk inpatients to reduce transmission and target drug- susceptibility testing where DST resources are limited. Addition- ally, our findings support the need for strengthening hospital infection control measures, including reducing the duration of hospitalization in high HIV prevalence settings.
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Mortality among MDR-TB cases: comparison with drug-susceptible tuberculosis and associated factors.

Mortality among MDR-TB cases: comparison with drug-susceptible tuberculosis and associated factors.

This study includes over 200 cases of MDR-TB under a directly-observed treatment scheme (DOTS), which is a notable strength. In addition, sample size allowed us to control for several variables in our proposed models. Nevertheless, this study has several limitations. First, non- TB related deaths such as accidents or other chronic diseases could have been included as the death certificate stating specific cause of death was not available. Although this might propose a bias in our findings, the results are greatly compatible and comparable with literature. Sec- ond, it was not possible to obtain drug-susceptibility test data for non-MDR TB participants. Drug-susceptibility and cultures are performed only in those with high risk or suspected MDR- TB, yet are not done in patients without such risk factors. Third, the starting point of evalua- tion, especially in the situation of MDR-TB cases, can be an issue as potentially resistant forms of tuberculosis may need longer periods of diagnosis and have previously administered treat- ment. Therefore, our results might be overestimated. Nonetheless, our findings are comparable to the investigations previously mentioned—many of which consider the beginning of treat- ment as their starting point of analysis. In addition, data from the ESNPCT maintains a certain level of objectivity and uniformity as it bases its clinical records on clinical forms and notifica- tions. Fourth, there is a possibility of misclassification of MDR-TB into the drug-susceptible group as MDR-TB is widely under-diagnosed. Nevertheless, our findings show a high propor- tion of MDR-TB cases (about 20%), greater than previous studies using cultures to detect resis- tant cases [11] and even greater than the official ESNPCT surveillance report [5]. Finally, the data concerning smoking, alcohol and drug use was collected as a self-report notification. No clinical parameters, questionnaires or scales were applied to properly define the use of these substances. Due to its small amount, we believe that the risk of misclassification is non-differ- ential, thus allowing the report of a true association.
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A conglutination test for rapid detection of antibodies against Babesia bigemina

A conglutination test for rapid detection of antibodies against Babesia bigemina

Serological tests are very important in accomplishing these t asks. Over t he last few decades, various serological t ech- niques have been developed to increase sensitivity and specifi- city (Wright 1990). Highly purified antigens have recently been obt ained t hrough molecular biological met hods. Subunit antigens with defined specificity have been used in enzyme- linked immunosorbent assay (ELISA) (Goff et al. 1989, Böse et al. 1995), but in spite of these improvements, the sensitivity obtained was not superior to that of the indirect fluorescent antibody technique (IFAT). Other desirable test characteristics besides specificity and sensitivity would include simplicity, economy and rapid results such that the assay could be used in minimally equipped laboratories or under field conditions. Agglut inat ion t est s meet most of t hese requirement s, however, usually agglutination test sensitivity is lower than that of other serological tests. The introduction of conglutinin, considerably increased the sensitivity of the card agglutination test for detection of antibodies against Anaplasma marginale (Amerault et al. 1972, Rose et al. 1974). The present paper descr i bes t he devel opm ent and eval uat i on of a r api d conglut inat ion t est (RCT) for t he det ect ion of ant ibodies against B. bigemina .
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Quím. Nova  vol.32 número4

Quím. Nova vol.32 número4

In order to obtain a simple, cheaper, faster, less environmental toxic method for the quantitative assay of dexamethasone in tablets (drug assay and dissolution test), this study aimed to validate a spectrophotometric method, employing mainly distilled water, as solvent. The validation procedure was carried out according to the ICH guideline and the parameters evaluated were specificity, linearity, range, precision, accuracy, and robustness. 22

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Fast detection of Mycobacterium tuberculosis in culture-positive sputum samples by nitrate reductase activity

Fast detection of Mycobacterium tuberculosis in culture-positive sputum samples by nitrate reductase activity

The nitrate-supplemented Middlebrook broth (7H9- N) proved to be better for the detection of bacillus growth in clinical specimens. The 7H9-N assay revealed an easy and fast evidence of the presumptive M. tuberculosis growth by the strong reduction of nitrate into nitrite when compared to the solid media, OK and OK-N. Our results corroborate those by Rageade et al. (2014). The difference between solid and broth media is well explained due to favorable growth in broth medium and the need to visualize colonies in solid form to perform nitrate reductase reaction. Nonetheless, OK-N or OK allows the visual observation of typical colony morphology and pigment production. The OK medium was chosen for sodium nitrate supplementation in current assay due to its buffered formulation and to the easy and fast sputum decontamination protocol, by which specimen cultures may be feasible in any clinical laboratory for implementing TB diagnosis.
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Nitrate reductase activity in the diatom

Nitrate reductase activity in the diatom

Nutritional and pboto-period pre-conditionings: The concentration of nitrate, nitrite and NR activity were measured for populations grown under three different culture [r]

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Use of Lot Quality Assurance Sampling to Ascertain Levels of Drug Resistant Tuberculosis in Western Kenya.

Use of Lot Quality Assurance Sampling to Ascertain Levels of Drug Resistant Tuberculosis in Western Kenya.

Further, we encountered several logistical challenges that may have compromised sampling and thus may have biased results. For example, flooding at the Mukhobola clinic (rural setting), resulted in a month long closure to enrollment. In the rural clinics, several occurrences of sup- ply shortages, inadequate staffing, and prolonged turn around time for routine microscopy limited laboratories’ capacity for case detection. Maintaining a cold chain during specimen transport was also an obstacle in that a number of specimens were contaminated, up to 11% per clinic, by the time they arrived at the MRL. This problem is common to surveys regardless of design that do not conduct DST on site, suggesting that rapid, on site resistance testing may improve sampling. The validity of our results assume that each of these issues resulted in potentially eligible patients being omitted from the study at random with respect to drug resis- tance, an assumption which is reasonable, but not testable with the available data.
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Detection of group A beta-hemolytic Streptococcus employing three different detection methods: culture, rapid antigen detecting test, and molecular assay

Detection of group A beta-hemolytic Streptococcus employing three different detection methods: culture, rapid antigen detecting test, and molecular assay

We thank Mr. Marcel Frederico de Lima Taga from the Dept. of Preventive Medicine, Biostatistical Division, UNIFESP (São Paulo) for his kindness in assisting us with the statistical analyses. We also thank much Dr. Lee Harker; Deputy Director of the Boystown R.C. (Omaha) for his generous help in revising the text. This paper was presented at the American Academy of Otolaryngology- Head and Neck Surgery Meeting held in San Diego, California, USA, (September 22-25, 2002).

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Rapid induction of GFP expression by the nitrate reductase promoter in the diatom Phaeodactylum tricornutum

Rapid induction of GFP expression by the nitrate reductase promoter in the diatom Phaeodactylum tricornutum

Bowler C, Allen AE, Badger JH, Grimwood J, Jabbari K, Kuo A, Maheswari U, Martens C, Maumus F, Otillar RP, Rayko E, Salamov A, Vandepoele K, Beszteri B, Gruber A, Heijde M, Katinka M, Mock T, Valentin K, Verret F, Berges JA, Brownlee C, Cadoret J-P, Chiovitti A, Choi CJ, Coesel S, De Martino A, Detter JC, Durkin C, Falciatore A, Fournet J, Haruta M, Huysman MJJ, Jenkins BD, Jiroutova K, Jorgensen RE, Joubert Y, Kaplan A, Kro¨ger N, Kroth PG, La Roche J, Lindquist E, Lommer M, Martin-Je´ze´quel V, Lopez PJ, Lucas S, Mangogna M, McGinnis K, Medlin LK, Montsant A, Oudot-Le Secq M-P, Napoli C, Obornik M, Parker MS, Petit J-L, Porcel BM, Poulsen N, Robison M, Rychlewski L, Rynearson TA, Schmutz J, Shapiro H, Siaut M, Stanley M, Sussman MR, Taylor AR, Vardi A, von Dassow P, Vyverman W, Willis A, Wyrwicz LS, Rokhsar DS, Weissenbach J, Armbrust EV, Green BR, Van de Peer Y, Grigoriev IV. 2008. The Phaeodactylum genome reveals the evolutionary history of diatom genomes. Nature 456(7219):239–244 DOI 10.1038/nature07410.
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Sequential analysis as a tool for detection of amikacin ototoxicity in the treatment of multidrug-resistant tuberculosis

Sequential analysis as a tool for detection of amikacin ototoxicity in the treatment of multidrug-resistant tuberculosis

Objective: To investigate early detection of amikacin-induced ototoxicity in a population treated for multidrug-resistant tuberculosis (MDR-TB), by means of three different tests: pure-tone audiometry (PTA); high-frequency audiometry (HFA); and distortion-product otoacoustic emission (DPOAE) testing. Methods: This was a longitudinal prospective cohort study involving patients aged 18-69 years with a diagnosis of MDR-TB who had to receive amikacin for six months as part of their antituberculosis drug regimen for the first time. Hearing was assessed before treatment initiation and at two and six months after treatment initiation. Sequential statistics were used to analyze the results. Results: We included 61 patients, but the final population consisted of 10 patients (7 men and 3 women) because of sequential analysis. Comparison of the test results obtained at two and six months after treatment initiation with those obtained at baseline revealed that HFA at two months and PTA at six months detected hearing threshold shifts consistent with ototoxicity. However, DPOAE testing did not detect such shifts. Conclusions: The statistical method used in this study makes it possible to conclude that, over the six- month period, amikacin-associated hearing threshold shifts were detected by HFA and PTA, and that DPOAE testing was not efficient in detecting such shifts.
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Multidrug-Resistant Tuberculosis in Patients with Chronic Obstructive Pulmonary Disease in China.

Multidrug-Resistant Tuberculosis in Patients with Chronic Obstructive Pulmonary Disease in China.

Some limitations should be mentioned in our study. Firstly, as a hospital-based retrospective observational study, our data was limited by the relatively small numbers of MDR-TB and COPD patients, and reflective of clinical practice in 2011–2014. Furthermore, some of the heavy smoking patients who did not undergo spirometry might be suffering from uncharac- terised, undiagnosed COPD. A larger sample and prospective study should be done to verify these associations. Secondly, in our study, the results of spirometry in COPD patients were recorded before TB diagnosis, thus the spirometry is the inability to reflect the lung function at the time of diagnosis of MDR-TB. However, in clinical practice, spirometry could be avoided in positive sputum culture patients owing to preventing the spread of TB. Thirdly, inhaled ste- roid therapy in COPD is a potential risk factor for the development of pneumonia. However, the association between inhaled steroid therapy and MDR-TB was not significant in this study, maybe due to missing data or an insufficient number of patients. The underlying mechanism association warrant further studies. Lastly, the role of antibiotics and systemic steroids therapy in COPD was not evaluated because the data of dosage and term prior to admission were not sufficiently robust due to a high percentage of unknown/unreliable results for self-reporting.
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Major Challenges in Clinical Management of TB/HIV Coinfected Patients in Eastern Europe Compared with Western Europe and Latin America.

Major Challenges in Clinical Management of TB/HIV Coinfected Patients in Eastern Europe Compared with Western Europe and Latin America.

participants in EE received inadequate treatment regimens. These results emphasize the need for improved diagnostic facilities and laboratory capacity as a political and public health prior- ity, particularly in the Eastern European region [22]. Additionally, of those patients from EE who had a DST available, only half with MDR-TB were additionally tested for XDR-TB. Rapid identification of patients infected with R resistant strains, a surrogate marker for MDR-TB, would allow for “up-front” adjustment of anti-TB treatment and thereby providing clinicians the opportunity to initiate a more accurate and effective treatment regimen. The WHO recom- mends that the Xpert MTB/RIF test, an automated molecular test for Mtb and resistance to R, should be used as the initial diagnostic test in individuals suspected of having MDR-TB or HIV-associated TB [23]. Early detection of MDR-TB is essential to reduce death rates, lower spread and prevent further development of drug resistance including development of XDR-TB, and the Xpert MTB/RIF test has been shown to be particularly effective in HIV-positive patients who more often present with smear-negative disease [24].
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DETECTION OF RABIES VIRAL ANTIGEN IN CATTLE BY RAPID IMMUNOCHROMTOGRAPHIC DIAGNOSTIC TEST

DETECTION OF RABIES VIRAL ANTIGEN IN CATTLE BY RAPID IMMUNOCHROMTOGRAPHIC DIAGNOSTIC TEST

antigen. This is a chromatographic immune assay. For each sample, 10% brain homogenate was prepared in PBS. Then the sample was collected using swab and mixed in the sample diluents tube provided in the test kit. Finally, sample was added into the sample hole of the test device using a disposable dropper. The purple color band moved across the result window in the centre of the test device indicating proper loading of the sample. Results were interpreted within 5-10 minutes.

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Rational design, synthesis, and biological evaluation of heterocyclic quinolones targeting the respiratory chain of Mycobacterium tuberculosis

Rational design, synthesis, and biological evaluation of heterocyclic quinolones targeting the respiratory chain of Mycobacterium tuberculosis

TB, tuberculosis; MDR, multidrug resistant; XDR, extensively drug resistant; Mtb, Mycobacterium tuberculosis; NADH, nicotinamide adenine dinucleotide; ETC, electron transport chain; ATP, adenosine triphosphate; ETF, electron transferring flavoprotein; FRD, fumarate reductase; nar, nitrate reductase; HTS, high throughput screen; DMPK, drug metabolism and pharmacokinetics; SAR, structure −activity relationship; DMF, dimethylformamide; GSK, GlaxoSmithKline; NBS, N-bromo succinamide; DCM, dichloromethane; PCC, pyridinium chlor- ochromate; EDC, 1-ethyl-3-(3-(dimethylamino)propyl)- carbodiimide; NHS, N-hydroxy succinamide; GLU, glucose; PPB, plasma protein binding; CL, clearance; AUC, area under the curve; TI, therapeutic index; hERG, human ether-a ̀-go-go- related gene; NC, not calculated; ND, not determined; ID, identi fication; M, metabolite; SD, Sprague−Dawley; HPLC, high performance liquid chromatography; TLC, thin layer chroma- tography; DMSO, dimethyl sulfoxide; NADPH, nicotinamide adenine dinucleotide phosphate; MTT, 3-(4,5-dimethylthiazol- 2-yl)-2,5-diphenyltetrazolium bromide; DMEM, Dulbecco ’s Modified Eagle’s Medium; FBS, fetal bovine serum; HEPES, (4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid; FCS, fetal calf serum; TEER, trans-epithelial electrical resistance; HBSS, Hank ’s balance salt solution; LC-MS, liquid chromatograph− mass spectrometry
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Detection of Cryptosporidium parvum oocysts in calf fecal samples by direct immunofluorescence assay

Detection of Cryptosporidium parvum oocysts in calf fecal samples by direct immunofluorescence assay

The aim of this study was to produce a conjugate containing anti-Cryptosporidium parvum polyclonal antibodies and standardize a Direct Immunofluorescence Assay (DIF) for detecting C. parvum oocysts in fecal samples from calves. In order to obtain anti-C. parvum polyclonal antibodies, two New Zealand rabbits were immunized with a purified solution of C. parvum oocysts and Freund’s adjuvant. Purification of the immunoglobulin G (IgG) fraction was performed by means of precipitation in ammonium sulfate and chromatography using a DEAE-cellulose column. The anti-C. parvum polyclonal antibody titer was determined by means of the enzyme-linked immunosorbent assay (ELISA). The rabbit anti-C. parvum IgG fraction was conjugated with fluorescein isothiocyanate and standardization of the DIF was performed using various dilutions of conjugate on slides positive for C. parvum oocysts. The cross-reactivity of the anti-C. parvum conjugate was tested using oocysts of Cryptosporidium serpentis, Cryptosporidium andersoni, Escherichia coli, Eimeria sp., and Candida sp. An anti-C. parvum conjugate was successfully produced, thus allowing standardization of DIF for detection of Cryptosporidium oocysts in fecal samples. Cross-reactivity of anti-C. parvum polyclonal antibodies with C. andersoni and C. serpentis was also observed.
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Evaluation of the Rapid Diagnostic Test OptiMAL for Diagnosis of Malaria due to Plasmodium vivax

Evaluation of the Rapid Diagnostic Test OptiMAL for Diagnosis of Malaria due to Plasmodium vivax

This phenomenon has been described by Palmer et al. and in other studies, both for P. vivax and P. falciparum diagnosis, with 100% sensitivity for parasitemia higher than 1,000 parasites/ul, and 40% for values lower than 100 parasites/ul [23]. The explanation for this phenomenon could be that the quantity of P. vivax lactate dehydrogenase enzyme, the antigen detected by OptiMAL, is in direct proportion to the number of parasites in the blood [24]. This problem must be considered when this test is used in the field. Another limitation of the OptiMAL test is that it cannot identify patients with mixed infections of P. falciparum and P. vivax. The reason is that one of detected antigens is P. falciparum specific, but the other is not specific, because is a panmalaric antigen; therefore in mixed infections, the test will show a P. falciparum infection. Although the number of patients with mixed infection is low, it can be a therapeutic problem in endemic areas where more than one Plasmodium species coexists, and it can be as high as 8%-10% [6]. This was not our case, as Pangoa is an endemic area for P. vivax and P. malarie only. We did not encounter any cases of P. malarie; and we saw one case of P. falciparum diagnosed by OptiMAL, which in the thick smear was found to be P. vivax, although ideally, a PCR should have been made.
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