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Table 3.

Summary of Available Tests for Infection, in Decreasing Order of Sensitivity

Must be combined with a toxin test.

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Table 3.

Summary of Available Tests for Infection, in Decreasing Order of Sensitivity

Must be combined with a toxin test.

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The other reference method is the cell cytotoxicity neutralization assay (CCNA), which detects toxin directly in stool. This assay begins with preparation of a stool filtrate, which is applied to a monolayer of an appropriate cell line, such as Vero cells, or human fibroblasts, among others. Following incubation, the cells are observed for cytopathic effect (CPE); duplicate testing is usually carried out simultaneously with neutralizing antibodies to Clostridium sordellii or C. difficile toxin, to ensure that the observed CPE is truly caused by C. difficile toxins and not by other substances in the stool. Incubation continues for up to 48 hours, but the majority of positives are detected after overnight incubation. This method is cumbersome, time-consuming, and lacks standardization, although if optimized, it is one of the most sensitive and specific methods available for C. difficile toxin detection. As laboratories abandoned their viral cell culture facilities in favor of antigen and molecular tests, CCNA became less popular. Enzyme immunoassays, initially for toxin A detection alone, and later both toxins, became available and replaced the above reference methods for routine clinical testing in the late 1980s and early 1990s. EIAs use monoclonal or polyclonal antibodies to detect C. difficile toxins and there are numerous commercial assays available. Performance is variable and their overall poor performance sparked development of other methods such as GDH immunoassays and molecular tests for toxin gene detection [ 174 , 176 , 177 ]. While toxin EIAs remain insensitive in the detection of toxigenic C. difficile when compared with these successive technologies, sensitivities vary among available toxin EIA tests. Results across both sponsored and nonsponsored studies should be considered to select a relatively more sensitive EIA for general use [ 174 ]. Also, there is some evidence that newer EIAs have improved sensitivity compared with those examined in older studies [ 178 ].

Glutamate dehydrogenase immunoassays detect the highly conserved metabolic enzyme (common antigen) present in high levels in all isolates of C. difficile . Since this antigen is present in both toxigenic and nontoxigenic strains, GDH immunoassays lack specificity and must be combined with another (usually toxin) test. GDH testing is the initial screening step in 2- and 3-step algorithms that combine it with a toxin test and/or a molecular test for toxin gene detection. The combination has allowed for rapid results and improved sensitivity compared with toxin EIA testing alone, and can be economical [ 174 , 176 , 177 ].

The application of anthropomorphic techniques to the field of paleoanthropology has proven to be an extremely valuable scientific method for studying human evolution through fossil remains. In particular, craniometry has been used to measure various skull and facial characteristics to evaluate prehistoric fossils. Such measurements have been critical in the study of human evolution, as craniometrics have allowed physical anthropologists to quantify the gradual changes in pre-human skull size and shape as an adaptation to an increased brain volume. Furthermore, both craniomorphic and other anthropomorphic measurements have been essential for the current theories regarding the evolution of bipedalism and the large brain size in humans.

In the late 1800’s, there was a movement towards the application of anthropometry to the field of psychology. While some physical anthropometric measurements were used, such as body size, height, arm length, etc., psychologists began to assess these attributes in association with other human measurements, including sight (e.g., color, distance, and clarity), touch (e.g., sensitivity, weight, and pain), movement (e.g., rate and reaction time), memory, and mental fatigue.

Originating with Bertillon’s anthropometric classification system applied to the field of criminology, forensic anthropometry involves the application of anthropometrics to the identification of human remains. The goal of forensic anthropometrics is to establish the age at the time of death, stature, body type (somatotype), sex, and any other distinguishing characteristics based on physical and skeletal measurements to identify the deceased individual. In particular, forensic anthropometry employs somatometry and osteometry to establish age, sex, stature, and ethnicity to establish a positive identification.

Anthropometric measurements can be used to describe particular human physiques, known as somatotypes. There are three main somatotypes as illustrated below (endomorph, ectomorph, and mesomorph), although some individuals may represent a hybrid of two somatotypes.

An endomorph refers to humans whose tissues are predominantly derived from the endoderm, exhibited by a soft, round shape, large digestive viscera, fat accumulation, large trunk, and tapering extremities. The degree of endomorphy is calculated based on the measurement of triceps, subscapular, and suprailiac skinfold thickness corrected for height as an indication of the amount of fat in the body. To ensure validity, these measurements are typically combined with at least one other measurement of percent body fat, such as underwater measurements.

Ectomorph refers to humans whose tissues are derived primarily from the ectoderm, exhibited by a linear body shape, large surface area, thin muscles and subcutaneous tissue, and moderately developed digestive viscera. Ectomorphy is calculated by obtaining height and mass measurements and assessing the level of linearity. In the Heath-Carter method, a cubic relationship known as the cf Ponderal Index is used.

avoidance of exploitation

Reciprocity is the notion that, because one party (X) benefits another (Y), Y is obliged to benefit X in return. Reason Mentions classed under reciprocity differed as to the identity of X (participants or the host community) and of Y (the sponsor, researchers, society, the world, any host country non-participant or host country non-participants who have the same medical condition as participants). Eight of the 12 possible combinations of X and Y were mentioned. Some reciprocity Reason Mentions differed also regarding why participants/communities may be entitled to benefit, e.g. because they assumed risk ( Lie, 2000 ; Chang, 2002 ; Macpherson, 2004 ; Ashcroft, 2005 ; Merritt, 2007 ; Carse and Little, 2008 ; Sachs, 2009 ; Shah et al. , 2009 ) or were used to create benefit for mankind ( Gostin, 1991 ).


Role Reason Mentions collectively reflected conflicting views regarding various role-related obligations, powers, and limits to the powers of researchers, sponsors and governments. For example, many reasons for the view that PTA need not be ensured appealed to researchers’ or sponsors’ lack of influence on health policy or on the drug approval process. A key conflict regarded whether researchers have the same role as doctors (implying that researchers should ensure PTA) or different role (implying that researchers need not ensure PTA); reasons appealing to the purpose of research or to the relationship between researchers and participants/communities were similarly polarized.

purpose of research relationship

Although logistical obstacles were most often left unspecified, a broad range was mentioned. Such obstacles were almost without exception taken to imply that PTA need not be ensured. Concerns about the safety and/or efficacy of the trial drug were only used to argue for the view that PTA need not be ensured in specific cases or against the view that PTA should always be required.

logistical obstacles safety and/or efficacy

Fourteen non-maleficence Reason Mentions appealed to the view that participants should not be worse off after the trial, but completed ‘not be worse off after the trial than … with respect to … ’ differently. For most such Reason Mentions (11, 76%), participants should not be worse off than during the trial; for two (14%), than before it; for one (7%), than if they had not participated . For most (13, 92%), the relevant respect was health, whereas for one (7%) it was health care.


Publications endorsing 4 a narrow reason for a conclusion agreed about whether the reason was for ensuring PTA or for the view that PTA need not be ensured. The most frequently endorsed reasons 5 included ones used just for ensuring PTA ( avoid exploiting participants, participants’ health need ), and others used just to argue that PTA need not be ensured ( host community’s interests may be better served by receiving benefit other than PTA ).

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