Routine pretransfusion testing before primary total hip or knee arthroplasty are an expensive and wasteful routine. Systematic review and meta-analysis

BACKGROUND

The excessive routine ordering of pretransfusion tests (blood typing, screening, and cross-matching) for surgical cases incurs significant unnecessary costs and places an undue burden on transfusion services. This study aims to systematically review the literature regarding the necessity of routine pretransfusion tests before total hip arthroplasty (THA) or total knee arthroplasty (TKA) and summarize their outcomes.

STUDY METHODS

A systematic review and meta-analysis were performed. The study's characteristics, the prevalence of over-ordering pretransfusion tests, transfusion rates, and potential cost savings to the healthcare system were analyzed.

RESULTS

The study included 17,667 patients. Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI: 0.92-1.00; p < 0.001) among patients undergoing primary THA or TKA. The pooled prevalence of hospital transfusion rate was 3.6%. Notably, there were statistically significant differences in preoperative hemoglobin (Hb) levels between patients not requiring transfusion (Hb = 13.9 g/dl; 95% CI 12.59-15.20; p < 0.001) and those needing transfusion (Hb = 11.9 g/dl; 95% CI 10.69-13.01; p < 0.001) (p = 0.03). The per-patient total cost savings ranged from 28.63 to 191.27 dollars.

DISCUSSION

Our study suggests that routine pre-transfusion testing for all patients undergoing primary THA or TKA may be unnecessary. We propose limiting pretransfusion test orders to patients with preoperative hemoglobin levels below 12 g/dl in unilateral primary TKA or THA. This targeted approach can result in significant cost savings for healthcare systems and transfusion services by reducing the over-ordering of pretransfusion tests in these surgical procedures.

Adductor canal block performed 20 hours after total knee arthroplasty to improve postoperative analgesia and functional recovery: a double-blind randomized controlled clinical trial

BACKGROUND

The goal of postoperative pain protocols in total knee arthroplasty (TKA) is to get pain free patients throughout severe pain period without impairing walking ability. The aim of the study was to investigate if an adductor canal block performed 20 hours after TKA, in patients treated with systemic analgesia and intraoperative local infiltration anaesthesia (LIA), improves postoperative pain and functional outcomes.

METHODS

A prospective randomized, double blinded controlled study was conducted. One hundred eighty-three patients undergoing primary TKA were randomized to receive either a sham block or an adductor canal block with 20 ml of ropivacaine 0.5%. The primary outcome was resting and dynamic pain scores using the numerical pain rating scale (NPRS). Secondary outcomes included opioid rescue requirements, quadriceps and adductor muscle strength, patient ability for ambulation and complications.

RESULTS

Two hours after the block, in adductor canal block group NPRS was significantly lower at rest (1[0-2] vs. 3[2-5], P<0.001) and with mobilization (5[3-6] vs. 6[5-8], P<0.001), and quadriceps strength was significantly higher (3.7[2.7-6] vs. 3(1.7-4.9), P=0.023). The differences were not maintained beyond 24 hours post-block. In the first 24 hours the percentage of patients with tramadol requirements was lower in the adductor canal block group (36[38.3] vs 52[58,4], P =0.006). Other secondary outcomes were similar between groups. There were no patient falls.

CONCLUSIONS

An adductor canal block done 20 hours after total knee arthroplasty reduces pain and opioid requirements without increasing the risk of falls. An optimal pain control, especially at movement was not achieved.

Implementing mHealth-Enabled Integrated Care for Complex Chronic Patients With Osteoarthritis Undergoing Primary Hip or Knee Arthroplasty: Prospective, Two-Arm, Parallel Trial

Background

Osteoarthritis is a disabling condition that is often associated with other comorbidities. Total hip or knee arthroplasty is an effective surgical treatment for osteoarthritis when indicated, but comorbidities can impair their results by increasing complications and social and economic costs. Integrated care (IC) models supported by eHealth can increase efficiency through defragmentation of care and promote patient-centeredness.

Objective

This study aims to assess the effectiveness and cost-effectiveness of implementing a mobile health (mHealth)–enabled IC model for complex chronic patients undergoing primary total hip or knee arthroplasty.

Methods

As part of the Horizon 2020 Personalized Connected Care for Complex Chronic Patients (CONNECARE) project, a prospective, pragmatic, two-arm, parallel implementation trial was conducted in the rural region of Lleida, Catalonia, Spain. For 3 months, complex chronic patients undergoing total hip or knee arthroplasty and their caregivers received the combined benefits of the CONNECARE organizational IC model and the eHealth platform supporting it, consisting of a patient self-management app, a set of integrated sensors, and a web-based platform connecting professionals from different settings, or usual care (UC). We assessed changes in health status (12-item short-form survey [SF-12]), unplanned visits and admissions during a 6-month follow-up, and the incremental cost-effectiveness ratio.

Results

A total of 29 patients were recruited for the mHealth-enabled IC arm, and 30 patients were recruited for the UC arm. Both groups were statistically comparable for baseline characteristics, such as age; sex; type of arthroplasty; and Charlson index, American Society of Anesthesiologists classification, Barthel index, Hospital Anxiety and Depression scale, Western Ontario and McMaster Universities Osteoarthritis Index, and Pfeiffer mental status questionnaire scores. Patients in both groups had significant increases in the SF-12 physical domain and total SF-12 score, but differences in differences between the groups were not statistically significant. IC patients had 50% fewer unplanned visits (P=.006). Only 1 hospital admission was recorded during the follow-up (UC arm). The IC program generated savings in different cost scenarios, and the incremental cost-effectiveness ratio demonstrated cost-effectiveness.

Conclusions

Chronic patients undergoing hip or knee arthroplasty can benefit from the implementation of patient-centered mHealth-enabled IC models aimed at empowering patients and facilitating transitions from specialized hospital care to primary care. Such models can reduce unplanned contacts with the health system and reduce overall health costs, proving to be cost-effective. Overall, our findings support the notion of system-wide cross-organizational care pathways supported by mHealth as a successful way to implement IC for patients undergoing elective surgery.

Validation of a second-generation appropriateness classification system for total knee arthroplasty: a prospective cohort study

BACKGROUND

To test the validity of a second-generation appropriateness system in a cohort of patients undergoing total knee arthroplasty (TKA).

METHODS

We applied the RAND/UCLA Appropriateness Method to derive our second-generation system and conducted a prospective study of patients diagnosed with knee osteoarthritis in eight public hospitals in Spain. Main outcome questionnaires were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short-Form-12 (SF-12), and the Knee Society Score satisfaction scale (KSS), completed before and 6 months after TKA. Baseline, changes from baseline to 6 months (journey outcome), and 6-month scores (destination outcome) were compared according to appropriateness category. Percentage of patients attaining the minimal clinically important difference (MCID) and responders according to Outcome Measures in Rheumatology-Osteoarthritis Research Society (OMERACT-OARSI) criteria were also reported.

RESULTS

A total of 282 patients completed baseline and 6-month questionnaires. Of these, 142 (50.4%) were classified as Appropriate, 90 (31.9%) as Uncertain, and 50 (17.7%) as Inappropriate. Patients classified as Appropriate had worse preoperative pain, function, and satisfaction (p < 0.001) and had greater improvements (i.e., journey scores) than those classified as Inappropriate (p < 0.001). At 6 months, destination scores for pain, function, or satisfaction were not significantly different across appropriateness categories. The percentage of patients meeting responder criteria (p < 0.001) and attaining MCID was statistically higher in Appropriate versus Inappropriate groups in pain (p = 0.04) and function (p = 0.004).

CONCLUSIONS

The validity of our second-generation appropriateness system was generally supported. The findings highlight a critical issue in TKA healthcare: whether TKA appropriateness should be driven by the extent of improvement, by patient final state, or by both.

Implementing Mobile Health-Enabled Integrated Care for Complex Chronic Patients: Patients and Professionals' Acceptability Study

Background

Integrated care (IC) can promote health and social care efficiency through prioritization of preventive patient-centered models and defragmentation of care and collaboration across health tiers, and mobile health (mHealth) can be the cornerstone allowing for the adoption of IC.

Objective

This study aims to assess the acceptability, usability, and satisfaction of an mHealth-enabled IC model for complex chronic patients in both patients and health professionals.

Methods

As part of the CONNECARE Horizon 2020 project, a prospective, pragmatic, 2-arm, parallel, hybrid effectiveness-implementation trial was conducted from July 2018 to August 2019 in a rural region of Catalonia, Spain. Home-dwelling patients 55 years and older with chronic conditions and a history of hospitalizations for chronic obstructive pulmonary disease or heart failure (use case [UC] 1), or a scheduled major elective hip or knee arthroplasty (UC2) were recruited. During the 3 months, patients experienced an mHealth-enabled IC model, including a self-management app for patients, a set of integrated sensors, and a web-based platform connecting professionals from different settings or usual care. The Person-Centered Coordinated Care Experience Questionnaire (P3CEQ) and the Nijmegen Continuity Questionnaire (NCQ) assessed person-centeredness and continuity of care. Acceptability was assessed for IC arm patients and staff with the Net Promoter Score (NPS) and the System Usability Scale (SUS).

Results

The analyses included 77 IC patients, 58 controls who completed the follow-up, and 30 health care professionals. The mean age was 78 (SD 9) years in both study arms. Perception of patient-centeredness was similarly high in both arms (usual care: mean P3CEQ score 16.1, SD 3.3; IC: mean P3CEQ score 16.3, SD 2.4). IC patients reported better continuity of care than controls (usual care: mean NCQ score 3.7, SD 0.9; IC: mean NCQ score 4.0, SD 1; P=.04). The scores for patient acceptability (UC1: NPS +67%; UC2: NPS +45%) and usability (UC1: mean SUS score 79, SD 14; UC2: mean SUS score 68, SD 24) were outstanding. Professionals’ acceptability was low (UC1: NPS −25%; UC2: NPS −35%), whereas usability was average (UC1: mean SUS score 63, SD 20; UC2: mean SUS score 62, SD 19). The actual use of technology was high; 77% (58/75) of patients reported physical activity for at least 60 days, and the ratio of times reported over times prescribed for other sensors ranged from 37% for oxygen saturation to 67% for weight.

Conclusions

The mHealth-enabled IC model showed outstanding results from the patients’ perspective in 2 different UCs but lacked maturity and integration with legacy systems to be fully accepted by professionals. This paper provides useful lessons learned through the development and assessment process and may be of use to organizations willing to develop or implement mHealth-enabled IC for older adults.

Telangiectatic osteosarcoma

PURPOSE

To review records of 8 patients with telangiectatic osteosarcoma (TOS) and determine whether pathologic fractures correlate with recurrence and survival.

METHODS

Records of 4 men and 4 women aged 17 to 44 (mean, 28) years treated for TOS were reviewed. RESULTS; Of the 8 patients, 4 developed a pathologic fracture and 4 did not. In each group, 2 patients underwent limb salvage surgery and 2 underwent amputation. All patients received neoadjuvant and adjuvant chemotherapy with a combination of at least 2 of the following drugs: doxorubicin, methotrexate, cisplatin, and vincristin. After a mean follow-up of 5.6 (range, 2-16) years, all 4 patients with a pathologic fracture and 2 of the 4 patients without a pathologic fracture were still alive and disease-free. For the remaining patients, one died after 31 months from progression of a lung metastasis, and the other was alive with the disease and had had 2 recurrences, a lung metastasis, and an infection with Klebsiella oxytoca that eventually led to an amputation.

CONCLUSION

The presence of a pathologic fracture in patients with TOS was not associated with worse outcome in terms of recurrence and survival.

Osteosíntesis percutánea con tornillo mini-Acutrak en las fracturas agudas de escafoides

Objetivos. Evaluamos nuestra experiencia con el tornillo canulado percutáneo mini-Acutrak en el tratamiento de las fracturas agudas de escafoides.

Material y Método. Desde noviembre de 2007 a septiembre del 2008 realizamos un estudio retrospectivo en 22 pacientes con fractura de escafoides. El patrón de fractura se dividió según la clasificación de Herbert y por los criterios de inestabilidad propuestos por Cooney et al. No se incluyen las fracturas de cuerpo de escafoides inestables. Las fracturas mínimamente o no desplazadas de cuerpo de escafoides se trataron con un tornillo percutáneo vía palmar. En las fracturas de polo proximal y oblicuas de cuerpo se colocó el tornillo vía dorsal. Posterior a la osteosíntesis se realiza una inmovilización de 10 días y seguidamente fisioterapia.

Resultados. De los 22 pacientes intervenidos uno fue una mujer y 21 fueron varones de edad media 27 años (rango: 18-47). El seguimiento medio fue de 6 meses (rango: 3-10). La osteosíntesis percutánea se indicó en 15 fracturas mínimamente o no desplazadas de cuerpo escafoides (Herbert tipo A2 o B2), 3 fracturas oblicuas (Herbert tipo B1) y 4 de polo proximal (Herbert tipo B3). Todos los pacientes obtuvieron resultados buenos/excelentes con un tiempo de curación entre las 8 y 12 semanas (media de 6 semanas) y con un arco de movilidad completo. La tomografía axial computerizada fue útil en 8 casos para confirmar la consolidación. La longitud media de los tornillos fue de 18 mm (rango: 16-22). Como complicación tuvimos un caso de ruptura de la aguja guía en el interior del tornillo. No hemos apreciado casos de seudoartrosis, inestabilidad, infección, aflojamiento del tornillo ni cambios degenerativos.

Conclusiones. El tornillo de compresión percutáneo puede evitar el abordaje y los posibles daños de la osteosíntesis abierta. Si se realiza una indicación y vía de entrada correcta puede, en las fracturas agudas de escafoides mínimamente o no desplazadas, permitir la consolidación de la fractura con un tiempo de inmovilización menor y una incorporación precoz a las actividades habituales.

First detection of group C rotavirus in children with acute diarrhea in Spain

Group C rotavirus causes sporadic cases and outbreaks of acute diarrhea in children and adults in many countries, but has never been detected among children in Spain. In a recently conducted surveillance study to screen fecal specimens for bacteria and viruses from a cohort of 822 young children who were treated for acute diarrhea in Madrid, no pathogens were detected in fecal specimens from 238 (29%) children. In this study, we examined 147 of those specimens for group C rotavirus by EIA and PCR and found 22 (15%) were positive. Our findings demonstrate that group C rotavirus is an important cause of childhood diarrhea in Spain.

New immunochromatographic method for rapid detection of rotaviruses in stool samples compared with standard enzyme immunoassay and latex agglutination techniques

Three different commercial immunologic tests for rapid detection of group A rotavirus (an immunochromatographic method, latex agglutination, and enzyme immunoassay) were used to evaluate 228 faecal specimens obtained from Spanish children with acute gastroenteritis. After resolution of 30 (13.2%) discordant results by reverse transcription-polymerase chain reaction for rotavirus, the statistical values of the enzyme immunoassay, latex agglutination, and immunochromatographic method were respectively 96%, 68%, and 99% for sensitivity; 99%, 99%, and 96% for specificity; 98%, 96%, and 92% for positive predictive value; and 98%, 88%, and 99% for negative predictive value. The immunochromatographic technique showed high sensitivity and specificity and was rapid and easy to perform in the routine clinical laboratory.

[The molecular epidemiology of the rotavirus in Spanish children. The Rotavirus Study Group (GER)]

BACKGROUND

Rotavirus are the most common etiologic agent of acute gastroenteritis in childhood. The knowledge of the circulating antigenic types is important in development of future vacunes.

METHODS

Faeces from children (age < 4 years) with acute gastroenteritis admitted in the two hospitals (Hospital Severo Ochoa-Madrid and Hospital General Vic-Barcelona) have been studied prospectively during one year (October-1996 to October-1997). The detection of rotavirus was performed by ELISA (IDEIA, Dako). All samples were G-serotyping by EIA-Mabs (Silenius Laboratories) and the indeterminate or non-serotypable samples were G-genotyping by RT-PCR. P genotypes were identified by RT-PCR.

RESULTS

322 (45%) patients with acute diarrhoea causing for rotavirus were confirmed, 242 coming from the Madrid metropolitan area and other 80 from the Barcelona area. The EIA-Mabs technique made it possible to identify the G serotypes in 287 cases (89%), corresponding 207 to G1 serotype, 70 to G4 serotype and 6 to G3 serotype. In 4 patients both G1 and G4 serotypes were detected. The EIA-Mabs could not determined the serotype in 35 (11%) patients, all of whom were confirmed by RT-PCR (12 belonged to serotype G1 and 23 to serotype G4). Analysis of P genotypes was carried out in 25 patients obtained from Madrid and 17 from Barcelona; all cases were classified in the P[8] genotype.

CONCLUSIONS

The most frequent serotype in both hospitals was G1. The EIA-Mabs technique were showed a high sensitivity, however, the RT-PCR technique used were even more efficient, making it possible for us to identify all the non-serotypable EIA-Mabs cases. The temporal study of circulating serotypes/genotypes of rotavirus is necessary to evaluate the efficiency of vaccines.

Rotavirus-specific cytotoxic T lymphocytes recognize overlapping epitopes in the amino-terminal region of the VP7 glycoprotein

Rotavirus-specific cytotoxic T lymphocytes (CTL) play an important role in the resolution of rotavirus infection. The outer capsid glycoprotein, VP7, elicits a class I MHC-restricted CTL response. Vaccinia virus recombinants expressing the VP7 genes from simian rotavirus SA11 (serotype G3) and from the RF strain of bovine rotavirus (serotype G6) were used to analyze the CTL activity to this antigen in BALB/c (H-2(d)) and C57BL/6 (H-2(b)) mice neonatally infected with homologous and heterologous rotaviruses. A vaccinia virus recombinant expressing the first amino-terminal 88 amino acids of VP7 was constructed and used to search for cross-reactive CTL against this region of the protein. By using synthetic Kb, Db, and Kd motif-fitting peptides two overlapping CTL epitopes have been identified located in the first hydrophobic domain (H1) of VP7. Splenocytes obtained from rotavirus SA11-infected C57BL/6 mice induced the strongest CTL response against target cells sensitized with a peptide containing a Kb-restricted CTL epitope (amino acids 8-16). A second Kd-restricted epitope (residues 5-13) was recognized by splenocytes derived from rotavirus-infected BALB/c mice. These findings reveal the existence of CTL epitopes in the H1 signal sequence of the VP7 glycoprotein that coexist with a CTL epitope (residues 31-40) previously described within the H2 region.

Viral proteins VP2, VP6, and NSP2 are strongly precipitated by serum and fecal antibodies from children with rotavirus symptomatic infection

Rotavirus-specific IgA has been correlated with immune protection against rotavirus reinfection and symptomatic disease. Systemic and mucosal antibody responses were determined by an enzyme-linked immunosorbent assay in 11 infants with severe rotavirus gastroenteritis. Geometric mean titers of antirotavirus serum IgG and IgA antibodies were significantly higher during the convalescence of the disease (P < 0.001 vs. acute-phase titers). Rotavirus-specific fecal sIgA antibodies increased 4 times during the convalescence in 9 (81.8%) children (P < 0.001). The serum IgG and IgA antibody and fecal sIgA antibody responses to individual rotavirus polypeptides were characterized by radioimmunoprecipitation assay (RIPA) using Staphylococcus aureus protein A and the lectin jacalin to precipitate IgG- and IgA-immune complexes, respectively. The main IgG response was directed toward the structural viral proteins VP2, VP4, and VP6 and toward the nonstructural protein NSP2. Serum IgA reactivity was detected by RIPA in all serum samples, with major responses to VP2, VP6, and NSP2. Interestingly, fecal sIgA in convalescent samples reacted strongly toward NSP2 and VP6. These data reinforce the antigenic importance of rotaviral proteins other than VP4 and VP7, such as VP2, VP6, and NSP2, as main targets in the immune response to rotavirus.

[Virus-specific serum and fecal antibodies response in children with acute rotavirus gastroenteritis]

BACKGROUND

The analysis of the immune response to rotavirus infection and the characterization of the viral antigens recognized by specific antibodies are of great concern in evaluating the protection against rotavirus.

MATERIAL AND METHODS

The levels of rotavirus-specific fecal (sIgA) and serum antibodies (IgM, IgG and IgA) were evaluated by ELISA in 25 children with acute gastroenteritis for rotavirus, in 11 of them during the acute and convalescent phases. The specificity of serum antibodies to viral polypeptides was characterized by immunoblotting.

RESULTS

Serum IgM antibodies with a geometric mean titer (GMT) of 1/3,973 were the predominant antibodies detected during the acute phase. In comparison, IgG and IgA serum antibodies and sIgA coproantibodies levels were higher in the convalescent phase (GMT = 1/5,799, 1/257 and 1/137 respectively). Significant differences were observed for all the isotypes of immunoglobulins evaluated during the infection and in the convalescence (p < 0.01). Rotavirus-specific serum antibodies recognized mainly the structural VP6, VP7 and VP3/VP4 proteins. Other polypeptides also detected were VP1, VP5 and the non-structural NS34 protein.

CONCLUSIONS

Rotavirus infection produce an intense humoral immune response both in serum and in the gut. Specific antibodies react against structural proteins of the internal (VP6) and external (VP7) capsids of rotavirus.

[Enzymatic activities of Campylobacter jejuni, C. coli, and C. lari]

Susceptibility to nalidixic acid has been considered for a long time as an important test in the identification of the different species of the genus Campylobacter. However, due to the increasing development of resistance new laboratory tests are needed to carry out an accurate identification to the species level in combination with other typing schemes. We have evaluated the enzymatic activity of 180 Campylobacter spp. strains isolated from clinical specimens performing the Api ZYM system (bioMérieux) in order to assay whether different enzymatic patterns could help to characterize these microorganisms. Thirteen of the 19 enzymatic activities detected by the system (lipase-C14, valine arylamidase, cystine arylamidase, trypsin, chymiotrypsin, alpha-galactosidase, beta-galactosidase, beta-glucuronidase, alpha-glucosidase, beta-glucosidase, N-acetyl-beta-glucosaminidase, alpha-manosidase and alpha-fucosidase) were negative for all the strains tested, whereas 3 enzymes (alkaline phosphatase, acid phosphatase and naphtol-A-S-BI-phosphohydrolase) were detected in 96.6% of the strains. Esterase-C1, esterase lipase-C8 and leucin arylamidase showed a variable reactivity depending on isolates. Enzymatic activity patterns clearly differentiate all the C. lari strains from other Campylobacter species. No significant differences were detected among the enzymatic activities of C. jejuni and C. coli strains. Our study suggests that the Api ZYM system is easy to perform and a valuable method to be applied in the characterization of the campylobacteria as a complement to other biotyping and serotyping schemes.

[Corneal ulcer caused by Nocardia asteroides after penetrating keratoplasty]

We report the case of a 43-years-old patient, to whom a corneal transplantation was made because he presented a Salzmann nodular degeneration in his left eye. The patient was observed every week and his development during the following months was good. Nine weeks later he was attended at the emergency room of the hospital, with an intensive secretion and partial loss of vision in the operated eye. It was detected a peripheral ulcer of a diffused borders with a loss of epithelium and anterior stroma in the superior temporal part of the cornea. Five days later, the microbiological cultures confirmed the presence of Nocardia asteroides. In spite of the initial good evolution of the ulcer treated topically with a 20% sulfacetamide and trimetoprim-sulfadiacine p.o., the graft ended unsuccessfully.

Evaluation of reverse transcription and polymerase chain reaction (RT/PCR) for the detection of rotaviruses: applications of the assay

Our aim was to evaluate the reverse transcription and polymerase chain reaction (RT/PCR) technique for the detection of rotavirus shedding by infected children as a routine diagnostic procedure, in comparison to the enzyme-linked immunosorbent assay (ELISA), electron microscopy (EM) and polyacrylamide gel electrophoresis (PAGE) of rotavirus double-stranded RNA. Two-hundred and twenty stool specimens were collected from infants and young children with diarrhoea, and 10-20% faecal suspensions were made. Several methods of rotavirus dsRNA extraction were assayed. Electrophoretic analysis of viral RNA was carried out on 10% polyacrylamide gels followed by silver staining. RT/PCR was performed using oligonucleotide primers specific for both 3' and 5' ends of the rotavirus gene encoding VP7 which are highly conserved among group A rotaviruses. Following RNA extraction with phenol-chloroform and ethanol precipitation, RT/PCR could detect rotaviral RNA in only 11 of 25 samples known to contain rotaviruses by conventional methods. The purification of RNA extracts by CF11 cellulose and the application of the RNAID method were equally effective in extracting RNA and/or removing inhibitory substances from the faecal samples. RT/PCR led to the detection of 66 positive samples from 220 specimens tested (30%), whilst 64 specimens were positive by ELISA (29%), 59 (26.8%) by PAGE and 56 (25.4%) by EM. In our study, RT/PCR was 100 times more sensitive than the ELISA test in detecting rotaviruses serially diluted in a faecal suspension. Although RT/PCR is theoretically much more sensitive than ELISA, PAGE and EM for detection of rotaviruses, great care must be taken to remove inhibitory substances from the enzymatic reactions. We do not consider that RT/PCR should replace immunoassays with high sensitivity and specificity for rotavirus testing in faecal samples, although this technique has other applications, like the search for rotavirus in different clinical specimens (sera, cerebrospinal fluid, respiratory secretions, etc.) and in environmental samples, as well as the typing of viral strains using serotype-specific primers.

[Systemic cryptococcosis and pneumocystosis in an HIV-positive patient]

Cryptococcosis is one of the most common opportunistic infections in AIDS patients. Neurological symptoms are the most frequent clinical presentation of this fungal infection, and pulmonary involvement is clinically much less evident. We report the case of a patient who was treated in the emergency room for acute respiratory failure but who did not survive. Microbiologic and histopathologic studies demonstrated simultaneous pulmonary infections with Cryptococcus neoformans and Pneumocystis carinii. We discuss this clinical presentation of cryptococcosis with no neurological manifestations, and the importance of concurrent infections by several opportunistic organisms that may go unrecognized.

[The liver and AIDS]

Hepatic disorders in AIDS are very common, although the injuries observed are usually non-specific. This is the reason why the real usefulness of hepatic biopsy in this patients is being currently discussed. In this work, such aspect and the hepatic injuries observed in patients with AIDS are discussed. Current indications for hepatic biopsy are summarized, as well as its later manipulation in order to obtain maximum profitability of it.

[Nephrotic syndrome associated with ampulloma]

A patient is reported who presented simultaneously classic nephrotic syndrome and adenocarcinoma of the Vater ampulla. Morphological study of the renal biopsy revealed changes characteristic of membranous glomerulonephritis and subepithelial deposits. These deposits stained specifically for IgG and C'3 with a granular pattern, but deposits of CEA-antiCEA immune complexes were not found in glomerular capillaries. The association of nephrotic syndrome with lymphoproliferative diseases and a large variety of solid tumors, like carcinoma of the breast, bronchogenic, colon and stomach has been communicated, but the present case constitutes the first known association with adenocarcinoma of the Vater ampulla.