Search

Background As promising novel treatments develop for malignant pleural mesothelioma (MPM), early prognostication has become increasingly important. Circulating and local inflammatory cells are known to play a significant role in other tumour types. We assessed the proportion of lymphocyte populations within blood, pleural fluid and tumour stroma to prognosticate patients with MPM at diagnosis. Methods Consecutive patients diagnosed with biopsy-proven MPM were prospectively recruited to an observational cohort study and followed up for a minimum of 7.5 years. Blood and pleural fluid results at presentation were extracted from the medical records. Biopsy specimens were independently reviewed by 2 pathologists who scored the degree of lymphocytic and neutrophilic infiltration. Results Baseline results were available for 184 patients. The predominant pleural fluid cell type was calculable for 84 patients and 118 patients had biopsy specimens available for review. A low blood neutrophil/lymphocyte ratio (NLR p p p Conclusions Lymphocyte predominance within tumour stroma, pleural fluid or blood infers a better prognosis in patients with MPM.

Background: Haematological malignancy is an important cause of pleural effusion. Pleural effusions secondary to haematological malignancy are usually lymphocyte predominant. However, several other conditions such as carcinoma, tuberculosis, and chronic heart failure also cause lymphocytic effusions. Lymphocyte subset (LS) analysis may be a useful test to identify haematological malignancy in patients with lymphocytic effusions. However, research into their utility in pleural effusion diagnostic algorithms has not yet been published. Objectives: We aimed to determine the clinical utility of pleural fluid LS analysis and whether it can be applied to a diagnostic algorithm to identify effusions secondary to haematological malignancy. The secondary aim was to evaluate the diagnostic value of pleural fluid differential cell count. Methods: Consecutive consenting patients presenting to our pleural service between 2008 and 2013 underwent thoracentesis and differential cell count analysis. We proposed an algorithm which selected patients with lymphocytic effusions (>50%) to have further fluid sent for LS analysis. Two independent consultants agreed on the cause of the original effusion after a 12-month follow-up period. Results: A total of 60 patients had samples sent for LS analysis. LS analysis had an 80% sensitivity (8/10) and a 100% specificity for the diagnosis of haematological malignancy. The positive and negative predictive values were 100 and 96.1%, respectively. Overall 344 differential cell counts were analysed; 16% of pleural effusions with a malignant aetiology were neutrophilic or eosinophilic at presentation. A higher neutrophil and eosinophil count was associated with benign diagnoses, whereas a higher lymphocyte count was associated with malignant diagnoses. Conclusions: LS analysis may identify haematological malignancy in a specific cohort of patients with undiagnosed pleural effusions. A pleural fluid differential cell count provides useful additional information to streamline patient pathway decisions.

The vast majority of undiagnosed unilateral pleural effusions have fluid sent for cytological analysis. Despite widespread use, there is uncertainty about its sensitivity to diagnose malignant pleural effusions (MPEs). Our aim was to ascertain the utility of cytology using a large prospective cohort.Consecutive patients presenting with an undiagnosed unilateral pleural effusion were recruited to this UK-based study. All had pleural fluid sent for cytological analysis. Cytological sensitivity was based on the final diagnosis at 12 months, confirmed by two consultants.Over 8 years, 921 patients were recruited, of which 515 had a MPE. Overall sensitivity of fluid cytology to diagnose malignancy was 46% (95% CI 42–58%). There was variation in sensitivity depending on cancer primary, with mesothelioma (6%) and haematological malignancies (40%) being significantly lower than adenocarcinomas (79%). MPEs secondary to ovarian cancer had high pick-up rates (95%). In asbestos-exposed males with exudative effusions, the risk of MPE was 60%, but cytological sensitivity was 11%.This is the largest prospective study of pleural fluid cytology and informs discussions with patients about the likely requirement for investigations following thoracentesis. In patients presenting with a clinical suspicion of mesothelioma, cytological sensitivity is low, so more definitive investigations could be performed sooner.

Introduction Blood and tissue lymphocyte subsets (LS) analysis are routinely used in the diagnosis of a number of haematological conditions. Samples cost £25 to process and are technically labour intensive. The 2010 BTS pleural guidelines suggest LS may be useful in cases of suspected lymphoma, but there is no evidence supporting their utility or position in pleural diagnostic algorithms. Methods Using a prospectively-maintained database of all undiagnosed pleural effusions, we analysed patients presenting to our service from 2009–2011. Fluid was initially sent for cytology and cell differential. Patients with ≥ 50% fluid lymphocytes at first sampling, with no definite cytological evidence of carcinoma, and who underwent a further pleural procedure, had a second sample sent for LS analysis. The cause of the original effusion was agreed by two independent consultants after a minimum 12 month follow-up period. Results 395 patients with undiagnosed effusions were seen, of which 124(31%) were found to be lymphocytic on initial examination. 35(28.2%) patients were excluded due to confirmed (non-haematological) malignancy (11 initial cytology, 24 biopsy). A further 46(37.1%) patients were excluded with confirmed benign diagnoses including inflammatory pleuritis, heart failure and pleural infection. 39/43 (90.7%) patients therefore had samples sent for LS analysis. 7/43 (16.3%) patients’ effusions were diagnosed at 12 months as primarily due to lymphoma, with 5 having a previous diagnosis of such. Their characteristics are described in the table below. LS analysis was diagnostic in 4 and negative in 35 cases. There were no false positive results. Therefore, based on these data, for determining whether there is haematological malignancy in lymphocytic pleural fluid, LS analysis has a sensitivity of 57.1%, a specificity of 100%, and a positive and negative predictive value of 100% and 91.4% respectively. Conclusions LS analysis appears useful in a selected subgroup of patients presenting with undiagnosed effusions. It should only be considered in those patients with a lymphocytic effusion which shows negative initial cytology and/or no firm diagnosis established on pleural biopsy, or those with a past medical history of a lymphoma. A negative LS result does not exclude the possibility of a haematological cause for the effusion.

I have been teaching biology at a boys' grammar school for more than 20 years and am responsible for the health education programme. I am also a teacher governor of the school. For a long time now,...

This paper presents two maps summarising all available published data on the world distribution of gallstones as recorded from autopsy studies. It is suggested that further autopsy studies are required, especially in Asia, Russia, the Middle Eastern and Mediterranean countries and South America. Such studies could be readily carried out and would contribute to our understanding of the aetiology of gallstones.

An immunoperoxidase technique was used to compare the presence of serum proteins in tumour cells in twenty cerebral gliomas and four intracerebral metastatic carcinomas, with the serum protein content of reactive astrocytes around four cerebral infarcts. Rabbit antiserum to human immunoglobulins and albumen was applied to paraffin sections of tumour biopsies and of infarcts from postmortem brains. All the reactive astrocytes surrounding infarcts stained positively for immunoglobulins and albumen. In the gliomas, a continuous range of staining was observed in plump astrocytic tumour cells varying from strongly positive to unstained. Very few poorly-differentiated glioma cells stained for serum proteins; metastatic tumour cells, areas of capillary endothelial proliferation, and spindle cells in gliosarcomas remained unstained. These results suggest that the astrocytic function of serum protein uptake from the extracellular fluid is often lost in poorly-differentiated glioma cells, but is retained to a variable degree by those tumour cells which histologically resemble reactive astrocytes.

Based on lengthy quotations from the children themselves, this article explores how they felt and what was learned from being witnesses to birth. Their advice to peers— often eloquent and protective—is quoted. Thirty-five children, age 2 1 2 to 15, were interviewed using both tape recorder and play techniques. The question of sibling bonding is considered; the critical importance of a sensitive support person for the child and of adequate preparation for the entire family is emphasized. The research was developed at Booth Maternity Center, Philadelphia, in conjunction with the sibling program there. Begun in 1980, the program now includes a preparation sequence, formal requirements, and written guidelines.