Rapidly recurring massive pleural effusion as the initial presentation of sarcoidosis: A case report

RATIONALE

Sarcoidosis is a multisystem granulomatous disease with unknown etiology. It affects mainly the lungs, but it can affect almost any other organ. Nevertheless, pleural involvement with the development of pleural effusion is relatively rare. It is usually mild and responsive to treatment with systemic steroids. Here we present a case of rapidly recurring massive unilateral pleural effusion caused by sarcoidosis that was resistant to systemic steroids.

PATIENT CONCERNS

A 55-year-old lady presented with shortness of breath of 2-months duration. No other respiratory symptoms were reported. On physical examination, there were signs of left-sided pleural effusion, splenomegaly, and inguinal lymph nodes. These findings were confirmed by chest x-ray showing massive pleural effusion. Work up of the effusion revealed an exudative effusion with lymphocyte predominance. Pan-computed tomography scan revealed multiple thoracic, abdominal and inguinal lymphadenopathy; additionally, a left-sided pleural effusion and an enlarged spleen; that contained variable hypodense nodular lesions. Positron emission tomography-computed tomography showed intense uptake in the spleen and the lymph nodes. Inguinal lymph node biopsy showed non-necrotizing granulomatous inflammation. Due to suspicion of malignancy, left medical thoracoscopy was done, and biopsy of the parietal pleura showed nonspecific inflammation without evidence of malignancy or tuberculosis.

DIAGNOSIS

Sarcoidosis was diagnosed based on the finding of the non-necrotizing granulomatous inflammation with no evidence of malignancy or infection on several microbiological and pathological samples.

INTERVENTIONS

The patient was treated with repeated pleural fluid drainage. Steroids failed to prevent pleural effusion recurrence. Surgical left side pleurodesis was eventually performed.

OUTCOMES

At more than 1 year follow up, the patient showed no recurrence of pleural effusion or development of any other symptoms.

LESSONS

Sarcoidosis may rarely present with massive pleural effusion, as this presentation is rare; it is imperative to rule out other causes of massive pleural effusion. Massive pleural effusion in sarcoidosis may be steroid-resistant. Pleurodesis may have a role in such a scenario.

Relation between Ovarian Carcinoma-Associated Antigens in Tumor Tissue and Detached Cyst Fluid Cells of Patients with Ovarian Neoplasms

Aims

The expression and potential diagnostic value of ovarian carcinoma-associated antigens were estimated in different types of epithelial ovarian neoplasms. The comparison of antigenic expression was performed on solid tumor tissues and loose cyst fluid cells in individual cases of malignant and benign ovarian neoplasms.

Methods

All studies were performed using monoclonal antibodies (mAbs) against ovarian carcinoma-associated antigens (OC125, OV-TL3, OV632, 10B, 8C) by 3-step peroxidase-antiperoxidase test.

Results

All ovarian carcinoma-associated antigens were detected in most serous and endometrioid carcinomas. In mucinous carcinomas as well as in benign ovarian neoplasms these antigens were present only in some cases. Significant inter- and intratumoral immunological heterogeneity was evident; however, the antigens detectable in tissue sections were also found in detached cyst fluid cells.

Conclusions

Our results show that mAb show OV-TL3 is the best marker for endometrioid carcinomas and confirmed that mAbs OV632, OC125 and OV-TL3 could be good complementary markers for differentiating malignant and benign lesions in the ovary. The percentage content of all ovarian carcinoma-associated antigens in solid tumors and respective cyst fluid cells was comparable.

Cytomorphologic Characterization of Cell Subsets Isolated by Density Gradient Centrifugation from Tumor Effusions of Ovarian Endometrioid Carcinoma

Aims

Cytomorphologic characterization of tumor cell subsets, according to the stage of pathologic differentiation, and comparison of cellular composition in tumor cyst and ascitic fluids were carried out on individual patients with ovarian endometrioid carcinoma.

Methods

A density gradient centrifugation technique was applied to fractionate the cells from tumor effusions.

Results

The enrichment of cell forms representing individual stages of pathologic differentiation by gradient centrifugation facilitated their cytomorphologic characterization. According to cytomorphologic features, 5 discrete cell subpopulations were identified and catalogued. The cellular composition of tumor cyst and ascitic fluids in individual patients was similar, but the number of fractions and percentage of cell subsets differed.

Conclusions

The estimation of precise cytomorphologic criteria for cell forms in tumor effusions facilitated the cytologic diagnosis of ovarian endometrioid carcinoma. The possibility to concentrate poorly differentiated, frankly malignant cell subsets in low densities could significantly improve the diagnosis of tumor effusions.

Morphologic Analysis of Serous Effusion Cells by Scanning Electron Microscopy

The authors used scanning electron microscopy (SEM) to examine the cells obtained from serous effusions of patients affected with a neoplasm or benign disease. Cellular morphology was studied in non-neoplastic effusions to distinguish benign cells from cancer cells with which they are almost always suspended in malignant effusions. Tumor cells differ in some features such as shape, size, arrangement and especially in surface structures (microvilli), the latter being very noticeable when using this method. The investigation enabled us to note several changes in the cell surface that could reflect particular activities of the cells themselves. For this reason we believe that the technique may be considered very useful to gain knowledge of cellular morphology. However, it cannot be considered suitable for making routine diagnostic conclusions.

Conjunctival Scrapings and Impression Cytology in Chronic Conjunctivitis. Correlation with Microbiology

To assess the utility of exfoliative cytology in the diagnosis of chronic conjunctivitis, we compared its findings with microbiological examination and established the correlation between cytology and microbiology in 32 patients with conjunctivitis lasting four weeks or more, with a nonspecific clinical picture. The material for cytology was collected by scraping and by imprint of the ocular surface on Millipore filter paper. The specimens were stained with Giemsa. Material for bacterial culture and fluorescent antibody test for viruses and Chlamydia were obtained at the same time. In 12 patients neutrophils predominated in cytology, in six eosinophils were found and in four there were more lymphocytes. One patient had a basophilic intracytoplasmic inclusion specific for Chlamydia infection. In eight patients coagulase-negative Staphylococcus species and in one Staphylococcus aureus were isolated, in two the fluorescent antibody test for Chlamydia was positive and in three for viruses. In all patients with a positive bacterial culture, a predominance of neutrophils was observed. All patients with a positive test for viruses had lymphocytosis in conjunctival scrapings. In two patients microbiology detected Chlamydia, but characteristic intracytoplasmic inclusions were observed only in one. Scrapings gave more specific results, that correlated well with microbiology in bacterial and viral infection, whereas the results of impression cytology showed minor metaplastic changes of epithelial cells that were nonspecific for the type of inflammation. Cytology remains a useful non-invasive tool and is an adjunct to clinical and microbiological examination. It proved especially helpful in allergic conjunctivitis.

[CHANGES OF PH AND CYTOLOGICAL PICTURE AT VARIOUS STAGES OF WOUND HEALING IN PATIENTS WITH VENOUS GENESIS TROPHIC ULCERS OF THE LOWER LIMBS]

The analysis of 82 patients medical records with venous trophic ulcers (VTU) of the lower limbs were presenting. pH in patients with VTU determined in three locations: the surface of ulcers, venous modified and unmodified skin and ulcers. Cytological examination of secretions from wounds conducted in 32 (39.1%) patients using smears. In 19 (23.2%) patients prevailed exudation stage, in 37 (45.1%) – granulation, in 26 (31.7%) - epithelialization. At all stages of wound healing at a distance from the ulcers observed values change skin pH to the acid side. Typical sings of first phase of wound healing were degenerative–inflammatory and inflammatory type of cytogram, and for the granulation phase – inflammatory–regenerative and regenerative one.

Segmentation and classification of bright lesions to diagnose diabetic retinopathy in retinal images

In view of predicting bright lesions such as hard exudates, cotton wool spots, and drusen in retinal images, three different segmentation techniques have been proposed and their effectiveness is compared with existing segmentation techniques. The benchmark images with annotations present in the structured analysis of the retina (STARE) database is considered for testing the proposed techniques. The proposed segmentation techniques such as region growing (RG), region growing with background correction (RGWBC), and adaptive region growing with background correction (ARGWBC) have been used, and the effectiveness of the algorithms is compared with existing fuzzy-based techniques. Images of eight categories of various annotations and 10 images in each category have been used to test the consistency of the proposed algorithms. Among the proposed techniques, ARGWBC has been identified to be the best method for segmenting the bright lesions based on its sensitivity, specificity, and accuracy. Fifteen different features are extracted from retinal images for the purpose of identification and classification of bright lesions. Feedforward backpropagation neural network (FFBPNN) and pattern recognition neural network (PRNN) are used for the classification of normal/abnormal images. Probabilistic neural network (PNN), radial basis exact fit (RBE), radial basis fewer neurons (RB), and FFBPNN are used for further bright lesion classification and achieve 100% accuracy.

Peritumoral tissue compression is predictive of exudate flux in a rat model of cerebral tumor: an MRI study in an embedded tumor

MRI estimates of extracellular volume and tumor exudate flux in peritumoral tissue are demonstrated in an experimental model of cerebral tumor. Peritumoral extracellular volume predicted the tumor exudate flux. Eighteen RNU athymic rats were inoculated intracerebrally with U251MG tumor cells and studied with dynamic contrast enhanced MRI (DCE-MRI) approximately 18 days post implantation. Using a model selection paradigm and a novel application of Patlak and Logan plots to DCE-MRI data, the distribution volume (i.e. tissue porosity) in the leaky rim of the tumor and that in the tissue external to the rim (the outer rim) were estimated, as was the tumor exudate flow from the inner rim of the tumor through the outer rim. Distribution volume in the outer rim was approximately half that of the inner adjacent region (p < 1 × 10(-4)). The distribution volume of the outer ring was significantly correlated (R(2) = 0.9) with tumor exudate flow from the inner rim. Thus, peritumoral extracellular volume predicted the rate of tumor exudate flux. One explanation for these data is that perfusion, i.e. the delivery of blood to the tumor, was regulated by the compression of the mostly normal tissue of the tumor rim, and that the tumor exudate flow was limited by tumor perfusion.

[THE TECHNOLOGY "CELL BLOCK" IN CYTOLOGICAL PRACTICE]

The article presents summary information concerning application of "cell block" technology in cytological practice. The possibilities of implementation of various modern techniques (immune cytochemnical analysis. FISH, CISH, polymerase chain reaction) with application of "cell block" method are demonstrated. The original results of study of "cell block" technology made with gelatin, AgarCyto and Shadon Cyoblock set are presented. The diagnostic effectiveness of "cell block" technology and common cytological smear and also immune cytochemical analysis on samples of "cell block" technology and fluid cytology were compared. Actually application of "cell block" technology is necessary for ensuring preservation of cell elements for subsequent immune cytochemical and molecular genetic analysis.

[APPLICATION OF A ONE-PORTED VIDEOTHORACOSCOPY IN DIAGNOSIS AND TREATMENT OF A PLEURAL EXUDATE]

The results of examination and treatment of 71 patients for pleural exudates (PE) of various origin were analyzed. The efficacy of application of a one-ported thoracoscopy in diagnosis and treatment of a PE in patients with noncomplicated course of intrathoracic pathological processes was proved. The reduction of the PE quantity by (15 ± 4)% and duration of exudation by (15 ± 9)% was noted after performance of a one-ported thoracoscopic interventions, reduction of operative trauma and subjective sensation of pain, as well as best cosmetic effect.

[THE MORPHOMETRY IN CYTOLOGICAL ANALYSIS OF EXUDATIVE FLUIDS]

The cytological technique takes a leading position in diagnostic of tumor processes according exudative fluids. However, its results depend on large number of subjective factors. The morphometry is one of techniques by virtue of which objectification of data of cytological analysis is possible. The study was carried out to establish differences of morphometric parameters of benign and malignant cells of pleural effusion. The morphometric analysis of cells of mesothelium, breast cancer, adenocarcinoma of lung and adenocarcinoma of stomach was implemented. The parameters characterizing size (area, perimeter) and form (form factor) of nucleus and cell, nucleus-cytoplasm ratio. The results demonstrated that in pleural effusion between cells of proliferating mesothelium and malignant neoplasms exist significant differences in morphometric parameters (p<0.001). The differences between area of nuclei and cells are especially significant. The comparison of data of morphometry of cells of breast cancer; adenocarcinoma of lung and adenocarcinoma of stomach demonstrated that despite of some morphological similarities, analysis of morphometric parameters can provide important data for proper establishment of cytological diagnosis.

DIFFERENCES IN CLINICAL MANIFESTATIONS AND PLEURAL FLUID CHARATERISTICS BETWEEN TUBERCULOUS AND MALIGNANT PLEURAL EFFUSIONS

Tuberculous and malignant pleural effusions share similar clinical and radiographic findings and both may produce lymphocytic-predominant exudative effusions. This study aimed to determine distinguishing clinical features between the two diseases. We conducted a retrospective study among 47 patients with tuberculous pleural effusions (TBPE) and 73 with malignant pleural effusions (MPE). Demographic data, clinical features, pleural fluid characteristics, and radiographic findings were obtained for each patient and the 2 groups were compared. Sixty-nine (57.5%) patients were males. The mean (+/- SD, range) age was 60.2 (+/- 16.9, 19-94) years. Mean (+/- SD) symptom duration was 31.6 (+/- 51.6) days. Univariate analysis identified 20 clinical, pleural fluid and radiological differences between the two groups. Multivariate logistic regression analysis revealed 3 independent predictors of TBPE: fever (OR=8.2; 95% CI: 1.9 - 35.9; p=0.005), having a non-serosanguinous effusion (OR=6.1; 95% CI: 1.1 - 33.6; p=0.038), and a fluid adenosine deaminase level > 30 U/I (OR=86.7; 95% CI: 4.3 - 1735; p=0.004). Fever, non-serosanguinous pleural effusions and high adenosine deaminase levels were suggestive of a TBPE and could be clinically useful when evaluating a pleural effusion of unknown etiology.

Isolation of mast cells from the peritoneal exudate of the teleost fish gilthead sea bream (Sparus aurata L.)

Inflammation is the first response of animals to infection or tissue damage. Sparus aurata (Perciformes) was the first fish species shown to possess histamine-containing mast cells at mucosal tissues. We report a separation protocol for obtaining highly enriched (over 95% purity) preparations of fish mast cells in high numbers (5-20 million mast cells per fish). The peritoneal exudate of S. aurata is composed of lymphocytes, acidophilic granulocytes, macrophages and mast cells. We separated the lymphocyte fraction through discontinuous density gradient centrifugation. The remaining cells were cultivated overnight in RPMI-1640 culture medium containing 5% fetal calf serum, which allowed macrophages to adhere to the cell culture flasks. Finally, acidophilic granulocytes were separated from the mast cells though a Magnetic-Activated Cell Separation (MACS) protocol, using a monoclonal antibody against these cells. The purity of mast cells-enriched fractions was analyzed by flow cytometry and by transmission electron microscopy. The functionality of purified mast cells was confirmed by the detection of histamine release by ELISA after stimulation with compound 48/80 and the induction of the pro-inflammatory cytokines IL-1β and IL-8 following stimulation with bacterial DNA. This fish mast cells separation protocol is a stepping stone for further studies addressing the evolution of vertebrate inflammatory mechanisms.

Improving ductoscopy with duct lavage and duct brushing

AIM

To assess the combined technique of duct lavage (DL) and duct brushing (DB) performed during ductoscopy in pathological nipple discharge (PND).

MATERIALS AND METHODS

The study was conducted in two hospitals: Rea (Greece) and in Meet Ghmmr Oncology Center (Egypt), from January 2011 to April 2013. Sixty-four women were enrolled. A sample of cells was collected with the use of DB. Afterwards, DL was performed. For each case, liquid cytology was compared to the final histology.

RESULTS

From the 19 histological diagnosis of duct ectasia, cytology by DL plus DB (CDLDB) was correct in 17 cases (89.5%). For 28 papillomas, CDLDB was correct in 19 cases (67.9%). For breast cancer (six cases), CDLDB was correct in five cases (83.3%). Also, CDLDB found 45.5% of miscellaneous benign cases. In total, cytology performed by CDLDB was correct in 46 of 64 patients: 71.9%. Thus, the sensitivity of CDLDB ranged from 67% to 90%, depending on the histological diagnosis.

CONCLUSION

This technique showed a high accuracy, in contrast to other studies that used only DL.

New diagnostic technique for rapid fluorescence immunocytochemical staining of adenocarcinoma and mesothelial cells using liquid-based cytology

OBJECTIVE

To evaluate the expression of antibodies against calretinin, cytokeratin 5/6, desmin, D2-40, HBME-1, mesothelin, thrombomodulin, WT1, Ber-EP4, CEA, EMA and MOC-31 individually and to compare it with a new rapid procedure for fluorescence immunocytochemistry (ICC) using liquid-based cytology (LBC).

STUDY DESIGN

Sixty-four peritoneal cell specimens prepared with the LBC method were stained with these markers to evaluate their usefulness and develop a rapid fluorescence immunostaining method using Ber-EP4 that is applicable to intraoperative cancer cytodiagnosis.

RESULTS

The adenocarcinoma markers were positive in 92% of adenocarcinoma cases, 57% of cases with suspicion of adenocarcinoma, and 5% of negative cases (reactive mesothelial cells). On the other hand, the mesothelial cell markers were positive in 8-15% of adenocarcinoma cases, 43-57% of cases with suspicion of adenocarcinoma, and 93-95% of negative cases. The rapid new fluorescence ICC procedure clearly stained only the adenocarcinoma cells within 20 min.

CONCLUSION

Immunocytochemical examination with the LBC method is a powerful ancillary technique for discriminating adenocarcinoma cells from mesothelial cells. This rapid new fluorescence ICC procedure can be used as an ancillary technique for accurate detection of adenocarcinoma cells in the intraoperative cytological examination of peritoneal or pleural washing fluid.

Comparison of logistic regression and neural network classifiers in the detection of hard exudates in retinal images

Diabetic Retinopathy (DR) is a common cause of visual impairment in industrialized countries. Automatic recognition of DR lesions in retinal images can contribute to the diagnosis and screening of this disease. The aim of this study is to automatically detect one of these lesions: hard exudates (EXs). Based on their properties, we extracted a set of features from image regions and selected the subset that best discriminated between EXs and the retinal background using logistic regression (LR). The LR model obtained, a multilayer perceptron (MLP) classifier and a radial basis function (RBF) classifier were subsequently used to obtain the final segmentation of EXs. Our database contained 130 images with variable color, brightness, and quality. Fifty of them were used to obtain the training examples. The remaining 80 images were used to test the performance of the method. The highest statistics were achieved for MLP or RBF. Using a lesion based criterion, our results reached a mean sensitivity of 95.9% (MLP) and a mean positive predictive value of 85.7% (RBF). With an image-based criterion, we achieved a 100% mean sensitivity, 87.5% mean specificity and 93.8% mean accuracy (MLP and RBF).

Anti-inflammatory activity of lipoic acid in mice peritonitis model

This work aimed to investigate the effect of lipoic acid (LA) on sulfane sulfur (S*) level, infiltration of neutrophils and vascular permeability in a model of zymosan-induced peritonitis. The study showed that lipoic acid increased the sulfane sulfur level. Also, it decreased count of neutrophils and inhibition of intensity of early vascular permeability compared to the control group. These studies indicated that LA exhibits antiinflammatory activity. LA serves as a sulfane sulfur acceptor and releases sulfane sulfur in the form of hydrogen sulfide (H2S), which is probably responsible for its anti-inflammatory activity.

Clinical outcomes of percutaneous drainage of breast fluid collections after mastectomy with expander-based breast reconstruction

PURPOSE

To determine clinical outcomes of patients who underwent imaging-guided percutaneous drainage of breast fluid collections after mastectomy and breast reconstruction.

MATERIALS AND METHODS

A retrospective review was performed including all consecutive patients who underwent percutaneous drainage of fluid collections after mastectomy with tissue expander-based reconstruction between January 2007 and September 2012. During this period, 879 mastectomies (563 patients) with expander-based breast reconstruction were performed. Fluid collections developed in 28 patients (5%), which led to 30 imaging-guided percutaneous drainage procedures. The median follow-up time was 533 days. Patient characteristics, surgical technique, microbiology analysis, and clinical outcomes were reviewed.

RESULTS

The mean age of patients was 51.5 years (range, 30.9-69.4 y), and the median time between breast reconstruction and drainage was 35 days (range, 4-235 d). Erythema and swelling were the most common presenting symptoms. The median volume of fluid evacuated at the time of drain placement was 70 mL. Drains were left in place for a median 14 days (range, 6-34 d). Microorganisms were detected in the fluid in 12 of 30 drainage procedures, with Staphylococcus aureus being the most common microorganism. No further intervention was needed in 21 of 30 drainage procedures (70%). However, surgical intervention (removal of expanders) was needed after 6 (20%) drainage procedures, and additional percutaneous drainage procedures were performed after 3 (10%) drainage procedures.

CONCLUSIONS

Percutaneous drainage is an effective means of treating postoperative fluid collections after expander-based breast reconstruction and can obviate the need for repeat surgery in most cases.

The inflammatory cell influx and cytokines changes during transition from acute inflammation to fibrous repair around implanted materials

The inflammatory and fibrous responses in a subcutaneous rat model were evaluated around degradable polyurethane urea (PUUR; Artelon), with titanium and tissue culture polystyrene (PS) discs having different surface chemical properties but similar surface topography. Cytokines, viability, cellular response, differentiation of cells and fibrous capsule formation and vascularization was investigated after 1, 7 and 21 days of implantation. The exudates retrieved from the pockets were analysed with respect to the total cell numbers, the proportions of cell types, the differentiation of monocytes/macrophages (ED1, ED2), the DNA content and the viability (LD, Trypan blue). Tumour necrosis factor alpha ((h)TNF-alpha) and interleukin-10 ((h)IL-10) were quantified by ELISA. The number of blood vessels, blood vessel luminal area, blood vessel distribution and the fibrous capsule thickness were analysed. The highest number of cells in the exudates around all implants was detected during the early phase of healing (1-7 days). The proportion of ED2-positive cells in the exudates increased from 2-8% at 1 day to 43-56% at 21 days. The levels of TNF-alpha were low with a decrease at 7 days. After 21 days high amounts of IL-10 in the exudates were detected, in particular around PUUR. This study shows that the transition from inflammation to repair (1-21 days) around PUUR, Ti and PS materials was characterized by a decrease in inflammatory cell influx, an increasing proportion of ED2-expressing macrophages, a biphasic TNF-alpha secretion, an increase of IL-10 and a fibrous capsule formation similar to all materials tested.

Exudate-based diabetic macular edema detection in fundus images using publicly available datasets

Diabetic macular edema (DME) is a common vision threatening complication of diabetic retinopathy. In a large scale screening environment DME can be assessed by detecting exudates (a type of bright lesions) in fundus images. In this work, we introduce a new methodology for diagnosis of DME using a novel set of features based on colour, wavelet decomposition and automatic lesion segmentation. These features are employed to train a classifier able to automatically diagnose DME through the presence of exudation. We present a new publicly available dataset with ground-truth data containing 169 patients from various ethnic groups and levels of DME. This and other two publicly available datasets are employed to evaluate our algorithm. We are able to achieve diagnosis performance comparable to retina experts on the MESSIDOR (an independently labelled dataset with 1200 images) with cross-dataset testing (e.g., the classifier was trained on an independent dataset and tested on MESSIDOR). Our algorithm obtained an AUC between 0.88 and 0.94 depending on the dataset/features used. Additionally, it does not need ground truth at lesion level to reject false positives and is computationally efficient, as it generates a diagnosis on an average of 4.4s (9.3s, considering the optic nerve localisation) per image on an 2.6 GHz platform with an unoptimised Matlab implementation.

Benznidazole treatment attenuates liver NF-κB activity and MAPK in a cecal ligation and puncture model of sepsis

Recent studies have shown that Benznidazole (BZL), known for its antiparasitic action on Trypanosoma cruzi, modulates pro-inflammatory cytokines and nitric oxide (NO) release in activated macrophages by blocking NF-κB through inhibition of IKK in vitro. As so far, little is known about the mechanism by which BZL provokes the inhibition of inflammatory response in sepsis in vivo, we aimed to delineate the possible role of BZL as a modulator in liver inflammation in mice with sepsis induced by cecal ligation and puncture (CLP). Specifically, we analyzed leukocytes, liver production of TNF-α and NO and the intracellular pathways modulated by these mediators, including NF-κB and MAPKs, in the liver of mice 24 h post-CLP. Our results show that BZL reduces leukocytes in peripheral blood accompanied by an increase in peritoneal macrophages 24h after CLP. In the liver of these septic mice, BZL decreased expression of mRNA and protein for TNF-α and NOS-2 by inhibition of NF-κB and MAPK (p-38 and ERK). The body of evidence suggests that the immunomodulatory effects of BZL could act selectively, as it is able to decrease the systemic inflammatory reaction and the hepatic response but it can increase the number of cells in the site of infection.

Evaluation of nipple discharge cytology and diagnostic value of red blood cells in cases with negative cytology: a cytohistologic correlation

OBJECTIVE

To evaluate the sensitivity and specificity of nipple discharge cytology and to determine the diagnostic value of the presence of red blood cells (RBCs) in cases with negative cytology.

STUDY DESIGN

Samples were received either as air-dried or alcohol-fixed slides. All cytology cases were reported by cytopathologists in the Hammersmith Pathology Department.

RESULTS

We identified 98 consecutive female patients with nipple discharge cytology in the Hammersmith and Charing Cross hospitals during the period of May 2007 to May 2009. The cytodiagnoses were as follows: 86 cases had negative cytology, 9 cases were C3 (atypia but likely benign), and 3 cases were suspicious for or consistent with malignancy. Thirty of these cases had subsequent biopsy and showed: 9 benign cases, 3 cases with atypical papilloma and 3 cases with a malignant diagnosis (in situ and/or invasive ductal carcinoma). All suspicious and malignant cases with available macroscopic description (whether positive or negative on nipple discharge cytology) were blood stained and on microscopy contained RBCs.

CONCLUSION

Nipple discharge cytology is a useful method in the diagnosis of malignant and suspicious cases. Further evaluation is needed to assess the value of the presence of RBCs in cases with negative cytology and its correlation with a subsequent diagnosis of malignancy.

Three-dimensional analysis of retinal layer texture: identification of fluid-filled regions in SD-OCT of the macula

Optical coherence tomography (OCT) is becoming one of the most important modalities for the noninvasive assessment of retinal eye diseases. As the number of acquired OCT volumes increases, automating the OCT image analysis is becoming increasingly relevant. In this paper, a method for automated characterization of the normal macular appearance in spectral domain OCT (SD-OCT) volumes is reported together with a general approach for local retinal abnormality detection. Ten intraretinal layers are first automatically segmented and the 3-D image dataset flattened to remove motion-based artifacts. From the flattened OCT data, 23 features are extracted in each layer locally to characterize texture and thickness properties across the macula. The normal ranges of layer-specific feature variations have been derived from 13 SD-OCT volumes depicting normal retinas. Abnormalities are then detected by classifying the local differences between the normal appearance and the retinal measures in question. This approach was applied to determine footprints of fluid-filled regions--SEADs (Symptomatic Exudate-Associated Derangements)--in 78 SD-OCT volumes from 23 repeatedly imaged patients with choroidal neovascularization (CNV), intra-, and sub-retinal fluid and pigment epithelial detachment. The automated SEAD footprint detection method was validated against an independent standard obtained using an interactive 3-D SEAD segmentation approach. An area under the receiver-operating characteristic curve of 0.961 +/- 0.012 was obtained for the classification of vertical, cross-layer, macular columns. A study performed on 12 pairs of OCT volumes obtained from the same eye on the same day shows that the repeatability of the automated method is comparable to that of the human experts. This work demonstrates that useful 3-D textural information can be extracted from SD-OCT scans and--together with an anatomical atlas of normal retinas--can be used for clinically important applications.

Neutralization of TNFalpha alters inflammation in guinea pig tuberculous pleuritis

Previously, treatment with anti-gpTNFalpha antibody enhanced TNFalpha mRNA expression in pulmonary granulomas microdissected from non-vaccinated guinea pigs, and modified splenic granuloma architecture. In this study, pleural fluid, cells, and granulomatous tissues were collected 3, 5, and 8 days post-pleurisy induction in guinea pigs treated with anti-gpTNFalpha or normal serum control. Neutralizing TNFalpha reduced the percentage of macrophages in the pleural exudate while increasing the proportions of neutrophils and lymphocytes. Cell-associated mycobacterial loads were increased in guinea pigs treated with anti-gpTNFalpha antibody. Cells from the pleural exudate in both treatment groups at day 3 expressed predominantly TNFalpha and IFNgamma mRNA. By day 5, treatment with anti-gpTNFalpha antibody significantly reduced TNFalpha mRNA and increased TGFbeta and iNOS mRNA expression, a transition which did not occur in the control group until day 8. TNFalpha mRNA overwhelmed the cytokine milieu of microdissected pleural granulomas in the control group at day 3 whereas TNFalpha, IFNgamma, and TGFbeta mRNA dominated the anti-gpTNFalpha-treated group. At day 8, granulomas from the control group began shifting towards an anti-inflammatory profile with increased levels of TGFbeta mRNA. Neutralization of TNFalpha hastened the transition to an anti-inflammatory cytokine response in guinea pig pleural granulomas and exudate cells.

[Differential diagnosis of pleural effusions]

The role of clinical and instrumental studies into the nature of pleural effusion obtained through transthoracic puncture was ascertained in 639 with pulmonary pathology. An algorithm was developed for the application of this method to differential diagnosis of different forms of pleuritis. Etiopathogenetic groups of patients with terminal differentiation of this pathology were distinguished.

Application of liquid-based preparation to non-gynaecologic exfoliative cytology

Thin-layer cytology (TLC) is an automated method for processing cells harvested in a liquid solution and collected onto a single slide. The leftover material can be used for other techniques such as immunocytochemistry, molecular biology and flow cytometry. TLC has been applied with good results in exfoliative cytology of pulmonary, urinary, gastrointestinal and oral districts as well as in the evaluation of serous effusions. The main advantages of TLC over conventional techniques (CS) are: (a) simplification of the sampling technique; (b) decrease in cellular artefacts leading to a lesser amount of inadequate diagnoses; and (c) applicability of additional investigations. The limits of TLC are: (a) changes in the morphologic picture of some lesions; (b) increase of the workload for technical staff; and (c) increased cost. The application of TLC to non-gynaecologic specimens favours many innovative developments and can be regarded as an appropriate substitute for CS.

Percutaneous needle peritoneal biopsy in the diagnosis of exudative ascites

BACKGROUND

Percutaneous needle peritoneal biopsy in diagnosis of exudative ascites has gained wide acceptance and many workers have utilized it with a high diagnostic yield and no significant complications. Present study has been carried out to determine the efficacy of percutaneous needle peritoneal biopsy in the diagnosis of exudative ascites of unknown aetiology.

METHODS

It is a descriptive case study conducted in Medical 'C' Unit, Lady Reading Hospital, Postgraduate Medical Institute, Khyber Medical University Peshawar over a period of 2 years, i.e., from Nov, 2003 to December 2005. A total of 45 patients having unexplained exudative ascites underwent blind needle peritoneal biopsy. The biopsy specimen was subjected to histopathology. Ascitic fluid was also obtained for analysis. Post biopsy patients were observed for 24 hours for any untoward complications.

RESULTS

A total of 45 patients (17 male and 28 female) with age range from 20 to 65 years and having exudative ascites were studied. The commonest presentation of our patients was abdominal distension (93.3%), pain abdomen (46.67%), fever (44.4%) and weight loss (33.3%). Histopathology of the peritoneal biopsies was reported as follows. Eighteen cases (40%) showed non specific chronic inflammation, 10 (22.2%) cases showed caseating granulomatous inflammation suggestive of tuberculosis and 6 (13.3%) cases showed metastatic adenocarcinoma. In one patient peritoneal mesothelioma was reported. In the remaining 10 patients (22.2%) biopsies were either non representative or inconclusive. The ascitic fluid showed predominantly lymphocytes in 86.6% of cases. Only three patients were reported to be having atypical cells on fluid cytology. The procedure was found safe. No patient was lost due to complications related to the procedure. Only one patient had evidence of intra peritoneal bleed. The commonest problem post biopsy was pain (91.1%) and mild swelling (53.3%) at biopsy site.

CONCLUSION

Peritoneal biopsy is fairly safe and inexpensive procedure with good diagnostic efficacy in patients with undiagnosed exudative ascites.

Breast ductal secretions: clinical features, potential uses, and possible applications

BACKGROUND

Nipple discharge accounts for approximately 5% of visits to a breast specialist surgical practice and may be encountered as the chief complaint by many other types of physicians. The vast majority of breast cancers originate in the ductal system, which prompted interest in the evaluation of the intraductal approach to breast cancer. Ductoscopy, nipple aspiration, and ductal lavage have emerged as innovative fields of study that may have clinical applications.

METHODS

We performed a literature search of published manuscripts using the keywords nipple discharge, breast ductal secretions, and intraductal approach. We also report our single-institution experience in managing nipple discharge.

RESULTS

We present our institutional algorithm for the management of nipple discharge. The possible etiologies of nipple discharge and the appropriate workup are reviewed. Three evolving minimally invasive techniques for the evaluation of high-risk patients include ductoscopy, nipple aspiration, and ductal lavage. Nipple aspiration and ductal lavage fluid may be assayed for cytology, genomic, gene expression, and proteomic studies. Several different translational approaches are being undertaken to investigate the local microenvironment associated with the development and progression of breast carcinoma.

CONCLUSIONS

Nipple aspiration fluid and ductal lavage offer the opportunity to study the local microenvironment of the ductal system, which is where most breast cancers originate. These powerful approaches to biomarker analysis could be applied to the prevention and treatment of breast cancer.

ERCC1 and BRCA1 mRNA expression levels in metastatic malignant effusions is associated with chemosensitivity to cisplatin and/or docetaxel

BACKGROUND

One of the major challenges in currently chemotherapeutic theme is lacking effective biomarkers for drug response and sensitivity. Our current study focus on two promising biomarkers, ERCC1 (excision repair cross-complementing group 1) and BRCA1 (breast cancer susceptibility gene 1). To investigate their potential role in serving as biomarkers for drug sensitivity in cancer patients with metastases, we statistically measure the mRNA expression level of ERCC1 and BRCA1 in tumor cells isolated from malignant effusions and correlate them with cisplatin and/or docetaxel chemosensitivity.

METHODS

Real-time quantitative PCR is used to analysis related genes expression in forty-six malignant effusions prospectively collected from non-small cell lung cancer (NSCLC), gastric and gynecology cancer patients. Viable tumor cells obtained from malignant effusions are tested for their sensitivity to cisplatin and docetaxel using ATP-TCA assay.

RESULTS

ERCC1 expression level is negatively correlated with the sensitivity to cisplatin in NSCLC patients (P = 0.001). In NSCLC and gastric group, BRCA1 expression level is negatively correlated with the sensitivity to cisplatin (NSCLC: P = 0.014; gastric: P = 0.002) while positively correlated with sensitivity to docetaxel (NSCLC: P = 0.008; gastric: P = 0.032). A significant interaction is found between ERCC1 and BRCA1 mRNA expressions on sensitivity to cisplatin (P = 0.010, n = 45).

CONCLUSION

Our results demonstrate that ERCC1 and BRCA1 mRNA expression levels are correlated with in vitro chemosensitivity to cisplatin and/or docetaxel in malignant effusions of NSCLC and gastric cancer patients. And combination of ERCC1 and BRCA1 may have a better role on predicting the sensitivity to cisplatin than the single one is considered.

[Mammary ductoscopy--diagnostic opportunites for the assessment of women with pathologic nipple discharge]

The aim of this study to analyse the diagnostic possibilities of mammary ductoscopy in the patients with pathologic nipple discharge.

MATERIAL AND METHODS

The target of this prospective study are 29 patients who have been through ductal lavage and mammer ductoscopy. We used local anastetic to induct the lacrimal dilatators (dimeter from 0.35 to 1.00 mm from which we infuse and aspirate from 5 to 18 ml 1% Lidocain and 0.9% NaCl) through the openiting of the secreting cannal. After the ductal lavage follows ductoscopy with mammary ductoscope of Karl-Starz endoscope with outside diameter of 0.89 mm.

RESULTS

The ductoscopy in which we visualized the ductal lumen was successful released on 23 of patients. A good correlasy was established between the macroscopic finding ductoscopy, the cytology study of ductal secret and the postoperative hystologic diagnosis.

CONCLUSIONS

The mammar ductoscopy gives an important information which leads to target to approach for the assessment and treatment of women with pathologic nipple discharge.

Acute immune and non-immune inflammatory response in spontaneously hypertensive rats and normotensive rats. Role of endogenous nitric oxide

The present study investigated the acute inflammatory response (increase in vascular permeability and leukocytes migration) in the pleura of spontaneously hypertensive rats (SHR) and normotensive rats (NTR), using two different stimulus: carrageenan and active anaphylaxis. In addition, the role of endogenous nitric oxide in these responses was investigated.

RESULTS

The inflammatory response induced by intrapleural carrageenan injection in SHR developed similarly to that in NTR. Treatment with L-NAME, reduced the intensity of this response in both groups of rats. The inflammatory response induced by active anaphylaxis in SHR and NTR was different. The increase in vascular permeability occurred later in the SHR compared to NTR. The number of leukocyte present in inflammatory exudates was increased at 4 h in both groups of rats. L-NAME treatment did not inhibit exudation at the intervals under analysis, however, reduced the number of mononuclear cells in the inflammatory exudate of SHR.

CONCLUSION

The development of the inflammatory response in SHR differs from that in NTR, depending on the nature of the inflammatory stimulus. Endogenous NO plays a clear role in carrageenan-induced inflamma-tion, but not in immunologically mediated inflammation in the analyzed period.

Modulatory effect of killed Propionibacterium acnes and its purified soluble polysaccharide on peritoneal exudate cells from C57Bl/6 mice: major NKT cell recruitment and increased cytotoxicity

Propionibacterium acnes has been described as a potent adjuvant to immune responses in vitro and in vivo. Presently, we analysed the modulation of peritoneal exudate cells (PEC) by heat-killed P. acnes or its purified soluble polysaccharide (PS), both injected intraperitoneally in C57Bl/6 mice, aiming at their recruitment and cytotoxicity. Both treatments induced an increase in macrophages, immature dendritic cells, B1a lymphocytes and NK1.1(+) CD3(+) cells. The bacterium caused a remarkable increase in a NK1.1(+) CD3(+) CD4(-) CD8(-) cells subpopulation, whereas the PS component seemed responsible for the recruitment of mainly macrophage cells. To assess P. acnes and PS adjuvant effect on PEC cytotoxicity we evaluated their in vitro effect on murine B16F10 melanoma cells. The effector cells from the heat-killed bacteria and PS-treated groups lysed melanoma cells in co-cultures with PEC. Mice genetically deficient in IFN-gamma, when stimulated with P. acnes or PS, had reduced PEC cytotoxicity, and the cytotoxic effect was completely abrogated in PEC from iNOS(-/-) mice. The tumoricidal activity of PEC from P. acnes-treated mice was mediated by macrophages and NKT cells stimulated with IL-12. In PS-treated mice the cytotoxicity was mediated mainly by macrophages. Moreover, both treatments increased IL-4 and IFN-gamma production by NKT cells. In conclusion, we show that P. acnes act mainly by recruiting and activating NKT double-negative cells in PEC, which were shown to be tumoricidal in vitro when induced by IL-12. Macrophages induced by both P. acnes and PS have their antitumour effect dependent on NO production.

Inhibition of inducible nitric oxide synthase in vitro and in vivo by a water-soluble extract of Wendita calysina leaves

Wendita calysina is a Paraguayan herbaceous plant commonly known as burrito. Our previous study indicated that burrito leaves are a very good source of phenylpropanoid glycosides, principally verbascoside. From W. calysina leaves, a standardized, water-soluble extract (WSE) rich in phenylpropanoid glycosides has been developed on an industrial scale to be used as a food supplement, cosmetic, phytomedicine, and ingredient of different formulations. In this study, we investigated the effect of the W. calysina WSE both in vitro in murine macrophage cell line J774.A1 stimulated with lipopolysaccharide (LPS) and, in vivo in an animal model of acute inflammation, carrageenan-induced pleurisy. Here we report that W. calysina WSE (0.05, 0.1, and 0.5 mg/ml) inhibited inducible nitric oxide synthase (iNOS) expression and activity in LPS-stimulated J774.A1. In vivo experiments showed that injection of carrageenan (2%) into the pleural cavity of rats elicited an acute inflammatory response characterized by iNOS expression, intercellular adhesion molecule-1 (ICAM-1) up-regulation, nitrotyrosine and poly (ADP-ribose) synthase (PARS) formation, and lung tissue damage-all parameters significantly reduced by W. calysina WSE (500 mg/kg per os). These results report, for the first time, that a treatment with W. calysina WSE exerts anti-inflammatory effects both in vitro and in vivo.

Exudative pleural effusion: effectiveness of pleural fluid analysis and pleural biopsy

The study compared pleural fluid analysis and pleural biopsy in the diagnosis of 100 patients with exudative pleural effusion (PE) in Babol, Islamic Republic of Iran. Tuberculous pleurisy and malignant pleural effusion were confirmed by the identification of acid-fast bacilli from body fluids or tumour cells from tissue specimens. Malignant diseases and tuberculosis were the causes of exudative PE in 43% and 33% of patients respectively. The diagnostic sensitivity of pleural biopsy in patients with tuberculous PE and malignant PE was 70% and 54%, and the diagnostic sensitivity of pleural fluid analysis was 33% and 70% respectively. Combined pleural biopsy and pleural fluid analysis were positive in 97% of tuberculous PE cases and 91% of malignant PE.

Male urethritis with and without discharge: relation to microbiological findings and polymorphonuclear counts

OBJECTIVE

We studied the relation between the presence or absence of urethral discharge, urethral pathogens, and polymorphonuclear (PMN) counts on Gram stained urethral smears in men with symptomatic urethritis.

METHODS

The study population was composed of 630 sexually active heterosexual men (aged 18-45 years) who had urethral symptoms and signs (discharge, dysuria or urethral discomfort). Participants were divided into two groups: the first (n=320) was comprised of men with urethral discharge confirmed on examination, while the other (n=310) was composed of patients with urethral symptoms but without discharge. Urethral swabs for Gram stained smears and microbiological analyses (N. gonorrhoeae, C. trachomatis, T. vaginalis and U. urealyticum) were taken from all study participants. Polymorphonuclear leukocytes (PMN) on Gram-stained urethral smears were counted in 5 oil immersion x1000 PMN per high power fields (phpf). Urethritis was defined as the presence of > or =5 PMN/hpf.

RESULTS

N. gonorrhoeae was isolated only in men with urethritis accompanied by discharge. The prevalence of T. vaginalis, C. trachomatis and U. urealyticum was significantly higher (F=8.854, P<0.01) in urethral swabs of urethritis patients with discharge compared to patients with no discharge. The most common urethral pathogen in both groups of patients was T. vaginalis (31.56% and 26.45%, respectively). One or more microorganisms were isolated in 258 (81%) subjects with urethritis with discharge, and in 166 (53.5%) urethritis patients without discharge. There was a positive correlation between the significant number of PMN in Gram stained urethral smears and positive microbiological findings in men with urethritis both with and without urethral discharge (Spearmanns coefficients rho=0.986 and rho=0.993, respectively; P<0.01).

CONCLUSIONS

The study found a relatively high prevalence of T. vaginalis among our men with urethritis irrespective of the presence or absence of urethral discharge, and showed that taking into account both discharge found on examination, and relevant PMN counts on Gram stained urethral smears fails to detect only 4.2% of oligosymptomatic urethritis patients who are infected with one of the strict urethral pathogens.

Sanguinarine-dependent induction of apoptosis in primary effusion lymphoma cells

Primary effusion lymphoma (PEL) is an incurable, aggressive B-cell malignancy that develops rapid resistance to conventional chemotherapy. In efforts to identify novel approaches to block proliferation of PEL cells, we found that sanguinarine, a natural compound isolated from the root plant Sanguinaria canadendid, inhibits cell proliferation and induces apoptosis in a dose-dependent manner in several PEL cell lines. Our data show that sanguinarine treatment of PEL cells results in up-regulation of death receptor 5 (DR5) expression via generation of reactive oxygen species (ROS) and causes activation of caspase-8 and truncation of Bid (tBid). Subsequently, tBid translocates to the mitochondria causing conformational changes in Bax, leading to loss of mitochondrial membrane potential and release of cytochrome c to the cytosol. Sanguinarine-induced release of cytochrome c results in activation of caspase-9 and caspase-3 and poly(ADP-ribose) polymerase (PARP) cleavage, leading to induction of caspase-dependent apoptosis. In addition, we show that pretreatment of PEL cells with carbobenzoxy-Val-Ala-Asp-fluoromethylketone, a universal inhibitor of caspases, abrogates caspase and PARP activation and prevents cell death induced by sanguinarine. Moreover, treatment of PEL cells with sanguinarine down-regulates expression of inhibitor of apoptosis proteins (IAP). Finally, N-acetylcysteine, an inhibitor of ROS, inhibits sanguinarine-induced generation of ROS, up-regulation of DR5, Bax conformational changes, activation of caspase-3, and down-regulation of IAPs. Taken together, our findings suggest that sanguinarine is a potent inducer of apoptosis of PEL cells via up-regulation of DR5 and raise the possibility that this agent may be of value in the development of novel therapeutic approaches for the treatment of PEL.

Heparanase expression: a potential ancillary diagnostic tool for distinguishing between malignant cells and reactive mesothelium in body cavity effusions

OBJECTIVE

Heparanase, an endoglycosidase that cleaves heparan sulphate, is frequently expressed in carcinomas and was suggested to play a role in cell invasion and metastasis. We investigated whether heparanase expression may serve as a reliable marker to discriminate benign mesothelial cells from malignant cells shed into body cavities.

METHODS AND RESULTS

Cytological smears of effusions from 51 hospitalized patients were immunostained for heparanase. Strong immunoreactivity was noted in 35 of 40 (88%) carcinoma samples and in all three malignant mesothelioma cases. Only rare (<3%) reactive mesothelial cells were noted showing a faint negligible staining. Specificity was 100%, sensitivity 88%, and positive and negative predictive values were 100% and 89% respectively.

CONCLUSIONS

Our results suggest that heparanase may be of value as a complementary component in a diagnostic panel of markers, contributing to its reliability and accuracy.

Fiberoptic ductoscopy combined with cytology testing in the patients of spontaneous nipple discharge

Fiberoptic ductoscopy system (FDS) offers a safe alternative to ductography in diagnosing intraductal lesions and serves as a guide for subsequent surgery in women with nipple discharge. In this article, we reported the outcomes of FDS combined with cytology testing for diagnosis of spontaneous nipple discharge. From 1997 to 2005, 1,048 women (1,093 breasts total) in the outpatient department underwent successful diagnostic FDS. Discharge was unilateral (86.8%), single ductal (93.4%), and serous (57.9%) or bloody (36.0%). Among 437 (40.0%) of the FDS-positive breasts, we revealed 49 (11.2%) breast carcinomas, 228 (52.2%) central papillomas, and 5 (1.1%) cases of atypical ductal hyperplasia. Ten patients with positive cytology testing received microdochectomy in spite of having a negative FDS, which revealed two additional ductal carcinomas in situ (DCIS), and four papillomas. About 489 breasts were negative for both FDS and cytology testing and were subjected to follow up. About 77 (15.7%) of the breasts underwent tissue diagnosis within a median follow-up time span of 19 months, and one DCIS was detected. The sensitivity of FDS for detection of malignant lesions was 94.2% and increased to 98.1% when combined with cytology testing. Nevertheless, it was less sensitive (p<0.01) if we used cytology testing only (58.3%), mammography (48.6%), high-frequency sonography (36.4%), or combination of mammography and sonography (56.8%) to detect these malignant lesions. These data confirmed the value of FDS combined with cytology testing as a diagnostic procedure in women with nipple discharge.

[Ductal approaches in mammary diagnostics]

OBJECTIVE

Information about new possibilities of early diagnostics in mammary lesions.

TYPE OF STUDY

Review.

SETTING

Gynecology-Obstetrics Clinic, 1st Medical Faculty and General Teaching Hospital, Prague.

SUBJECT AND METHODS

Most malignant tumors of the breast originate from ductal epithelium. A direct examination of the ductal system, could significantly improve diagnostics of breast cancer as well as its preinvasive stages (DCIS) and to influence mortality. The concept of ductal approaches includes several techniques and ductal lavage and duscoscopy.

CONCLUSIONS

Ductal approaches represent an attractive area for minimal load upon the patients. Specificity and sensitivity of these methods have some limits, which will be subject to change in relation to understanding of carcinogenesis and in a close relation to the knowledge of biomarkers, genomics and proteomics. Ductoscopy appears to be the ideal method for the future due to possibilities of direct visualization of epithelium in combination with biopsy and ductal lavage. It other advantages include minimal invasiveness, minimal risk and the origin of possible complications for the patient.

Adjunctive diagnostic value of ultrasonography evaluation in patients with suspected ductal breast disease

PURPOSE

The purpose of this study was to evaluate the adjunctive diagnostic value of breast ultrasonography (US) in the study of benign ductal breast disease.

MATERIALS AND METHODS

Fifty-two patients underwent US examinations for bloody nipple discharge, palpable retroareolar masses, retroareolar opacities or ductal pattern on mammography. US enabled visualisation of mammary-duct ectasia (simple or pseudocystic, retroareolar and/or peripheral) and focal masses (endoluminal or periductal, with ill-defined or regular margins). All patients with nipple discharge underwent cytological evaluation. After the US examination, all focal masses with ill-defined margins underwent fine-needle aspiration biopsy (FNAB), if necessary. The benign alterations were followed up.

RESULTS

In 38/52 cases, US diagnosed mammary-duct ectasia and in 30/52 cases, the presence of focal masses (mean size 7 mm). In the nine women who underwent biopsy, histopathological evaluation diagnosed five solitary papillomas, one solitary papilloma with a focal area of ductal carcinoma in situ (DCIS), two multiple papillomas of the nipple and one papillomatosis.

CONCLUSIONS

High-frequency US plays an important role in the detection of benign ductal disease both for the diagnosis and classification of focal masses and mammary-duct ectasia. US can be used as a complementary imaging method to galactography or as a valuable alternative when galactography is not available.

Pleural fluid analysis with traditional and additional parameters

36 patients with pleural effusion were studied clinically with pertinent investigations and pleural fluid analysis. The pleural fluid analysis was done with routine protocol including study of traditional parameters like protein and cell count and additional parameters like pleural LDH, GOT(AST) and their ratio with serum LDH and GOT respectively. The utility of these parameters was studied critically. Amongst the isolated parameters cell count enjoyed highest (100%) specificity and positive predictive value. LDH ratio had highest (79.1%) sensitivity. Pleural LDH showed highest (52.6%) negative predictive value and diagnostic accuracy (69.4%). Amongst the combination of two parameters protein with LDH ratio had highest (87.5%) sensitivity, cell count with LDH ratio showed highest specificity (100%), positive predictive value (75%) and diagnostic accuracy (88.9%). Amongst the combination of three parameters pleural protein and cell count with LDH ratio and GOT ratio respectively enjoyed best sensitivity (87.5%), specificity and positive predictive value (100%), negative predictive value (80%) and diagnostic accuracy (90.6%). Similarly competent were the combinations offour parameters namely p rotein and cell count with LDH and its ratio and GOT and its ratio respectively. Combination of all parameters exhibited similar degree of utility.

Role of pleural viscosity in the differential diagnosis of exudative pleural effusion

OBJECTIVE AND BACKGROUND

Determining the aetiology of an effusion involves assessing if it is an exudate or a transudate. However, a reliable test for determining the aetiology of a pleural effusion is lacking. Pleural viscosity has a high sensitivity and specificity and a high positive and negative predictive value for discriminating exudative and transudative pleural effusions. The aim of this study was to use pleural fluid viscosity to discriminate between various aetiologies of exudative effusions, namely malignant, parapneumonic and tuberculous.

METHODS

Seventy consecutive patients (24 women, 46 men, mean age = 67 years) with exudative pleural effusion due to pneumoniae in 24 patients, tuberculous pleurisy in 21 and lung cancer in 25 were studied prospectively. Measurements of pleural fluid and plasma viscosity were performed using Brookfield DV-II viscometer.

RESULTS

Pleural viscosity and pleural LDH were highest in the tuberculous pleurisy patients and lowest in the lung cancer patients. Pleural viscosity > or = 1.57 was found to be indicative of tuberculous pleurisy with a sensitivity of 100% and specificity of 95%. Pleural viscosity < 1.39 was found to be indicative of lung cancer with a sensitivity of 100% and specificity of 94%. Pleural viscosity was significantly correlated with pleural albumin (r = 0.34, P = 0.004), protein (r = 0.40, P = 0.001), LDH (r = 0.70, P < 0.001) and plasma viscosity (r = 0.44, P < 0.001), having the most significant value with pleural LDH.

CONCLUSION

The pleural fluid viscosity of patients with parapneumonic, tuberculous and malignant effusions are significantly different from each other. Among these groups, tuberculous effusions had the highest viscosity, and malignant effusions from lung cancer the lowest.

Analysis of pleural effusions in acute pulmonary embolism: Radiological and pleural fluid data from 230 patients

BACKGROUND AND OBJECTIVE

The aims of this study were to describe the frequency and radiographical characteristics of pleural effusions in a large population of patients with acute pulmonary embolism (PE) and characterize the pleural fluid biochemistry in those patients who underwent diagnostic thoracentesis.

METHODS

This was a retrospective observational single-centre study. A total of 230 consecutive patients with a diagnosis of PE over a 9-year period were enrolled. Spiral CT pulmonary angiography (52%) and high-probability ventilation and perfusion scans (42%) were used as the main reference methods.

RESULTS

Pleural effusions were observed in 32% and 47% of patients by CXR and CT, respectively. Typically, pleural effusions were small (90% occupied less than one third of the hemithorax) and unilateral (85%), but occasionally they reached more than a half of the hemithorax. On CT, 21% of pleural effusions showed loculation. In patients with loculated pleural fluid the diagnosis of PE had been delayed for a mean of 12.2 days after symptoms developed. The presence of pleural fluid was not related to infarction. Twenty-six of 93 (28%) patients with effusions on imaging underwent thoracentesis. All the fluids met Light's criteria for exudate, 58% contained erythrocyte counts >10,000/microL and 46% showed neutrophilic predominance.

CONCLUSIONS

Small pleural effusions, mostly unsuitable for diagnostic thoracentesis, were present in about one third of patients with PE. All the pleural effusions due to PE were exudates. If PE diagnosis was delayed the pleural effusion tended to become loculated.

Mammary ductoscopy for the evaluation of nipple discharge and comparison with standard diagnostic techniques

STUDY OBJECTIVE

To describe performance of breast duct endoscopy and compare the method with conventional diagnostic techniques.

DESIGN

Canadian Task Force classification III.

SETTING

Interdisciplinary Breast Unit of a university hospital.

PATIENTS

Consecutive and unselected series of 15 female patients including 20 breasts with nipple discharge.

INTERVENTIONS

Prospective data assessment on all patients with ductoscopy for nipple discharge between April 2003 to April 2004. All preoperative (mammography, ultrasonography, nipple smear) and minimally invasive (galactography, fine needle aspiration cytologic study) diagnostics were evaluated and compared with ductoscopy.

MEASUREMENTS AND MAIN RESULTS

Mammography on 20 breasts showed BI-RADS-I (5%), BI-RADS-II (50%), and BI-RADS-III (45%). Breast ultrasound scanning showed abnormalities, classified as BI-RADS-III equivalent lesions in all cases. Nipple smear showed in 69.2% a normal cytology and in most cases revealed a papilloma later (n=8/9). Unilateral galactography was performed in 46.7% who had spontaneous nipple discharge. Two galactography results were unremarkable, and open biopsy demonstrated 1 atypical ductal hyperplasia and papilloma. On 20 breasts of 15 women, 19 ductoscopies were successfully performed (95%). In 17 cases open biopsy followed ductoscopy, and 1 ductal carcinoma in situ (DCIS), 3 atypical ductal hyperplasia (ADH), 1 ductal hyperplasia without atypias, and 12 ductal papillomas were found.

CONCLUSION

Compared to nipple smear, the diagnostic value of ductoscopy in this study is superior but marginally inferior to galactography and highly specialized breast ultrasound scanning. Therefore ductoscopy needs to be evaluated on a larger scale, preferably in multicenter trials to further determine its potential and indications.

Autoimmune properties of nucleus pulposus: an experimental study in pigs

STUDY DESIGN

Assessment of activated T and B cells in a subcutaneous chamber filled with autologous nucleus pulposus using flow cytometry and immunohistochemistry.

OBJECTIVES

To examine if subcutaneously placed autologous nucleus pulposus may attract activated T and B cells in an animal model.

SUMMARY OF BACKGROUND DATA

Nucleus pulposus has been suggested to trigger an autoimmune response if exposed to the immune system, for example, in association with disc herniation. T-cell activation represents a hallmark in the generation of an autoimmune response, subsequently leading to the differentiation of B cells, but a causal association between the exposure of nucleus pulposus to the systemic circulation and T and B cell activation is still lacking.

METHODS

Autologous nucleus pulposus was harvested from the intervertebral disc of 9 pigs and placed subcutaneously in perforated titanium chambers. In order to control for the effect of the titanium chamber, an additional empty chamber was placed subcutaneously in each pig. After 7 days, the pigs were killed and the chambers were harvested. Flow cytometry and immunohistochemistry were used for analysis of T-helper cells (CD4+), cytotoxic T cells (CD8+), and B cells (Igkappa) in the chamber exudates and T cells (CD45RC) in the remaining blood clot tissue of the chamber.

RESULTS

As compared with the empty chambers, the proportion of activated T cells (CD4+ and CD8+) was significantly higher in the exudate of the nucleus pulposus filled chamber. The proportion of activated B cells expressing immunoglobulin kappa (Igkappa) was also significantly elevated in the exudate of the nucleus pulposus chambers. The analysis of the remaining chamber tissue revealed a significantly higher amount of T cells (CD45RC) in the nucleus pulposus chambers than in the empty chambers.

CONCLUSIONS

The present findings indicate that nucleus pulposus attracts activated T and B cells. However, since the cell population in the nucleus pulposus of young pigs may differ from that of adult humans, the obtained data may not be directly transferred to the human situation of a disc herniation. The observations in the present study may nevertheless explain some of the local tissue reactions occurring in association with disc herniation and nerve root involvement, thereby providing further insight into the pathophysiology of sciatica.

[Pleural effusion--which diagnosis is significant?]

Although many different diseases may cause a pleural effusion the most common causes are congestive heart failure, pneumonie, and cancer. The first step in the diagnosis of pleural effusion is the distinction between exudates and transudates. Because of their high sensitivity Light's criteria, which differentiate transudative effusions from exudative effusions by measuring the levels of total protein and lactate dehydrogenase in the pleural fluid and serum, have become the standard method for making this distinction. Aim of this article was to mention the various parameters and their usefulness in closer characterication of pleural effusion.

Biological roles of carboxymethyl-chitin associated for the growth factor production

Many techniques to restore cartilage defection have been tried. However, the development is still under way because of problems, including loosening of artificial joint, degenerative change of compensated tissue, risk of viral transmission via allograft/autograft, and cost of therapeutic materials for repair. In the previous research, we found that complementing cartilage defective part with carboxymethyl-chitin (CM-chitin)/beta-tricalcium phosphate composite induced regeneration of cartilage in rabbits in vivo, and it is presumable that CM-chitin plays a key role in chondrogenesis causing the regeneration of cartilage. However, the induction mechanism of chondrogenesis with CM-chitin is still unclear. In this study, we investigated the cell responses to CM-chitin by using peritoneal exudate cell (PEC) in mice and found that CM-chitin induced the expression of inflammatory cytokines and growth factors, both of which are both considered to correlate with chondrogenesis. After intraperitoneal injection CM-chitin showed enhanced expressions of mRNA of interleukin-1beta (IL-1beta), interleukin-6 (IL-6), keratinocyte-derived chemokine, tumor necrosis factor-alpha, and transforming growth factor-beta1 (TGF-beta1) in PEC as observed by reverse transcriptase polymerase chain reaction. Productions of TGF-beta1 protein were confirmed by enzyme linked immunosorbant assay. It was also shown that mononuclear cells in PEC were responsible for the TGF-beta1 production. These results suggest that CM-chitin is an inductor of inflammatory cytokines and growth factors and may contribute to regeneration of cartilage.