Thoracoscopy is the most accurate yet most expensive tool for establishing the diagnosis of tuberculous (TB) pleurisy. However, most high TBincidence regions have limited financial resources, lack the infrastructure needed for routine thoracoscopy and require an alternative, cost-effective diagnostic approach for pleural effusions.Altogether, 51 patients with undiagnosed exudative pleural effusions were recruited for a prospective, direct comparison between bronchial wash, pleural fluid microbiology and biochemistry (adenosine deaminase (ADA) and cell count), closed needle biopsy, and medical thoracoscopy.The final diagnosis was TB in 42 patients (82%), malignancy in five (10%) and idiopathic in four patients (8%). Sensitivity of histology, culture and combined histology/culture was 66, 48 and 79%, respectively for closed needle biopsy and 100, 76 and 100%, respectively for thoracoscopy. Both were 100% specific. Pleural fluid ADA of o50 U?L -1 was 95% sensitive and 89% specific. Combined ADA, lymphocyte/ neutrophil ratio o0.75 plus closed needle biopsy reached 93% sensitivity and 100% specificity.A combination of pleural fluid adenosine deaminase, differential cell count and closed needle biopsy has a high diagnostic accuracy in undiagnosed exudative pleural effusions in areas with high incidences of tuberculosis and might substitute medical thoracoscopy at considerably lower expense in resource-poor countries. Eur Respir J 2003; 22: 589-591. Tuberculous (TB) pleurisy remains a diagnostic challenge. A high regional incidence for TB often correlates with poor financial resources necessitating a cost-effective diagnostic strategy. Pleural fluid staining for acid fast bacilli (AFB) and culture of M. tuberculosis has a poor yield and sputum or bronchial sampling via bronchoscopy can diagnose only a minority of cases with additional open lung tuberculosis. Closed needle pleural biopsy has a yield of 60-80% for TB pleurisy and 50% for malignancy [1,2]. Its role is controversial, as pleural fluid cytology has a high yield in malignancy and medical thoracoscopy is diagnostic in w90% of TB and malignant pleural effusions [3]. Adenosine deaminase (ADA) is raised in TB pleural effusions and has gained popularity in high-incidence areas for TB. High diagnostic accuracy has been reported and the test is cheap and readily available [4]. The drawbacks of relying on ADA alone are the low number of TB cultures yielded on pleural fluid and the possibility of false positives. Specificity can be improved by including the lymphocyte/neutrophil-ratio (L:N) into the test [5].Although the different diagnostic options have been studied alone, this study is the first prospective head-to-head comparison of bronchial wash, pleural fluid microbiology, pleural fluid biochemistry and closed needle biopsy versus thoracoscopic biopsy in a series of patients with undiagnosed exudative pleural effusions. The study was conducted at Tygerberg Hospital, Cape Town, South Africa, situated in a region with a very high incidence of TB (588 cas...

Patients with impaired pulmonary function are at increased risk for the development of postoperative complications. Recently exercise testing and predicted postoperative (ppo) function have gained increasing importance in the evaluation of lung resection candidates. We prospectively evaluated an algorithm for the preoperative functional evaluation that was developed at our institution. This algorithm incorporated the cardiac history including an electrocardiogram (ECG), and the three parameters FEV 1 , diffusing capacity of the lungs for carbon monoxide (D L CO ), and maximal oxygen uptake ( O 2 max), as well as their respective ppo values (FEV 1 -ppo, D L CO -ppo, and O 2 max-ppo) calculated based on radionuclide perfusion scans. A consecutive group of 137 patients (mean age 62 yr; range 23 to 81; 102 males, 35 females) with clinically resectable lesions underwent assessment according to our algorithm. Five patients were deemed functionally inoperable, 132 passed the algorithm and underwent pulmonary resections with standard thoracotomy: 9 segmental or wedge resections, 85 lobectomies (inclusive 3 bilobectomies), and 38 pneumonectomies. All patients were extubated within 24 h. The mean stay in the ICU was 1.4 ( Ϯ 1.8) d, and the mean hospital stay was 14.6 ( Ϯ 5) d. Postoperative complications (within 30 d) occurred in 15 patients (11%), of whom two died (overall mortality rate 1.5%). In comparison to our previous series this meant a 50% reduction in complications whereas the percentage of inoperable patients remained unchanged (4% now, 5% before). We conclude that adherence to our algorithm resulted in a very low complication rate (morbidity and mortality), and excluded more rigorous patient selection as a bias for the improved results. . V . VPatients with lung cancer who undergo evaluation for lung resection are usually smokers and therefore often have concomitant heart and lung disease. This puts them at increased risk for the development of postoperative complications, including permanent respiratory disability and death. Therefore, the functional assessment of their cardiorespiratory reserves is very important. This assessment has recently undergone major changes; apart from preoperative measurement of pulmonary function (FEV 1 , diffusing capacity of the lungs for carbon monoxide [D L CO ]), exercise testing with the determination of maximal oxygen uptake ( O 2 max) has gained increasing importance. Recently the emphasis has shifted to the prediction of postoperative function (predicted postoperative = ppo). The parameter, most firmly established, is the FEV 1 -ppo, but also D L CO -ppo (1-3), and most recently O 2 max-ppo (3) have been suggested.Despite increasing enthusiasm for exercise testing and split function studies, one has to remember that many patients undergoing lung resections up to pneumonectomy do not need extensive tests for the assessment of their cardiorespiratory reserves. We therefore developed an algorithm for the preoperative functional evaluation (Figure 1) incorporating the cardiac...

Background and Objectives: We prospectively compared five techniques to estimate predicted postoperative function (ppo F) after lung resection: recently proposed quantitative CT scans (CT), perfusion scans (Q), and three anatomical formulae based on the number of segments (S), functional segments (FS), and subsegments (SS) to be removed. Methods: Four parameters were assessed: FEV₁, FVC, DL_CO and VO_2max, measured preoperatively and 6 months postoperatively in 44 patients undergoing pulmonary resection, comparing their ppo value to the postoperatively measured value. Results: The correlations (r) obtained with the five methods were for CT: FEV₁ = 0.91, FVC = 0.86, DL_CO = 0.84, VO_2max = 0.77; for Q: 0.92, 0.90, 0.85, 0.85; for S: 0.88, 0.86, 0.84, 0.75; for FS: 0.88, 0.85, 0.85, 0.75, and for SS: 0.88, 0.86, 0.85, 0.75, respectively. The mean difference between ppo values and postoperatively measured values was smallest for Q estimates and largest for anatomical estimates using S. Stratification of the extent of resection into lobectomy (n = 30) + wedge resections (n = 4) versus pneumonectomy (n = 10) resulted in persistently high correlations for Q and CT estimates, whereas all anatomical correlations were lower after pneumonectomy. Conclusions: We conclude that both Q- and CT-based predictions of postoperative cardiopulmonary function are useful irrespective of the extent of resection, but Q-based results were the most accurate. Anatomically based calculations of ppo F using FS or SS should be reserved for resections not exceeding one lobe.

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Induction of pleurodesis offers benefit for patients with metastatic tumors and symptomatic malignant pleural effusions, but the best method for achieving this is still unknown. In this prospective, randomized comparison of two well-established pleurodesis procedures, 36 patients with malignant pleural effusions, expanded lungs after drainage, and expected survival of > 1 mo received either bleomycin instillation (60E) via a small-bore thoracostomy tube or thoracoscopic talc poudrage (5 g) under local anesthesia. Efficacy, safety, and cost could be evaluated for 32 treatments (17 bleomycin, 15 talc) in 31 patients. Recurrence rates of effusion with bleomycin and talc poudrage after 30 d were 41% and 13% (p = 0.12), respectively, those after 90 d were 59% and 13%, respectively (p = 0.01), and those after 180 d were 65% and 13% (p = 0.005), respectively. Neither procedure showed any major adverse effect, and both were equally well tolerated. Cost estimation favored thoracoscopic talc poudrage, both for the initial hospitalization and with regard to recurrences. In conclusion, thoracoscopic talc pleurodesis under local anesthesia is superior to bleomycin instillation for pleurodesis in cases of malignant pleural effusion.