Accurate diagnosis of bile duct strictures as malignant or benign is imperative for optimal patient management, but is frequently difficult. Histological and cytological samples can be obtained at ERCP. Various techniques have been studied and reported specificities are generally very high. Sensitivities are modest and variable. The reported sensitivity is 33–57% for brush cytology and 43–81% for transpapillary histology. The yield may be increased by combining two sampling methods.
Methods
Data was collected prospectively on all patients with bile duct strictures who underwent histology and cytology. Transpapillary, intraductal biopsies were obtained using a paediatric biopsy forceps (Boston Scientific, Radial Jaw 4, 2.0mm paediatric biopsy forceps, Hemel Hempstead, UK). Fluoroscopic guidance was used to selectively target the stricture. A minimum of 4 biopsies were obtained. Cytological samples were obtained using an over the wire brush (Boston Scientific, RX Biliary brush 2.1mm, Hemel Hempstead, UK). This involved multiple passes through the stricture and withdrawal of the brush in to the catheter after the final pass. On retrieval, the catheter was flushed with the cytology fixation fluid in to the cytology collection container and the brush was cut off and sent in the same container. The sample was delivered to the lab for processing to the lab immediately after the procedure. Patients diagnosed with benign strictures had a follow up with median length of 20 months (range 4–35).
Results
96 strictures were sampled using dual modality. 70 were malignant of which 49 were in the peri-hilar and proximal CBD and 21 in distal CBD. The sensitivity in diagnosis of malignant biliary strictures was 74% with an overall accuracy for all strictures of 81%. Histology was positive in 33/52 cases (63%) and cytology was positive in 29/52 cases (56%). Taken together, they yielded a significantly better result of 74%. The sensitivity was higher for peri-hilar (82%) as compared to distal strictures (57%). There were no false positives. No complications as direct result of either tissue acquisition techniques occurred.
Conclusion
A highly systematic approach and combination of histology and cytology offers a significant advantage in diagnostic accuracy for both malignant and benign strictures. The high yield on cytology in our study may reflect attention to detail and prompt processing in the lab. None of the techniques adopted required specialised equipment or skills and could be adopted by any ERCP unit
Disclosure of Interest
O. Noorullah: None Declared, V. Lekharaju: None Declared, C. W. Wadsworth: None Declared, K. Brougham: None Declared, N. Stern: None Declared, S. Hood: None Declared, C. Kaltsidis: None Declared, M. Terlizzo: None Declared, R. Sturgess Conflict with: Advisory board member and in receipt of honoraria from Olympus UK and Boston Scientific
Abstract Jason Brennan’s Why Not Capitalism? provides a direct response to G.A. Cohen’s moral defence of the value of socialism, arguing that, even under the utopian conditions Cohen specifies, capitalism would be recognized as the most attractive form of social organization. Yet, in one respect, Brennan’s account of utopia seems oddly out of keeping with the capitalist system it is taken to represent: the freedom of the characters within it seems almost totally untouched by the pressure of competitive market forces. I argue that this absence cannot be explained simply by an appeal to the positive intentions of utopian individuals as, even with such motivations in place, competition would still be unavoidable. This means that, even if we agree with Brennan that people would want a utopia in which they had the greatest possible scope to pursue their own personal plans, they may still have good reason to reject his capitalist ideal in favour of a system that would secure for them fair terms on which to compete.
Fungal infections affect virtually all patients with the Acquired Immunodeficiency Syndrome (AIDS). Superficial infection (seborrheic dermatitis, tinea capitis, tinea corporis and tinea cruris) is more common than in the general population and can be difficult to eradicate. Mucosal disease (oropharyngeal, oesophageal and vaginal candidosis) is very common and often recurs. In advanced AIDS, patients usually fail to respond to topical therapy and often to systemic therapy and isolates of Candida spp. from these patients are frequently resistant in vitro to fluconazole and other azoles. Systemic fungal infection is less common but life threatening. The commonest such infection is Pneumocystis carinii pneumonia (PCP) although prophylaxis is usually successful in preventing either the first episode or recurrent episodes. Histoplasmosis, coccidioidomycosis and Penicillium marneffei infections are common in endemic areas. Cryptococcal meningitis and invasive aspergillosis occur worldwide. The prophylaxis and treatment of all these except PCP are discussed and reviewed.
Serum concentration of Carbohydrate Antigen 19-9 (CA19-9) has been related to survival of patients with Cholangiocarcinoma (CCA). We evaluated the cut-off value of serum CA19–9 to define predictive management strategies in patients with CCA.
Method
Three hundred and forty-one (341) Patients were retrospectively reviewed at a regional hepatobiliary centre in Liverpool, UK. The hospital integrated database was used to extract clinical and laboratory data. The receiver operating characteristic curve (ROC) of serum concentration of CA19–9 by location of tumour and type of treatment offered were assessed. The cut-off value of CA19–9 providing optimal prognosis was used to evaluate differences in survival of the patients using Kaplan-Meier survival log-rank test.
Results
One hundred and sixty-four (48%) patients had valid pre-treatment CA19–9 measurements. Among treatment groups; biliary stent was placed in 67(41%); surgical resection in 43 (26.2%); chemotherapy in 36 (22.0%); while 18 (11%) had supportive care. For site of lesion, ROC for CA19–9 was 0.74 (95% CI: 0.62–0.84; sensitivity: 80.9%; specificity: 60.0%, p = 0.0002). For prognosis of intrahepatic disease and ROC for hilar lesions was 0.62 (95% CI: 0.51–0.71; sensitivity: 90.2%; specificity: 36.1%, p = 0.05). By treatment modality, surgical resection showed significant relationship with pre-treatment CA19–9 value (ROC: 0.75; 95% CI: 0.60–0.87). Serum concentration of >34 IU/ml was defined as the cut-off predictive of prognosis for those who had surgical resection (sensitivity: 76.9% and specificity: 73.3%, p = 0.001). The median survival of patients who had surgical resection with serum CA19–9 >34 IU/ml was 18 months whereas for those with a value ≤34 IU/ml, 5 year survival was 80%.
Conclusion
Serum CA19–9 concentration is a useful predictor of prognosis in patients with intrahepatic lesions as well as those undergoing resection for IHBD tumours. Validation of this cut-off value requires further studies.
Journal Article Brecht on Radio Get access Stuart Hood Stuart Hood Search for other works by this author on: Oxford Academic Google Scholar Screen, Volume 20, Issue 3-4, Winter 1979, Pages 16–23, https://doi.org/10.1093/screen/20.3-4.16 Published: 01 December 1979
We developed and compared five scoring systems designed to quantitate therapeutic response in cases of oropharyngeal candidiasis. We utilized prospectively collected data on 114 patients treated with several doses of the azole D0870. Patients were infected with fluconazole-susceptible (n = 49) or-resistant organisms (MIC, ≥16 mg/mL; n = 61). Patients with fluconazole resistance had lower CD4+ cell counts at baseline; more symptoms (P = .0006); a higher frequency of dysgeusia (P = .004), dysphagia (P = .006), and throat pain (P = .0034); and greater oral coverage by plaques of Candida. There was no difference between the two groups in terms of colony-forming units, and any change did not correlate with response to therapy. Resolution of dysphagia (P < .01) and oral pain (P < .01) correlated well with response to therapy, unlike retrosternal pain and throat pain, which were also less frequent. Xerostomia, a “furry” taste, and dysgeusia were frequent nonspecific symptoms. Scoring system C, weighting resolution of a symptom higher than absence of a symptom at baseline, yielded the best correlation with global outcome (r = 0.86) and allows the quantitation of incomplete but clinically beneficial responses to therapy.
The incidence and mortality of Intrahepatic bile duct cholangiocarcinoma (CCA) has risen worldwide over the past few decades. Over the last four decades, an exponential rise in the age-standardised mortality rate of CCA has been recorded in England and Wales. We examined the factors affecting survival from CCA at a regional hepato-biliary centre.
Method
We retrospectively reviewed 340 patients with confirmed CCA to evaluate the factors affecting survival over a period of six years (2009–2014). The hospital integrated data base was used for clinical, radiological, histological and endoscopic details. Overall survival by modality of treatment was examined by Kaplan-Meier log rank test. Factors contributing to mortality were assessed by Cox proportional hazards.
Results
There was a female preponderance of CCA (n = 174, 51.2%), histology being the most prevalent mode of diagnosis (n = 154, 45.3%) and palliative biliary stenting most utilised treatment (n = 171, 50.3%). Intrahepatic CCA had the largest tumour diameter versus extrahepatic CCA (median: 6.2 cm vs 3.0 cm, p= <0.0001). Overall median survival was 8 months (range 7–11). The median survival for those treated with chemotherapy, biliary stent and best supportive care were 16 (11–18), 5 (4–6) and 4 (2–7) months, respectively. 5 year survival post resection was 80%. Surgical resection and chemotherapy were associated with improved survival (HR: 0.13; 95% CI: 0.06–0.28, p < 0.0001) and (HR: 0.33; 95% CI: 0.17–0.60, p = 0.0003) respectively, whereas the presence of biliary calculi at diagnosis conferred a negative impact on survival (HR: 1.83; 95% CI: 1.19–2.81, p = 0.006). Presence of biliary calculi was a significant independent predictor of survival in patients with hilar CCA.
Conclusion
Similar to experience elsewhere, we observed that surgical resection and chemotherapy offered survival benefit to CCA patients. The association of increased mortality in presence of biliary calculi prompts further prospective investigation of the possibility that the diagnosis of stone disease delays recognition of coexisting bile duct tumours.
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