A bronchoscopic scoring system for airway secretions--airway cellularity and microbiological validation.

There is currently no validated scoring system for quantification of airway secretions in children. A user friendly, valid scoring system of airway secretions during flexible bronchoscopy (FB) would be useful for comparative purposes in clinical medicine and research. The objective of this study was to validate our bronchoscopic secretion (BS) scoring system by examining the relationship between the amount of secretions seen at bronchoscopy with airway cellularity and microbiology. In 106 children undergoing FB, the relationship of BS grades with bronchocalveolar lavage (BAL) cellularity and infective state (bacterial and viral infections) were examined using receptor operator curves (ROC). BAL was obtained according to European Respiratory Society guidelines; first lavage for microbiology and second lavage for cellularity. Area under the ROC was significant for total cell count (TCC) and neutrophil % but not for lymphocyte %. BS grade significantly related to infection positive state (chi(trend) (2) = 5.85, P = 0.016). The area under the ROC for infection positive state versus BS grade was 0.645, 95% CI 0.527-0.763. The BS scoring system is a valid method for quantifying airway secretions in children undergoing bronchoscopy. The system related well to airway cellularity and neutrophilia, as well as to an airway infective state. However, the system is only complementary to cell counts and cultures and cannot replace these laboratory quantification techniques.

'Free' surfactant in gastric aspirates and bronchoalveolar lavage in children with and without reflux oesophagitis.

AIM: Dipalmitoylphosphatidycholine (DPPC) is the characteristic and main constituent of surfactant. Adsorption of surfactant to epithelial surfaces may be important in the masking of receptors. The aims of the study were to (i) compare the quantity of free DPPC in the airways and gastric aspirates of children with gastroesophageal reflux disease (GORD) to those without and (ii) describe the association between free DPPC levels with airway cellular profile and capsaicin cough sensitivity. METHODS: Children aged <14 years were defined as 'coughers' if a history of cough in association with their GORD symptoms was elicited before gastric aspirates and nonbronchoscopic bronchoalveolar lavage (BAL) were obtained during elective flexible upper gastrointestinal endoscopy. GORD was defined as histological presence of reflux oesophagitis. Spirometry and capsaicin cough-sensitivity test was carried out in children aged >6 years before the endoscopy. RESULTS: Median age of the 68 children was 9 years (interquartile range (IQR) 7.2). Median DPPC level in BAL of children with cough (72.7 microg/mL) was similar to noncoughers (88.5). There was also no significant difference in DPPC levels in both BAL and gastric aspirates of children classified according to presence of GORD. There was no correlation between DPPC levels and cellular counts or capsaicin cough-sensitivity outcome measures. CONCLUSION: We conclude that free DPPC levels in the airways and gastric aspirate is not influenced by presence of cough or GORD defined by histological presence of reflux oesophagitis. Whether quantification of adsorbed surfactant differs in these groups remain unknown. Free DPPC is unlikely to have a role in masking of airway receptors.

Airway cellularity, lipid laden macrophages and microbiology of gastric juice and airways in children with reflux oesophagitis.

BACKGROUND: Gastroesophageal reflux disease (GORD) can cause respiratory disease in children from recurrent aspiration of gastric contents. GORD can be defined in several ways and one of the most common method is presence of reflux oesophagitis. In children with GORD and respiratory disease, airway neutrophilia has been described. However, there are no prospective studies that have examined airway cellularity in children with GORD but without respiratory disease. The aims of the study were to compare (1) BAL cellularity and lipid laden macrophage index (LLMI) and, (2) microbiology of BAL and gastric juices of children with GORD (G+) to those without (G-). METHODS: In 150 children aged < 14-years, gastric aspirates and bronchoscopic airway lavage (BAL) were obtained during elective flexible upper endoscopy. GORD was defined as presence of reflux oesophagitis on distal oesophageal biopsies. RESULTS: BAL neutrophil% in G- group (n = 63) was marginally but significantly higher than that in the G+ group (n = 77), (median of 7.5 and 5 respectively, p = 0.002). Lipid laden macrophage index (LLMI), BAL percentages of lymphocyte, eosinophil and macrophage were similar between groups. Viral studies were negative in all, bacterial cultures positive in 20.7% of BALs and in 5.3% of gastric aspirates. BAL cultures did not reflect gastric aspirate cultures in all but one child. CONCLUSION: In children without respiratory disease, GORD defined by presence of reflux oesophagitis, is not associated with BAL cellular profile or LLMI abnormality. Abnormal microbiology of the airways, when present, is not related to reflux oesophagitis and does not reflect that of gastric juices.

The sensitivity of rapid (partial) review of cervical smears.

Rapid review involves a daily rapid (e.g. 30 s) review of all smears not normally double-screened. It has been suggested that the method may increase the sensitivity of cervical cytology by identifying abnormalities not reported on initial screening, true false negatives (TFN). Rapid screening is reported to have high sensitivity for cervical neoplasia when used as a preview tool. To be effective, however, in a review mode it must be able to detect TFN. Several studies have found that many TFN result from factors such as low numbers of abnormal cells or subtle expression of diagnostic criteria. Studies on the sensitivity of rapid screening for detecting TFN would therefore provide a more reliable estimate of its value as a review tool. The sensitivity of rapid re-screening was evaluated using a test set of 200 cases. Each of 15 screeners rapidly reviewed (30 s partial screen) the set over a 2-week period. The set consisted of 129 normal, 28 low-grade squamous lesions (CIN I), 37 high-grade lesions (CIN II, III and adenocarcinoma in situ (AIS)) and six invasive carcinomas. The abnormals included 20 TFN cases. The median sensitivity for abnormalities was 62%. Rapid review was more sensitive for CIN II and CIN III (67%) and invasive carcinoma (66.7%) than for CIN I (53%). Great variation was apparent in the sensitivity for individual screeners, with a range of 41-86% for all abnormalities. The sensitivity for TFN cases varied even more (10-75%, median 35%) and for most screeners was significantly (P < 0.05) lower than for cases which were detected on initial screen (53-90%, median 70.6%). Following this trial rapid review was used routinely for a period of 3 months. In this time 11,413 cases were rapidly reviewed. This led to the full review of 415 slides (3.5%) and the identification of 16 cases of undetected CIN (12 CIN I, three CIN II, one CIN III). Based on current estimates of our laboratory false-negative rate this represents between a quarter and half of the TFN cases of CIN that probably occurred in this period. In conclusion, rapid screening is likely to be significantly less sensitive when used in a review rather than a preview mode. In routine practice the method requires a daily commitment of screener time, but does provide a higher yield of TFN smears than does random review, and allows amendment of these results prior to reporting.

A clinicopathological study of adenocarcinoma in situ of the cervix. The influence of cervical HPV infection and other factors, and the role of conservative surgery.

Adenocarcinoma in situ (ACIS) of the uterine cervix is an increasingly recognized disease. Thirty-seven cases were reviewed to determine the effect of HPV, marital status, parity, smoking habit and age on the topography and behaviour of this lesion. Using a commercial probe, 25% of 28 lesions tested were positive for HPV 16/18. The presence of HPV and a history of smoking appeared to exert no significant influence upon the topography and behaviour of ACIS. Nulliparity and a history of never being married was associated with a significant reduction in the incidence of coexisting CIN lesions. Age less than 36 years was associated with a significant reduction in the proximal linear extent of ACIS. While hysterectomy is probably the definitive treatment for ACIS of the cervix, there is an important place for conservative management by conization alone. Patients younger than 36 years are most likely to be desirous of retained fertility and appear to have the lesions most amenable to conservative surgery.