Urinary cytology and the Paris system for reporting urinary cytology: Implications for urological management.

By reducing the rate of indeterminate (atypical) diagnoses and standardising reporting terminology, The Paris System for Reporting Urine Cytology helps focus the application of cytology towards the detection primarily of high-grade urothelial carcinoma. We present a urology-based perspective of how the new system has influenced clinical decision-making.

The fine needle aspiration of translocation sarcomas.

INTRODUCTION: Soft tissue sarcomas comprise a heterogeneous group of clinically aggressive cancers that are often hard to classify on limited cytological samples. "Translocation sarcomas" (TS) are a diverse subset of such cancers, different from pleomorphic sarcomas, and characterised by unique single chromosomal translocations in each sarcoma subtype. Interestingly, despite their high-grade biological behaviour, TS have deceptively monotonous and bland cytomorphology, therefore creating diagnostic issues on limited samples. MATERIALS AND METHODS: A retrospective search was conducted of the cytopathology archives of The Johns Hopkins Hospital revealing 147 translocation sarcoma cases over a 25-year period. RESULTS: The common morphological denominators for most translocation sarcomas were: hypercellularity, cellular monotony, mostly discohesive and single cells, round-to-oval or short spindled cells and a lack of necrosis. The exceptions were an inflammatory myofibroblastic tumour, in which cellular monotony was not present owing to the prominence of lymphocytes and plasma cells, and low-grade fibromyxoid sarcoma, in which the specimens were generally hypocellular. Ancillary testing, especially immunoperoxidase staining, was often required for primary lesions. CONCLUSION: Distinct morphological clues and subsequent ancillary testing (particularly immunoperoxidase staining) provide an accurate diagnosis on cytological interpretation of both, primary and recurrent/metastatic lesions.

A review of the Paris system for reporting urinary cytology.

After the 2013 International Congress of Cytology in Paris, consensus groups were formed to establish an international reporting system for urinary tract (UT) specimens. The recommended guidelines, known as The Paris System (TPS) for Reporting Urinary Cytology, focus on reducing the rate of unnecessary indeterminate diagnoses while maintaining the excellent performance UT cytology has for identifying high-grade urothelial carcinoma. This review highlights the major features of TPS.

Dramatically reduced surface expression of NK cell receptor KIR2DS3 is attributed to multiple residues throughout the molecule.

Using flow cytometry, fluorescent microscopy and examination of receptor glycosylation status, we demonstrate that an entire killer cell immunoglobulin-like receptor (KIR) locus (KIR2DS3)--assumed earlier to be surface expressed--appears to have little appreciable surface expression in transfected cells. This phenotype was noted for receptors encoded by three allelic variants including the common KIR2DS3*001 allele. Comparing the surface expression of KIR2DS3 with that of the better-studied KIR2DS1 molecule in two different cell lines, mutational analysis identified multiple polymorphic amino-acid residues that significantly alter the proportion of molecules present on the cell surface. A simultaneous substitution of five residues localized to the leader peptide (residues -18 and -7), second domain (residues 123 and 150) and transmembrane region (residue 234) was required to restore KIR2DS3 to the expression level of KIR2DS1. Corresponding simultaneous substitutions of KIR2DS1 to the KIR2DS3 residues resulted in a dramatically decreased surface expression. Molecular modeling was used to predict how these substitutions contribute to this phenotype. Alterations in receptor surface expression are likely to affect the balance of immune cell signaling impacting the characteristics of the response to pathogens or malignancy.

Simplified prediction rule for prognosis of patients with severe community-acquired pneumonia in ICUs.

STUDY OBJECTIVES: To develop a simplified prognostic prediction rule for patients admitted to ICUs for severe community-acquired pneumonia (CAP). SETTING: Six ICUs in the north of France. PATIENTS: Five hundred five patients admitted to ICUs over a 9-year period (from 1987 to 1995) for severe CAP. INTERVENTIONS: Retrospective prognosis analysis and multivariate analysis using a credit scoring technique. MEASUREMENTS: The primary outcome measure was ICU mortality. RESULTS: Among the 505 patients, 472 were eligible for the prognosis study. The ICU mortality rate was 22.9%. Multivariate analysis identified, on the basis of the patient's medical history and initial examination on ICU admission, six independent predictors of mortality: age > or = 40 years, anticipated death within 5 years, nonaspiration pneumonia, chest radiograph involvement > 1 lobe, acute respiratory failure requiring mechanical ventilation, and septic shock. An initial risk score based on these factors classified patients into three risk classes of increasing mortality: 4% in class I, 25% in class II, and 60% in class III. Multivariate analysis of events occurring during ICU stay identified three independent predictors of mortality: hospital-acquired lower respiratory tract superinfections, nonspecific CAP-related complications, and sepsis-related complications. An adjustment risk score based on these factors was essential to accurately predict the final outcome of patients in the initial risk class II. CONCLUSIONS: As an aid to clinicians in stratifying the prognosis of patients with severe CAP, the simplified prediction rule used in this study could be useful for therapeutic decisions and appropriate care.

Community-acquired pneumonia in the intensive care unit: epidemiological and prognosis data in older people.

OBJECTIVES: To compare epidemiological data, etiology, and prognosis of severe community-acquired pneumonia (CAP) in the intensive care unit (ICU) according to age (< or > or = 65 years) and to determine prognostic factors of CAP in older people. DESIGN: A retrospective (1987-1992) and prospective (1993-95) multicenter study. SETTING: Six ICUs in the north of France. PATIENTS: Five hundred five patients admitted to an ICU for severe CAP. MEASUREMENTS: Patient characteristics were compared with regard to age. Prognosis of CAP in older patients was studied by stepwise discriminant analysis. RESULTS: Two hundred seventy-eight patients (55%) were aged 65 years or older. Comparison of epidemiological data between older and younger patients revealed a higher prevalence of women (38% vs 29%), more severe underlying comorbidities (anticipated death within 5 years: 59% vs 26%), and more frequent chronic respiratory insufficiency (48% vs 33%) in the older patients. In this study group, 224 organisms were isolated from 172 patients (62%); those identified most frequently were Gram-negative bacilli (34%), S. pneumoniae (32%), and Staphylococcus sp. (19%). Compared with younger patients, no significant differences in bacteriological data were observed. However, crude and attributable mortality rates were significantly higher in the older patients (33% vs 21% and 30% vs 19%, respectively). Prognosis analysis identified four independent predictors of mortality in the older patients: initial septic shock (relative risk (RR) = 3), sepsis-related complications (RR = 4.3), hospital-acquired lower respiratory tract superinfections (RR = 2), and nonspecific pneumonia-related complications (RR = 2.8). CONCLUSION: The bacterial etiology provides some approaches to empirical therapy for older patients with severe community-acquired pneumonia. In addition, the inappropriateness of withholding intensive care for reasons of age alone is emphasized.

Epidemiological features and prognosis of severe community-acquired pneumococcal pneumonia.

OBJECTIVE: To describe risk factors of severe pneumococcal community-acquired pneumonia and to study variables influencing outcome. DESIGN: Retrospective (1987-1992) and prospective (1993-1995) study. SETTING: Three participating ICUs from primary care hospitals. PATIENTS: Five hundred and five patients (mean age: 63 +/- 17 years) with severe community-acquired pneumonia (CAP). Three groups of patients were defined: pneumococcal CAP (group 1), CAP with microbial diagnosis other than Streptococcus pneumoniae (group 2), CAP from group 2 and CAP without microbial diagnosis (group 3). MEASUREMENTS AND RESULTS: Admission data and data on the disease's course were recorded. The mean Simplified Acute Physiologic Score (SAPS) was 12.5 +/- 5.4. On admission 288 (57 %) patients were mechanically ventilated (mv) and 82 (16.2 %) required inotropic support. A microbial diagnosis was established for 309 (61.2%) patients. S. pneumoniae was isolated in 137 (27.1%) patients. Severe pneumococcal CAP was independently associated with male sex (p = 0.01), lack of antibiotics use before admission (p = 0.0001), non-aspiration pneumonia (p = 0.01) and septic shock (p = 0.0001). The overall mortality rate was 27.5 % (29.2 % in group 1). In patients with severe pneumococcal CAP, multivariate analysis showed that leukopenia less than 3,500/mm3 (p = 0.0004), age over 65 years (p = 0.01), septic shock (p = 0.01), sepsis related complications (p = 0.0001), ICU complications (p = 0.001) and inadequacy of antimicrobial therapy (p = 0.002) worsened the prognosis. CONCLUSIONS: Few features facilitate the identification of pneumococcal CAP on ICU admission. The prognosis is mostly related to severity of illness (leukopenia, septic shock) while comorbidities do not seem to influence outcome. Sepsis-related disorders, ICU complications and adequate antimicrobial chemotherapy are the major variables affecting the outcome during an ICU stay.

Severe community-acquired pneumonia in ICUs: prospective validation of a prognostic score.

OBJECTIVE: To determine predictors of intensive care unit (ICU) mortality in patients with community-acquired pneumonia (CAP), to develop a pneumonia-specific prognostic index, and to evaluate this index prospectively. DESIGN: Combined retrospective and prospective clinical study over two periods: January 1987-December 1992 and January 1993-December 1994. SETTING: Four medical ICUs in the north of France. PATIENTS: Derivation cohort: 335 patients admitted to one ICU were retrospectively studied to determine prognosis factors and to develop a pneumonia-specific prognostic index. Validation cohort: 125 consecutive patients, admitted to four ICUs, were prospectively enrolled to evaluate this index. RESULTS: In the derivation cohort, 16 predictors of mortality were identified and assigned a value directly proportional to their magnitude in the mortality model: aspiration pneumonia (-0.37), grading of sepsis > or = 11 (-0.2), antimicrobial combination (-0.01), Glasgow score > 12+mechanical ventilation (MV) (+0.09), serum creatinine > or = 15 mg/l (+0.22), chest involvement shown by X-ray > or = 3 lobes (+0.28), shock (+0.29), bacteremia (+0.29), initial MV (+0.29), underlying ultimately or rapidly fatal illness (+0.31), Simplified Acute Physiology Score > or = 12 (+0.49), neutrophil count < or = 3500/ mm3 (+0.52), acute organ system failure score > or = 2 (+0.64), delayed MV (+0.67), immunosuppression (+1.38), and ineffective initial antimicrobial therapy (+1.5). An index was obtained by adding each patient's points. According to a receiver operating characteristic curve, the cut-off value of this index was 2.5. In the validation cohort, an index of > or = 2.5 could predict death with a positive predictive value of 0.92, sensitivity 0.61, and specificity 0.98. CONCLUSION: This index, which performs well in classifying patients at high-risk of death, may help physicians in initial patient care (appropriateness of the initial antimicrobial therapy) and guide future clinical research (analysis and design of therapeutic trials).

The use of problem-based learning in dealing with cultural minority groups.

Minority peoples like the Romanies have divergent cultures. Typical cultural aspects for medical personnel to consider would include greetings and other communication, family and social support, dressing and habits of cleanliness, marriage and sexuality, honor, and other issues of importance to any human being. Some minority cultures have no geographic boundaries but they still may adopt the lifestyles of the country they live in. Physicians have to reckon with these different cultural patterns when dealing with patients. Patients must be treated equally at the same time when their personal needs require individual consideration. This consideration is reflected in both verbal and non-verbal communication with the other. Both the sender and the receiver of a message would need to know of the other. Minority groups tend to know more about the majority groups than vice versa. Most health care providers belong to the majority group and would be expected to learn more about the other. Problem-based learning can help students to understand attitudes of minority patients (like the Romanies) and handle the situation. In this instance, the students collected theory base from existing legal, cultural, and other resources and interviewed a Romany woman to verify that the information pertaining to the female case was correct. This combination of theory and experience was considered useful in preparing a case presented to a seminar with 116 medical and dental students in 1994.

Community-acquired aspiration pneumonia in intensive care units. Epidemiological and prognosis data.

Over a 9-yr period, among 505 patients exhibiting severe community-acquired pneumonia and admitted into a total of six medical ICUs in the north of France, we collected 116 patients (23%) meeting the usual criteria for aspiration pneumonia. Main medical grounds of ICU admission were respiratory distress in 54 patients and neurological disturbances in 62 patients. The main underlying risk factor for aspiration pneumonia was drug overdose (39%). Mechanical ventilation was required for 73 patients. Initial shock was present in 15 patients. Pulmonary involvement was bilateral in 27 patients. There were 94 aerobic organisms isolated from 70 patients (60%), the most frequent being gram-negative bacilli (n = 38), Staphyloccus spp. (n = 27) and Streptococcus pneumoniae (n = 22). Overall mortality was 22%, but only 11 (11%) deaths were directly or indirectly related to aspiration pneumonia. Stepwise multivariate analysis identified four independent predictors of mortality: ineffective initial antimicrobial therapy (p = 0.0001), positive initial blood culture (p = 0.0001), hospital-acquired lower respiratory tract superinfections (p = 0.0054), and use of inotropic support (p = 0.0078). The importance of prevention of hospital-acquired superinfections and permanent optimization of our antimicrobial strategies warranting efficacy of the initial antimicrobial therapy is underlined.

Reliability of quantitative cultures of protected specimen brush after freezing.

Protected specimen brush (PSB) is considered to be one of the standard methods for diagnosing mechanical ventilator-acquired pneumonia at a threshold value > or = 10(3) cfu/ml. Nevertheless, this procedure requires immediate cultures which are not always possible 24 h per day. We therefore wanted to appreciate the diagnostic value of delayed quantitative cultures after specimen freezing. PSB was performed by fiberoptic bronchoscopy on 43 mechanically ventilated patients with suspicion of nosocomial bronchopneumonia. After PSB procedure, two aliquots of 0.5 ml were prepared. One aliquot was plated immediately on different culture media (Group 1). A second aliquot was frozen at -80 degrees C for 24 h, then plated on the same culture media as Group 1 (Group 2). All samples were incubated for 48 h. The diagnostic value threshold of PSB was 10(3) cfu/ml. A total of 47 samples were performed on 43 patients. In Group 1, cultures from PSB were positive in 26 samples and revealed 41 species yielding > or = 10(3) cfu/ml. In Group 2, PSB cultures were positive in 24 samples and revealed 36 species yielding > or = 10(3) cfu/ml. Despite a mean decrease in bacterial count of 1.00 +/- 1.44 log 10 (p < 0.001), most important for Streptococcus pneumoniae and Escherichia coli (respectively 3.22 +/- 2.21 log10 and 2.41 +/- 0.52 log 10), sensitivity and specificity of quantitative cultures after specimen freezing, compared with immediate cultures, were 88% and 100% respectively. We concluded that specimens from PSB could be frozen at -80 degrees C with good reliability except for S. pneumoniae and E. coli, enabling PSB procedure to be performed around the clock.