SUMMARY AND CONCLUSIONSFirearm related injuries are a major cause of morbidity and mortality in urban areas. The incidence of firearm injury is strongly related to race or ethnic group, sex and age.So the aim of this work was to study the fatal cases due to firearm injuries that came from Alexandria and Matrouh governorates over the period of sex months from January to June 2004 regarding age, sex, anatomical sites, nature of injury, time passed from injury to death and type of weapon used. In addition blood samples were taken for estimation of serum creatinine and uric acid.The cases included in this study were divided into three groups:Group (I): 7 cases of firearm cases from Matrouh.Group (II): 5 cases of firearm cases from Alexandria.Group (III): 12 cases of normal deaths used as control.The results showed that the mean age of the studied cases was 31.42 ? 10.65 years. 83% of the cases were males and 17% were females. The nature of injury was homicide in 50% of cases, unintentional in 42% and suicide in 8%. 58% of cases were from Matrouh governorate and 42% were from Alexandria. 92% of cases had far firing and 8% had near fining. The site of injury was skull in 33% of cases, the abdomen in 33%, the chest in 17% and the back in 17%. 58% of cases died immediately after injury and 42% were hospitalized for variable periods. The cause of death was skull fracture and brain haemorrhage in 33% of cases, internal organs lacerations and haemorrhage in 33.5% and sepsis in 33.5%. Handgun was used in 84% of cases, shotgun in 8% and military rifle was used in 8% of cases. Relative relationship was found in 35.33% of cases.In laryngeal expansion surgery for subglottic and tracheal stenosis, after vertically dividing the stenotic segment in the midline and insertion of graft material between the divided segments, either prolonged stenting with tracheostomy (4-6 weeks) or short-term stenting using endotracheal tube with sedation or mechanical ventilation (1-2 weeks) is required until the airway is stabilized. The postoperative period is far more difficult and requires meticulous skillful care. This experimental study was designed to explore the use of microplates and auricular cartilage graft in providing immediate airway stability and to determine the surgical outcome of this procedure. Subglottic stenosis was ceriated in 11 dogs using repeated abrasive technique to the mucosa and perichondrium. All 11 dogs underwent laryngotracheal reconstruction without intraoperative complications. Immediately after reconstruction, the airway diameter returned to the prestenotic diameter and was maintained till the end of this study 6 weeks postoperatively as measured by endotracheal tube sizing. Histological examination revealed complete epithelization over all the grafted regions except at small areas with minimal granulations in 4 dogs. Viable grafts were identified in 8 cases and 3 cases with insignificant necrosis. This study suggests that rigid distraction of the stenotic airway with microplates and auricular cartilage graft has a good surgical outcome. Allowing repair of the stenosis without stenting or tracheostomy and provides immediate airway stability.ConclusionIn conclusion, the technique of using external fixation with microplates to provide immediate rigid external support and auricular cartilage graft promise to be very helpful in maintaining distraction of the divided anterior cricoid and upper tracheal segments obviating the need for tracheostomy or prolonged stenting.The auricular cartilage is a useful grafting material for LTR because it closely resembles the strength and width of the tracheal cartilage and can be used effectively for a grade I or II stenosis. It has the advantage of having minimal donor site morbidity the auricular cartilage graft-in laryngotracheal reconstruction is more successful than the anterior cricoid split operation treating mild to moderate SGS we have had limited success with ACGs in grade III stenosis and are reluctant to use them in grade IV stenosis, staged reconstruction long-segment SGS, long-segment tracheal stenosis, or revision of a failed auricular or costal cartilage LTR.Summary and ConclusionIn laryngeal expansion surgery for subglottic and tracheal stenosis, after vertically dividing the stenotic segment in the midline and insertion of graft material between the divided segments, either prolonged stenting with tracheostomy (4-6 weeks) or short-term stenting using endotracheal tube with sedation or mechanical ventilation (1-2 weeks) is required until the airway is stabilized. The postoperative period is far more difficult and requires meticulous skillful care. This experimental study was designed to explore the use of microplates and auricular cartilage graft in providing immediate airway stability and to determine the surgical outcome of this procedure. Subglottic stenosis was ceriated in 11 dogs using repeated abrasive technique to the mucosa and perichondrium. All 11 dogs underwent laryngotracheal reconstruction without intraoperative complications. Immediately after reconstruction, the airway diameter returned to the prestenotic diameter and was maintained till the end of this study 6 weeks postoperatively as measured by endotracheal tube sizing. Histological examination revealed complete epithelization over all the grafted regions except at small areas with minimal granulations in 4 dogs. Viable grafts were identified in 8 cases and 3 cases with insignificant necrosis. This study suggests that rigid distraction of the stenotic airway with microplates and auricular cartilage graft has a good surgical outcome. Allowing repair of the stenosis without stenting or tracheostomy and provides immediate airway stability.ConclusionIn conclusion, the technique of using external fixation with microplates to provide immediate rigid external support and auricular cartilage graft promise to be very helpful in maintaining distraction of the divided anterior cricoid and upper tracheal segments obviating the need for tracheostomy or prolonged stenting.The auricular cartilage is a useful grafting material for LTR because it closely resembles the strength and width of the tracheal cartilage and can be used effectively for a grade I or II stenosis. It has the advantage of having minimal donor site morbidity the auricular cartilage graft-in laryngotracheal reconstruction is more successful than the anterior cricoid split operation treating mild to moderate SGS we have had limited success with ACGs in grade III stenosis and are reluctant to use them in grade IV stenosis, staged reconstruction long-segment SGS, long-segment tracheal stenosis, or revision of a failed auricular or costal cartilage LTR.Summary and ConclusionIn laryngeal expansion surgery for subglottic and tracheal stenosis, after vertically dividing the stenotic segment in the midline and insertion of graft material between the divided segments, either prolonged stenting with tracheostomy (4-6 weeks) or short-term stenting using endotracheal tube with sedation or mechanical ventilation (1-2 weeks) is required until the airway is stabilized. The postoperative period is far more difficult and requires meticulous skillful care. This experimental study was designed to explore the use of microplates and auricular cartilage graft in providing immediate airway stability and to determine the surgical outcome of this procedure. Subglottic stenosis was ceriated in 11 dogs using repeated abrasive technique to the mucosa and perichondrium. All 11 dogs underwent laryngotracheal reconstruction without intraoperative complications. Immediately after reconstruction, the airway diameter returned to the prestenotic diameter and was maintained till the end of this study 6 weeks postoperatively as measured by endotracheal tube sizing. Histological examination revealed complete epithelization over all the grafted regions except at small areas with minimal granulations in 4 dogs. Viable grafts were identified in 8 cases and 3 cases with insignificant necrosis. This study suggests that rigid distraction of the stenotic airway with microplates and auricular cartilage graft has a good surgical outcome. Allowing repair of the stenosis without stenting or tracheostomy and provides immediate airway stability.ConclusionIn conclusion, the technique of using external fixation with microplates to provide immediate rigid external support and auricular cartilage graft promise to be very helpful in maintaining distraction of the divided anterior cricoid and upper tracheal segments obviating the need for tracheostomy or prolonged stenting.The auricular cartilage is a useful grafting material for LTR because it closely resembles the strength and width of the tracheal cartilage and can be used effectively for a grade I or II stenosis. It has the advantage of having minimal donor site morbidity the auricular cartilage graft-in laryngotracheal reconstruction is more successful than the anterior cricoid split operation treating mild to moderate SGS we have had limited success with ACGs in grade III stenosis and are reluctant to use them in grade IV stenosis, staged reconstruction long-segment SGS, long-segment tracheal stenosis, or revision of a failed auricular or costal cartilage LTR.Summary and ConclusionIn laryngeal expansion surgery for subglottic and tracheal stenosis, after vertically dividing the stenotic segment in the midline and insertion of graft material between the divided segments, either prolonged stenting with tracheostomy (4-6 weeks) or short-term stenting using endotracheal tube with sedation or mechanical ventilation (1-2 weeks) is required until the airway is stabilized. The postoperative period is far more difficult and requires meticulous skillful care. This experimental study was designed to explore the use of microplates and auricular cartilage graft in providing immediate airway stability and to determine the surgical outcome of this procedure. Subglottic stenosis was ceriated in 11 dogs using repeated abrasive technique to the mucosa and perichondrium. All 11 dogs underwent laryngotracheal reconstruction without intraoperative complications. Immediately after reconstruction, the airway diameter returned to the prestenotic diameter and was maintained till the end of this study 6 weeks postoperatively as measured by endotracheal tube sizing. Histological examination revealed complete epithelization over all the grafted regions except at small areas with minimal granulations in 4 dogs. Viable grafts were identified in 8 cases and 3 cases with insignificant necrosis. This study suggests that rigid distraction of the stenotic airway with microplates and auricular cartilage graft has a good surgical outcome. Allowing repair of the stenosis without stenting or tracheostomy and provides immediate airway stability.ConclusionIn conclusion, the technique of using external fixation with microplates to provide immediate rigid external support and auricular cartilage graft promise to be very helpful in maintaining distraction of the divided anterior cricoid and upper tracheal segments obviating the need for tracheostomy or prolonged stenting.The auricular cartilage is a useful grafting material for LTR because it closely resembles the strength and width of the tracheal cartilage and can be used effectively for a grade I or II stenosis. It has the advantage of having minimal donor site morbidity the auricular cartilage graft-in laryngotracheal reconstruction is more successful than the anterior cricoid split operation treating mild to moderate SGS we have had limited success with ACGs in grade III stenosis and are reluctant to use them in grade IV stenosis, staged reconstruction long-segment SGS, long-segment tracheal stenosis, or revision of a failed auricular or costal cartilage LTR.Summary and ConclusionIn laryngeal expansion surgery for subglottic and tracheal stenosis, after vertically dividing the stenotic segment in the midline and insertion of graft material between the divided segments, either prolonged stenting with tracheostomy (4-6 weeks) or short-term stenting using endotracheal tube with sedation or mechanical ventilation (1-2 weeks) is required until the airway is stabilized. The postoperative period is far more difficult and requires meticulous skillful care. This experimental study was designed to explore the use of microplates and auricular cartilage graft in providing immediate airway stability and to determine the surgical outcome of this procedure. Subglottic stenosis was ceriated in 11 dogs using repeated abrasive technique to the mucosa and perichondrium. All 11 dogs underwent laryngotracheal reconstruction without intraoperative complications. Immediately after reconstruction, the airway diameter returned to the prestenotic diameter and was maintained till the end of this study 6 weeks postoperatively as measured by endotracheal tube sizing. Histological examination revealed complete epithelization over all the grafted regions except at small areas with minimal granulations in 4 dogs. Viable grafts were identified in 8 cases and 3 cases with insignificant necrosis. This study suggests that rigid distraction of the stenotic airway with microplates and auricular cartilage graft has a good surgical outcome. Allowing repair of the stenosis without stenting or tracheostomy and provides immediate airway stability.ConclusionIn conclusion, the technique of using external fixation with microplates to provide immediate rigid external support and auricular cartilage graft promise to be very helpful in maintaining distraction of the divided anterior cricoid and upper tracheal segments obviating the need for tracheostomy or prolonged stenting.The auricular cartilage is a useful grafting material for LTR because it closely resembles the strength and width of the tracheal cartilage and can be used effectively for a grade I or II stenosis. It has the advantage of having minimal donor site morbidity the auricular cartilage graft-in laryngotracheal reconstruction is more successful than the anterior cricoid split operation treating mild to moderate SGS we have had limited success with ACGs in grade III stenosis and are reluctant to use them in grade IV stenosis, staged reconstruction long-segment SGS, long-segment tracheal stenosis, or revision of a failed auricular or costal cartilage LTR.Summary and ConclusionIn laryngeal expansion surgery for subglottic and tracheal stenosis, after vertically dividing the stenotic segment in the midline and insertion of graft material between the divided segments, either prolonged stenting with tracheostomy (4-6 weeks) or short-term stenting using endotracheal tube with sedation or mechanical ventilation (1-2 weeks) is required until the airway is stabilized. The postoperative period is far more difficult and requires meticulous skillful care. This experimental study was designed to explore the use of microplates and auricular cartilage graft in providing immediate airway stability and to determine the surgical outcome of this procedure. Subglottic stenosis was ceriated in 11 dogs using repeated abrasive technique to the mucosa and perichondrium. All 11 dogs underwent laryngotracheal reconstruction without intraoperative complications. Immediately after reconstruction, the airway diameter returned to the prestenotic diameter and was maintained till the end of this study 6 weeks postoperatively as measured by endotracheal tube sizing. Histological examination revealed complete epithelization over all the grafted regions except at small areas with minimal granulations in 4 dogs. Viable grafts were identified in 8 cases and 3 cases with insignificant necrosis. This study suggests that rigid distraction of the stenotic airway with microplates and auricular cartilage graft has a good surgical outcome. Allowing repair of the stenosis without stenting or tracheostomy and provides immediate airway stability.ConclusionIn conclusion, the technique of using external fixation with microplates to provide immediate rigid external support and auricular cartilage graft promise to be very helpful in maintaining distraction of the divided anterior cricoid and upper tracheal segments obviating the need for tracheostomy or prolonged stenting.The auricular cartilage is a useful grafting material for LTR because it closely resembles the strength and width of the tracheal cartilage and can be used effectively for a grade I or II stenosis. It has the advantage of having minimal donor site morbidity the auricular cartilage graft-in laryngotracheal reconstruction is more successful than the anterior cricoid split operation treating mild to moderate SGS we have had limited success with ACGs in grade III stenosis and are reluctant to use them in grade IV stenosis, staged reconstruction long-segment SGS, long-segment tracheal stenosis, or revision of a failed auricular or costal cartilage LTR.Summary and ConclusionIn laryngeal expansion surgery for subglottic and tracheal stenosis, after vertically dividing the stenotic segment in the midline and insertion of graft material between the divided segments, either prolonged stenting with tracheostomy (4-6 weeks) or short-term stenting using endotracheal tube with sedation or mechanical ventilation (1-2 weeks) is required until the airway is stabilized. The postoperative period is far more difficult and requires meticulous skillful care. This experimental study was designed to explore the use of microplates and auricular cartilage graft in providing immediate airway stability and to determine the surgical outcome of this procedure. Subglottic stenosis was ceriated in 11 dogs using repeated abrasive technique to the mucosa and perichondrium. All 11 dogs underwent laryngotracheal reconstruction without intraoperative complications. Immediately after reconstruction, the airway diameter returned to the prestenotic diameter and was maintained till the end of this study 6 weeks postoperatively as measured by endotracheal tube sizing. Histological examination revealed complete epithelization over all the grafted regions except at small areas with minimal granulations in 4 dogs. Viable grafts were identified in 8 cases and 3 cases with insignificant necrosis. This study suggests that rigid distraction of the stenotic airway with microplates and auricular cartilage graft has a good surgical outcome. Allowing repair of the stenosis without stenting or tracheostomy and provides immediate airway stability.ConclusionIn conclusion, the technique of using external fixation with microplates to provide immediate rigid external support and auricular cartilage graft promise to be very helpful in maintaining distraction of the divided anterior cricoid and upper tracheal segments obviating the need for tracheostomy or prolonged stenting.The auricular cartilage is a useful grafting material for LTR because it closely resembles the strength and width of the tracheal cartilage and can be used effectively for a grade I or II stenosis. It has the advantage of having minimal donor site morbidity the auricular cartilage graft-in laryngotracheal reconstruction is more successful than the anterior cricoid split operation treating mild to moderate SGS we have had limited success with ACGs in grade III stenosis and are reluctant to use them in grade IV stenosis, staged reconstruction long-segment SGS, long-segment tracheal stenosis, or revision of a failed auricular or costal cartilage LTR.Summary and ConclusionIn laryngeal expansion surgery for subglottic and tracheal stenosis, after vertically dividing the stenotic segment in the midline and insertion of graft material between the divided segments, either prolonged stenting with tracheostomy (4-6 weeks) or short-term stenting using endotracheal tube with sedation or mechanical ventilation (1-2 weeks) is required until the airway is stabilized. The postoperative period is far more difficult and requires meticulous skillful care. This experimental study was designed to explore the use of microplates and auricular cartilage graft in providing immediate airway stability and to determine the surgical outcome of this procedure. Subglottic stenosis was ceriated in 11 dogs using repeated abrasive technique to the mucosa and perichondrium. All 11 dogs underwent laryngotracheal reconstruction without intraoperative complications. Immediately after reconstruction, the airway diameter returned to the prestenotic diameter and was maintained till the end of this study 6 weeks postoperatively as measured by endotracheal tube sizing. Histological examination revealed complete epithelization over all the grafted regions except at small areas with minimal granulations in 4 dogs. Viable grafts were identified in 8 cases and 3 cases with insignificant necrosis. This study suggests that rigid distraction of the stenotic airway with microplates and auricular cartilage graft has a good surgical outcome. Allowing repair of the stenosis without stenting or tracheostomy and provides immediate airway stability.ConclusionIn conclusion, the technique of using external fixation with microplates to provide immediate rigid external support and auricular cartilage graft promise to be very helpful in maintaining distraction of the divided anterior cricoid and upper tracheal segments obviating the need for tracheostomy or prolonged stenting.The auricular cartilage is a useful grafting material for LTR because it closely resembles the strength and width of the tracheal cartilage and can be used effectively for a grade I or II stenosis. It has the advantage of having minimal donor site morbidity the auricular cartilage graft-in laryngotracheal reconstruction is more successful than the anterior cricoid split operation treating mild to moderate SGS we have had limited success with ACGs in grade III stenosis and are reluctant to use them in grade IV stenosis, staged reconstruction long-segment SGS, long-segment tracheal stenosis, or revision of a failed auricular or costal cartilage LTR.Summary and Conclusion3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendationligament was incised in 13.33% of cases.VI- Complication:- Seven cases had transient dysphagia- One patient had superficial wound infection- One patient had urinary tract infection.VII- Outcomes:A) In Radiclopathic group: excellent, outcome was noted in(19%) of cases and good outcome was present in (61.9%)of cases.B) In Myelopathic group: no patient was present in theexcellent, group and (44.4%) had good outcome.ConclusionDiagnosis of degenerative cervical disc disease depends on the clinical basis and magnetic resonance image. CT images of the cervical spine can be difficult for two reasons. First, the shoulders can often produce strip shaped artifacts in the cervicothrocic spines. Second, the epidural space is poorly visualized. This is due to the fact that the cervical dural sac is directly adjacent to the bone in contrast to lumber spine. It is not possible to diagnose a suspected prolapsed disc on the basis of the obliterated epidural space.Anterior cervical descectomy is usually sufficient method of surgical treatment in most cases of degenerative cervical disc disease.Anterior cervical descectomy with bone graft fusion is needed only in cases in which marked bone is removedMyelopathic cervical disc disease is absolute indication for surgery.All efforts should be directed toward early detection of cases with cervical disc herniation and early surgery is indicated before development of severe root or cord dysfunction.