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Pulmonary Medicine
Malignant Pleural Effusion
What every physician needs to know:
- Are you sure your patient has malignant pleural effusion? What should you expect to find?
Beware: there are other diseases that can mimic malignant pleural effusion
How and/or why did the patient develop malignant pleural effusion?
Which individuals are at greatest risk of developing malignant pleural effusion?
- What laboratory studies should you order to help make the diagnosis, and how should you interpret the results?
- What imaging studies will be helpful in making or excluding the diagnosis of malignant pleural effusion?
What non-invasive pulmonary diagnostic studies will be helpful in making or excluding the diagnosis of malignant pleural effusion?
- What diagnostic procedures will be helpful in making or excluding the diagnosis of malignant pleural effusion?
- What pathology/cytology/genetic studies will be helpful in making or excluding the diagnosis of malignant pleural effusion?
- If you decide the patient has malignant pleural effusion, how should the patient be managed?
What is the prognosis for patients managed in the recommended ways?
What other considerations exist for patients with malignant pleural effusion?
What's the evidence?
What every physician needs to know:
Malignant pleural effusion is a common clinical problem that results in disabling breathlessness for patients with advanced malignancy. It represents disseminated disease and confers a poor prognosis. Patients often require multiple invasive procedures in order to gain a diagnosis and manage their symptomatic pleural effusions, which impacts on their quality of life.
The diagnosis can be elusive, particularly in the context of malignant mesothelioma, where interpretation of pleural fluid cytology and pleural biopsies is a challenging specialist field. Radiological techniques, including ultrasound, CT, MRI and PET, can help characterize the disease further. Thoracoscopic techniques, which are increasingly used to gain a tissue diagnosis, have the advantage of draining the fluid and performing a pleurodesis in the same setting.
Indwelling pleural catheters, which continue to gain in popularity, allow patients to be managed successfully in the community with intermittent fluid drainages performed without the need for a hospital admission. Alternative methods of managing malignant effusions include chest tube drain with pleurodesis and surgical decortication in cases of trapped lung.
Primary Pleural Malignancy
Secondary Pleural Malignancy
GI tract
Skin (melanoma)
Unknown primary
Are you sure your patient has malignant pleural effusion? What should you expect to find?
The clinical history of patients with malignant pleural effusion (MPE) can be variable. Most patients will be symptomatic, although up to 25 percent may be asymptomatic, with the effusion discovered incidentally during imaging for another reason.
Respiratory symptoms include breathlessness, cough and chest pain. Dyspnoea, which can vary greatly in its severity, may be progressive as the effusion enlarges. Breathlessness is often noted on exertion and may be exacerbated when the patient lies on the contralateral side to the effusion. Breathlessness is related to mechanical restriction of chest wall and diaphragmatic movements by the fluid, along with mediastinal shift. Therefore, symptoms may improve significantly once a thoracocentesis is performed. Breathlessness may also be exacerbated by co-existing pathology due to the underlying malignancy, such as pulmonary embolism (PE), endobronchial obstruction by the tumour or lymphangitis in the underlying lung.
With an isolated pleural effusion, the cough is usually dry. In the context of co-existing infection or endobronchial tumour, patients may have a cough productive of purulent sputum or even haemoptysis, although these symptoms can not be directly attributed to the effusion itself.
Chest pain is not a common finding in malignant pleural effusion except in certain situations. Pleuritic chest pain may suggest a co-existing pathology, such as PE. Chronic, diffuse chest wall pain, a common finding in mesothelioma, may be severe and may develop early in the disease course, sometimes prior to the development of an effusion. Pathological fractures caused by bone metastases to the spine, ribs or sternum can also cause significant pain. Chest wall invasion by tumor, particularly involving the ribs or parietal pleura, can also be very painful.
Patients may complain of constitutional symptoms related to the underlying cancer, such as weight loss, fevers and sweating (a particular feature of mesothelioma), poor appetite, lethargy and tiredness. Early satiety can be caused by a pleural effusion, as the fluid results in diagphragmatic flattening, which can compress the stomach.
Symptoms attributed to primary tumor depend on the primary tumor site. A thorough review of systems may help to identify previously unreported symptoms that highlight a potential primary source.
Clinical signs of a pleural effusion are present once more than 300ml of pleural fluid have accumulated in the pleural cavity. Malignancy is the most common cause of massive pleural effusion and, if this is the case, clinical signs may be obvious.
Chest signs consistent with the pleural effusion include reduced expansion, dull percussion note, reduced breath sounds, and reduced vocal resonance.
In large pleural effusions, mediastinal shift usually occurs away from side of the effusion unless co-existing bronchial obstruction is present, in which case the mediastinum may be central or shifted toward the effusion.
Signs of underlying malignant disease to be aware of on examination include:
breast masses
organomegaly or abdominal masses
adenexal masses
skin lesions
Beware: there are other diseases that can mimic malignant pleural effusion
The differential diagnosis for a unilateral pleural effusion is broad so clinical findings and investigations will help to guide the clinician to the diagnosis. Specific diagnoses that may mimic malignancy include:
Tuberculosis. Often described as the great mimic, TB is often confused with malignancy at presentation because of its similar constitutional symptoms. A high degree of diagnostic suspicion is required, as the diagnosis of TB pleuritis may be elusive.
Benign asbestos pleural effusion (BAPE). In patients who present with a pleural effusion in the context of previous asbestos exposure, benign asbestos pleural effusion is in the differential diagnosis. However, the effusion is usually small, and it tends to occur with a shorter time lag after asbestos exposure than mesothelioma does. BAPE is a diagnosis of exclusion, so careful clinical and radiological follow-up is required before making the diagnosis.
In the context of underlying malignancy, effusions can develop indirectly for reasons other than pleural tumor involvement. Examples of these effusions, which are often described as para-malignant effusions, include:
pulmonary emboli, which causes increased permeability of the pulmonary capillaries and increased pressure in the pulmonary circulation, resulting in a pleural effusion
parapneumonic effusion resulting from bronchial obstruction and subsequent post-obstructive pneumonia
chylothorax from trauma or obstruction to the thoracic duct
hypoalbuminaemia, causing a transudative effusion
pericardial effusion, causing a secondary pleural effusion from right ventricular impairment
superior vena cava obstruction, resulting in increased hydrostatic pressure in the SVC and thoracic duct and subsequent pleural effusion
mediastinal lymph node enlargement secondary to tumor, resulting in impaired pleural fluid resorption.
How and/or why did the patient develop malignant pleural effusion?
The mechanisms involved in the development of malignant pleural effusion are thought to be multiple, and the pathogenesis may vary depending on the type of tumor. Spread of tumor to the pleura may occur by various mechanisms, including:
direct invasion of the pleura by tumor from nearby structures, such as the breast, the lung, or mediastinal structure
haematogenous spread of tumor from distant primary
invasion of the pulmonary vasculature by tumor with subsequent embolization of tumor cells to the visceral pleura
The precise mechanism by which pleural fluid develops in MPE is not fully understood. An excess of pro-inflammatory cytokines, particularly vascular endothelial growth factor (VEGF), have been implicated in the process. VEGF is thought to stimulate angiogensis and to increase vascular endothelium permeability, resulting in increased pleural fluid accumulation. Further research is required to clarify the role of VEGF in this process.
Tumor can also block lymphatic drainage of the pleural fluid, leading to reduced resorption from the pleural cavity and contributing to fluid build-up. Other mechanisms unrelated to pleural tumor infiltration may also contribute to the effusion (as described above).
Which individuals are at greatest risk of developing malignant pleural effusion?
Mesothelioma has a close association with previous asbestos exposure, with crocidolite (blue) and amosite (brown) asbestos fibers posing the highest risk because of their slender, amphibole shape, although exposure to chrysotile (white) asbestos still poses a significant risk. There is a latency period, which may be as short as fifteen years but can be up to sixty-five years, between exposure and development of the disease. In most cases, the exposure is occupational. Other potential risk factors for mesothelioma include exposure to erionite (a naturally occurring fibrous substance found in Turkey) and exposure to ionizing radiation.
Certain tumors, including lung, breast, urogenital, ovarian, haematological, GI tract, and skin (melanoma), are more likely to metastasize to the pleura, and in this context the development of MPE represents disseminated malignancy. Specific risk factors depend on the type of malignant cell involved.
With regard to clinical predictors suggestive of underlying pleural malignancy at presentation, a prospective study of patients undergoing thoracoscopy for an undiagnosed effusion found that predictors of an underlying malignant process included symptom duration of more than one month, absence of fever, blood-tinged pleural fluid, and a CT chest suggestive of malignancy.
What laboratory studies should you order to help make the diagnosis, and how should you interpret the results?
Blood tests
LDH/Total Protein - The majority of MPE are exudates, and the measurement of blood LDH and total protein is necessary to apply Light's criteria. However, up to 10 percent of malignant effusions are transudates, so the diagnosis of MPE must still be considered in the context of transudative effusions.
Anaemia, hypercalcaemia, low albumin - These tests may see non-specific findings that may raise the suspicion of underlying malignancy.
Tumor markers - Measurement of tumor markers have no routine role for the investigation of an undiagnosed pleural effusion because of their poor negative predictive value. However, their measurement may be helpful in some situations, particularly if there is a diagnostic suspicion of a specific malignancy. Mesothelin, a glycoprotein that can be measured in blood and pleural fluid, is under evaluation as a potential biomarker of mesothelioma.
A recent study evaluating its role in the diagnostic workup for undiagnosed effusions found it to be significantly higher in mesothelioma compared to other types of malignant and benign effusions and to be more sensitive and specific than cytology in the diagnosis and exclusion of mesothelioma. In clinical practice, its diagnostic utility may be limited by a number of false negative results in sarcomatoid mesothelioma; however, it may be useful in patients with suspicious cytology who are not fit to undergo a biopsy and in monitoring disease progression.
Pleural Fluid Tests
Biochemistry - LDH, Protein, Glucose - When compared with serum levels, LDH and total protein of pleural fluid can be used to differentiate transudates and exudates. A low pleural fluid glucose may be a non-specific finding in MPE.
pH - Approximately a third of malignant pleural effusions have a low pH. This is thought to be due to impaired glucose, hydrogen ion, and carbon dioxide transfer across the diseased pleura, resulting in a lower pleural fluid glucose concentration and a lower pH, rather than local acid production. pH may be lower in mesothelioma compared with secondary pleural malignancies because of the extensive pleural thickening, which exacerbates the problems with glucose and hydrogen ion flux.
In the context of malignancy, a pleural fluid pH lower than 7.3 is a marker of more extensive disease, a poorer prognosis, and a lower chance of successful pleurodesis when compared with those malignant effusions with a normal pH. However, a recent meta-analysis has shown that pH alone is not sufficient to select patients for pleurodesis, so this decision should be made in conjunction with other factors, such as performance status and type of tumor.
Differential cell count - A differential cell count on the pleural fluid may help guide the clinician to a specific diagnostic pathway. Malignant pleural effusions are most commonly lymphocytic, but they may be neutrophilic or eosinophilic, and although the differential cell count may help narrow the differential diagnosis, it will not make the diagnosis of MPE. Other causes of a lymphocytic effusion include TB, lymphoma, cardiac failure, and other chronic disease processes, such as rheumatoid arthritis, sarcoidosis, and yellow nail syndrome.
Cytology/lymphocyte subsets - Pleural fluid cytology, a quick and easy method of obtaining material for analysis, can potentially confirm the diagnosis of malignant pleural effusion by identification of malignant cells. Sixty percent of MPE will have positive cytology, although this figure is lower in mesothelioma. Once malignant cells have been identified, immunocytochemistry can be used to differentiate malignant cell type. In the context of an undiagnosed lymphocytic effusion where lymphoma is suspected, flow cytometry of the pleural fluid can help to identify abnormal lymphocyte subsets.
What imaging studies will be helpful in making or excluding the diagnosis of malignant pleural effusion?
Chest X Ray
The chest radiograph is a useful initial test in malignant pleural effusion (See
Figure 1.
A chest x-ray showing a left-sided loculated pleural effusion in a patient with mesothelioma.
Other signs on the chest radiograph may suggest a malignant cause for the effusion. In the context of a large effusion, mediastinal shift toward the side of the effusion should alert the clinician to the possibility of bronchial obstruction, which may be caused by malignancy. Other diagnostic clues on the chest radiograph include the presence of a pulmonary or mediastinal mass, lympadenopathy, or lytic bony lesions.
The use of ultrasound in the investigation of pleural disease has increased in recent years. Nodularity or thickening of the diaphragm or pleura and the presence of liver metastases can be useful signs on ultrasound to differentiate benign from malignant effusions with a high specificity. Other features, such as septations within the effusion, echogenicity, and swirling within the fluid suggest the effusion is an exudate, although these findings are less specific for malignancy. Ultrasound also allows for the detection of smaller effusions than may be evident on chest radiography.
Ultrasound also has a critical role in guiding diagnostic interventions, such as thoracoentesis and pleural biopsies, to improve both the safety and yield of these procedures.
Computed tomography (CT)
Contrast-enhanced CT scanning has a critical role in the investigation of malignant pleural disease, as it provides information on the likelihood and extent of pleural malignancy, as well as the primary cause and tumor stage. The pleura may appear nodular, irregular, and thickened on CT, and it commonly enhances with contrast. These findings are highly specific for a malignant process, although differentiating between malignant cell type on the basis of CT is more difficult. See
Figure 2.
A CT scan showing nodular, circumfrential pleural thickening and calcified pleural plaques in a patient who was subsequently diagnosed with mesothelioma.
On occasion, CT may identify an occult primary tumor elsewhere--such as in the bowel, the breast, or the lung--and other features, such as lymphadenopathy, bony deposits, and adrenal and liver metastases, may help with disease staging. In addition, CT may detect other paramalignant causes of an effusion, such as pulmonary emboli and superior vena cava obstruction.
As with ultrasound, CT is also commonly used to direct biopsies of the pleura, with an improved diagnostic yield compared to blind pleural biopsies.
magnetic resonance imaging (MRI)
The precise role for MRI in the investigation of malignant pleural disease is still subject to debate. MRI signal intensity on T2-weighted images differentiates malignant and benign pleural thickening with a level of accuracy similar to that of CT, so it may be useful in difficult cases where there is ambiguity about the CT results. MRI visualizes soft tissue, such as the diaphragm and chest wall well, allowing for careful delineation of local infiltration, but respiratory and cardiac motion artifact may impair image quality and the views of other thoracic structures. For example, images of the lungs themselves are poorer than they are using CT.
In mesothelioma, the use of gadalinium contrast and different phase sequences may allow more precise evaluation of local disease invasion than other imaging modalities and hence may be useful to acurately stage the disease. Early studies suggest that the use of MRI may also have a role in monitoring response to chemotherapy in mesothelioma.
PET scanning using 18-fluorodeoxyglucose (FDG) is still under evaluation in pleural disease. Despite success as an imaging modality in other thoracic malignancies, in the context of pleural disease its use is limited by the high false positive rate in other common pleural conditions, such as empyema and following talc pleurodesis. That said, FDG PET is considered to have a good negative predictive value in young people, who are at lower risk of pleural malignancy. FDG PET has also been used in conjunction with CT to differentiate benign asbestos related pleural disease from mesothelioma, and it is under evaluation for monitoring disease response and prognostication in mesothelioma. However, its role in this context is yet to be fully defined.
What non-invasive pulmonary diagnostic studies will be helpful in making or excluding the diagnosis of malignant pleural effusion?
No specific non-invasive pulmonary studies will help make the diagnosis of malignant pleural effusion. Lung function testing may be necessary to risk-stratify patients prior to performing a surgical procedure to gain a histological diagnosis.
What diagnostic procedures will be helpful in making or excluding the diagnosis of malignant pleural effusion?
Pleural fluid aspiration
Pleural fluid aspiration is the best initial invasive investigation in a suspected malignant effusion. With direct ultrasound guidance, pleural fluid aspiration is a predominantly safe and minimally invasive procedure that can be performed quickly and easily with minimal discomfort to the patient. It can provide symptomatic relief from breathlessness caused by the effusion if sufficient fluid is aspirated. Cytological results can be available quickly, and alternative differential diagnoses, such as pleural infection, can be investigated.
Malignant cells are identified by cytology in about 60 percent of malignant pleural effusions, so a significant proportion of patients will still have to undergo a more invasive test to finalize the diagnosis. The yield of pleural fluid cytology is less in mesothelioma, where cytology may appear benign or may mimic alternative malignant conditions, particularly adenocarcinoma, so a biopsy is usually required to clarify the diagnosis.
Blind pleural biopsy
Pleural biopsy is the mainstay of diagnosis, particularly in mesothelioma, where cytology can be falsely negative or misleading. Blind pleural biopsies using an Abram's cutting needle are not recommended, as the yield is only marginally superior to that of pleural fluid cytology, and the procedure may be associated with significant pain and complications. The yield from an image-guided biopsy in suspected malignancy is much higher than that in a blind biopsy (80% with a CT-guided biopsy compared to 47% with an Abram's biopsy in a recent randomized trial). Abrams biopsies also have a higher complication rate than CT-guided biopsies, and pain, pneumothorax, and vasogal reactions are common. In addition, there is a small (<1%) but relevant risk of serious hemorrhage.
Image-guided pleural biopsy
CT-guided biopsy using a tru-cut needle has a sensitivity of nearly 90 percent, and even small areas of pleural thickening can be successfully biopsied in areas that an Abram's cutting needle would not reach. Specific areas of pleural thickening can be targeted, and in general, patients can be discharged from the hospital the same day as the procedure. There is a risk of iatrogenic pneumothorax, so spirometry is often requested prior to the procedure to ensure there is sufficient respiratory reserve should iatrogenic pneumothorax occur. CT-guided biopsy may be particularly useful if local anesthetic thoracoscopy is not possible and the patient is not fit for the general anesthetic required for a surgical biopsy.
Pleuroscopy (local anesthetic thoracoscopy)
Pleuroscopy has the benefit of being able to visualize the pleural cavity directly and to allow biopsies, complete fluid drainage, and pleurodesis to be performed in one procedure. Pleuroscopy, which is performed under sedation, is generally well tolerated, has a low complication rate, and can be performed with only a short in-patient stay. The diagnostic yield is high (95% in recent studies) and comparable to that of a surgical VATS biopsy, but it removes the need for a general anesthetic.
In cases in which the lung is tethered or the effusion is heavily septated, preventing the lung from collapsing during a local anesthetic thoracoscopy, a surgical procedure may be necessary to obtain diagnostic material. Video-assisted thoracoscopic surgery (VATS) has the benefit of allowing the surgeon to perform other techniques at the same time, such as breaking down loculations or performing a decortication or pleurodesis at the end of the procedure. Larger biopsies are also possible, and a more comprehensive view of the pleural cavity is obtained than is possible with local anaesthetic thoracoscopy.
However, the procedure requires a general anesthetic and an induced pneumothorax, so patients with severe underlying lung disease and the elderly may not be able to tolerate it. The diagnostic yield of a VATS is high, and complications are rare. If the visceral and parietal pleura are completely opposed and tethered together, a VATS may not be possible, necessitating a larger operative procedure, such as a thoracotomy.
In the context of mesothelioma, malignant cells may be seeded into the subcutaneous tissues during invasive pleural procedures, and tumor can spread along the procedure track, resulting in painful procedure tract metastases (PTM). The chances of developing a PTM is highest with large chest wall incisions, so prophylactic radiotherapy is often given to reduce this risk. However, the currently available clinical trial data evaluating its use is conflicting, so its routine use is somewhat controversial.
What pathology/cytology/genetic studies will be helpful in making or excluding the diagnosis of malignant pleural effusion?
Pleural fluid cytology is the initial investigation of choice in patients with a suspected malignant effusion, as it identifies malignant cells in about 60 percent of patients with the condition, and it is minimally invasive. Diagnostic yield increases if both a smear and a cell block are prepared from the pleural fluid sample.
Differentiating between the primary tumor type can be challenging, as cytological appearances can be similar, so additional stains are required in order to define the cell type conclusively. This is a particular problem in mesothelioma, where cells may mimic atypical mesothelial cells or metastatic adenocarcinoma. In this context, even in the hands of an experienced cytologist, cytology can be misleading or inaccurate, so a pleural biopsy should be obtained if mesothelioma is suspected and the patient is fit enough. Immunocytochemistry to identify patterns of cell surface marker expression is useful to confirm the malignant cell type.
Lymphocyte subsets
Flow cytometry can be used in conjunction with pleural fluid cytology to identify abnormal proliferation of specific lymphocyte subsets. Flow cytometry has a particular role in undiagnosed lymphocytic effusions where lymphoma is suspected.
Histological evaluation of a pleural biopsy can offer significant additional information when the cytology has been inconclusive. A large specimen, which also allows for improved characterization of tumor structure and morphology, can be obtained by various methods described above. Interpretation of pleural histology is notoriously challenging because benign and malignant conditions may share some histological features and because differentiating between malignant cell types can be difficult, especially on small tissue samples.
Particularly in mesothelioma, histological features may be similar to those of benign reactive mesothelial hyperplasia and fibrous pleuritis. Immunohistochemistry assists in differentiating between them, as well as in identifying the presence of malignant features, particularly local invasion.
In addition, adenocarcinoma can resemble mesothelioma, both macroscopically and microscopically, and differentiating between the two relies on immunohistochemistry. Positivity for calretinin (a calcium-binding protein present on mesothelial cells), CK 5/6, and epithelial membrane antigen (EMA) on the tumor epithelium is found in mesothelioma. In cases of adeoncarcinoma, carcinoembryonic antigen (CEA), CD15, and thyroid transcription factor 1 (TTF1) may be positive. Hence, a full panel of immunostains should be performed on tissue to confirm the precise diagnosis.
If you decide the patient has malignant pleural effusion, how should the patient be managed?
The treatment modalities available to patients with malignant pleural effusions are expanding, and they depend on patient choice, clinical condition, and availability. Strategies focus on removal of the pleural fluid and attempts to prevent further fluid reaccumulation. There are no current therapies that target the underlying problem of excess fluid production, but this is the subject of ongoing research.
Thoracentesis allows quick relief of symptoms and provides fluid for cytology to make a diagnosis and although it may successfully manage a patients symptoms on a temporary basis, in the vast majority of cases of malignant pleural effusion, the fluid will reaccumulate, requiring a more conclusive intervention to be performed later. If large volumes of fluid are removed quickly, there is a risk of re-expansion pulmonary edema, which can be potentially serious. Over many years, studies have evaluated the use of pleural manometry to monitor intrapleural pressure changes during fluid removal; theoretically, if drainage is stopped when the intrapleural pressure falls below a certain level, the occurrence of re-expansion pulmonary edema may be reduced.
In certain situations, repeated therapeutic pleural aspirates may be performed to control patients' symptoms. This may be necessary if the underlying condition is predicted to respond quickly to chemotherapy (such as in some cases of lymphoma), if a patient would be unable to tolerate a more conclusive procedure, if the prognosis is less than three months, or if fluid reaccumulation is very slow. However, repeated thoracocenteses may induce a further inflammatory response within the pleura, increasing the risk of development of a septated and loculated effusion, which may become subsequently more difficult to treat.
Chest drainage and pleurodesis
Chest drainage and pleurodesis have been the mainstays of treatment of malignant effusions for many years. Fluid is drained using an intercostal chest tube, and after complete drainage, a pleurodesis agent is instilled into the pleural cavity via the chest tube in an attempt to seal the pleural cavity and prevent fluid reaccumulation. This technique allows the lung to re-expand and relieves breathlessness and if pleurodesis is successful, it can provide long-term relief of symptoms. However, pleurodesis is not universally successful, with success rates in clinical trials ranging from 70-90 percent. The rate of sucessful pleurodesis in routine practice is perceived to be at the lower end of this estimate.
Parietal and visceral pleura apposition is essential for pleurodesis to be effective, so if the lung cannot fully expand to fill the chest cavity (i.e. if it is 'trapped') because of a visceral pleural "peel: or endobronchial obstruction, pleurodesis will be ineffective. A low pleural fluid pH may also be a marker of potential pleurodesis failure; however, this marker cannot be used in isolation for patient selection.
The agents that have been adopted for pleurodesis include talc, bleomycin, tetracycline, and mustine. Talc, which has been found to be the most effective, can be administered at the time of thoracoscopy via poudrage or through the chest tube as a slurry. In the largest study to date to compare the two administration methods, no significant difference was found with regard to pleurodesis efficacy. However, in a subgroup analysis, patients with underlying lung and breast cancer appeared to have a higher success rate with talc poudrage. Ongoing trials are looking at optimal analgesia and drain size to maximize pleurodesis efficacy.
The side effects of pleurodesis include pain, fever, and breathlessness. Acute respiratory distress is a rare but well documented side effect of talc pleurodesis, which is caused by small talc particles being absorbed into the systemic circulation. Graded talc, which remains within the pleural cavity poses a lower risk of actue respiratory distress.
In a subgroup of patients who have heavily septated or loculated malignant effusions, pleurodesis is less effective than in those with a simple effusion, as the discrete pockets of fluid created by the septations prevent complete drainage of the effusion and, thus, visceral and parietal pleural apposition. The use of intrapleural fibrinolytics in an attempt to break down septations and loculations and to allow more complete drainage prior to pleurodesis has shown promise in some small-scale clinical trials. A larger, randomized trial to define its role further is currently underway. There is a theoretical risk of intrapleural hemorrhage with these agents, although large-scale trials of fibrinolytics in pleural infection have not shown any increased risk.
Indwelling pleural catheters (IPC)
In patients with trapped lung and in those who wish to avoid an in-patient hospital stay, long-term indwelling pleural catheters are commonly used, as they allow frequent drainage of pleural fluid in the community. The procedure, which is performed under local anesthetic (and sedation in some cases) as a day case procedure, is usually well tolerated. The majority of patients gain good symptomatic relief of breathlessness once the IPC is inserted. Early complications include bleeding, although the risk of serious bleeding is less than 1 percent, and pain.
Later, there is a small risk of infection (both skin cellulitis and empyema), catheter blockage, and tracking of tumor along the catheter insertion tract. In up to half of patients with an IPC, spontaneous pleurodesis occurs, allowing the catheter to be removed with no recurrence of the effusion. Indwelling pleural catheters have a particular role in trapped lung, where chest drain and pleurodesis is ineffective because of failure of pleural apposition.
On occasion, a surgical decortication may be necessary to break down intrapleural loculations and septations and to release underlying trapped lung in order to improve patients' symptoms of breathlessness. Patients must be well enough to tolerate general anesthesia, and usually the procedure can be performed by a video-assisted thoracoscopic surgery (VATS) approach. However, some patients may require a thoracotomy. Pleurodesis can also be performed at the time of surgery to prevent fluid reaccumulation.
What is the prognosis for patients managed in the recommended ways?
The involvement of the pleura in a malignant process is a sign of advanced disease, so treatment is palliative. Current management strategies to remove fluid and prevent reaccumulation do not alter the prognosis but do allow improved quality of life by improving symptoms of breathlessness. Depending on the underlying tissue type, various palliative treatments, including chemotherapy, which may improve prognosis, may be available.
Prognosis depends on the underlying tumor cell type, with breast and ovarian carcinoma having the best prognosis, and patients with lung cancer having a shorter survival. Studies that have evaluated prognostic markers in malignant pleural disease have shown baseline performance status to predict prognosis, so management strategies may differ, depending on these factors.
What other considerations exist for patients with malignant pleural effusion?
Because of the close association between mesothelioma and previous asbestos exposure, many patients are eligible for financial compensation. The systems and funds available will depend on patient circumstances, the history of asbestos exposure, and the country of residence. It is important that patients with a new diagnosis of mesothelioma are made aware of this potential financial support to allow them to pursue compensation should they wish to do so.
Involvement of the palliative care team may be required for patients with malignant pleural effusions in order to improve symptom control and provide practical and emotional support for patient and their families. Palliative care input is considered more effective if it is initiated earlier rather than later, so palliative care should be considered early in the patient's disease course if possible.
What's the evidence?
Agarwal, PP, Seely, JM, Matzinger, FR, MacRae, RM, Peterson, RA, Maziak, DE. "Pleural mesothelioma: sensitivity and incidence of needle track seeding after image-guided biopsy versus surgical biopsy.". Radiology. vol. 241. 2006. pp. 589-94.(A retrospecitve review of one hundred patients with mesothelioma shows that those who underwent a surgical biopsy were at a higher risk of PTMs than those who had image-guided biopsy.)
Boutin, C, Rey, F, Viallat, JR. "Prevention of malignant seeding after invasive diagnostic procedures in patients with pleura mesothelioma". Chest. vol. 108. 1995. pp. 754-8.(The first study evaluating the role of prophylactic radiotherapy in mesothelioma in forty patients shows a reduction in PTM rate in the treatment arm.)
Burrows, CM, Mathews, C, Colt, HG. "Predicting survival in patients with recurrent symptomatic malignant pleural effusions". Chest. vol. 117. 2000. pp. 73-78.(Prospective study of eighty-five patients with MPE, correlating features at presentation with survival.)
Bydder, S, Phillips, M, Joseph, DJ, Camerson, F, Spry, NA, DeMelker, Y. "A randomised trial of single-dose radiotherapy to prevent procedure tract metastasis by malignant mesothelioma.". Br J Cancer . vol. 91. 2004. pp. 9-10.(A small RCT of fifty-eight patients with mesothelioma shows no reduction in tract metastasis rate from giving a single dose of prophylactic radiotherapy.)
Davies, CWH, Traill, ZC, Gleeson, FV, Davies, RJO. "Intrapleural streptokinase in the management of malignant multiloculated pleural effusions". Chest. vol. 115. 1999. pp. 729-33.(A pilot study of ten patients with loculated or septated malignant effusions, who were given intrapleural streptokinase. All had a radiographic improvement in effusion size.)
Davies, HE, Sadler, RS, Bielsa, S, Maskell, NA, Rahman, NM, Davies, RO. "Clinical impact and reliability of pleural fluid mesothelin in undiagnosed pleural effusions.". Am J Respir Crit Care Med . vol. 180. 2009. pp. 437-44.(A thorough paper delineating the current role for serum and pleural fluid mesothelin in the diagnostic workup for suspected mesothelioma.)
Dresler, CM, Olak, J, Herndon, JE, Richards, WG, Scalzetti, E. "Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion.". Chest. vol. 127. 2005. pp. 909-915.(A randomized trial that compares administration methods for talc pleurodesis.)
Falaschi, F, Battolla, L, Mascalchi, M, Cioni, R, Zampa, V, Lencioni, R. "Usefulness of MR signal intensity in distinguishing benign from malignant pleural disease.". ARJ . vol. 166. 1996. pp. 963-968.(A prospective study that evaluates the role of MR signal intensity in differentiating benign and malignant pleural disease in forty-five patients with pleural lesions.)
Ferrer, J, Roldan, J, Teixidor, J, Pallisa, E, Gich, I, Morell, F. "Predictors of pleural malignancy in patients with pleural effusion undergoing thoracoscopy.". Chest . vol. 127. 2005. pp. 1017-22.(Prospective study of ninety-three patients who underwent thoracoscopy, designed to identify baseline predictors of pleural malignancy.)
Heffner, JE, Niertert, PJ, Barbieri, C. "Pleural fluid pH as a predictor of survival for patients with malignant pleural effusions". Chest. vol. 117. 2000. pp. 79-86.(Assessment of data from 417 patients with MPE shows that, although low pleural fluid pH was a predictor of poor survival, it did not predict pleurodesis failure accurately enough to be used to select patients for pleurodesis.)
Heffner, JE, Klein, JS. "Recent advances in the diagnosis and management of malignant pleural effusions.". Mayo Clin Proc. vol. 83. 2008. pp. 235-50.(A comprehensive review of the current literature regarding diagnosis and treatment of MPE.)
Hooper, C, Lee, YCG, Maskell, N. "Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010". Thorax. vol. 65. 2010. pp. ii4-ii17.(Current UK guidelines on the investigation of undiagnosed effusions.)
Janes, SM, Rahman, NM, Davies, RJO, Gary Lee, YC. "Catheter-tract metastases associated with chronic indwelling pleural catheters". Chest. vol. 131. 2007. pp. 1232-4.(A case report of four patients who developed procedure-tract metastases at the site of indwelling pleural catheters.)
Light, RW, Gary Lee, YC. Textbook of pleural disease.. Hodder Arnold. 2008.(A review of the current literature on all aspects of pleural disease.)
Maskell, NA, Gleeson, FV, Davies, RJ. "Standard pleural biopsy versus CT-guided cutting-needle biopsy for diagnosis of malignant disease in pleural effusions: a randomised controlled trial". Lancet. vol. 361. 2003. pp. 1326-30.(A randomized trial that confirms the improved yield of CT-guided biopsy compared with blind pleural biopsy in suspected malignant pleural disease.)
Maskell, NA, Lee, YC, Gleeson, FV, Hedley, EL, Pengelly, G, Davies, RJ. "Randomized trials describing lung inflammation after pleurodesis with talc of varying particle size". Am J Respir Crit Care Med. vol. 170. 2004. pp. 377-82.(Two randomized trials that evaluate the effect of pleurodesis on lung and systemic inflammation and show poorer gas exchange and higher systemic inflammation after the use of mixed talc, compared with graded talc.)
O'Rourke, N, Garcia, JC, Paul, J, Lawless, C, McMenemin, R, Hill, J. "A randomised controlled trial of intervention site radiotherapy in malignant pleural mesothelioma". Rad Onc. vol. 84. 2007. pp. 18-22.(RCT of sixty-one patients that evaluates the role of prophylactic irradiation in mesothelioma and shows no benefit of this treatment in reducing tract metastases.)
Putnam, JB, Walsh, GL, Swisher, SG. "Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter.". Ann Thorac Surg . vol. 69. 2000. pp. 369-75.(A retrospective comparison of indwelling pleural catheters and chest tube and pleurodesis.)
Qureshi, NR, Rahman, NM, Gleeson, FV. "Thoracic ultrasound in the diagnosis of malignant pleural effusion". Thorax. vol. 64. 2009. pp. 139-43.(A study evaluating the diagnostic accuracy of specific features on thoracic ultrasound in suspected malignancy.)
Roberts, ME, Neville, E, Berrisford, RG, Antunes, G, Ali, NJ. "Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010". Thorax. vol. 65. 2010. pp. ii32-40.(The current UK guidelines, highlighting all the current evidence in this area as well as expert opinion.)
Shaw, P, Agarwal, R. "Pleurodesis for malignant pleural effusions.". Cochrane Database Syst Rev.. 2004.(A meta-analysis of the current data on pleurodesis in MPE.)
Traill, ZC, Davies, RJO, Gleeson, FV. "Thoracic computed tomography in patients with suspected malignant pleural effusions". Clinical Radiology. vol. 56. 2001. pp. 193-6.(A prospective study evaluating the sensitivity and specificity of CT features in the diagnosis of malignant pleural disease.)
Tremblay, A, Michaud. "Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion.". Chest. vol. 129. 2006. pp. 362-8.(A retrospective review of 250 indwelling pleural catheter insertions, their outcomes, and complications.)
Vogelzang, N, Rusthoven, JJ, Symanowski, J. "Phase III study of pemetrexed in combination with cisplatin versus cisplatin aone in patients with malignant pleural mesothelioma.". J Clin Onc. vol. 21. 2003. pp. 2636-44.(The seminal paper evaluating the role of cisplatin and pemetrexed chemotherapy in malignant pleural mesothelioma.)
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9971 Wireless Recording with Built In Bridge?
- Silver, 250 points or more
Has anyone tried to use a wireless 9971 phone and SIP recording to Zoom/etc? I have a wired 9971 recording fine with Zoom but a wireless 9971 does not record with same phone settings. If I disable wireless on 9971 and plug it in it records fine.
I'm not able to find any cisco docs on wireless versus wired for recording feature.

subset: commoncrawl


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NVIDIA Shield Portable Gaming Device
Project Shield, NVIDA's new portable gaming device…
NVIDIA has unveiled its new portable gaming device, Project Shield. Although the Shield is still a prototype – which means its name could change before the release date – company CEO Jen-Hsun Huang took to the stage at CES to give an overview of what we can expect.
The Shield bears a resemblance to an Xbox controller with an additional flip up 5-inch 720p retinal multi-touch display. The device features an A15 quad-core Tegra processor and runs on the Android operating systems. The onboard 802.11n 2x MIMO game-speed Wi-Fi provides enough bandwidth to stream 4K video to your TV, as well as access Steam, Android, TegraZone and PC games for those with compatible GeForce graphics cards.
Other notable features include onboard sound, a micro SD slot, and all standardized ports.
Aside from the computing power, the device's main selling point is it's full sized gaming console-grade controls with two analog joysticks and ample physical control buttons.
The battery provides up to 5-10 hours gameplay, which may not seem like a huge amount compared with other portable devices, but since all ports are standard, you'll be able to charge it from any USB device.


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One of the country's oldest survivors of D-Day and World War II has been living in Pulaski for over 60 years. Fred Ersal Hendrick was born Oct. 16, 1919 on a farm near the Blue Ridge Parkway in Carroll County. In 1941 he enlisted in the Army and received his military training at Ford Mead, Md. as well as locations in Virginia, North Carolina and South Carolina.
Hendrick was assigned to the 29th Infantry, 116th Division, 111th Field Artillery Unit and on Sept. 27, 1942 he was deployed to Eurore aboard the Queen Mary. The trip was not without trouble, as the ship encountered heavy fog and struck a British ship, breaking it in two and killing many British soldiers.
Upon arriving in Scotland, Hendrick was transferred to Bainberg, England where he completed 20 months of training in the Field Artillery Unit and was promoted to Staff Sergeant.
From Bainberg, Hendrick was deployed to Normandy Beach. While landing there, his landing barge sank and his unit lost all of their supplies and much of their equipment. Hendrick fought in the Normandy Beach Invasion in France and then on into Germany. He served with honor until the end of the war in 1945.
In 1951, Hendrick married Esther Ayers Dawson and went to work as a security guard at the Radford Arsenal. In 1953, he moved his family of five to Pulaski where he rented a home on Pine Street (later named State Street). Hendrick and his family joined the Pulaski First Church of the Brethern in 1959 and were baptized by Pastor Eugene Khale.
According to his good friend, John Crable, Hendrick enjoys his days by sitting at his window with his Bible open on the table and reading his favorite passages.
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Clint Black has had a profound effect on the music industry, not only through his own recordings, but also through the establishment of his brainchild, Equity Music Group, a record company he co-founded in 2003.
He is a profound, not to mention prolific, songwriter. To date, he has written, recorded and released more than 100 songs, a benchmark in any artist's career. An astounding one third of the songs eligible for single release achieved hit song status at Country Radio. He has sold over 20 million albums worldwide. As a musician, he profoundly astounds -- he is an accomplished guitarist, and humbly describes himself as proficient on drums, harmonica, bass guitar and an assortment of percussion instruments.
Black will be playing for the charity, International Rett Syndrome Foundation.
Clint's charity is the International Rett Syndrome Foundation International Rett Syndrome Foundation - Home
PERSONAL CONNECTION: In 2003, Clint lost his 16-year old niece to Rett syndrome, a devastating neuro-developmental disorder. Clint is grateful for the opportunity to be working for the International Rett Syndrome Foundation, which funds research for treatment of the disease. Clint hopes that fundraising efforts may help find a cure for the disease that took his niece's life


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NYC Street Walker Holiday Charm
Because we all need a reminder that at some point in our lives we made room for frivolity and excess, even if that time is now.
Comfort and warmth now costs $140. Remember when UGG was a brand bought by poor people? :-)Tags: fashion, winter, gifts, shoes, Clothes, accessories, style, boots, womens shoesAdded 9 Years Ago from Neiman Marcus Online
Every girl needs a little lamb.


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SE Amps with Variable Impedance Loads
Hey guys,
I am in the process of designing a SE 807 amp. In triode mode, I expect approximately 3.4W. I have already ordered Edcor GXSE15-8-5K OTs for this project. I wanted a low power amp for my newly-restored Klipsch Heresy speakers. However, my research tells me that the Heresy speakers vary their impedance from 10 ohms up to 70 ohms or so. Since transformers reflect the impedance of the secondary load to the primary, I can deduce that these speakers would NOT work well with a single-ended amplifier. Is this correct?
If that's the case, how much of a difference would it make if I put a 15 ohm resistor on the outputs? That should keep the impedance within what I would consider an acceptable load. What will this resistor do to the frequency response, and do you think I'd notice an appreciable drop in volume?
The 15 ohm resitor would certainly help and whilst it would take a bit of power it won't be noticable.
I'd be inclined to include the transformer secondary in the cathode circuit. If you have a cathode bypass cap then instead of connecting it to ground, connect it to the speaker output (with the other end to ground). you will need to experiment as to which way round one of the windings is connected (pri or sec). one way will give you lower gain and smoother respose, and the other will give more gain, and may even oscillate.
I haven't really heard of putting the secondary in the cathode circuit before. That's definitely an interesting idea.
I got my info from here, and the general consensus was that the Heresy was not SE-friendly. http://community.klipsch.com/forums/p/77869/771253.aspx
Also, many people say never to run a tube amp into no load, which is infinite impedance, technically. Since 70 ohms is much higher than 8 ohms, I would guess that it's not very good for it. That'd be reflecting 43.8KΩ into the primary, I believe.
The impedance of a typical speaker is relatively high at bass resonant frequency.
Fortunately there is a cure for this. The proper amount of negative feedback. This reduces the negative effects of varying load impedance.
The worst results will exist with pentode-connected amplifier. With and without feedback.
Best results exist with UL-connected amplifier and little worse with triode-connected. Also with and without feedback.
My current design is looking like either a 6SL7 single-ended front end or a 6SL7 SRPP, both possibly with an LED bias, just for fun. Right now I don't have any feedback (that I know of). If I did use negative feedback, what would I need to do and how would I calculate the values?
If the higher impedance really isn't a problem, then why do people say not to run a tube amp into no load? What will happen?
I plan on having a switch to switch between UL and triode modes. I'm working on my schematic(s) right now, so we'll see how it goes.
A 15R resistor would waste 40% of your output power. Not a good idea.
Triode or UL should be OK. They will help damp the bass resonance. As you are going for SE I assume you don't want a low distortion design with global feedback.
No load is a problem, especially at higher frequencies. A higher resistance is not a problem, especially at lower frequencies. If you want to use feedback then you either need to learn a bit more or copy an existing design, as feedback can create as many problems as it solves if not done carefully.
The 70 ohm impedance will not be a problem. That is at a resonant frequency and obviously your amp will not make much power into that load.
But it won't have to, nor would you want it too, as if the amp made the same power, it would be *way* too pronounced at that frequency. If I were you, I'd give it a shot- certainly it will not be hard on the amp :)
Okay, great. I first have to get the amp built, and then get some tweeter diaphragms for the K-77s.
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Reed has been working exclusively as a website designer since April 1997. Its need for a mixture of creativity and technical expertise is well suited to his way of working.
He has given talks on website usability and accessibility at the London Macromedia User Group and was on the Macromedia development team for HomeSite 6 before the project was dropped when Macromedia was taken over by Adobe. He also helped with the development of the HTML and CSS editor TopStyle 5, writing the CSS3 style definition.
The links below will open new browser tabs/windows for sites that Reed has designed or produced.
A network of business coaches united by a belief in its ability to support break-though performance in individuals and teams.
Belmont, Mill Hill's preparatory school takes pride in being a happy and caring community offering an excellent education.
An artist living and working in Suffolk whose work includes series of monochrome portraits of people from Sierra Leone.
Lisa Carter MPsych, CPsychol, Chartered Clinical Psychologist - providing psychological assessment and psychotherapy in London.
Counselling & Psychotherapy in High Wycombe, Buckinghamshire with Toby Ingham.
Delivered are a Thames Valley based delivery company offering overnight parcels and pallets, and international delivery.
Ealing Civic Society are working to preserve and improve their borough.
EBM is a unique, world class mentoring programme aimed at the next generation of FTSE Chief Executives, Chief Financial Officers and board Directors.
ECG's Robert Hartshorne is an award winning composer for film, television, radio, commercials and live events.
Joy Flanagan Design offers a collaborative, creative and engaging design service, culminating in bespoke interiors for residential and commercial projects.
Grimsdell is a co-educational Pre-Preparatory School in the green belt of North West London - a part of the Mill Hill Foundation.
Paul Jackson is a well known and highly successful studio potter based near Bodmin in Cornwall.
Lygon Group are an independent executive search and board consulting partnership, operating from London.
The senior school of the Mill Hill Foundation offers both full and weekly boarding and day education to boys and girls aged from 13 to 18.
The Mill Hill School Foundation offers education to boys and girls aged between 3 and 18 in its four schools.
The Mount, Mill Hill International
The Mount, Mill Hill International is a new co-educational boarding and day school for international pupils.
Website for a book that proposes a radical new theory for the location of Homer's Ithaca (in Greek and English).
Performance and Wellbeing's executive coaching services help people in organisations to achieve a sustainable improvement in their performance and fulfil their potential.
Socialist International Women is the women's organisation of the socialist, social democratic and labour parties affiliated to the Socialist International.
Weaverbird is an international independent executive search consultancy with an exclusive focus on finding talented digital and technology leaders and the rising stars within their teams.


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Awesomely Affordable: 10 Summer-Ready Maxi Dresses Under $50
Why wear a maxi dress during the summer? It's simple: Shaving your legs every friggin' day gets so tedious. Plus, maxi dresses are a femme, flow-y way to stay cool in the face of 90 degree heat and humidity. Throw one over your head, slip on some sandals and you're ready for work, the beach — just about anywhere. Maxis are the best, so you're probably gonna want to have at least a couple to get you through the warmer months, which is why I've found 10 great options, all under $50 each. Maxify your life with abandon!


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Posts tagged 'perception of university'
Adjunct Faculty are Unionizing
I wonder if this is the start of a trend that will change higher education. The job of being faculty is becoming harder, especially in CS as enrollments rise without a rise in faculty numbers. Adjunct faculty are particularly put upon in universities, and unionizing is one way for them to push back.
Part-time faculty members at downtown Pittsburgh's Point Park University have voted to join the Adjunct Faculty Association of the United Steelworkers AFA-USW.The group filed a petition with the National Labor Relations Board NLRB in April to hold a mail ballot election. A total of 314 part-time Point Park instructors were eligible to vote, and the ballots were counted this morning at the NLRB's downtown offices.
via Point Park Adjunct Faculty Votes to Join AFA-USW Union | United Steelworkers.
Understanding CS Ed Research in The Soul of the Research University
The below-linked article is highly recommended. It's an insightful consideration of the different definitions of "University" we have in the US, and how the goals of helping students become educated for middle class jobs and of being a research university are not the same thing.
This article gave me new insight into the challenges of discipline-based education research, like computing education research. We really are doing research, as one would expect in a research university, e.g., trying to understand what it means for a human to understand computation and how to improve that understanding. But what we study is a kind of activity that occurs at that other kind of university. That puts us in a weird place, between the two definitions of the role of a university. It gives me new insight into the challenges I faced when I was the director of undergraduate studies in the College of Computing and when I was implementing Media Computation. Education research isn't just thrown over the wall into implementation. The same challenges of technology adoption and, necessarily, technology adaption have to occur.
At the "TIME Summit on Higher Education" that the Carnegie Corporation of New York and Time magazine co-sponsored in September 2013 along with the Bill & Melinda Gates Foundation and the William and Flora Hewlett Foundation, the disconnect between the views of the research university from inside and outside was vividly on display. A procession of distinguished leaders of higher education mainly emphasized the need to protect—in particular, to finance adequately—the university's research mission. A procession of equally distinguished outsiders, including the U.S. secretary of education, mainly emphasized the need to make higher education more cost-effective for its students and their families, which almost inevitably entails twisting the dial away from research and toward the emphasis on skills instruction that characterizes the mass higher-education model. Time's own cover story that followed from the conference hardly mentioned research it was mainly about how much economically useful material students are learning, even though the research university was explicitly the main focus of the conference.
via The Soul of the Research University – The Chronicle Review – The Chronicle of Higher Education.
A theory for why there's so little CS Ed in the US
I have a theory that predicts when (if?) we will see more computing education research students in the US. I think that it might also help understand when computer science education (e.g., an AP course in CS) might reach the majority of US high schools.
Why are there so few CS Ed research students in the US?
Recently, I hosted a visit from Dr. Nick Falkner (Associate Dean (IT), Faculty of Engineering, Mathematical and Computer Sciences) and Dr. Katrina Falkner (Deputy Head and Director of Teaching, School of Computer Science) from the University of Adelaide. We got to talking about the lack of CS education research (CER) graduate students in the United States. There are lots of PhD students studying CER in Australasia, Europe, and Israel. To offer a comparison point, when we visited Melbourne in 2011, they had just held a doctoral consortium in CS Ed with 20 students attending, all from just the Melbourne area. The ICER doctoral consortium at UCSD in August had 14 students, and not all 14 were from the US. The Australasian Computing Education will have its own DC, and they're capping enrollment at 10, but there are far more CER PhD students than that in the region. I get invitations regularly to serve on review committees for dissertations from Australia and Europe, but rarely from the US.
Why is CER so much more popular among graduate students outside of the US? I've wondered if it's an issue of funding for research, or how graduate students are recruited. Then it occurred to us.
Check out the Falkners' titles: Associate Dean, Deputy Head (Katrina will be Head of School next year), Director. I remarked on that, and Nick and Katrina started naming other CS education research faculty who were Chairs, full Professors, and Deans and Directors in Australia. We went on naming other CS education researchers in high positions in New Zealand (e.g., Tim Bell, Professor and Deputy Head of Department), England (e.g., the great Computing Education Group at Kent), Denmark (e.g., Michael Caspersen as Director of the Center for Science Education), Sweden (e.g., CS Education Research at Uppsala), Finland, Germany, and Israel.
Then I was challenged to name:
- US CS Education researchers who are full Professors at research intensive universities;
- US CS Education researchers who are Chairs of their departments or schools;
- US CS Education researchers who are Deans or Center Directors.
I'm sure that there would be some quibbling if I tried to name US researchers in these categories. I don't think anyone would disagree that none of these categories requires more than one hand to count — and I don't think anyone needs more than a couple fingers for that last category.
We have great computing education researchers in the United States. Few are in these kinds of positions of visible prestige and authority. Many in the ICER community are at teaching institutions. Many who are at research intensive universities are in teaching track positions.
Computing Education Research is not as respected in US universities as it is in other countries. In these other countries, a graduate student could pursue computing education research, and might still be able to achieve tenure, promotion, and even an administrative position in prestigious institutions. That's really rare in the United States.
There are many reasons why there isn't more CER in research-intensive universities. Maybe there's not enough funding in CER (which is an outcome of lack of respect/value). Most people don't buy into computing for all in the US. Unless there's more CER in schools, maybe we don't need much CER in Universities. I'm actually not addressing why CER gets less respect in the US than in other countries — I'm hypothesizing a relationship between two variables because of that lack of respect.
The status of CER is definitely on the mind of students when they are considering CER as a research area. I've lost students to other areas of research when they realize that CER is a difficult academic path in the US. My first CS advisor at U-Michigan (before Elliot Soloway moved there) was strongly against my plans for a joint degree with education. "No CS department will hire you, and if they do, they won't tenure you." I succeeded into that first category (there was luck and great mentors involved). It's hard for me to say if my personal path could ever reach categories 2 or 3, and if barriers I meet are due more to my research area than my personal strengths and weaknesses. All I can really say for sure is that, if you look around, there aren't many CER people in those categories, which means that there is no obvious evidence to a graduate student that they can reach those kinds of success.
So, here's my hypothesis:
Hypothesis: We will see more computing education research graduate students in the US when CER is a reasonable path to tenure, promotion, and advancement in research-intensive US universities.
Why is there so little computing education in US high schools?
Other countries have a lot more computing education in their high schools than we do in the United States. Israel, New Zealand, Denmark, and England all have national curricula that include significant computer science. In Israel, you can even pursue a software engineering track in high school. They all have an advantage over the US, since we have no national curricula at all. However, Germany, which has a similarly distributed education model, still has much more advanced computing education curricula (the state of Bavaria has a computing curriculum for grades 6-12) and CS teacher professional development. What's different?
I suspect that there are similar factors at work in schools as in Universities. Computing education is not highly valued in US society. That gets reflected in decisions at both the University and school systems. I don't know much about influence relationships between the University and the K-12 system. I have suggested that we will not have a stable high school CS education program in the United States without getting the Schools of Education engaged in teacher pre-service education. I don't know how changes in one influence the other.
However, I see a strong correlation, caused by an external social factor — maybe some of those I mentioned earlier (not enough funding for CER, don't need more CER, etc.). Professors and University administrators are not separate from their societies and cultures. The same values and influences are present in the University as in the society at large. What the society values has an influence on what the University values. If a change occurs in the values in the society, then the University values will likely change. I don't know if it works in the other way.
So here's where I go further out on a limb:
Second Hypothesis: We will see the majority of US high schools offering computer science education (e.g., AP CS) when CER is a reasonable path to tenure, promotion, and advancement in research-intensive US universities.
Here are two examples to support the hypothesis:
- Consider Physics. No one doubts the value of physics. Within society, we're willing to spend billions to find a Higgs Boson, because we value physics. Similarly, we strive to offer physics education to every high school student. Similarly, physics faculty can aspire to become Deans and even University Presidents. Physics is valued by society and the University.
- Consider Engineering Education Research. Twenty years ago, engineering education research was uncommon, and it had little presence in K-12 schools. Today, there are several Engineering Education academic units in the US — at Purdue, Clemson, and Virginia Tech. (There's quite a list here.) Engineering education researchers can get tenured, promoted, and even become head of an engineering education research academic unit. And, Engineering is now taught in K-12 schools. Recently, I've been involved in an effort to directly interview kids in schools that offer AP CS. We can hardly find any! Several of the schools in the Atlanta area that used to offer AP CS now offer Engineering classes instead. (Maybe the belief is that engineers will take care of our CS/IT needs in the US?) Engineering has a significant presence in K-12 education today.
I don't think that this hypothesis works as a prescriptive model. I'm not saying, "If we just create some computing education research units, we'll get CS into high schools!" I don't know that there is much more CS Ed in schools in Australia, Sweden, or Finland than in the US, where CER is a path to advancement. I hypothesize a correlation. If we see changes at the Universities, we'll be seeing changes in schools. I expect that the reverse will also be true — if we ever see the majority of US high schools with CS, the Universities will support the effort. But I thnk that the major influencer on both of these is the perception of CER in the larger society. I'm hypothesizing that both will change if the major influence changes.
(Thanks to Briana Morrison, Barbara Ericson, Amy Bruckman, and Betsy DiSalvo on an earlier draft of this post.)
CS/IT higher-ed degree production has declined since 2003
I couldn't believe this when Mark Miller sent the below to me. "Maybe it's true in aggregate, but I'm sure it's not true at Georgia Tech." I checked. And yes, it has *declined*. In 2003 (summing Fall/Winter/Spring), the College of Computing had 367 graduates. In 2012, we had 217. Enrollments are up, but completions are down.
What does this mean for the argument that we have a labor shortage in computer science, so we need to introduce computing earlier (in K-12) to get more people into computing? We have more people in computing (enrolled) today, and we're producing fewer graduates. Maybe our real problem is the productivity at the college level?
I shared these data with Rick Adrion, and he pointed out that degree output necessarily lags enrollment by 4-6 years. Yes, 2012 is at a high for enrollment, but the students who graduated in 2012 came into school in 2008 or 2007, when we were still "flatlined." We'll have to watch to see if output rises over the next few years.
Computer-related degree output at U.S. universities and colleges flatlined from 2006 to 2009 and have steadily increased in the years since. But the fact remains: Total degree production (associate's and above) was lower by almost 14,000 degrees in 2012 than in 2003. The biggest overall decreases came in three programs — computer science, computer and information sciences, general, and computer and information sciences and support services, other.
This might reflect the surge in certifications and employer training programs, or the fact that some programmers can get jobs (or work independently) without a degree or formal training because their skills are in-demand.
Of the 15 metros with the most computer and IT degrees in 2012, 10 saw decreases from their 2003 totals. That includes New York City (a 52% drop), San Francisco (55%), Atlanta (33%), Miami (32%), and Los Angeles (31%).
via In the Spotlight: Higher Ed Degree Output by Field and Metro | Newgeography.com.
Experiences with Media Computation at U. Adelaide
Katrina Falkner has written up an excellent reflection (with gorgeous example student work) on her new MediaComp course at the University of Adelaide. I loved the artwork she shared, and I was particularly struck by the points she made about the value of "slowness" of the language, the challenges of helping students decontextualize programming after learning MediaComp, and the students complaining about using a curriculum "not invented here."
The students didn't really like working with Jython as it was very slow, but this had an unintended consequence, in that they became aware of the efficiency of their algorithms. I don't think I have ever taught a first year course where students introduced efficiency as a discussion point on their own initiative. However, when working with their own images, which could sometimes be huge, they had to start thinking about whether there was a better way of solving their problems. I think this was a big win.
Creativity and ownership. The last assignment we ran was a group assignment, where the students had to develop a piece of art using and extending the techniques they had learnt in the course. This was fantastic. We had run a similar assignment in previous years where the students developed JavaScript games, and that worked reasonably well, but I think Media Computation produced a better result as the outcomes were more individual, and creative. The students had a lot more fun sharing their results.
via Experiences with Media Computation | Katrina Falkner.
The challenges of integrated engineering education
I spent a couple days at Michigan State University (July 11-12) learning about integrated engineering education. The idea of integrated engineering education is to get students to see how the mathematics and physics (and other requirements) fit into their goals of becoming engineers. In part, it's a response to students learning calculus here and physical principles there, but having no idea what role they play when it comes to design and solving real engineering problems. (Computer science hasn't played a significant role in previous experiments in integrated engineering education, but if one were to do it today, you probably would include CS — that's why I was invited, as someone interested in CS for other disciplines.) The results of integrated engineering education are positive, including higher retention (a pretty consistent result across all the examples we saw), higher GPA's (often), and better learning (some data).
But these programs rarely last. A program at U. Massachusetts-Dartmouth is one of the longest running (9 years), but it's gone through extensive revision — not clear it's the same program. These are hard programs to get set up. It is an even bigger challenge to sustain them.
The programs lie across a spectrum of integration. The most intense was a program at Rose-Hulman that lasted for five years. All the core first year engineering courses were combined in a single 12 credit hour course, co-taught by faculty from all the relevant disciplines. That's tight integration. On the other end is a program at Wright State University, where the engineering faculty established a course on "Engineering Math" that meets Calculus I requirements for Physics, but is all about solving problems (e.g., using real physical units) that involve calculus. The students still take Calculus I, but later. The result is higher retention and students who get the purpose for the mathematics — but at a cost of greater disconnect between Engineering and mathematics. (No math faculty are involved in the Engineering Math course.)
My most significant insight was: The greater the integration, the greater the need for incentives. And the greater the need for the incentives, the higher in the organization you need support. If you just want to set up a single course to help Engineers understand problem-solving with mathematics, you can do that with your department or school, and you only have to provide incentives to a single faculty member each year. If you want to do something across departments, you need greater incentives to keep it going, and you'll need multiple chairs or deans. If you want a 12 credit hour course that combines four or five disciplines, maybe you need the Provost or President to make it happen and keep it going.
Overall, I wasn't convinced that integrated engineering education efforts are worth the costs. Are the results that we have merely a Hawthorne effect? It's hard to sustain integrated anything in American universities (as Cuban told us in "How Scholars Trumped Teachers"). (Here's an interesting review of Cuban's book.) Retention is good and important (especially of women and under-represented students), but if Engineering programs are already over-subscribed (which many in the workshop were), then why improvement retention of students in the first year if there is no space for them in the latter years? Integration probably leads to better learning, but there are deeper American University structural problems to fix first, which would reduce the costs in doing the right things for learning.
Carl Wieman Finds Colleges Resist Measuring Teaching
I've just started my subscription to The Chronicle of Higher Education, and the first print issue I received had a great article about Carl Wieman, whom I have written about previously (here and here and here, for just three). The story (online here: Crusader for Better Science Teaching Finds Colleges Slow to Change – Government – The Chronicle of Higher Education) was about his efforts to get the White House to measure teaching practices.
At the White House, Mr. Wieman tried to figure out what might actually get colleges and their faculty members to adopt proven teaching practices. His centerpiece idea was that American colleges and universities, in order to remain eligible for the billions of dollars the federal government spends annually on scientific research, should be required to have their faculty members spend a few minutes each year answering a questionnaire that would ask about their usual types of assignments, class materials, student interaction, and lecture and discussion styles.
Mr. Wieman believed that a moment or two of pondering such concepts might lead some instructors to reconsider their approaches. Also, Mr. he says, data from the responses might give parents and prospective students the power to choose colleges that use the most-proven teaching methods. He hoped the survey idea could be realized as either an act of Congress or a presidential executive order.
I hadn't heard about this survey, but my immediate thought was, "What a great idea!" We need better ways to measure teaching (like with Sadler's recent work), and this seems like a great first step. I was surprised to read the response
College leaders derided it as yet another unnecessary intrusion by government into academic matters.
"Linking federal funding for scientific research to pedagogical decisions of the faculty would have set a terrible precedent for policy makers," said Princeton University's Shirley M. Tilghman, one of several presidents of major research institutions who wrote to the White House to complain about Mr. Wieman's idea. "It is naïve to think that the 'surveys' will not have consequences down the line."
Wouldn't "consequences" be a good thing? Shouldn't we reward schools that are doing more to improve teaching and adopt better practices? Shouldn't we incentivize schools to do better at teaching? I guess I'm the one who is naïve — I was surprised that there was so much resistance. In the end, Wieman lost the battle. He's now left the White House, dealing with multiple myeloma.
Perhaps the saddest line in the piece is this one:
"I'm not sure what I can do beyond what I've already done," Mr. Wieman says.
Is it really impossible to get universities to take teaching seriously?


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Contribute your own thoughts, experience, questions, and knowledge for the benefit of all MedPage Today Healthcare Professionals and Expert Patients™.Post a comment
david perns DC
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2011-10-21 / Family
Inaugural county book fair coming
More than 1,000 bookworms and aspiring authors are expected to celebrate the written word at the inaugural Ventura County Book & Author Fair in Camarillo on Sat., Nov. 5.
The free festival is from 10 a.m. to 4 p.m. at the Pleasant Valley Community Park auditorium, 1605 Burnley St.
"There is a burgeoning group of people in this county who want to learn more about writing," said Kate Sexton, the event coordinator and a local author. "I think the written word is something we need to cherish and keep developing."
A free book expo will be open to the public. No registration is needed, but visitors who register online before the event will receive a coupon for 20 percent off their first book purchase at the fair.
Authors will read excerpts from their latest books throughout the day at the expo. There will also be a children's reading corner.
The 50 exhibitors at the expo will include new authors, independent book publishers, writing clubs and literary associations.
With few locally owned book shops, Sexton said, the fair introduces the public to up-and-coming authors who don't have the chance to be featured in large chain bookstores.
"Nowadays there's no way to get in the bookstores unless you're with a major publisher," Sexton said. "The fair is a great way to meet new authors, and everyone at the fair loves books. Books are also great presents with the holidays coming up."
Budding writers can participate in the fair's classes to sharpen their craft.
Best-selling authors, literary agents and publicists will teach eight educational writing workshops. The classes cover getting published, writing a memoir, mastering comedic writing, writing young adult fiction, self-promotion, self-publishing, building characters and knowing what agents look for.
The workshop instructors will speak for 90 minutes and allow 20 minutes for questions. Each seminar costs $25, and online registration closes Wed., Nov. 2. Visitors can register on the day of the fair if there is space available.
Sexton said the fair's workshops promote the art of writing rather than the mass production of it.
"People want to get their voice out there in something besides Twittering," Sexton said. "Writing is more than 140 characters with your thumb."
Santa Barbara-based nonprofit Pacific Institute for Professional Writing is the main sponsor for the fair. Any proceeds from the event will benefit the group's youth writing programs, workshops and other projects.
Ten volunteers have offered to help before and at the event, Sexton said, but another 10 are needed for ticket taking, registration desk, door monitoring, flier distribution and assisting exhibitors.
For more informat ion or to volunteer, visit www.vcbookandauthorfair.com or call Sexton at (805) 633-1506.


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Everything You Know About CSS Is Wrong!, By Rachel Andrew & Kevin Yank
Edition: 1st
Price: $29.95
Pages: 130
Published: October 2008
This aggressively titled, well-written book is about CSS tables. As you may know, most browsers already support CSS tables, meaning the CSS properties "display: table," "display: table-row," "display: table-cell," and so on.
"Most browsers" does not, unfortunately, equate to "most people using browsers." The big issue here is that the most prevalent browser at most sites is Microsoft Internet Explorer (IE), and that prior to version 8 IE did not support CSS tables. Sure, let's tell 80 percent of our visitors that they can't view our content correctly. Gulp. NOT!
Now that IE 8 is about to ship, it might start to make sense to use CSS tables instead of CSS floats, which are hard to do well on multiple browsers, or HTML tables, which are easy to use but often don't look that great. But what can we do about people with IE 7 and IE 6? This is 2001 all over again, with IE 7 taking the place of Netscape 4, and the one big thing we learned back then is that people don't take kindly to being told what browser to use: they want the site to accommodate to the browser currently in use.
Andrew and Yank make a compelling case for the position that it is time to adopt CSS tables, while handling older versions of IE with conditionally included CSS. They provide short, clear examples of how to do this, at least for some relatively simple common cases. The basic argument here is that adopting CSS tables is the way to move forward; the secondary argument is that using standard CSS tables and adding the conditionally included CSS for IE 6 and IE 7 is less of a development and testing burden than using CSS floats and tuning them to work on seven different browsers.
That's right, seven browsers -- in my experience, if you want to cover the gamut, you need to test on IE 8, IE 7, IE 6, Firefox, Safari, Opera, and Chrome. Most other browsers are variations on the above seven that don't introduce additional rendering engines or extensions, although that could change at any time; it was only a few months ago that I had to add Chrome to my testing list, and Google didn't exactly give us a lot of warning about it.
Not everyone will agree with Andrew and Yank's position, least of all people with thousands of existing pages already designed, tested, debugged, and serving multiple browsers. But it's certainly an argument worth examining, especially when your next site redesign comes around.
By the way, the first printing of Everything You Know About CSS Is Wrong! has sold out. It's available as a PDF now and will be in print again in mid-January.


text: Politics 12 March 2010 Tories promise 100Mbps broadband in technology manifesto The Tories have launched their technology manifesto, promising that they will provide broadband spee Sign up for our weekly email * The party said it plans to provide these super-fast broadband connections to most British homes by 2017. It aims to achieve this by boosting private investments through opening up of network infrastructure, making planning rules easy and increasing competition. The Tories said they would take a cut out of the BBC license fee to rollout the broadband project in rural areas. The Tory manifesto also talks about giving access to government data on a contract basis. The Tories will break large government IT projects into smaller chunks so that small and medium-size businesses could benefit. Subscribe from just £1 per issue More


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Mr. McCONNELL. Mr. President, I rise today to pay tribute to one of the great national parks in the Commonwealth of Kentucky, Cumberland Gap National Historical Park, located southeastern Kentucky, near Middlesboro. The park will celebrate its 50th anniversary this year.
In the 1920s, the idea of creating the Cumberland Gap National Historical Park was formed, and after 30 years of planning and hard work, the park was finished and dedicated, 50 years ago this coming July.
The park will hold several special events in July celebrating the anniversary of the historic dedication, including the gathering of oral histories from people who were present during the creation, early days, and dedication of the park.
At the time of the dedication, Cumberland Gap National Historical Park included 20,184 acres--10,679 in Kentucky, 7,478 in Virginia, and 2,027 in Tennessee. Until 1980, it was the largest historical park in the country. It is estimated that more than 1 million people will visit the park this year.
Efforts have been made by the National Park Service since 1997 to prevent surface coal mining in the area surrounding Fern Lake. In cooperation with my friend in the House, Congressman Hal Rogers, we were able to pass legislation that authorized the Secretary of the Interior to acquire Fern Lake and the surrounding watershed to preserve this natural resource.
I value the importance of this park and have consistently secured funds to help acquire and preserve the lake. Located just southeast of Middlesboro, Fern Lake serves as the primary water source for the community and is visible from the Pinnacle Overlook, which is a popular visitor attraction at the Cumberland Gap National Park.
This park shows the importance Kentuckians place on our natural environment, and I applaud the work of the individuals who helped make this park a reality and those who continue to safeguard its natural beauty for many generations to come.
Mr. President, I ask my colleagues to join with me in celebrating the 50th anniversary of the dedication of one of our Nation's most beautiful historical parks.
Source: http://thomas.loc.gov


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To be considered for the role, you should have a minimum three years' experience within B2B PR; agency or in-house experience gained within a similar role would be ideal. Alongside this experience, you will have excellent copywriting and proofreading skills, and most of all, enjoy working within in a small PR team, where there is plenty of scope for accountability and personal development. Importantly, you should also be friendly and pleasant combined with a positive attitude and a genuine interest in B2B PR.
The company is looking to recruit someone quickly, so if you have the skills, experience, and a real interest in B2B PR, then send your CV through to firstname.lastname@example.com, or call Simon or Sara on 0161 425 7352 for further information.


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Los Angeles, June 9 (IANS) Late pop legend Michael Jackson's ex wife Debbie Rowe says she wants to help their 15-year-old daughter Paris Jackson, who attempted suicide earlier this week.
Rowe said she is also willing to take custody of Paris if she agrees.
"Debbie's door has always been open to Paris, and she will do whatever it takes to help her daughter," femalefirst.co.uk quoted a source as saying.
Debbie was married to the legendary musician for three years, and gave full custody of their children - Prince, 16, and Paris, to Michael Jackson, during their divorce proceedings in 1999.


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At Least the German Economy's Growing
The U.S. economy is still an unholy mess, but someone is doing something right over in Germany, which reported record growth over the three-month period from April through June — the biggest such spike since the once-split nation reunified. The fiscal situation was slightly improved in France and Spain, but Greece? Down 1.5 percent. –KA
"Such quarter-on-quarter growth has never been recorded before in reunified Germany," the national statistics office, Destatis, said.
The main reason for the higher-than-expected growth was strong exports, helped by a weaker euro.
The eurozone economy grew by 1% during the quarter.
This compares with growth of 0.2% in the first three months of the year, the area's official statistics agency, Eurostat, said.


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A new iPad application for Farm Market iD's Grower Relationship Management (GRM) system was introduced today.
Farm Market iD specializes in agriculture databases "containing information on more than 3.9 million owners, operators and farmers which provides detailed, actionable information—including crops, acres, yield, farm income—and covers nearly all growers in the country."
The iPad application was established so that sales teams can have access to information while they are on the road making sales calls and "expedite the sales process," according to Chris Sidles, vice president national sales for Farm Market iD.
He claims the "on the go" accessing of information was hugely popular with field sales teams of beta testers.


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Roy Halladay's no-hitter is still percolating inside me, resonating in many different ways. Here's just a sample:
This magical year for Halladay has come 15 years after he was drafted. I can still clearly remember Halladay, in his second major-league start in 1998, coming within an out of a no-hitter (that would have been a perfect game if not for a Toronto error).
Two years later, in 2000, he pitched 67 2/3 innings and gave up 80 runs.
By the end of the decade, Halladay was long established as an elite pitcher, but from a team standpoint, it was all for naught. Not a single postseason appearance, and no guarantee at age 32 that one would ever come.
Today, he is on top of the baseball world.
Tomorrow – who knows?
And the funniest thing about this roller-coaster ride? If you're anything like me, you feel like you go through these kinds of ups and downs on an hourly basis.
Don't get too high or too low is the advice. But sometimes I just wonder, how can you not? I'm not made of stone, man.
Congrats again to Halladay …