Over a 2-year period (1987-1988), 31 children (3% of 960 operations) were found to have a paralysed diaphragm following cardiac surgery. The median age was 5 months with 65% less than 1 year of age. In the 31 patients, 38 paralysed diaphragms were identified. The phrenic nerve injury was on the right in 8 cases, the left in 16, bilateral in 7 and 40% were related to modified Blalock Taussig shunts. The time to extubation was analysed for each patient in two separate groups: Group A: (greater than 1 year): 11 children of whom 5 were extubated without difficulty, 4 had non-respiratory reasons for prolonged ventilation and only 2 were plicated--both were extubated within 4 days. Group B: (less than 1 year): 20 infants of whom 16 were plicated and 4 were not. Three of the children who were plicated died from cardiac causes. Of the 13 survivors, there were 3 who had other reasons for prolonged ventilation. Thus 10 infants required prolonged ventilation (mean 11 days) because of respiratory difficulties. All underwent plication and were extubated at a mean of 2.4 days postoperatively. The 4 who were not plicated were extubated at a mean of 11 days postoperatively. In infants in whom there is no cardiac cause for failure to wean from ventilation, diaphragmatic paralysis should be suspected and plication performed if not extubated 2 weeks after operation.

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SUMMARY The accuracy of diagnosis in 656 patients with the four common histopathological types of primary lung cancer has been assessed by comparing the cell type diagnosis made on cytological and histological investigation with that determined by examination of the surgically resected or necropsy specimen. The accuracy of diagnosis achieved by cytological examination of sputum and bronchial aspirate, and by bronchial biopsy histology was over 85%. The least accurate diagnostic procedure was percutaneous needle biopsy (62%). Squamous and small cell tumours were accurately diagnosed by all four investigations but errors were made in the diagnosis of large cell and adenocarcinomas. Nearly half the number of patients (43%) with large cell carcinoma were later reclassified as having squamous carcinoma and of the patients with adenocarcinoma 32% had been predicted to be squamous and 18% large cell carcinoma. We consider such quality control of pretreatment diagnosis mandatory in management of individual patients and before enrolment in clinical trials.In 1979 a study was reported from Papworth Hospital, Cambridge which examined the accuracy of diagnosis of cell type in patients with primary lung cancer.' The presumptive cell type as predicted by cytology and biopsy techniques was compared with the true histological cell type as determined by histological examination of tumour tissue obtained at surgical resection or necropsy. The results indicated that the true cell type was most accurately predicted by sputum cytology (88 Y.), closely followed by bronchial aspiration (84%) and bronchial biopsy (80 %). The least accurate procedure was percutaneous needle biopsy (48 %). Diagnostic accuracy was highest in patients with squamous cell carcinoma while particular difficulty was experienced in diagnosis of patients with adenocarcinoma.Inevitably, with such a study limited to a four-year period in a single hospital, the number of patients in each histological group was relatively small. We have therefore undertaken a larger study of 673 patients with confirmed lung cancer seen at two centres, Papworth Hospital, Cambridge and Brompton Hospital, London and this includes the results of the original work from Papworth.

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