Pleural Effusion in Meigs’ Syndrome—Transudate or Exudate?: Systematic Review of the Literature

Although Meigs’ syndrome is regarded as a well-defined entity, contradictory data on pleural fluid characteristics have been presented, with some papers classifying it as a transudate, whereas others stating that it is an exudate.The aims of the study were: (1) to evaluate pleural fluid characteristics in patients with Meigs’ syndrome and (2) to analyze the prevalence of transudative and exudative pleural effusion in relation to the applied definition of the syndrome.We performed a search through medical databases (MEDLINE, EMBASE, SCOPUS, and GOOGLE SCHOLAR) to identify papers on Meigs’ syndrome published between 1940 and 2013. Two authors independently reviewed each paper searching for prespecified data: (1) signs and symptoms, (2) tumor characteristics, (3) clinical and laboratory data on ascites, (4) clinical, radiological, and laboratory data on pleural fluid, (5) clinical course after tumor removal. All case reports were reclassified according to a new unequivocal classification of Meigs’ syndrome-related entities.A total of 653 papers were initially identified, and 454 articles reporting 541 patients were included in the final analysis. After reclassification according to our case definitions, there were 196, 113, and 108 patients defined as classic Meigs’ syndrome, nonclassic Meigs’ syndrome, and pseudo-Meigs’ syndrome, respectively. Significantly more patients presented with right-sided than left-sided and bilateral pleural effusions (P < 0.001). Median volume of withdrawn pleural fluid was 2950 (1500–6000) mL. The classification of pleural effusion with the use of Light''s criteria was possible in only 7 patients. In 6 of these patients pleural effusion met the criteria for an exudate. When the protein concentration > 3.0 g/dL was applied as a criterion of pleural exudate, 88.8% (80/90) of effusions were classified as exudates. Increasing the cut-off level to 3.5 g/dL resulted in only a modest decrease in the percentage of exudative effusions (81%, 73/90).Surprisingly few reports on Meigs’ syndrome present data reliably defining the character of pleural effusion. The available data indicate, however, that the majority of pleural effusions in patients with this entity are exudates. This finding may be a prerequisite for the verification of some earlier presented concepts.     

The Role of Pleural Fluid-Serum Gradient of Tumor Necrosis Factor-α Concentration in Discrimination Between Complicated and Uncomplicated Parapneumonic Effusion

In a previous preliminary study an excess of tumor necrosis factor- (TNF) was found in pleural fluid of patients with complicated parapneumonic effusion (CPPE), and its levels in pleural fluid of these patients were shown to be significantly higher than those in patients with uncomplicated parapneumonic effusion (UCPPE). This larger population study was undertaken to investigate, for the first time, the role of pleural fluid-serum gradient of TNF (TNFgradient) in discrimination between UCPPE and CPPE. Using a commercially available high sensitivity ELISA kit, levels of TNF were measured in serum and pleural fluid of 51 patients with UCPPE and 30 patients with nonempyemic CPPE. The mean±SEM values of serum TNF (TNFserum), pleural fluid TNF (TNFpf), and TNFgradient in the UCPPE group were 6.65±0.48 pg/mL, 10.85±0.74 pg/mL, and 4.2±0.38 pg/mL respectively, and in the CPPE group they were 7.59±0.87 pg/mL, 54.02±5.43 pg/mL, and 46.43±5.34 pg/mL, respectively. While no significant difference was found between the two groups regarding levels of TNFserum (p=0.31), a highly significant difference between these two groups was found regarding levels of TNFpf and TNFgradient (p < 0.0001 for both variables). A significant correlation was found between levels of TNFserum and levels of TNFpf in the UCPPE group (r=0.89, p < 0.0001), but not in the CPPE group (r=0.18, p < 0.33). TNFgradient at an optimal cut-off level of 9.0 pg/mL was found to be a good marker for discrimination between UCPPE and CPPE (sensitivity, 96.7%, specificity, 98%, accuracy, 97.5%, and p < 0.0001). In conclusion, levels of TNFpf but not TNFserum are significantly higher in CPPEs than those in UCPPEs where TNFgradient at an optimal cut-off level of 9.0 pg/mL is a good marker for discrimination between UCPPE and CPPE.     

Denonvilliers’ Fascia Lies Anterior to the Fascia Propria and Rectal Dissection Plane in Total Mesorectal Excision

PURPOSE Opinion is divided whether Denonvilliers fascia lies anterior or posterior to the anatomic fascia propria plane of anterior rectal dissection in total mesorectal excision. This study was designed to evaluate this anatomic relationship by assessing the presence or absence of Denonvilliers fascia on the anterior surface of the extraperitoneal rectum in specimens resected for both nonanterior and anterior rectal cancer in males.METHODS Surgical specimens were collected prospectively from males undergoing total mesorectal excision for mid and low rectal cancer, with a deep dissection of the anterior extraperitoneal rectum to the pelvic floor. Specimens were histopathologically analyzed using best practice methods for rectal cancer. The anterior aspects of the extraperitoneal rectal sections were examined microscopically for the presence or absence of Denonvilliers fascia.RESULTS Thirty rectal specimens were examined. Denonvilliers fascia was present in 12 (40 percent) and absent in 18 specimens (60 percent). Denonvilliers fascia was significantly more frequently present when tumor involved (55 percent) rather than spared the anterior rectal quadrant (10 percent; difference between groups 45 percent; 95 percent confidence interval, 30–60 percent; P = 0.024, Fishers exact test).CONCLUSIONS When tumors were nonanterior, rectal dissection was conducted on fascia propria in the usual anatomic plane, and Denonvilliers fascia was not present on the specimen. It was almost exclusively found in anterior tumors, deliberately taken by a radical extra-anatomic anterior dissection in the extramesorectal dissection plane. Denonvilliers fascia lies anterior to the anatomic fascia propria plane of anterior rectal dissection and is more closely applied to the prostate than the rectum.Presented at the meeting of the Association of Coloproctology of Great Britain and Ireland, Brighton, United Kingdom, July 10 to 12, 2000.Reprints are not available.     

Gender Bias in Gastroparesis: Is Nitric Oxide the Answer?

Accumulating evidence suggests that gender-related differences are prominent in gastric motility functions in both health and disease. Women are more susceptible to gastroparesis than men. Though the mechanism(s) involved are not fully understood, impairment of the nitrergic system is one of the main factors responsible for the disease. Uncoupling of neuronal nitric oxide synthase (nNOS) causes a decreased synthesis of NO leading to a reduction in smooth muscle relaxation. Tetrahydrobiopterin (BH₄) (an essential cofactor for nNOS) is a key regulator of nNOS activity for stomach dysfunction and gastroparesis. In addition, BH₄ has been shown to be a potent antioxidant and anti-inflammatory agent. Well established by results from our laboratory, a diminished intracellular (BH₄:total biopterin) ratio in diabetic female rats significantly impairs nNOS activity and function. Recent research has been focused on BH₄ biosynthesis and gastroparesis because reduced BH₄ cofactor levels can alter the production of NO by nNOS. Researchers are now paying more attention to the possibility of using BH₄ as a therapeutic strategy in gastroparesis. The purpose of this review is to provide an overview of the regulation and function of nNOS by sex hormones and BH₄ and its potential role in the treatment of gastroparesis.     

Has the Frequency of Precocious Puberty and Rapidly Progressive Early Puberty Increased in Girls During the COVID-19 Pandemic?

Objective:Early puberty is development of secondary sex characteristics earlier than the expected normal age range. We subjectively observed an increased frequency of early puberty during the Coronavirus disease-2019 (COVID-19) lockdown and aimed to show the clinical, demographic characteristics of the cases and the change in its incidence.Methods:Female patients with central precocious puberty (CPP, n=28) and rapidly progressive early puberty (RPEP, n=61), presenting to our clinic before (January 2019-March 2020) and during the COVID-19 pandemic (April 2020-June 2021) were included.Results:Among 28 CPP cases, six (21%) presented before the pandemic lockdown, whereas 22 (79%) were diagnosed during the COVID-19 pandemic lockdown. While RPEP was seen in 16 (26%) patients before the pandemic, 45 (74%) patients were diagnosed during the lockdown period. Presentation with menarche was seen in 15 RPEP patients; two (13%) were in the prepandemic period and 13 (87%) were in the lockdown period. Chronological age, bone age, bone age to chronological age ratio, height, weight, and body mass index standard deviation scores of patients with RPEP and CPP were similar between the prepandemic and pandemic period.Conclusion:In this cohort, the frequency of CPP and RPP cases were significantly (p<0.001) increased during the COVID-19 pandemic, possibly due to environmental changes.     

Development of Self‐Administered Versions of Modified Baseline and Transition Dyspnea Indexes in COPD

In this study we developed self‐administered versions of modified baseline and transition dyspnea indexes and compared the scores obtained by this method with the mean value obtained by two trained interviewers. Twenty‐five patients (14 males/11 females) with chronic obstructive disease who had a chief complaint of “breathlessness” were tested. Age was 66 ± 11 years; forced expiratory volume in one second was 48 ± 23% predicted. The baseline total scores were 5.0 ± 1.8 for the interviewers and 5.4 ± 2.0 for the self‐administered method. For the baseline dyspnea scores the correlations were 0.83 (p < 0.0001) between self‐administration and the mean value of two interviewers and 0.75 (p < 0.0001) between the two interviewers. The transition total scores, obtained an average of 102 days (range, 7–377 days) later, were ? 0.1 ± 3.0 for the interviewers and ? 0.4 ± 3.0 for the self‐administered method. For the transition dyspnea scores the correlations were 0.94 (p < 0.0001) between self‐administration and the mean value of two interviewers and 0.83 (p < 0.0001) between the two interviewers. The self‐administered dyspnea scores had similar correlations with measures of lung function as did the interview dyspnea scores. We conclude that self‐administered versions of the modified baseline and transition dyspnea indexes provide comparable scores as those obtained by trained and experienced interviewers. The advantages of the self‐administered versions include standardized methodology and computerized scoring.