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PubMed1996

Serum/ascites albumin gradient: its value as a rational approach to the differential diagnosis of ascites.

BACKGROUND: The utility of differentiating ascites into 'transudate' and 'exudate' has recently been challenged. The aim of the present study was to compare the diagnostic accuracy of the serum/ascites albumin gradient, proposed as a new biochemical criterion for the differential diagnosis of ascites, with the markers traditionally used for the classification of peritoneal fluid into transudate and exudate. METHODS: Paired ascitic fluid and serum samples from 51 patients were examined with an established method for the diagnosis of the cause of ascitic fluid collection. Included in the study were 32 patients with ascites related to portal hypertension (cirrhosis, n = 28; 'cardiac' ascites, n = 2; Budd-Chiari, n = 2) and 19 patients with ascites not related to portal hypertension (peritoneal carcinomatosis, n = 17; tuberculous peritonitis, n = I; secondary bacterial peritonitis, n = 1). Specimens were collected during an episode of spontaneous bacterial peritonitis in 7 of 28 patients with cirrhosis. The serum/ascites albumin gradient was compared with ascitic fluid total protein, ascites/serum total protein ratio, ascites lactic dehydrogenase concentration, and ascites/serum lactic dehydrogenase ratio. RESULTS: The diagnostic accuracy was 98% for the serum/ascites albumin gradient compared with only 52%-80% for the four other markers tested. In patients with infected ascites, diagnostic accuracy was 89% for the albumin gradient and < or = 50% for the four other markers. CONCLUSIONS: The classification of ascites into transudate and exudate appears to be based on markers with low diagnostic accuracy. Differential diagnosis of ascites should be based on the serum/ascites albumin gradient, which is a reliable marker distinguishing ascites related to portal hypertension from all other causes of ascitic fluid collection, regardless of the presence of bacterial infection.

Ascites↗

PubMed1996

Pharmacokinetics and pharmacodynamics of ketoprofen enantiomers in the horse.

Pharmacokinetic and pharmacodynamic parameters were established for enantiomers of the non-steroidal anti-inflammatory drug (NSAID) ketoprofen (KTP), each administered separately at a dose level of 1.1 mg/kg to a group of six New Forest geldings, in a three-period cross-over study using a tissue cage model of inflammation. For both S(+)-and R(-)-KTP, penetration into tissue cage fluid (transudate) and inflamed tissue cage fluid (exudate) was rapid, and clearances from exudate and transudate were much slower than from plasma. AUC values were, therefore, higher for exudate and, to a lesser degree, transudate than for plasma. Unidirectional chiral inversion of R(-)-to S(+)-KTP was demonstrated. Administration of both enantiomers produced marked, time-dependent inhibition of synthesis of serum thromboxane B2 and exudate prostaglandin E2, indicating non-selective inhibition of cyclo-oxygenase (COX) isoenzymes COX-1 and COX-2 respectively. Administration of both enantiomers also produced partial inhibition of beta-glucuronidase release into inflammatory exudate and of bradykinin-induced skin oedema. It is suggested that, although S(+)-KTP is generally regarded as the eutomer, R(-)-KTP was probably at least as active in inhibiting bradykinin swelling. Pharmacokinetic/pharmacodynamic (PK/PD) modelling of the data could not be undertaken following R(-)-KTP administration because of chiral inversion to S(+)-KTP, but pharmacodynamic parameters, Emax, EC50, N, keO and t1/2(keO). were determined for s(+)-KTP using the sigmoidal Emax equation. PK/DP modelling provided a novel means of comparing and quantifying several biological effects of KTP and of investigating its mechanisms of action.

Animals↗

PubMed2000

[Examination of the pleural effusion and its interpretation].

Pleural effusion appears in the course of respiratory diseases and disorders of other organs. Examination of the effusion enables differentiation between exudate or transudate. It allows to estimate the severity of the disease, helps to choose the way of treatment and assesses its effects. In most cases Light's criteria are sufficient for differentiation between exudate and transudate. If the patient has an exudative pleural effusion additional tests are indicated to determine the etiology of the effusion. Laboratory tests which are useful in the further diagnostics of pleural effusion include: bacterial cultures, cytological and biochemical tests.

Exudates and Transudates↗

PubMed2000

Use of pleural fluid C-reactive protein in diagnosis of pleural effusions.

The aims of the study were to assess whether C-reactive protein (CRP) is a sensitive marker for discriminating between transudative and exudative and pleural effusions to evaluate whether it can be used to distinguish inflammatory pleural effusions from other types of effusion. Pleural fluid and serum CRP levels were obtained in 97 patients with pleural effusion, using an immunoturbidimetric method (Olympus AU-600 autoanalyser). We compared CRP levels between transudates and exudates, inflammatory effusions and other types of effusion. According to the criteria used, 16 patients were included in the transudate group and 81 patients in the exudate group. Pleural fluid CRP levels were significantly lower in the transudate group (P<0.04; 14.9 +/- 4.9 mg l(-1) and 35.5 +/- 4.9 mg l(-1) respectively). Also, the ratio of pleural fluid to serum was significantly lower in the transudate group (P<0.009; 0.8 +/- 0.5 mg l(-1) and 2.8 +/- 0.7 mg l(-1), respectively). In the exudate group, 35 patients had neoplastic effusions, 10 chronic non-specific pleurisy, 19 tuberculous pleurisy, 16 parapneumonic effusion and one Dressler Syndrome. When these sub-groups were compared, the parapneumonic effusion subgroup CRP levels (mean 89 +/- 16.3 mg l(-1)) were significantly higher than those in the other subgroups, other exudate of neoplastic effusion, tuberculous pleurisy and chronic non-specific effusion and the transudate group (P<0.0001; P<0.0001; P<0.0004 and P<0.0001, respectively). The ratio between pleural fluid and serum CRP was significantly higher in the parapneumonic effusion subgroup than in the neoplastic subgroup (P<0.0002; 6.6 +/- 2.7 mg l(-1) and 1 +/- 0.2 mg l(-1), respectively). Pleural fluid CRP levels > 30 mg l(-1) had a high sensitivity (93.7%) and specificity (76.5%) and a positive predictive value of 98.4%. In the differential diagnosis of pleural effusions, higher CRP levels may prove to be a rapid, practical and accurate method of differentiating parapneumonic effusions from other exudate types. Although the high level of CRP obtained in the exudate group may be due to the number of patients with parapneumonic effusion who were included, the pleural CRP level may also be helpful in discriminating between exudative and transudative pleural effusions.

Biomarkers↗

PubMed2005

The differential diagnostic values of cytokine levels in pleural effusions.

The aim is to examine whether the changes in pleural fluid interleukin (IL)-1beta, IL-2, IL-6, and IL-8 levels were significant in differential diagnosis of childhood pleural effusions. IL-1beta, IL-2, IL-6, and IL-8 levels in pleural fluids of all 36 patients were measured. The levels of IL-1beta, IL-2, IL-6, and IL-8 in pleural fluids were statistically significantly higher in the transudate group compared with those of the exudate group. The levels of IL-1 beta, IL-6, and IL-8 were also found to be statistically significantly higher in the empyema group compared with both the parapneumonic and the tuberculous pleural effusion groups. The levels of IL-2 and IL-6 were detected to be statistically significantly higher in the tuberculous pleural effusion group in comparison with those of the parapneumonic effusion group. The results showed that pleural fluids IL-1beta, IL-2, IL-6, and IL-8 could be used in pleural fluids exudate and transudate distinction.

Adolescent↗

PubMed2006

Pharmacokinetics and pharmacodynamics of cefovecin in dogs.

A series of in vivo, ex vivo and in vitro studies were conducted to determine the pharmacokinetic and pharmacodynamic properties of cefovecin, a new injectable cephalosporin, in dogs. Absolute bioavailability was determined in a two-phase cross-over study in dogs receiving 8 mg/kg bodyweight (b.w.) of cefovecin by either subcutaneous (s.c.) or intravenous (i.v.) route. After s.c. administration, cefovecin was fully bioavailable (100%), the mean maximum plasma concentration (Cmax) was 121 microg/mL and the mean apparent elimination half-life (t1/2) was 133 h. Clearance was measured to be 0.76 mL/h/kg after i.v. dosing. The concentration of cefovecin in urine measured 14 days after s.c. administration was 2.9 microg/mL. Plasma protein binding was determined by equilibrium dialysis; over concentrations ranging from 10 to 100 microg/mL (i.e. up to the approximate Cmax following an 8 mg/kg dose), protein binding of 98.7% to 96.0% was observed, however, binding was lower at higher concentrations. Total and free concentrations of cefovecin were determined in plasma, transudate and exudate collected from dogs previously implanted subcutaneously with tissue cages. Mean peak concentrations of free cefovecin were almost three times higher in transudate than in plasma and remained above 0.25 microg/mL for 19 days. The ex vivo antibacterial killing activity (vs. Staphylococcus intermedius, MIC 0.25 microg/mL) was measured in serum, transudate and exudate collected from dogs which had received 8 mg/kg b.w. of cefovecin subcutaneously. Transudate exhibited higher antimicrobial killing activity than serum. Activity in serum and exudate exhibited a mean reduction in bacterial counts of S. intermedius of at least three log units up to 72 h postadministration. Bactericidal activity (>3 log10 reduction of bacterial counts) was observed in transudate up to 12 days postadministration. The slow elimination and long lasting ex vivo antibacterial killing activity following administration of cefovecin are desirable pharmacokinetic and pharmacodynamic attributes for an antimicrobial drug with 14-day dosing intervals.

Animals↗

PubMedDate not supplied

Analysis of the density of pleural fluid analogs by computed tomography.

A noninvasive method for differentiating transudative and exudative pleural effusions could make thoracentesis unnecessary in many cases. Since computed tomography (CT) can be used to measure tissue densities, it has a potential use in assessing density of intrathoracic fluid. This study was performed to test this possibility. Plastic syringes containing water, saline, and three saline-albumin solutions with densities up to 1.021 g/cc were scanned individually in air, in a chest phantom, and in a dog thorax during apnea. We found significant positive correlations between specific gravity and CT density; coefficients ranged from 0.85 to 0.99. Regression lines for the different test conditions were not statistically different. However, CT number variability, as indicated by the average standard deviation (SD), did differ for the test conditions: 1) Syringes alone, average SD was 3.8 HU; 2) chest phantom, average SD was 5.5 HU adjacent to rib and 5.8 HU anterior to vertebral column; 3) dog chest average SD was 19.2 HU with heart motion and 9.4 HU without heart motion. These results suggest that heart motion is a major factor in CT number variability in vivo, and that differentiation of transudates from exudates is not possible with current CT methods.

Animals↗

PubMed1999

Enantiospecific pharmacokinetics and pharmacodynamics of ketoprofen in sheep.

Pharmacokinetic and pharmacodynamic parameters were established for the enantiomers of the 2-arylpropionic acid (APA) nonsteroidal anti-inflammatory drug (NSAID), ketoprofen (KTP). Each enantiomer was administered separately (1.5 mg/kg) and in a racemic mixture (3 mg/kg) intravenously (i.v.) to a group of eight sheep in a four-way, four-period cross-over study using a tissue cage model of inflammation. Plasma disposition of each KTP enantiomer was similar following separate administration of the pure compounds compared to administration of the racemic mixture. S(+)KTP volume of distribution (Vd(area)) was higher and clearance (ClB) faster than those of R(-)KTP. S(+) and R(-)KTP achieved relatively low concentrations in exudate and transudate. Unidirectional limited chiral inversion of R(-) to S(+)KTP was demonstrated. After R(-)KTP administration S(+)KTP was detected in plasma, but not in either exudate or transudate. Pharmacokinetic/pharmacodynamic (PK/PD) modelling of the data could not be undertaken following R(-)KTP administration because of chiral inversion to S(+)KTP, but the pharmacodynamic parameters, calculated maximum effect (Emax), concentration producing 50% effect (EC50), Hill's coefficient (N), rate constant of elimination of drug effect from the compartment (KeO) and mean equilibration half-life (t1/2KeO) were determined for S(+)KTP after administration of the racemic mixture as well as the pure compound.

Animals↗

PubMed2003

Effect of iatrogenic haemorrhage on biochemical parameters in pleural effusions.

AIM: Pleural fluid (PF) samples may become haemorrhagic due to trauma during diagnostic procedures. We aimed to evaluate the effect of increasing blood concentrations in pleural fluids on biochemical parameters which are used to discriminate transudates and exudates. METHODS: Sixty-seven pleural fluid samples were separated into five test tubes. Patient's own blood was added in the test tubes in different concentrations as follows: No blood in the first tube, 2% in the 2nd, 5% in the 3rd, 10% in the 4th, 20% in the 5th tube. RESULTS: After addition of blood, statistically significant changes in all biochemical parameters in transudate groups were detected. The characteristics changed from transudate to exudate 12.9%, 14%, 11.4%, 27% and 14.3% according to Light's criteria, serum-PF albumin gradient, cholesterol level, PF/serum cholesterol and PF/serum bilirubin, respectively. Results indicating an exudate according to Light's criteria were evident only in the 5th tube group, however, when other biochemical parameters were used, classification of samples could be altered with lower concentrations of blood. CONCLUSION: Contamination of blood, especially in borderline transudative pleural effusions, may result in misclassification as an exudate. Light's criteria appear to be the least effected and therefore the most reliable parameters in bloody effusions.

Bilirubin↗

PubMed1975

[Significance of lactate dehydrogenase levels in the fluid and serum in the diagnosis of pleural effusions].

Lactic acid dehydrogenase (LAD) levels were determined in 82 pleural effusion liquids and the respective blood samples from 58 patients. Effusions were classed as transudates and exudates on the basis of clinical and laboratory data. The 16 transudates had absolute protein levels of less than 3 g/100 ml and a liquid: serum protein ratio below 0.5. LAD values were below 100 mU/ml and the liquid: serum ratio was less than 0.33, whereas both these levels were exceeded in the case of the 66 exudates. The liquid: serum LAD ratio is better suited for the differentiation of transudates and exudates, particularly if it is related to the liquid: serum protein ratio. Neoplastic effusions have the highest absolute LAD values and liquid: serum LAD ratios. Slighter lower values are noted in TB. Taken in conjunction with other parameters, liquid and serum LAD levels enable a transudate to be distinguished from an exudate and assist in aetiological diagnosis.

Adult↗

PubMed1991

[Pleural cholesterol: a useful determination].

The difference between exudates and transudates is the first question a clinician must solve when facing a pleural effusion. A great number of parameters have been tried without a definite efficacy of any of them. Cholesterol is an easy, useful determination for distinguishing exudates from transudates. In our series of 86 patients a cholesterol value of 50 mg/dl allowed us to correctly classify 94.2% of effusions. The ratio between pleural fluid cholesterol/serum cholesterol was more efficient because it permitted to correctly classify 97.7% of effusions, in one of those major groups which constitute the binomial exudate/transudate.

Cholesterol↗

PubMed2006

[Reappraisal of the standard method (Light's criteria) for identifying pleural exudates].

BACKGROUND AND OBJECTIVES: Light's criteria remain the best method for separating pleural exudates from transudates. We assessed their operating characteristics, as well as those resulting from omitting the pleural fluid to serum lactate dehydrogenase (LDH) ratio from the original criteria (abbreviated Light criteria), in a large series of patients. We also searched for the best combination of pleural fluid parameters, including protein, LDH and cholesterol that identify exudates. PATIENTS AND METHOD: We conducted a retrospective study of 1,490 consecutive patients with pleural effusion who underwent a diagnostic thoracentesis. There were 1,192 exudates and 298 transudates. Sensitivity, specificity, area under ROC curve, and odds ratio for both individual and combined pleural fluid parameters were calculated. RESULTS: Light's criteria yielded 97.5% sensitivity and 80% specificity. Both abbreviated Light criteria (sensitivity: 95.4%; specificity: 83.3%) and the combined use in an "or" rule of pleural fluid protein and LDH (sensitivity: 95.4%; specificity: 80,2%) had similar discriminative properties than standard criteria. CONCLUSIONS: Diagnostic separation of pleural effusions into exudates or transudates can be done effectively thorough the abbreviated Light criteria when the serum LDH value is not available. On the other hand, if venipuncture wants to be avoided (an unusual circumstance) the combination of pleural fluid protein and LDH represents an alternative to Light's criteria.

Cholesterol↗

PubMed1979

Ultrasonic differentiation of types of ascitic fluid.

A review of 65 cases of proven ascites was done to assess the accuracy of ultrasound in distinguishing transudates from exudates. In 10 patients with malignant ascites, ultrasound suggested this in six by showing matted bowel loops, loculation, or hepatic metastasis. In each of the five patients with peritonitis, infected ascites was suggested by observing septations or debris within the fluid. A sonographic diagnosis of exudate was not made in any of the 50 confirmed transudates. The echographic characteristics which may suggest infected or malignant ascites are discussed.

Ascites↗

PubMed2001

The evaluation of pleural effusions in patients with heart failure.

PURPOSE: To determine the causes of pleural effusions in patients with heart failure, and the association of the characteristics of these statistics with the use of diuretics. SUBJECTS AND METHODS: Eighty-one patients with a definite diagnosis of heart failure who underwent thoracentesis were evaluated. Fluids were classified as transudates or exudates using Light's criteria. RESULTS: Forty-one effusions (in 34 patients) were transudates, and 54 (in 47 patients) were exudates. A specific cause was found for 32 of the exudates (27 patients); except for heart failure, no obvious cause was found for the remaining 22 fluids (20 patients). Exudates with a specific cause for an exudate were more likely to have at least two of Light's criteria (18 of 27 [67%]) than did exudates without a known cause (2 of 21 [10%]). Intravenous diuretic therapy in the 24 hours before thoracentesis was significantly more common among patients with exudates without a specific cause. CONCLUSIONS: Patients with heart failure may have exudative pleural effusions without an obvious cause except heart failure.

Aged↗

PubMed1986

Pleural effusions. 1. Preliminary evaluation--recognition of the transudate.

Part 1 of this two-part article describes how to document the presence and location of pleural effusion, perform thoracentesis, and differentiate transudates from exudates. If the pleural fluid is found to be a transudate, no further tests are indicated. Part 2, starting on page 181, details pleural fluid analysis, describes pleural biopsy and thoracoscopy, and presents a clinical strategy for evaluating pleural effusion.

Diagnosis, Differential↗

PubMed2003

Tissue chamber model of acute inflammation in farm animal species.

A tissue chamber model of acute inflammation for use in comparative studies in calves, sheep, goats and pigs has been established and validated. Tissue chambers were prepared from silicon rubber tubing, of inner diameter 12.7 mm, length 115 mm and volume 15 ml, with 10 holes, each of 6mm diameter, at each end. In each animal two or four chambers were inserted at subcutaneous sites. Six weeks after implantation an acute inflammatory reaction in a single cage was generated by the intracaveal injection of 0.5 ml of 1% carrageenan solution. Serial samples of exudate (injected chamber), transudate (non-injected chamber) and blood were collected for measurement of exudate and transudate leucocyte count, prostaglandin (PG)E(2) concentration in exudate and serum thromboxane (Tx)B(2) concentration. In addition, skin temperature changes over exudate and transudate chambers were recorded. In all four species, carrageenan induced an acute inflammatory response, indicated by increases to peak values followed by return towards baseline in skin temperature, leucocyte count and PGE(2) concentration. For each of these variables in calves, sheep and goats the increases were significantly greater for exudate than for transudate. The degree of intra-species variation in each variable was acceptable. Marked inter-species differences were recorded: skin temperature rise was greatest in calves and least in sheep and goats; exudate PGE(2) concentration was increased in the order sheep>goat>pig>calf; serum TxB(2) concentration was increased in the order calf>goat>sheep>pig and exudate leucocyte count was increased to a greater extent in the pig than in the three ruminant species. The model has advantages over some previously described tissue chamber models of inflammation and will be suitable for use in comparative studies of inflammatory mechanisms and the pharmacokinetics and pharmacodynamics of anti-inflammatory drugs.

Acute Disease↗

PubMed2000

Significance of alpha-2-macroglobulin, alpha-1-acid glycoprotein, and C-reactive protein in pleural effusion differentiation.

BACKGROUND: The differentiation between exudates and transudates is fundamental when investigating the cause of pleural effusions. Acute-phase proteins could be potentially useful markers in this discrimination. OBJECTIVE: The present study was designed to evaluate whether the acute-phase proteins: alpha(2)-macroglobulin (AMG), alpha(1)-acid glycoprotein (AAG) and C-reactive protein (CRP) are useful in investigating the pleural effusions. METHODS: We prospectively measured the concentrations of the above proteins in the serum and pleural fluid of 84 consecutive patients with various diseases using a nephelometric assay. RESULTS: Pleural effusion AMG, AAG and CRP were all significantly elevated in the group of patients with exudates compared to patients with transudates (p < 0.001, p < 0.001 and p < 0.01, respectively). An AAG value >63 mg/dl in a pleural effusion is predictive of an exudate with a sensitivity of 90% and a specificity 85%. Similarly, an AMG value >44 mg/dl in a pleural effusion is predictive of an exudate with a sensitivity and a specificity of 90% and 60%, respectively. Moreover, pleural AAG was significantly higher in cancerous exudates than in exudates and transudates of all other cause taken together (p < 0.001). Finally, to differentiate the same pleural effusion, the cut-off value of 1.0 mg/dl of pleural CRP has a sensitivity and a specificity of 74% and 74%, respectively. CONCLUSIONS: We conclude that both AAG and AMG concentrations in pleural effusions have a high sensitivity and are therefore useful parameters in distinguishing exudates from transudates, but the latter is inferior due to its unacceptably low specificity.

Adult↗

PubMed2000

Evaluation of CT findings for diagnosis of pleural effusions.

Computed tomography studies are usually used to assess patients with pleural effusions, and radiologists should be aware of the significance of different CT findings for the diagnosis of the effusion. The purpose of this study was to evaluate CT findings for etiological diagnosis of pleural effusions. Contrast-enhanced CT of the chest of 211 patients with pleural effusion of definite diagnosis were evaluated. The CT images were evaluated for the presence and extent of pleural effusion, thickening or nodules, extrapleural fat and other changes in the mediastinum or lung. The CT scans were read by two independent observers and correlation between them was evaluated. Comparison of CT findings between benign and malignant effusions, between exudates and transudates, and between empyemas and the other parapneumonic effusions were carried out. Kappa values for most CT findings were > 0.85. Loculation, pleural thickening, pleural nodules, and extrapleural fat of increased density were only present in exudative effusions. Multiple pleural nodules and nodular pleural thickening were the only pleural findings limited to malignant pleural effusions. The signs were also more frequently seen in empyemas than in other parapneumonic effusions. Computed tomography findings can help to distinguish between transudates and exudates. Although there is some overlap between benign and malignant pleural effusions, pleural nodules and nodular pleural thickening were present almost exclusively in the latter. Although differences between CT findings of empyemas and the other parapneumonic effusions exist, there is no finding which can definitely differentiate between them.

Adolescent↗