A Combination of Ultrasound Characteristics with Macroscopic and Biochemical Features to Diagnose the Etiology of Lymphocytic Pleural Effusions.

OBJECTIVES: The primary aim of this study was to improve the diagnosis of lymphocytic pleural effusions (LPEs) by combining their ultrasound characteristics with their macroscopic and biochemical features. METHODS: This prospective, single-center, clinical observational study was conducted over a period of three years. The possible malignant etiology of LPEs was assessed using several diagnostic criteria: 1. ultrasound characteristics of the LPEs; 2. typical combinations of macroscopic and ultrasound features; and 3. the logistic regression method with three parameters-pleural nodularity, absence of fibrin, and serum protein concentration. RESULTS: Eighty-four patients with LPEs were included in this study. Pleural nodularity (first criterion) was an ultrasound characteristic that yielded the best individual results (p < 0.001) in the differentiation of malignant and nonmalignant etiologies of LPEs (accuracy 73.81%). The combination of the second and third criteria yielded the best results in the prediction of a malignant etiology of LPEs (sensitivity 90.48%, specificity 83.33%, PPV 84.44%, NPV 89.74%, accuracy 86.90%). Based on the results of this prospective study, a protocol for the diagnostic procedure of lymphocytic pleural effusions without a definitive fluid diagnosis has been proposed. CONCLUSIONS: A combination of the ultrasound characteristics of LPEs and their macroscopic and biochemical features has improved the predictive accuracy for the malignant etiology of LPEs.

Rare Case of Multiple Perirenal, Extra-Adrenal Myelolipoma: Case Report, Current Management Options, and Literature Review.

Extra-adrenal myelolipomas are rare, asymptomatic entities, although large tumors may cause local symptoms or hemorrhage. When these lesions occur outside the adrenals in the retroperitoneum, they are radiographically easily confused with both primary and secondary retroperitoneal tumors, which tend to be aggressive. Although myelolipomas are benign and can be managed conservatively, if malignancy is suspected, a surgical procedure is an option. We report a case of a 68-year-old patient with multiple perirenal extra-adrenal myelolipomas. Initial abdominal ultrasound reviled an inhomogeneous mass surrounding the left kidney. Subsequent CT examination of the abdomen showed four separate, extrarenal, well-circumscribed, round-shaped, fat-containing retroperitoneal tumors. Given the significant size of the masses, that compressed major abdominal vessels and the suspicion of liposarcoma, a surgical excision of the lesions was performed. The tumors were easily separated, all surrounding structures were spared, and they were removed completely. Histologically, all masses consisted of hematopoietic and mature fat tissue and the final diagnosis was extra-adrenal myelolipoma. The patient was released from the hospital 7th day after surgery in good condition and at his baseline. Since myelolipomas are, by definition, nonfunctional benign tumors, there was no need for further follow-up. The radiological evaluation and fine needle biopsy are usually sufficient to establish the diagnosis, but in some cases of well-differentiated liposarcoma, the differentiation between myelolipoma and liposarcoma can be challenging. Therefore, considering that myelolipomas and liposarcomas have opposite prognoses, which affects the surgeon's decision on the extent of surgical procedure and further treatment, we also emphasize the importance of intraoperative assessment of the tumor, both by the surgeon and by intraoperative pathology consultation.

Easy to Perform Physical Performance Tests to Identify COPD Patients with Low Physical Activity in Clinical Practice.

Background: The study investigates which physical performance or muscle function/mass tests significantly correlate with objectively measured physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) and could potentially serve to identify physically inactive COPD patients in routine clinical practice. Methods: A cross-sectional, observational study was conducted in outpatients with moderate to very severe COPD. PA was measured during one week with the StepWatch Activity Monitor®, an ankle-worn accelerometer, and expressed in steps per day. Physical fitness and peripheral muscle function/mass were evaluated by the 4-meter gait speed (4MGS) test, the 6-minute walk distance (6MWD), the 30-second chair stand test (30sCST), the timed up and go test (TUGT), handgrip strength, arm muscle area, calf circumference, the fat-free mass index (FFMI), and ultrasound measurement of the quadriceps muscle. Spearman's rank correlation analysis and ROC analysis were performed. Results: The study population (N=111, 69% men, mean age 68 years) walked a mean of 8059 steps/day. The daily step count strongly correlated with the 6MWD (rho=0.684, p<0.001) and moderately with the 4MGS (rho=0.464, p<0.001), the TUGT (rho= -0.463, p<0.001), and the 30sCST (rho=0.402, p<0.001). The correlation with the FFMI was weak (rho=0.210, p=0.027), while the other parameters did not significantly correlate with the daily step count. The 6MWD had the best discriminative power to identify patients with very low PA defined as <5000 steps/day (AUC=0.802 [95% CI: 0.720-0.884], p<0.001), followed by the TUGT, the 4MGS, and the 30sCST. Conclusion: The 6MWD, the 4MGS, the TUGT, and the 30sCST are easy to perform in any clinical setting and may be used by clinicians in the screening of physically inactive COPD patients.

Nutritional Status of Patients with Chronic Obstructive Pulmonary Disease in Relation to their Physical Performance.

Nutritional abnormalities and physical inactivity are highly prevalent in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to determine the association between nutritional status/body composition and physical performance in patients with COPD. A cross-sectional observational study was conducted in outpatients with clinically stable, moderate to very severe COPD. In the assessment of nutritional status, we used dual energy X-ray absorptiometry, anthropometry, serum biomarkers, and the Mini-Nutritional Assessment (MNA) questionnaire. Physical performance was measured by the 6-minute walk distance (6MWD), 4-metre gait speed (4MGS), and physical activity. Univariate and multivariate analyses were performed. In 111 patients (mean age 68 years, 69% men), the mean 6MWD was 376 ± 119 m, 4MGS 0.9 ± 0.2 m/s, and the average daily step count 8,059 ± 4,757. Patients with low exercise capacity (6MWD ≤ 350 m) had a significantly lower lean mass index (LMI) (p < 0.01), fat-free mass index (FFMI) (p < 0.01), bone mineral content (p < 0.01), bone mineral density (p < 0.01), T-score (p < 0.05), MNA score (p < 0.01), and serum albumin and prealbumin levels (p < 0.05). Patients with low physical activity (daily step count ≤ median) had lower LMI, FFMI, MNA score, serum prealbumin (for all comparisons p < 0.05) and vitamin D levels (p < 0.01). However, none of the nutritional variables showed an independent association with low physical performance in the multivariate models. In conclusion, patients with low physical performance have deficient nutritional status, but we could not demonstrate an independent relationship between nutritional parameters and physical performance.

A population-based prospective 24-month study of stroke: incidence and 30-day case-fatality rates of first-ever strokes in Croatia.

BACKGROUND: In Central/Eastern European countries, cerebrovascular diseases are among the leading causes of mortality. We aimed to determine the incidence of first-ever stroke (FES) in the north-western part of Croatia. METHODS: A population-based prospective incidence study was conducted between July 1, 2007, and June 30, 2009. Cases were sought from multiple overlapping sources. Incidence rates by stroke type and gender were calculated. RESULTS: A total of 1,487 events were recorded, 1,017 of which were FESs. European age-adjusted incidence rates (per 100,000 population) were: total FESs 223.6 [women/men rate ratio (w/m RR) = 0.65 (95% CI 0.57-0.73)]; ischemic stroke 162.4 (w/m RR = 0.65, 0.56-0.76); intracerebral hemorrhage 28.4 (w/m RR = 0.44, 0.30-0.63); subarachnoid hemorrhage 7.2 (w/m RR = 1.18, 0.55-2.54); unknown etiology 25.5 (w/m RR = 0.78, 0.54-1.14). Adjusted incidence rates of ischemic strokes by subtype were: cardioembolic 52.9 (w/m RR = 0.77, 0.59-0.99); large-artery atherosclerosis 14.4 (w/m RR = 0.22, 0.13-0.38); small-artery occlusion 24.5 (w/m RR = 0.53, 0.37-0.77) and 'other or uncertain causes' 70.6 (w/m RR = 0.77, 0.62-0.97). Thirty-day case-fatality rate was 23.5% overall and 17.1% for ischemic stroke. CONCLUSIONS: The incidence of FES and 30-day mortality of patients with ischemic strokes in the studied population is higher than in Western European countries.

Aortic dissection presenting as crossed hemiparesis.

INTRODUCTION: Aortic dissection is frequently associated with ischemic stroke; however, a high clinical suspicion is necessary when the presentation is atypical. CASE REPORT: We present the atypical clinical picture of De Bakey type I (Stanford A) aortic dissection which presented as crossed hemiparesis in a 52-year-old previously healthy woman. CONCLUSION: This case emphasizes the need for assessing pulsations of peripheral arteries on both arms and both legs in the context of acute stroke as this could lead to the diagnosis of acute aortic dissection.

Higher mean platelet volume determined shortly after the symptom onset in acute ischemic stroke patients is associated with a larger infarct volume on CT brain scans and with worse clinical outcome.

OBJECTIVE: Mean platelet volume (MPV) determined shortly after the onset of acute ischemic stroke represents the pre-stroke values. Data on its relationship to stroke severity/outcome have been conflicting. We related MPV to infarct volume on CT brain scans and risk of death/dependence 7 days and 3 months post-stroke. METHODS: MPV (within 30h since stroke onset), infarct volume (13-83h since stroke onset) and clinical outcomes were evaluated in 81 consecutive patients (32 men, age 52-91 years, 10 small artery occlusion, 10 large artery atherosclerosis, 29 cardioembolic, 32 multiple probable/possible etiology). RESULTS: Higher MPV was independently associated with larger ln-infarct volume [estimate 0.259, 95% confidence interval (CI) 0.004-0.513, P=0.046], greater risk of death/dependence 7 days post-stroke [relative risk (RR)=1.077, 95% CI 1.005-1.115, P=0.036], and greater risk of death/dependence 3 months post-stroke (RR=1.077, 95% CI 1.001-1.158, P=0.048). Considered covariates: stroke etiology, CT scan timing, platelet count and other hematological parameters, demographic variables, history of cerebrovascular, cardiac or cardiovascular diseases, diabetes, serum chemistry, previous antiplatelet and statin use and treatments delivered after the index event. CONCLUSIONS: Data support the view about MPV as a determinant of severity/outcome of the acute ischemic stroke.

[Diagnostic methods in torsion of the spleen]. / Dijagnosticke metode kod torzije slezene.

Torsion of a spleen is a frequent complication of a rare entity--a wandering spleen. A wandering spleen is revealed occasionally, with physical and/or sonographic exam. However, it is often overseen. It has very unspecific simptoms, and can present a diagnostic problem. Splenic torsion manifets itself like an acute abdomen. We have presented a rare case of splenic torsion with unusual clinical findings, followed by a splenic infarction. Due to their promptness, sensitivity, uniqueness and availability, two diagnostic methods have definitive primacy in visualisation of splenic torsion: Color-Doppler sonography and CT with intravenous application of contrast medium.

Intracranial tumors in adult population of the Varazdin County (Croatia) 1996-2004: a population-based retrospective incidence study.

AIM: To estimate the incidence of intracranial tumors in the adult population of the Varazdin County, Croatia, for the 1996-2004 period. SETTING: Varazdin County General Hospital and four university hospitals in Zagreb, the capital of Croatia. STUDY PERIOD: January 1, 1996 to December 31, 2004. Incident patients: county residents admitted for newly diagnosed intracranial tumors according to the WHO diagnostic criteria. Demographic data were extracted from the 2001 Croatian census. Incidence rates (IRs) per 100,000 person-years (p-y) and annual IRs (per 100,000 persons) were determined and compared as incidence rate ratios (IRRs) with 95% CI. RESULTS: For primary intracranial tumors (PITs), IR was 12.1/100,000 p-y (95% CI: 10.3-14.2), comparable in men and women. The highest incidence was recorded for glioblastoma (IR 4.8, 3.7-6.2) and meningioma (IR 3.1, 2.2-4.2). The incidence of PIT was somewhat greater than that of metastatic tumors (IRR 1.58, 95% CI: 1.22-2.05, P < 0.001). Metastatic tumors were more frequent in men than in women, especially metastatic lung tumors (IRR 6.08, 2.32-20.16, P < 0.001). IRs of all PIT taken together, neuroepithelial tumors cumulatively, nonepithelial tumors cumulatively, glioblastoma and meningioma were higher in the population aged > or = 40 vs. population aged < or = 39 (all IRRs with 95% CI greater than 1, P < 0.05 or < 0.001), comparable in men and women. Women were somewhat older than men at the time of diagnosis of PIT: median difference -6 years (95.1% CI: -10 to -1, P < 0.05). Annual IRs for all these tumor categories showed increasing trends over the study period. CONCLUSION: Overall, there was an increasing trend in the incidence of primary intracranial tumors in the Varazdin County. Data did not allow estimation for most of the specific tumor types.