The effects of early or direct admission to a specialised spinal injury unit on outcomes after acute traumatic spinal cord injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: For acute traumatic spinal cord injury (ATSCI), this study aimed to determine differences in outcomes between patient groups stratified by admission time (⩽24 vs >24 h) to the Spinal Injury Unit (SIU) and by the nature of the admission (direct admission to the SIU vs indirect admission via another hospital). We also aimed to measure the effect on time to admission of a 'non-refusal' policy that triggered immediate acceptance of ATSCI cases to the SIU. SETTING: New South Wales, Australia. METHODS: Study population was all adult SCI patients admitted to the Prince of Wales SIU from 1 January 2001 to 31 December 2012. Patients admitted with chronic-stage SCI or with incomplete data for the duration of their stay were excluded. Comparison of outcomes was made between groups according to the setting of admission. Time to admission before and after initiation (2009) of the 'non-refusal' policy was compared. The prevalence of complications, lengths of stay (LOSs) and time to admission were compared by Mann-Whitney non-parametric methods. Count modelling was used to control for confounders of age and gender. RESULTS: A total of 460 cases were identified and 76 were excluded. The early group had fewer pressure areas (41.8% vs 63.2%; P<0.001) and shorter LOS (136 vs 172 days; P<0.001) than the late group. The direct group had fewer pressure areas (35.2% vs 54.9%, P<0.001), deep vein thrombosis (9.9% vs 24.6%, P=0.003) and shorter LOS (124 vs 158 days, P=0.007) than those admitted indirectly. Time to admission was reduced after introduction of the 'non-refusal' policy (1.53 vs 0.63 days; P=0.001). CONCLUSIONS: Early and direct admission to SIU reduced complication rates and LOS. A non-refusal policy reduced time to admission.

Adenocarcinoma developing in a patient with midline granuloma.

A 51-year-old man with midline granuloma was treated successfully with a combination of local radiation and oral cyclophosphamide. Six years after therapy, adenocarcinoma of the lung developed. Possible relationships between these two diseases are discussed.

Acute nephritis and pulmonary alveolitis following pneumococcal pneumonia.

Acute glomerulonephritis developed in a man with pneumococcal pneumonia. Serum complement studies revealed decreased levels of C4, properdin, and C3. Renal immunofluorescence studies demonstrated pneumococcal antigen, C1q, C4, C3 proactivator, properdin, C3, IgG, and IgM. Circulating cryoglobulin contained pneumococcal antigen and antibody, C3, and immunoglobulins. Serial pneumococcal antigen and antibody levels did not display patterns that were characteristic of classical immune elimination, but the patterns may have been influenced by the reentry of antigen. A diffuse, pulmonary alveolitis also developed in the patient. Lung immunofluorescence studies revealed pneumococcal antigen, IgG, and C3 in alveolar walls and capillary basement membranes. The glomerulonephritis and alveolitis resolved after a prolonged course. These findings provide presumptive evidence for pneumococcal, immune complex glomerulonephritis with complement activation via both classical and alternative pathways and suggest an immunologic pathogenesis for the pulmonary alveolitis.

Pulmonary manifestations of systemic lupus erythematosus: review of twelve cases of acute lupus pneumonitis.

Acute lupus pneumonitis was the presenting manifestation of systemic lupus erythematosus in six of 12 cases in this series. The clinical picture was characterized by severe dyspnea, tachypnea, fever and arterial hypoxemia. Radiographic findings included an acinar filling pattern which was invariably found in the lower lobes and was bilateral in 10 of the cases. Studies failed to reveal evidence of infection as a cause of the acute pulmonary infiltrates. All patients were treated with oxygen and corticosteroids; seven received azathioprine. Six patients survived and are clinically well 14 months to four years following their acute illness. Three of these patients have residual interstitial infiltrates with persistent pulmonary function test abnormalities indicating progression to chronic interstitial pneumonitis. Histologic sections of the lungs available from four patients revealed hyaline membranes and interstitial edema (four cases), acute alveolitis (two cases), arteriolar thrombosis (one case) and a prominent lymphocytic interstitial pneumonitis with organizing bronchiolitis (one case).

Interstitial lung disease in polymyositis and dermatomyositis: analysis of six cases and review of the literature.

Interstitial pneumonitis may be the presenting manifestation of polymyositis-dermatomyositis, or may occur later in the evolution of the disease. The clinical picture is characterized by non-productive cough, dyspnea and hypoxemia. The chest radiograph demonstrates interstitial infiltrates with predilection for the lung bases, often with an alveolar pattern in addition. The histopathologic features are those of organizing and interstitial pneumonitis and pleuritis, with variable fibrosis. In the present series, the patients with mixed alveolar and interstitial infiltrates on chest radiograph and organizing pneumonia and bronchiolitis obliterans in addition to interstitial pneumonitis. In one patient evolution from pulmonary inflammation to interstitial fibrosis was demonstrated. The etiology of primary lung disease in PM-DM is not known, but cell-mediated autoimmunity to an unidentified component of lung tissue is suggested. Including the present series, 50 percent of patients have responded favorably to corticosteroids with decreased dyspnea, clearing of the chest radiograph and improved pulmonary function tests.

Unsuspected pulmonary alveolar proteinosis complicating acute myelogenous leukemia.

A patient with acute myelogenous leukemia developed pulmonary alveolar proteinosis in the terminal phase of the leukemia. The diagnosis of pulmonary alveolar proteinosis was unsuspected during life and was established only at autopsy. Other reported cases of the same association are reviewed. This report serves to stress the importance of considering the diagnosis of pulmonary alveolar proteinosis in malignant hematologic diseases and the need for hematologic evaluations in pulmonary alveolar proteinosis.

Bronchiolitis obliterans. Report of three cases with detailed physiologic studies.

We describe three patients with bronchiolitis obliterans seen at our hospital during the last two years. Their ages were 25, 49 and 69 years. One developed the disease secondary to a probable viral infection, another inhaled fumes, and the third was exposed to unknown precipitating factors. Lung biopsy showed changes compatible with bronchiolitis obliterans in the first two, while in the third, changes were compatible with bronchiolitis obliterans and interstitial pneumonitis. Pulmonary function tests of patient 1 showed severe airflow limitation, increased total lung capacity, a shift of the pressure-volume curve upward with a normal slope, and an elevation of upstream resistance. In patient 3 (bronchiolitis obliterans with interstitial pneumonitis) total lung capacity was normal, the pressure volume curve was shifted slightly to the right and upstream resistance was increased. After treatment with steroids, clinical improvement was observed along with normalization of the pressure-volume curve and a decline in the upstream resistance.

Abnormalities in lung elastic properties and surfactant function in adult respiratory distress syndrome.

We have examined the lungs from five patients who died with the adult respiratory distress syndrome (ARDS). Pressure volume curves were obtained and bronchoalveolar lavage fluid was studied on a surface balance. The pressure volume curves revealed reduced compliance compared to normal or near normal lungs. A significant loss of volume was also found. The data obtained from the surface balance studies show a normal range of minimum surface tension when compared to "normals," but the ARDS lung lavage fluid revealed an increase in surface film compressibility relative to "normal." The increased compressibility may be an important factor contributing to the stiff lungs of patients with the adult respiratory distress syndrome.

Leukocytoclastic vasculitis.

Patients with leukocytoclastic vasculitis have purpuric, palpable lesions, most commonly on the lower part of the legs. Systemic involvement, particularly of the kidneys, is found frequently. Characteristic pathological features include necrosis of small vessels within the dermis, infiltration by polymorphonuclear leukocytes within and around the vessel walls, hemorrhage, and occasionally thrombosis. Immunofluorescence study frequently shows granular deposits of immunoglobulins and complement in vessel walls. Etiologic agents that have been implicated include infection, foreign proteins, chemicals, drugs, and a variety of diseases. The mechanism causing tissue damage is thought to be mediated by immune complexes, although specific antigens have only occasionally been unequivocally identified. Treatment includes bedrest, corticosteroids, and sometimes, cytotoxic agents.

The morphology and morphometry of small airways disease (relevance to chronic obstructive pulmonary disease).

The morphologic and morphometric characteristics of the small airways of the lung and their relationship to airflow as measured by forced expiratory volume in one second (FEV1) were determined in 37 excised human lungs. After fixation the lungs were graded as to the degree of emphysema and the degree of small airway pathology. The internal diameters of the small airways were measured and corrected for shrinkage during processing. The mean bronchiolar diameter was positively correlated with the % predicted FEV1 (p less than 0.001) and negatively correlated with the small airway fibrosis (p less than 0.01). We conclude that fibrosis of the small airways of the lung is associated with a decrease in airway dimension which is in turn correlated with decreased FEV1 in excised human lungs.

Spinal cord and related injuries after attempted suicide: psychiatric diagnosis and long-term follow-up.

STUDY DESIGN: Retrospective analysis of acute spinal cord injuries (ASCI). OBJECTIVES: Determine incidence of ASCI due to suicide attempt from 1970 to 2000. Describe demographics, injuries, mental illness, functional outcomes and nature of subsequent deaths. SETTING: State spinal cord injury services, New South Wales, Australia. METHODS: Retrospective record review and follow-up interview. RESULTS: Of 2752 ASCI admissions, 56 were because of attempted suicide (55 falls, one gun-shot wound). Thirty-six males and 20 females. Median age 30 years (15-74). Most common levels of vertebral injury were C5 and L1. Twenty-three had complete spinal cord injury. Thirty-two had an Injury Severity Score of >15. Forty had more than one major injury. There was a significant rise in the incidence of ASCI following self-harm over time (Poisson regression, P=0.004). There was a significant change in scene of injury away from hospitals over time (chi (2) test, df=1, P=0.0001). Psychiatric diagnoses were personality disorder 27; schizophrenia 16; depression 14; chronic alcohol abuse 10; mood disorder 10; chronic substance abuse 10; other four. Follow-up was available in 47 cases (84%) at an average of 8 years. Four subsequent deaths were by suicide. Domiciliary arrangements were: home 28; hospital five; nursing home three; group home/hostel four. CONCLUSIONS: Community placement outcomes for survivors were good. Subsequent death by suicide was high. There was a significant rise in cases and a change in injury scene away from hospitals over time.

Mild emphysema is associated with reduced elastic recoil and increased lung size but not with air-flow limitation.

Thirty-nine excised human lungs were examined to identify early changes in the small airways, their size distribution, and their elastic recoil in relation to mild degrees of emphysema. Elastic recoil measurement, single-breath nitrogen (SBN2) tests, and FEV1 were obtained from 18 lungs with no emphysema and 21 emphysematous lungs with no greater than Grade 5 emphysema score. The mean number of alveolar attachments per brochiole was determined from all the bronchioles cut in cross section. When the 2 groups of lungs were compared, the percentage of predicted elastic recoil of the nonemphysematous lungs was significantly greater at 50, 70, 80, and 90% of TLC than in the mildly emphysematous lungs. The TLC of the emphysematous lungs (% of predicted) was also significantly greater than in the nonemphysematous lungs. Pigment of the small airways was the only pathologic feature that was significantly greater in the emphysematous lungs than in the nonemphysematous lungs. Size distribution in the small airways was similar except for the airways zero to 0.2 mm, which were more frequent in the emphysematous lungs. When data from both groups were combined, elastic recoil was shown to be related to both the number of alveolar attachments (p less than 0.03) and the mean diameter of the small airways (p less than 0.01). We conclude that structural and functional changes in lungs with mild emphysema include reduced elastic recoil, increased lung size, and some size distribution changes in the small airways. Mild emphysema is not associated with air-flow limitation.

Small airway dimension and size distribution in human lungs with an increased closing capacity.

Pulmonary function tests were obtained in 7 emphysema-free and 27 emphysematous lungs with minimal small airway disease. The lungs were divided into 2 groups on the basis of whether they had a small or large, i.e., increased closing capacity. The lungs were subsequently fixed and the small airways (less than or equal to 2.00 mm) from 6 to 10 blocks of tissue were counted and inside diameters were measured. There was a significant increase in the number of airways measuring 0.40 mm or less (p less than 0.03) and a decrease of airways measuring 0.81 to 1.0 mm (p less than 0.03) in the lungs that had larger closing capacities. When the data of both groups were combined there was a negative correlation between the mean bronchiole inside diameter as a function of the percentage of predicted closing capacity (r = -0.381, p less than 0.03) and a positive correlation between small airway inside diameter and the forced expiratory volume in one second (r = 0.595, p less than 0.001) and the maximal mid-expiratory flow rate (r = 0.527, p less than 0.01). We conclude that in lungs that are normal or involved with minimal lung disease, function can be related to the caliber of the small airways.

Functional correlations with mild and moderate emphysema in excised human lungs.

The relation between mold to moderate emphysema and lung function tests, including tests reported to identify "early" or mild disease, were examined using 24 excised human lungs, 5 with no emphysema, 11 with grade 5 or less emphysema, and 8 with as much as grade 50 emphysema. Static pressure volume curves, single breath nitrogen (SBN2) tests, maximal exemphysema. Static pressure volume curves, single breath nitrogen (SBN2) tests, maximal expiratory flow volume (MEFV) curves with air and a mixture of 80% He and 20% O22, and forced expiratory volume in one second (FEV1) were measured in all lungs. Negative correlations were found (r - -0.489, p less than 0.02) between the emphysema grade and the per cent predicted static lung recoil at 50% of total lung capacity and the emphysema grade and the per cent predicted FEV1 (r = 0.428, p less than 0.05). There was no significant correlation between the grade of emphysema and the SBN2, or MEFV test. Negative correlations were found between the elastic recoil, expressed as per cent predicted slope of Phase III (r = 0.482 p less than 0.02), and the per cent predicted FEV1 (r = -0.619, p less than 0.01). We concluded that mild to moderate degrees of emphysema are not correlated with single breath nitrogen test or flow volume curves using air or helium, but are better related to loss of elastic recoil in excised human lungs.

Small airway disease is associated with elastic recoil changes in excised human lungs.

We studied 54 excised human lungs, 15 with no emphysema and 39 with varying degrees of emphysema, to examine the relationship of small airway disease and elastic recoil. We found a negative correlation between the total small airway pathology score and the mean internal bronchiolar diameter (r = -0.309, p = less than 0.03), as well as with other measurements of small airway size. The internal bronchiolar diameter correlated well with both the elastic recoil expressed as a percentage of predicted values at 70% of total lung capacity (r = 0.533, p less than 0.001) and elastic recoil expressed as an exponential constant k (r = -0.370, p less than 0.01). Fibrosis of the small airways was associated with a reduced internal bronchiolar diameter (r = 0.460, p less than 0.001), as well as the percentage of predicted elastic recoil at 70% of total lung capacity (r = -0.382, p less than 0.01) and elastic recoil expressed as an exponential constant k (r = 0.348, p less than 0.02). We have concluded that changes in elastic recoil seen in these lungs and fibrosis of small airways may be related by a common inflammatory process.

Prognosis after recovery from adult respiratory distress syndrome.

Ten patients who survived an acute episode of the adult respiratory distress syndrome were studied on recovery. Serial pulmonary function tests performed in 3 subjects revealed a tendency toward normalization of values at 4 to 6 months after the episode, with a subsequent serial decrease in maximal mid-expiratory flow rates, and a partial reversal by bronchodilators. Of the 10 patients, 6 had dyspnea on exertion and all but one of the 6 were smokers. The ventilatory tests revealed a predominantly restrictive pattern in 2 patients and an obstructive pattern in 4. The 4 asymptomatic patients had essentially normal pulmonary function. Pathologic features of the lung, available in 3 cases, are discussed.

Elastic recoil changes in early emphysema.

An attempt was made to determine if emphysema and static lung recoil were related in a group of 65 excised human lungs. We studied 23 normal lungs, 24 lungs with an emphysema score of 5 or less, and 18 lungs with an emphysema score greater than 5. A comparison of the percentage of predicted elastic recoil revealed that both emphysema groups were significantly different from normal lungs. In addition, the total lung capacities were significantly different between the three groups. In the group with an emphysema score greater than 5 we found a linear negative correlation between the extent of emphysema and percent of predicted elastic recoil at 90% total lung capacity (r = -0.696, p < 0.01). We found a negative correlation between the percentage of predicted elastic recoil and the lung volume (r = -0.612, p < 0.01). We conclude that a significant loss of elastic recoil and a significant increase in total lung capacity occurs in the early stages of emphysema.

Radial traction and small airways disease in excised human lungs.

We studied 47 excised human lungs in order to examine the relationship between the number of alveolar attachments surrounding bronchioles 2 mm or less in diameter and the presence of small airways disease and overall lung function. Expiratory pressure-volume curves, the FEV1, and the single-breath nitrogen washout were obtained from 11 lungs without emphysema and 36 lungs with various degrees of emphysema. The lungs were subsequently inflation-fixed at 20 cm H2O. Gough sections were used to measure emphysema. Six to 10 blocks of tissue were cut at random from a midsagittal slice of lung tissue for the small airways and alveolar attachment study. We measured the inside diameters of all nonrespiratory bronchioles (2 mm or less in diameter) and made corrections for shrinkage during processing. The number of alveolar attachments on the outside wall of the bronchioles cut in cross section were obtained from all the sections observed. The mean number of alveolar attachments per bronchiole was determined for each lung. The histopathologic features of the bronchioles were evaluated by the method of Cosio and coworkers (2). We found a positive correlation between the number of alveolar attachments and the percentage of predicted FEV1 (r = 0.328, p less than 0.03) and the percentage of predicted closing capacity (r = 0.553, p less than 0.01). There was a negative correlation of the mean number of alveolar attachments and the small airways fibrosis score (r = -0.344, p less than 0.02). A correlation also existed between the number of alveolar attachments and the mean internal bronchiolar diameter (r = 0.561, p less than 0.001). We conclude that the alveolar attachments and elastic recoil are related to the size and function of the small airways.

Interstitial pneumonia in angio-immunoblastic lymphadenopathy with dysproteinemia. A case report with special histopathologic studies.

A patient presented with characteristic historical, physical, and laboratory findings of angio-immunoblastic lymphadenopathy with dysproteinemia. This newly described entity apparently represents a nonneoplastic proliferation of the B-lymphocyte system with immunoblastic transformation of many lymphocytes and excessive production of immunoglobulins. It is associated with fever, sweats, weight loss, skin rash, lymphadenopathy, splenomegaly, hepatomegaly, and characteristic histologic features of the involved lymph nodes. Noteworthy in the patient reported here are the extent and course of radiographically and clinically evident pulmonary involvement and the biopsy documentation of an interstitial pneumonia marked by histopathologic changes closely resembling those found in the lymph nodes, with immunohistologic demonstration of immunoglobulins in the alveolar walls.