Comparison of survivors and nonsurvivors of diffuse alveolar hemorrhage: risk factors for in-hospital death

Background: The objective of this study was to identify the predictors of in-hospital mortality among patients with diffuse alveolar hemorrhage (DAH).Methods: We conducted a retrospective review of 89 patients hospitalized for DAH at our institution. 49 patients who died during hospitalization and 40 patients who survived were compared. We reviewed their clinical course, radiologic and pathologic findings, along with medical management. We then performed univariate and multivariate analyses to identify the risk factors associated with in-hospital mortality.Results: We identified 12 factors to be associated with mortality when comparing survivor versus non-survivor cohorts: smoking (67 versus 42%, p=0.02), malignancy (17 versus 49%, p=0.002), interstitial lung disease (0 versus 14%, p=0.01), liver failure (2 versus 28%, p=0.001), autoimmune diseases (40 versus 8%, p=0.0006), thrombocytopenia (7 versus 71%, p<0.0001), ICU admission (57 versus 85%, p=0.004), mean ICU stay (p=0.4), steroid use (90 versus 63%, p=0.003), plasma exchange (15 versus 0 %, p=0.005), mechanical ventilation (37 versus 75%, p=0.0007) and acute respiratory distress syndrome (22 versus 77%, p<0.0001). On multivariate analysis, thrombocytopenia (p<0.0001) and ARDS (p=0.0013) were associated with higher odds of mortality in DAH while steroid use (p=0.0004) was associated with a lower risk of in-hospital mortality in patients with DAH.Conclusions: In DAH, thrombocytopenia and ARDS were predictors of in-hospital mortality whereas the use of steroid was associated with a more favorable prognosis.

Lung and airway disorders in immunoglobulin G4- related disease

gG4-related disease (IgG4-RD) is an immune-mediated condition, characterized by the formation of fibroinflammatory tumefactive lesions that can cause progressive tissue damage and subsequent organ failure. Although initially described as a disease of unknown etiology confined to the pancreas, IgG4-RD has been realized over time as an important entity that has underlies numerous pathologic conditions such as autoimmune pancreatitis, Riedel thyroiditis, Mikulicz syndrome, inflammatory pseudotumors and many others. IgG4-RD can affect almost any organ. However, the most commonly affected are the pancreas, hepatobiliary system, exocrine glands (salivary, lacri mal), retroperitoneum, kidneys and intrathoracic structures. Within the thorax, involvement of the lung parenchyma, airways, mediastinum, and pleura have been reported. The pulmonary involvement, therefore, is very diverse and can present as pulmonary nodule(s) or mass(es), alveolar or interstitial infiltrates, airflow obstruction, lymphadenopathy, mediastinal fibrosis, and pleural thickening and/or effusion. It is therefore important to recognize the diverse manifestations of this condition, as it can involve multiple organs and have various forms of expression within the same organ. As a consequence, IgG4-RD has presented a fascinating diagnostic challenge for many different specialties. In this review, we focus on the diagnosis and management of the intrathoracic involvement in this multisystem disease

Advances in the management of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a common form of interstitial lung disease and usually results in progressive respiratory insufficiency and death. Steady progress has been made in understanding the pathogenesis of IPF and multiple clinical trials are ongoing, but effective therapy remains elusive

Exploratory Investigation of Downtown Branding as an Effective Downtown Revitalization Strategy: Downtown Business Owners Perspectives

The viability of the downtown is closely related to the economic health of a community. Community administrators have explored various strategies to revitalize their downtowns, and a brand-oriented approach has emerged as an effective strategy to revive downtowns. The primary objective of this study is to investigate the impacts of downtown branding on the performance of downtowns and their businesses from the perspectives of downtown business owners. More specifically, this study aims to examine the casual relationships between downtown business owners' exposure to internal communication about downtown branding and their congruence with downtown branding; congruence with downtown branding and their commitment to the downtown; and commitment to the downtown and their perceived evaluations of the downtown performance; and perceived evaluation of the downtown performance and that of their own business performance. The data was collected from 167 downtown business owners from fifteen communities in a Midwestern state. A Structural Equation Modeling (SEM) technique was used to test cause-effect relationships in the proposed conceptual model. Findings and Conclusions: Among proposed ten hypotheses, nine were found to be statistically significant. The first four hypotheses supported evidence that internal communication about downtown branding components - image, vision, culture, and positioning - improved downtown business owners' congruence with each component. The next set of hypotheses confirmed that downtown business owners' commitment to the downtown was driven by their congruence with downtown image, culture, and positioning. However, this study failed to establish that downtown vision increased business owners' commitment to the downtown. Results supported the relationship between commitment and the positive perception of downtown performance, as well as between the positive perception of the downtown performance and that of their own business performance. Findings suggested that "branding downtowns" may be an effective strategy to revitalize downtowns and to build a strong business environment for downtown businesses.Department of Design, Housing and Merchandisin

Shock Tube and Modeling Study of the H + O2 = OH + O Reaction over a Wide Range of Composition, Pressure, and Temperature

The rate coefficient of the reaction H + 02 = OH + 0 was determined using OH laser absorption spectroscopy behind reflected shock waves over the temperature range 1050-2500 K and the pressure range 0.7-4.0 atm. Eight mixtures and three stoichiometries were used. Two distinct and independent criteria were employed in the evaluation of k(sub 1). Our recommended expression for k(sub 1) is k(sub 1) = 7.13 x 10(exp 13)exp(-6957 K/T) cm(exp 3)mol(exp -1)s(exp -1) with a statistical uncertainty of 6%. A critical review of recent evaluations of k(sub 1) yields a consensus expression given by k(sub 1) = 7.82 x 10(exp 13)exp(-7105 K/7) cm(exp 3)mol(exp -1)s(exp -1) over the temperature range 960-5300 K. We do not support a non-Arrhenius rate coefficient expression, nor do we find evidence of composition dependence upon the determination of k(sub 1)

Display Brightness Based Camera Parameter Control for Selfie Capture in Darkness

When a user in a dark room captures a selfie image or video using a front camera of a device, the display brightness can impact the captured image or video. Oscillations can occur due to a feedback loop between the image captured by the camera which when displayed on the device screen causes changes in display brightness. This disclosure describes techniques to automatically estimate the impact of display illumination on the face of a subject and slow down convergence. Per the techniques, exposure and/or white balance parameters for the camera are estimated using display illumination (brightness), depth (distance of the subject), and reflectance. Machine learning techniques or a lookup table or regression on historical data can be used for estimation. Oscillations in the captured image or video due to a feedback loop are reduced or eliminated

Spectrum of Disorders Associated with Elevated Serum IgG4 Levels Encountered in Clinical Practice

IgG4-related disease (IgG4-RD) is a recently described systemic fibroinflammatory disease associated with elevated circulating levels of IgG4 and manifests a wide spectrum of clinical presentations. Although serum IgG4 level has been described to be the most sensitive and specific laboratory test for the diagnosis of IgG4-RD, it is recognized that an elevated serum IgG4 level can be encountered in other diseases. In this study, we sought to identify the frequency of IgG4-RD and other disease associations in patients with elevated serum IgG4 levels seen in clinical practice. Among 3,300 patients who underwent IgG subclass testing over a 2-year period from January 2009 to December 2010, 158 (4.8%) had an elevated serum IgG4 level (>140 mg/dL). IgG4 subclass testing was performed for evaluation of suspected IgG4-RD or immunodeficiency. Twenty-nine patients (18.4%) had definite or possible IgG4-RD. Among those patients without IgG4-RD, a broad spectrum of biliary tract, pancreatic, liver, and lung diseases, as well as systemic vasculitis, was diagnosed. We conclude that patients with elevated serum IgG4 levels encountered in clinical practice manifest a wide array of disorders, and only a small minority of them has IgG4-RD

Increased IgG4-Positive Plasma Cells in Granulomatosis with Polyangiitis: A Diagnostic Pitfall of IgG4-Related Disease

Granulomatosis with polyangiitis (Wegener's) (GPA) may mimic IgG4-related disease (IgG4-RD) on histologic examination of some biopsies, especially those from head and neck sites. IgG4 immunostain is often performed in this context for differential diagnosis with IgG4-RD. However, the prevalence of IgG4+ cells in GPA has not been explored. We examined the IgG4+ cells in 26 cases confirmed as GPA by a thorough clinical and pathologic assessment. Twenty-six biopsies consisted of 14 sinonasal/oral cavity/nasopharynx, 7 orbit/periorbital, 3 lung/pleura, 1 iliac fossa/kidney, and 1 dura specimens. Eight of 26 (31%) biopsies revealed increased IgG4+ cells (>30/HPF and >40% in IgG4+/IgG+ ratio). The IgG4+ cells and IgG4+/IgG+ ratio ranged 37–137/hpf and 44–83%, respectively. Eight biopsies with increased IgG4+ cells were from sinonasal (n = 4) or orbital/periorbital (n = 4) sites. In conclusion, increased IgG4+ cells are not uncommonly seen in sinonasal or orbital/periorbital biopsies of GPA, which could pose as a diagnostic pitfall

Wellness for older adults in daily life

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Saddle pulmonary embolism diagnosed by CT angiography: Frequency, clinical features and outcome

SummaryObjectiveTo assess the frequency, clinical presentation and outcome associated with saddle pulmonary embolism (PE) diagnosed by computed tomographic angiography (CTA).PatientsRetrospective review of 546 consecutive patients diagnosed to have acute PE by CTA from 1 September 2002 to 31 December 2003.ResultsFourteen of 546 patients (2.6%) had saddle PE; 10 were men (71%). None of these patients had pre-existing cardiopulmonary disease. Most common presenting symptoms included dyspnea (72%) and syncope (43%). Hypotension was documented in 2 patients (14%). The most common risk factor for PE was obesity (64%). CTA revealed saddle PE and additional filling defects in the main pulmonary arteries in all patients. Echocardiography was performed within 48h of the PE diagnosis in 10 patients and revealed right ventricular dysfunction in 8 (80%). All patients were initially managed in the hospital, median length of stay of 4 days (range, 1–45 days). Standard anticoagulant therapy with heparin and warfarin was administered to all patients. Five patients (36%) received additional therapy; thrombolytic therapy was administered to 1 patient (7%) and 4 patients (29%) received an inferior vena cava filter. None of the patients died during their hospitalization. Four patients (29%) died following their hospitalization after intervals of 1, 5, 6, and 12 months, respectively. Causes of death were known in 3 patients, all of whom died from progressive malignancy.ConclusionSaddle PE in patients without pre-existing cardiopulmonary disease is associated with a relatively low in-hospital mortality rate and may not necessitate aggressive medical management