Marked Emphysema Research Articles

P390 CARDIAC INVOLVEMENT IN A VERY RARE CASE OF CUTIS LAXA

Abstract The "Cutis Laxa" is a rare pathology of the connective tissue characterized by redundant skin and diffuse manifestations are identified by other organs (mainly heart and lungs). The low elasticity of the tissue is believed to be attributable to an anomalous elastin formation. Cutis Laxa is usually a genetic disease, but acquired forms have also been described. The case we describe is that of a 34 –year –old young woman with a diagnosis of Cutis Laxa acquired from the age of 15, complicated by a serious impairment at the pulmonary level in the form of marked emphysema and severe asthmatic framework. It came to our observation following the PEA type cardiovascular arrest episode during tracheostomy procedure, promptly resolved by resuscitation maneuvers according to the Als protocol. The echocardiogram was performed by the only belowocostal window by which a 4 –chamber apical projection was viewed, highlighting an anomalous position of the cardiac Hague (lower and media). The left ventricle appeared to be normal endocavity dimensions and parietal thicknesses with preserved indexes of systo–diastolic functionality in the presence of SIV discline; The right ventricle was instead slightly dilated, hypertrophic, with reduced Chinese of the free wall (nappese 18 mm), the tricuspid regurgitation was moderate with indirect signs of increased lung pressures. The echocardiographic appearance was therefore compatible with a chronic pulmonary heart frame, secondary to progressive pulmonary enfisema, and described in literature as the most fearful complication of Cuis Laxa syndrome, associated with an inauspicious prognosis and premature death.

Pituitary hypoadrenocorticism and hypothyroidism after immunochemotherapy followed by salvage surgery for lung cancer: a case report

BackgroundImmune checkpoint inhibitors (ICIs) have been shown to prolong the survival of patients with non-small cell lung cancer (NSCLC) and have allowed complete resection for advanced lung cancer. However, immune-related adverse events (irAEs) have been recognized as concerning side effects of ICIs.Case presentationA 62-year-old man visited our hospital because of fever, dyspnea, and anorexia. A tumor was found in the right hilum of the lung. It compressed the left atrium and was also thought to be invading the esophagus and a vertebral body. A bronchoscopic biopsy revealed squamous cell carcinoma of the lung (cT4N2M0-IIIB). We thought that a complete resection was impossible because of the N2 status of the tumor and because it had invaded several organs. Radiotherapy was thought to be contraindicated because of the patient’s marked emphysema. Therefore, we administered 4 courses of pembrolizumab plus carboplatin plus nab-paclitaxel immunochemotherapy.After immunochemotherapy, the tumor was downstaged to ycT2bN0M0-IIA and was determined to be acceptable for salvage surgery. A right lower lobectomy and systematic dissection of the mediastinal lymph nodes were performed. The histopathological examination of the resected specimen found that the proportion of the remaining tumor cells was 5%, indicating achievement of a major pathologic response.On postoperative day 79, the patient visited the emergency room because of anorexia. Blood tests showed hyponatremia, hypoglycemia, and eosinophilia. The serum thyroid hormone and thyroid-stimulating hormone levels were low and high, respectively. A corticotropin-releasing hormone stimulation test revealed levels of adrenocorticotropic hormone and cortisol far below the normal ranges. We speculated that the patient had developed pituitary hypoadrenocorticism and hypothyroidism as irAEs associated with ICI treatment. We administered hydrocortisone and levothyroxine, with improvement in the patient’s appetite and normalization of the patient’s serum sodium level. The patient has been receiving ongoing supplementation with oral hydrocortisone and levothyroxine and is doing well 11 months after surgery.ConclusionsThe increasing numbers of patients treated with perioperative ICIs might lead to increasing numbers of patients who develop perioperative irAEs. Careful attention should be paid to the possible development of irAEs during the perioperative management of patients undergoing surgery for lung cancer.

QUALITATIVE AND QUANTITATIVE EMPHYSEMA IS ASSOCIATED WITH HOSPITAL ADMISSION IN A LARGE CT LUNG SCREENING COHORT

SESSION TITLE: Tuesday Electronic Posters 3 SESSION TYPE: Original Inv Poster Discussion PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Stratifying risk of hospital admission can improve healthcare efficiency through better prospective direction of resource utilization. We conducted a prospective study analyzing the association between emphysema, assessed both qualitatively and quantitatively, and risk for hospital admission in a large clinical CT lung-screening (CTLS) cohort METHODS: Patients undergoing CTLS at Lahey Hospital and Medical Center between January 1, 2012 and September 30, 2014 who had a Lahey primary care physician were eligible for this study (n=1703). Follow up data was collected through September 30, 2017. Quantitative emphysema scores, defined as the percentage of low-attenuation areas measuring less than 950 Hounsfield units (%LAA -950), was obtained from baseline CTLS exams using Chest Imaging Platform workstation v 3.4.8 (www.chestimagingplatform.org). Qualitative emphysema scores, graded as none, mild, moderate, or marked, were reported on each baseline CTLS exam by a trained CTLS radiologist. Quantitative scores were divided by quartiles. The lowest quartile for %LAA and none for qualitative scores served as reference groups. Hospital admission data was collected through Lahey administrative coding data, and COPD, MI, CHF, PNA and stroke were characterized based on diagnosis codes per 2018 Centers for Medicare & Medicaid Services condition-specific measures. Cox proportional hazard regression for admission was adjusted for variables with a univariate p<0.2. Significance levels were set at p<0.05. All statistical analyses were performed using STATA14.1 software. RESULTS: 1,681 patients were included in our analysis with a mean age of 62.5 ± 6.2 years. 56.1% of the patients were male and 98.2% were white. A total of 508 (30%), 59 (3.5%) and 48 (2.9%) patients had at least one all-cause, COPD and PNA admission, respectively. Quartile 4 of %LAA and marked emphysema was associated with all cause hospital admission when adjusted for age, BMI, pack years, years quit, cancer and eligible group, HR 1.31 [1.02, 1.68, p=0.032] vs. 2.20 [1.54, 3.15, p<0.001]. CONCLUSIONS: Our results demonstrate that CTLS patients are at high risk for hospital admission and that both quantitative and qualitative emphysema is associated with all-cause hospital admission and with principle diagnosis of COPD and PNA. CLINICAL IMPLICATIONS: Quantitative emphysema scoring could be incorporated into admission prediction models to better direct resources towards highest-risk patients DISCLOSURES: no disclosure on file for Raul Estepar; No relevant relationships by Melissa Gawlik, source=Web Response No relevant relationships by Lee Gazourian, source=Web Response No relevant relationships by William Long, source=Web Response Speaker/Speaker's Bureau relationship with Covidien Please note: $1001 - $5000 Added 03/15/2019 by Andrea McKee, source=Web Response, value=travel Removed 03/15/2019 by Andrea McKee, source=Web Response Speaker/Speaker's Bureau relationship with Covidien Please note: $1001 - $5000 Added 03/15/2019 by Andrea McKee, source=Web Response, value=Salary Speaker/Speaker's Bureau relationship with Covidien Please note: $1-$1000 Added 03/15/2019 by Andrea McKee, source=Web Response, value=Travel No relevant relationships by Brady McKee, source=Web Response No relevant relationships by Lori Lyn Price, source=Web Response No relevant relationships by Shawn Regis, source=Web Response No relevant relationships by Giulia Rizzo, source=Web Response No relevant relationships by Ava Sanayei, source=Web Response No relevant relationships by Sandeep Somalaraju, source=Web Response No relevant relationships by Cristina Stefanescu, source=Web Response No relevant relationships by William Thedinger, source=Web Response Advisory relationship with Philips HealthTech Please note: $1001 - $5000 Added 03/15/2019 by Christoph Wald, source=Web Response, value=Honoraria<br no disclosure on file for George Washko

Airway smooth muscle as an underutilised biomarker: a case report

BackgroundSevere asthma and chronic obstructive pulmonary disease (COPD) can be challenging to manage, particularly when the clinical features may be similar. With the increased availability of advanced therapies for both entities, it is more important than ever to diagnose and phenotype accurately to inform appropriate treatment decisions. This case highlights the use of endobronchial biopsies to allow for histological evaluation of airways disease, and in particular the role of airway smooth muscle mass as an additional biomarker that could facilitate the diagnostic process.Case presentationA 65 year old woman presented with a diagnosis of severe COPD on the background of previous smoking and mild childhood asthma. Despite taking maximal inhaled pharmacotherapy, she had frequent exacerbations requiring corticosteroids and remained dyspnoeic on mild exertion. Lung function tests showed severe obstruction on spirometry (forced expiratory ratio 43%, forced expiratory volume in 1 s 47% predicted), and single breath Diffusing Capacity for Carbon Monoxide was moderately reduced at 45% predicted. Computed tomography revealed hyperinflation without marked emphysema. Quantitative CT for emphysema distribution demonstrated a relatively small lung fraction of 9.35% with <− 950 Hounsfield units. Bronchoscopy with endobronchial biopsy was undertaken to further determine the underlying pathology, and airway mucosa histology was consistent with typical findings of asthma. The patient was treated with bronchial thermoplasty as she did not meet prescribing criteria for monoclonal antibodies. Six months post treatment, she had a significant improvement in symptom control and medication usage, without any exacerbations.ConclusionsAirway smooth muscle histology is an underutilised biomarker that has a valuable role in phenotyping airways disease in the era of individualised medicine.

A diagnosis more than skin deep: A case of late-stage pulmonary langerhans’ cell histiocytosis with skin lesions

Introduction: Langerhans’ cell histiocytosis (LCH) is a group of rare diseases with a wide variety of presentations across age groups. We describe a case of pulmonary LCH diagnosed at a late stage despite having additional skin findings for several years.Case description: A 32-year-old male presented with acute exacerbation of chronic dyspnea resulting in markedly decreased functional capacity as well as cutaneous lesions. He had smoked cigarettes for 10 years with no occupational exposures. The patient also complained of a pruritic rash in his axillary and groin areas. His vitals were within normal limits. His exam was notable for diminished right lung sounds and expiratory wheezes bilaterally. A chest x-ray showed marked emphysema and bilateral upper lobe reticular opacities suggestive of scarring. Computerized tomography of the chest showed loculated right pneumothorax and hyperinflated lungs with destructive changes secondary to numerous irregular, thick walled cysts and scatteredirregular pulmonary nodules. Diagnosis was ultimately confirmed with biopsy of concomitant cutaneous lesions and characteristic radiographic findings on Chest CT. The patient started inhaled corticosteroids, inhaled anticholinergic, and inhaled short-acting beta agonists. He was sent home with oxygen and strongly encouraged to abstain from smoking.Discussion: LCH is characterized by end-organ infiltration of proliferating monoclonal Langerhans’ cells, a histiocyte involved in antigen presentation. The highest incidence of LCH is between ages 5-10 years; the adult incidence is estimated to be less than half as frequent than the pediatric, about one patient in 500,000. LCH most commonly involves the skin, bones, and lungs. Pulmonary LCH (PLCH) is interesting in that it has a peak incidence in ages 20-40 years and occurs almost exclusively in smokers (&gt; 90% of cases). Conclusion: Smoking cessation is the cornerstone of management of PLCH. It has been hypothesized that tobacco smoke can incite the production of cytokines by alveolar macrophages, leading to increased recruitment of histiocytes to the lung parenchyma. In isolated pulmonary pathology, lung transplant with smoking cessation is often curative.

Cough-Induced Lung Intercostal Hernia

A 73-year-old male with marked emphysema was admitted to the 2nd Department of Internal Medicine, University Hospital in Krakow because of chronic obstructive pulmonary disease (COPD) exacerbation. His medical history was significant for total laryngectomy due to laryngeal cancer in 2010.

Cough-Induced Lung Intercostal Hernia

A 73-year-old male with marked emphysema was admitted to the 2nd Department of Internal Medicine, University Hospital in Krakow because of chronic obstructive pulmonary disease (COPD) exacerbation. His medical history was significant for total laryngectomy due to laryngeal cancer in 2010.

Fetal pulmonary injury following single high-dose intra-amniotic betamethasone treatment in preterm goat kids

Fetal lung maturation is an extremely important process that is necessary for the survival of the neonates. Conventionally, corticosteroids are administered maternally for inducing fetal lung maturation in preterm fetuses. Alternatively, single-dose intra-amniotic (IA) treatment might be speculated to improve lung maturity. In the goat model, we recently showed that high-dose IA betamethasone (BM) was associated with an increased number of stillbirths and emphysematous changes. The aim of the present study is to expand our previous findings and evaluate the histopathological effects of IA injection of a single high-dose of BM 48 h before induced preterm delivery, using our previously collected specimens. Five hair goat fetal lungs that had received 8 mg/kg IA BM at gestational day 118 (term, 150 days) and scheduled for preterm delivery by cesarean section at day 120 of gestation were examined pathologically. Specimens were stained with hematoxylin and eosin (HE) and were interpreted by light microscopy. The histopathological examination of the fetal lungs revealed edema, hemorrhage, slight inflammatory reaction, marked emphysema, and desquamation of the pneumocytes and bronchiolar or bronchial epithelial cells. High-dose IA BM administrations to induce lung maturation can paradoxically cause severe pathological lesions in the fetal lungs. These might explain the toxic effects we encountered with this mode of treatment.

Toxic effect of formaldehyde on the respiratory organs of rabbits: A light and electron microscopic study

In this study, the effect of direct exposure of formaldehyde in different concentration was observed in 14 rabbits aged 3-6 months and weighing 1100-1200 g. The animals were divided into two groups with six animals in each group, and two animals were kept as control. The animals of group I were exposed to 10% formalin for 12 weeks and those of group II to 40% formalin solution for 6 weeks. After completion of the experimental periods, the animals were killed and the tissue samples were collected from the nasal cavity, trachea and lungs in 10% neutral buffered formalin and Karnovsky's fixative to examine the histological and electron microscopic changes in the organs. The mucosal cells of nasal cavity showed loss of cilia and epithelial metaplasia was observed in places. There was vascular congestion and mild subepithelial odema. The tracheal epithelium was organized with hyperchromatic nuclei. There was subepithelial odema along with lymphomononuclear cellular infiltration. There was marked emphysema evident as bulla formation of air spaces due to rupture of interalveolar septum. An increased cellularity of alveolar wall was observed, resulting in its thickening. The epithelial lining of bronchioles showed loss of mucosal folds and hyperplasia of cells along with peribronchial lymphomononuclear cellular infiltration. Thickening of wall of blood vessels was evident. Congestion and haemorrhages were observed in places. It is concluded that the histopathological changes were more remarkable in the animals exposed to 40% formaldehyde for short duration than the animals exposed to 10% formaldehyde for longer duration with a more severe effect on the upper part of the respiratory tract than the lower one.

Efeito da laserterapia de baixa potência na inflamação pulmonar em rattus novergicus

Introdução. A doença pulmonar obstrutiva crônica é uma enfermidade respiratória caracterizada pela presença de obstrução crônica do fluxo aéreo e manifestação inflamatória. Objetivo. Verificar o efeito da laserterapia de baixa potência no tratamento da inflamação pulmonar. Metodologia. Utilizou-se 30 ratos, divididos em três grupos de dez animais: grupo controle (recebeu apenas ar ambiente); grupo DPOC e grupo DPOC+laser (expostos à fumaça de cigarro durante 45 dias, sendo o grupo DPOC+laser tratado durante 12 dias com laser 904nm). Para análise dos resultados foi realizada histopatologia. Resultados. O grupo controle apresentou espaços aéreos normais com distorção arquitetural periférica do pulmão, o grupo DPOC demonstrou um enfisema acentuado, áreas de atelectasias e destruição das paredes alveolares. O grupo tratado houve uma regressão de enfisema acentuado para discreto. Conclusão. Na análise realizada, a inflamação pulmonar induzida pelo cigarro pode ser comprovada e a laserterapia de baixa potência mostrou-se eficaz na atenuação da inflamação.

Respiratory outcomes among South African coal miners at autopsy

Studies of dose-response relationships between respiratory outcomes at autopsy and coal dust exposure are limited. The Pathology Automation System (PATHAUT) database of South African miners, is one of the largest autopsy databases of occupational lung disease. This study described the prevalence of respiratory outcomes among South African coal miners at autopsy, and determined whether dose response relationships existed between emphysema and exposure. Autopsies conducted from 1975 to 1997 on coal miners with exclusive coal mining exposure and having exposure duration information (n = 3,167) were analyzed from PATHAUT. Logistic regression was used to determine relationships between exposure and outcomes, controlling for race, smoking and age on a subset for whom smoking history was available (n = 725). The mean duration of exposure was 11.0 years. Most were black miners (75.3%) with significant differences in the mean ages of black and white miners (37.9 and 55.3 years, respectively). Only 22.9% of cases had information on smoking. The prevalence of silicosis, tuberculosis (TB), coal workers' pneumoconiosis (CWP), and moderate and marked emphysema were 10.7%, 5.2%, 7.3%, and 6.4%, respectively. All diseases, except TB, were associated with exposure duration. Black miners had 8.3 and 1.2 fold greater risks for TB and CWP, respectively, than white miners. White miners had an increased risk of 1.4 and 5.4 for silicosis and moderate to marked emphysema, respectively. In models unadjusted for age, and including smoking, moderate to marked emphysema was strongly associated with exposure duration (OR = 3.4; 95% CI = 1.9-5.9 for highest tercile of exposure duration). Exposure-related risk estimates were reduced when age was introduced into the model. However, age and duration of exposure were highly correlated, (r = 0.68) suggesting a dilution of the exposure effect by age. There were significant dose related associations of disease, including emphysema, with coal dust exposure.

Transthoracic Needle Aspiration in Patients With Severe Emphysema: A Study of Lung Transplant Candidates

To describe the risks of transthoracic needle aspiration (TTNA) in a population of patients with severe lung disease: candidates for lung transplantation.Eight of 190 patients evaluated for lung transplantation underwent TTNA of nine pulmonary nodules (mean diameter, 14 mm; range, 0.8 to 2.2 cm). We evaluated pneumothorax rate, chest tube rate, duration of placement, and pulmonary function test results.All patients had emphysema; two had alpha 1-antitrypsin deficiency. The mean FEV1 of all patients was 0.64 L (22% of predicted; range, 17 to 28%), indicating severe air-flow obstruction. Six patients required a chest tube (50%); three chest tubes were placed emergently on the CT scanner table. Three patients required a second chest tube for persistent air leak. Tubes were in place for 1 to 22 days (mean, 10 days). One patient had chest tubes for 22 days and required intubation.TTNA in patients with marked emphysema is complicated by a high incidence of pneumothorax, rapid development of tension pneumothorax and chest tube placement. Since nodules in lung transplant candidates may represent bronchogenic carcinoma, serial CT scans to demonstrate lesion stability or growth, or thoracoscopic resection should be considered as an alternate approach to TTNA to avoid the significant morbidity of the procedure in these patients.

Placental Transmogrification of the Lung, A Histologic Variant of Giant Bullous Emphysema

Placental transmogrification of the lung was described by Chesney in 1978 as an unusual cystic lesion involving a single pulmonary lobe (3). We studied three additional cases with identical clinical and pathologic features. The patients were a 33-year-old woman and men aged 24 and 27 years. Each patient was first seen with respiratory distress; one had repeated pneumothoraces. Radiographically, an enlarging cystic lesion was present in a lower (two) or middle (one) lobe. The lesion had been present for 10 years in one patient. In two patients, mediastinal shift was noted. Lobectomy was curative in all instances. Grossly there was a uni- or paucilocular cyst lined by papillary structures. Microscopically, the papillae contained proliferating blood vessels, lymphoid nodules, smooth muscle, and fat. Sclerotic foci obliterated the vessels in some areas. The growth pattern and topography resembled those of placental villi. Systematic review of the histologic features in other lungs with marked emphysema revealed a spectrum of similar changes and suggested that the lesion in our patients may be a complication of bulla formation and is most likely the clinico-pathologic analog of the "vanishing lung" syndrome (idiopathic giant bullous emphysema).

Cor pulmonale and silicosis: a necropsy based case-control study.

The presence of cor pulmonale at death in relation to other factors such as emphysema, silicosis, and thromboembolism was analysed in a case-control study of 732 South African gold miners. Marked emphysema was the highest risk factor with an odds ratio of 21.32 (95% confidence interval (95% CI) 5.02-90.7), then extensive silicosis (OR 4.95, 95% CI 2.92-8.38) and thromboembolic disease (OR 1.92, 95% CI 1.37-2.69). Age and smoking were not significant predictors of cor pulmonale.

Different Patterns of Pulmonary Sequelae after Hyaline Membrane Disease: Heterogeneity of Bronchopulmonary Dysplasia?

In an autopsy study of 37 infants who suffered from hyaline membrane disease (HMD), two distinct patterns of pulmonary lesions could be defined. One pattern, characterized by marked interstitial fibrosis in the absence of airway abnormalities, was labelled 'interstitial-type' histology. A second type, labelled 'bronchiolar-type' histology, showed marked airway lesions and alveolar emphysema. Nine patients of each type were analysed. Nineteen other patients had a 'mixed-type' histology and were not further studied. Retrospectively, the clinical and radiological characteristics of both series were analysed. No differences in birth weight, gestational age and initial radiological HMD grade could be demonstrated. The pulmonary function of the bronchiolar-type patients however was significantly worse at the onset, and these infants needed more oxygen and ventilatory support during the first 10 days of life. They all died from respiratory failure whereas 4 patients from the interstitial group had non-pulmonary fatalities. In the bronchiolar group chest X-rays showed atelectasis and pulmonary interstitial emphysema in the early stages, and hyperinflation with bullae and irregular streaky densities in the later. Patients in the interstitial group had no or minor emphysema with more homogeneously spread densities over both lungs. We conclude that both types of evolution represent two extremes of the bronchopulmonary dysplasia spectrum.

Exercise stress and enzyme-induced emphysema.

Rats were exposed to an aerosol of 10% papain for 8 h found in pilot studies to produce marked emphysema. One week after exposure some animals were forced to exercise in a motor-driven activity wheel 2 h daily for 4 wk, while others remained at rest. Another group of rats which served as the control were exposed to saline under the same conditions and divided into exercise and rest groups. Elastic recoil pressure (Pst) of lung was measured from static deflation pressure-volume curves with air and saline. Pst measured in air-filled lungs was not significantly different between the emphysema-rest and emphysema-exercise groups. When inflated with saline the Pst was significantly reduced in the emphysema-exercise compared to the emphysema-rest group at high and mid (100, 80, 60%) lung volumes. Pst in air- and saline-filled lungs was not significantly different between the control-rest and control-exercise groups. We therefore conclude that mechanical stress resulting from physical exercise decreased Pst of lung tissue in emphysematous rats.

Peptic ulcer and pulmonary emphysema.

Most surgeons are unaware that patients with pulmonary emphysema have an inordinately high incidence of peptic ulceration and that these ulcers are of a peculiarly complicated and resistant nature. This paper is a review of the incidence of peptic ulcer in our own Emphysema Registry, an investigation of gastric secretory activity in 20 patients with marked emphysema, and a study of pathogenic factors that may relate to the two conditions. The clinical implications of these findings are discussed. <h3>I. Frequency of Coexistence of the Diseases</h3><h3>A. Incidence of Peptic Ulcer in Patients with Emphysema.</h3> —Green and Dundee,¹in 1952, found a 19% incidence of ulcer in both a clinical and an autopsy series of patients with proved emphysema. In a similar study, Flint and Warrack²found a 21% incidence of peptic ulceration in 87 autopsy patients with proved emphysema, as compared with an incidence of 1.6% in a

Radiological observations on 33 cases of primary interstitial myocarditis during an outbreak in the Haifa area

The radiological observations in 33 cases of primary interstitial myocarditis in the age-group 6 months to 3 ½ years are reported. The radiological features of the disease are presented. According to the size and shape of the heart, three stages of myopathic heart configuration are shown, presenting phases of the increasing myogenic dilatation of the heart. In cases that permitted further observation, gradual decrease of the size of the heart with eventual return to normal could be seen. The radiological appearances of passive pulmonary congestion, which were present in all but 4 cases, are discussed. Cases are presented with the typical appearances of arterial venous and lymphatic engorgement extending into the most peripheral parts of the lung fields (third zone) together with Kerley's B lines. In addition, cases are reported with a pathological interstitial pattern suggestive of diffuse interstitial pneumonia, these cases showing marked emphysema. The deduction is drawn that the combination of primary interstitial myocarditis with diffuse interstitial pneumonia must be a relatively frequent occurrence. This is supported by the fact that 11 out of 27 patients who died in 1957 showed on histopathological examination evidence of interstitial inflammatory infiltration of the lungs, in addition to interstitial myocarditis. Radiological evidence of pleural fluid was seen in 28 out of the 33 cases. Diminished or invisible cardiac pulsations may be of diagnostic aid. The radiological differential diagnostic considerations are discussed. The most important task of the radiologist is considered to be the differentiation between acute inflammatory pulmonary disease and myocarditis, the presenting severe clinical signs in both these conditions making a clinical differentiation sometimes very difficult. The differential diagnostic features between heart failure due to myocarditis and diffuse interstitial pneumonia are described, marked emphysema with a small heart and absence of Kerley's B lines pointing in favour of the latter. In addition the pathological interstitial pattern in diffuse interstitial pneumonia is usually limited to the paramediastinal regions (leaving the outer third free). The fine granular miliary pattern in acute bronchiolitis is thought to permit differentiation of this disease. The radiological signs of the combination of primary interstitial myocarditis with diffuse interstitial pneumonia are discussed, the most important feature being a marked emphysema and at the same time an enlarged heart. The differentiation from other forms of primary myocardial disease is mentioned; sub-endocardial fibro-elastosis offers no differentiating radiological signs. The radiological appearance of secondary myocarditis due to diphtheria, poliomyelitis, meningitis, nephritis, bacterial endocarditis, etc., presents no radiological differential diagnostic features. The differential diagnostic considerations between myocarditis and decompensated rheumatic carditis as well as decompensated congenital cardiac disease are mentioned. An important differential diagnostic sign between primary interstitial myocarditis and pericardial effusion (pericarditis) is believed to be the rare or very late occurrence of left heart failure (passive pulmonary congestion) in the latter.

Emphysema of one lung associated with atresia of the contralateral pulmonary artery

1. 1. Marked emphysema of one lung associated with absence of the pulmonary artery to the opposite lung may erroneously direct attention toward the pulmonary changes. 2. 2. Unilateral emphysema in an infant is quite suggestive of atresia of the contralateral pulmonary artery, after other causes of unilateral emphysema have been excluded. 3. 3. The anomaly appears to be associated with the tetralogy of Fallot more often than any other isolated cardiac defect. 4. 4. Most of the cases may be diagnosed by a routine x-ray of the chest, but in questionable cases, particularly those in which there is unilateral emphysema, angiocardiography may be necessary.

Experimental pneumokoniosis caused by beryl dust in guinea-pigs

1. The damaging effects of inhalation of beryl dust on guinea-pigs lung and other organs are studied using Hilton and Kettle technique. 2. It has been shown that beryl produces in the lungs chemical pneumonitis at the onset and later leads to marked atrophic emphysema. No evidence of fibriosis or silicious nodule formation was noted. 3. Other organs like liver and kidney showed signs of damage, but adrenal cortex showed definite pathological changes in the zona glomerulosa and zona fasciculata with the duration of the experiment. 4. The importance of concurrent study of the morphological chemistry of the dust in relation to its role in the production of silicosis is emphasised as such a method if followed by workers in this field may render a rational approach to the fundamental problem of silicosis.