Arizona Thoracic Society Notes

Rick Robbins, M.D. Rick Robbins, M.D.

March 2013 Council of Chapter Representatives Meeting and “Hill Day” Notes

March 18, 2013

As part of “Hill Day” the Council of Chapter Representatives meant on March 18, 2012 in Washington, D.C. beginning at 2:00 PM.

1. Welcome/Open meeting: Dona Upson 2:00 PM

Roll call determined there were representatives present from Arizona, Colorado, DC-Metro, Louisiana, Michigan, Mississippi, New York, and Washington. Linda Nicci, CCR Chair from Rhode Island, was delayed by weather and attended by conference call.

2. ATS Leadership Update 2:15pm

Presentations were given by Monica Kraft, ATS president, and Steven Crane, ATS executive director. Highlights of their presentations included –

  • A discussion of hospitalists eligibility for critical care boards
  • The ATS bottom line 
    • Bottom line was positive beginning in 2010 and growing in 2011 and 2012
    • Reserves have also increased (about 2/3 of a year)
  • Ken Adler will serve 3 more years as editor of the “Red Journal”
  • Annals of the ATS will be published shortly. It is hoped to be clinician friendly.
  • A 3 year core curriculum aligned to ABIM’s exam has been posted on the ATS website.
  • 2013 International Meeting
    • Over 5000 abstracts (1500 more than ERS and 3-4000 more than ACCP
    • 40% of revenue comes from ATS meeting
    • Registration down about 12% compared to San Francisco
  • Some drop in membership in 2013 attributed to the meeting not in San Francisco and Hurricane Sandy delayed processing applications-expect numbers to rise
  • ATS webinars have had over 1200 participants
  • 8000 are following ATS on Facebook and Twitter
  • ATS developing bridge funding for NIH grantees because of sequestration
  • ALL money given to the ATS Foundation goes for research-no administrative costs

 3. Chapter Activity Update 2:40pm

  • A handout was distributed with the 2012-13 Chapter Educational Meetings
  • A brief discussion was held of the Chapter publications from Arizona and California
  • Some inactive chapters showing renewed interest
  • A brief discussion of ALA relationship and administration

4. Outstanding Clinician Award (OCA) 3:00pm

  • The 2013 OCA finalists were from AZ, NM, WA
  • The ATS OCA for 2013 is Allen Thomas, MD, Arizona

5. Committee Updates by CCR reps 3:15pm

  • Verbal/written updates from CCR reps on committees they cover
    • Clinicians Advisory-Chris Fukui
    • Education-Linda Nici
    • Ethics and Conflict of Interest-Anthony Scardella
    • Health Policy-Dona Upson
    • Planning and Evaluation-Carol Welsh
    • Quality Improvement-Chris Fukui Wilhelm
    • Research Advocacy-Rajesh Bhagat
    • Training-Rajesh Bhagat

6. Advocacy Update - 3:45pm

Gary Ewart, ATS lobbyists, presented an advocacy update. Highlights included:

  • Advocacy by CCR
  • A review of the list of chapter ‘advocacy’ champions (CCR)
  • An open discussion other (potential) advocacy initiatives

7. Future Activity/Additional Role of CCR 4:25pm

  • Linda Nicci made a presentation.
  • Highlights of the discussion included
    • Increased CCR presence at International Conference
    • Officers to commit to times in Clinicians Center and Fellows Center.
    • Review of CCR brochure
    • CCR/ATS Foundation Partnership
    • Report on CCR involvement with Better Breathing Alliance

8. Great Cases Symposium at International Conference – organized by CCR 4:50pm

A reminder and a brief discussion was held of the Great Cases Symposium Organized by CCR: Session A83: Great Cases: Clinical, Radiologic and Pathologic Correlations by Master Clinicians

9. CCR Meeting date in Philadelphia 4:55pm

A CCR meeting will be held in Philadelphia on Saturday, May 18 from 11:00 AM-1:00 PM.

10. There being no further business the meeting was adjourned 5:00pm

March 19, 2013

1. Presentations were made by James Kiley, Director of the Division of Lung Diseases, and several staff from Congressional including the Veterans Affairs and research related committees from 8 AM-10 AM.

2. Meetings with Congressional representatives were held throughout the day. The offices were presented with handouts advocating (Click on title to be directed to the handouts)

Meetings with Arizona, New Mexico and Colorado representatives included:

 Arizona

  • Michael Nelson from the Office of Senator Jeff Flake (R-AZ)
  • Christopher Bowlin from the Office of Senator John McCain (R-AZ)
  • Lliam Morrison from the Office of Representative Matt Salmon (R-AZ)
  • Laurie Ellington from the Office of Representative Ed Pastor (D-AZ)

New Mexico 

  • Sandra Wilkniss from the Office of Senator Martin Heinrich (D-NM)
  • Representative Michelle Lujan Grisham (D-NM) and Kristin Palmer from her office
  • Lauren Arias from the Office of Tom Udall (R-NM)

Colorado

  • Representative Michael Coffman (R-CO and sponsor of the HR 792 tobacco bill) and legislative assistant Stephen Beck
  • Jacquelyn White, health policy fellow from the office of representative Dianna DeGette (D-CO)
  • Kristen Joyce legislative correspondent from the office of senator Mark Udall (D-CO)
  • Rina Shah, legislative fellow from the office of senator Michael Bennet (D-CO)
  • Morning coffee with Senator Michael Bennet (D-CO)

3. A dinner debriefing was held later that evening to discuss the advocacy efforts.

Richard A. Robbins, MD

Arizona CCR Representative

Reference as: Robbins RA. March 2013 council of chapter representatives meeting and "hill day" notes. Southwest J Pulm Crit Care. 2013;6(3):145-7. PDF

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Rick Robbins, M.D. Rick Robbins, M.D.

February 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 2/27/2013 at Scottsdale Shea beginning at 6:30 PM. There were 27 in attendance representing the pulmonary, critical care, sleep, infectious disease, nursing, pathology and radiology communities.

Dr. George Parides, Arizona Thoracic Society President, congratulated Allen Thomas on being named ATS 2013 Clinician of the Year.

Lewis Wesselius announced the ALA 2013 Fight for Air Walk. This will be at the Scottsdale Civic Center on April 27, 2013. To participate or sponsor a walker contact Lonie Padilla at lpadilla@lungarizona.org or 602-429-0007.

Rick Robbins, editor of the Southwest Journal of Pulmonary and Critical Care, announced Tim Kuberski has been named an associate editor.

A discussion was held regarding other states in the Southwest to partner with the Southwest Journal of Pulmonary and Critical Care.  

Seven cases were presented:

  1. Elijah Poulos, pulmonary fellow from the VA, presented a follow-up to a patient previously presented with optic neuritis, a positive ANCA at 1:40, a positive PR3 antibody at 1:8, and bilateral peribronchial consolidations right greater than left. The patient underwent a core needle biopsy of the lung with a final diagnosis of organizing pneumonia. The patient apparently declined rapidly and is now being given high dose methylprednisolone with the plan to begin cyclophosphamide shortly for a presumptive diagnosis of Wegner’s granulomatosis.
  2. George Parides, pulmonologist, presented a case of a 17 year old woman when first seen in 2006 in the Emergency Department with chest pain. A CT was done which showed probably bronchial atresia on the left. She also had a positive coccidiomycosis serology. A bronchoscopy was negative. She was treated with fluconazole for about 9 months and then lost to follow up. She next presented in 2009 without change in her CT scan and again had a negative bronchoscopy. Rick Helmers saw her later that year. An open lung biopsy was performed but the results are unknown. She again presented in January of 2013 with increasing consolidation at the bases. Coccidiomycosis was seen on smear and she was begun on amphotericin. She has had minimal improvement. Most felt that continuing her amphotericin was appropriate.
  3. Thomas Colby, pulmonary pathologist, presented a 68 year old woman who had a nonsmall cell carcinoma in 2011. She was treated with radiation therapy because her lung function was considered too compromised for pneumonectomy. She presented with increasing bilateral small nodules. A wedge biopsy showed many +CD1A cells and a diagnosis of histiocytosis X was made.
  4. Thomas Colby and Maria L. Cabanas, pulmonary pathologists from the Mayo Clinic, presented a case of a 67 year old that had pulmonary fibrosis on CT scan but was asymptomatic. The fibrosis progressed and biopsy showed adenocarcinoma.
  5. Tim Kuberski, infectious diseases from Maricopa, presented a 51 year old man who presented with cough. Chest x-ray revealed two large masses, one in the RUL and one in LUL, against a background of smaller nodules. The patient was a miner and a diagnosis of silicosis was made. He was followed and CT showed cavitation of one of the nodules. Quantiferon was negative as was PCR for Mycobacterium tuberculosis; however, his acid-fast smear was positive. He eventually grew Mycobacterium kansasii and is now on treatment.
  6. Al Thomas, pulmonologist at the VA, presented a 65 year old who had a large osteophyte with surrounding fibrosis.
  7. Gerald Swartzberg, pulmonologist, presented a 74 year old who had a squamous cell carcinoma resected who now has a fungus ball in a residual cough and has hemoptysis. Some suggested intracavitary amphotericin as a possibility for treatment.  

There being no further business, the meeting was adjourned at about 8 PM. The next meeting is Wednesday, March 20, 2013 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. Southwest J Pulm Crit Care. 2013;6(2):91-92. PDF

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January 2013 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 1/23/2013 at Scottsdale Shea beginning at 6:30 PM. There were 25 in attendance representing the pulmonary, critical care, sleep, infectious disease, thoracic surgery and radiology communities.

Dr. George Parides presented a plaque to Al Thomas for being voted Arizona’s Clinician of the Year (Figure 1).

Figure 1. George Parides, Arizona Thoracic Society President, presenting a plaque to Allen Thomas, Arizona Thoracic Society Clinician of the Year.

Rick Robbins, editor of the Southwest Journal of Pulmonary and Critical Care, gave a PowerPoint slide presentation updating the membership on the Arizona Thoracic Society’s official journal.

Five cases were presented:

  1. Tim Kuberski, chief of infectious disease at Maricopa Medical Center, presented a 29 year old diabetic who underwent a sinus operation for a sinus mass which proved to be a fungus ball. A biopsy was also done of the bone which showed osteomyelitis with cultures showing methicillin-sensitive Staphylococcus aureus. The patient received a 6 week course of daptomycin. Near the end of his daptomycin he began to complain of shortness of breath. Chest x-ray and thoracic CT scan showed peripheral lung consolidation with a “reverse batwing” appearance. The patient had 5% eosinophils in his blood. The symptoms and consolidation resolved with stopping the daptomycin. This was thought to be a drug reaction to the daptomycin.
  2. Andrew Goldstein, thoracic surgery, presented a case of a 71 year old man who developed an upper respiratory tract infection after a hunting trip. His complaints led to a chest x-ray which showed fullness in the right hilum and a question of oligemia in the right lung. Review of the patient’s old chest x-rays showed RLL collapse for at least a couple of years Thoracic CT showed the RLL collapsed with a question of a mass in the bronchus intermedius. PET scanning did not show increased metabolic activity. Bronchoscopy showed a mass in bronchus intermedius. Multiple biopsies were non-diagnostic. A rigid bronchoscopy was performed with multiple biopsies which showed an endobronchial hamartoma. The mass was endobronchially resected until both the RML and RLL bronchus were patent. Post-operatively the RLL was expanded.
  3. Heemesh Seth and John Roehrs, pulmonary at the Phoenix VA, presented a 34 year old man with progressive dyspnea since 2006 when was a Marine in Iraq injured by an IED. Chest x-ray and thoracic CT scan showed a mild left PA enlargement. Pulmonary function tests were normal. An echocardiogram showed pulmonic stenosis with a mild gradient and mild pulmonic regurgitation.  Referral to a pediatric cardiologist confirmed a diagnosis of pulmonic stenosis with pulmonic dilatation. Discussion regarding right heart catherization and optimal treatment ensued without a consensus being reached.
  4. Elijah Poulos and Allen Thomas, pulmonary at the Phoenix VA, presented a case of a 57 year old man who had been admitted with atrial fibrillation and a rapid ventricular response. He had a past medical history of COPD and optic neuritis of uncertain etiology. A chest x-ray revealed a right pleural effusion and scattered right central peribronchial lung consolidation with less on left. The patient was asymptomatic. Various diagnoses were discussed including sarcoidosis and lymphoma but most felt that diagnosis would require biopsy.
  5. Gerald Swartzberg presented three cases. All had been exposed to obnoxious fumes and developed vocal cord dysfunction. Most had diagnosed with asthma and all had extra thoracic obstruction on their flow-volume loops. Dr Schwartzberg reviewed irritant-associated vocal cord dysfunction and a discussion ensued regarding this poorly described disorder.

There being no further business, the meeting was adjourned at about 8 PM. The next meeting is Wednesday, February 27, 2013 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. January 2013 Arizona Thoracic Society notes. Southwest J Pulm Crit Care 2013;6(1):38-40. PDF

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November 2012 Arizona Thoracic Society Notes

A dinner meeting was held on Wednesday, 11/28/2012 at Scottsdale Shea beginning at 6:30 PM. There were 20 in attendance representing the pulmonary, critical care, sleep, infectious disease, pathology, and radiology communities.

Dr. George Parides stated he was unable to find further information on treating patients begun on biologicals for RA who developed a + QuantiFERON.

Four cases were presented:

  1. Dr. Suresh Uppalapu, a pulmonary fellow at Good Samaritan/VA, presented a case of a 29 yo woman with a rash and a myriad of nonspecific complaints. She had recently been a contestant in a reality TV show. Just prior to admission she developed a neurologic complaints including incontinence. Her CXR was negative but CT of the chest showed scattered areas of ground glass opacities peripherally. A MRI of the brain revealed nonspecific abnormalities. CBC showed an elevated eosinophil count of 8%. Coccidioidomycosis antigen was negative. An LP was performed which showed a protein of 144 mg/dL, a glucose of 33 mg/dL, and 553 cells/mm3 with 79% eosinophils. Biopsy revealed angiostrongylus. She is being treated with albendazole and steroids and is improving.
  2. Dr. Tom Colby, pulmonary pathologist from the Mayo Clinic, presented a case of a 61 yo man who presented with fever, chills and renal failure. He had diffuse patch ground glass opacities and a WBC scan localized to the lung. Open lung biopsy showed intravascular lymphocytes which stained positively for the B cell marker CD79a. The patient is receiving chemotherapy
  3. Dr. Tim Kuberski, chief of Infectious Disease at Maricopa Medical Center, presented a 56 yo homeless man with schizophrenia and alcoholism who was found to have Mycobacterium kansasii about a year ago. He was begun on INH, rifampin, ethambutol, and PZA. He was lost to follow up but returned with a LUL cavity and respiratory failure. He was intubated and placed on mechanical ventilation. Bronchoalveolar lavage was AFB+. He was again begun on INH, rifampin, ethambutol, and PZA. When he failed to improve after several weeks he was treated with moxifloxacin, azithromycin and amikacin. A repeat BAL was Coccidioidomycosis antigen positive although the serum Coccidioidomycosis antigen negative. He was treated with amphotericin and was improving.
  4. Dr. Jessica Hurley, a pulmonary fellow at St. Joseph, presented a 60 yo woman who underwent lung transplantation in May, 2012 for sarcoidosis. She developed progressive hypoxia and was intubated. CT scan showed multiple small nodules surrounded by ground glass opacities and mediastinal adenopathy. A VATS biopsy was performed which showed spindle shaped CD34+ positive cells consistent with Kaposi’s sarcoma. Her Mycophenolate was stopped and she was begun on doxorubicin.

There being no further business, the meeting was adjourned at about 8 PM. There being no meeting in December, the next meeting is Wednesday, January 23, 2013 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. November 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:270-1. PDF

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October 2012 Arizona Thoracic Society Notes

A dinner meeting was held on 10/24/2012 at Scottsdale Shea beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, infectious disease, pathology, and radiology communities.

An announcement was made that the Colorado Thoracic Society has accepted an invitation to partner with the Arizona and New Mexico Thoracic Societies in the Southwest Journal of Pulmonary and Critical Care Medicine.

Discussions continue to be held regarding a combined Arizona Thoracic Society meeting with Tucson either in Casa Grande or electronically.

Six cases were presented:

Dr. Tim Kuberski, chief of Infectious Disease at Maricopa Medical Center, presented a 48 year old female who had been ill for 2 weeks. A CT of the chest revealed a left lower lobe nodule and a CT of the abdomen showed hydronephrosis and a pelvic mass. Carcinoembryonic antigen (CEA) was elevated. All turned out to be coccidioidomycosis on biopsy.  CEA decreased after the pelvic mass was resected.

Dr. Tom Colby, pulmonary pathologist from the Mayo Clinic, presented a 60 year old man with a past medical history of a transbronchial biopsy showing nonspecific interstitial lung disease. CT scan showed bilateral hilar lymphadenopathy and multifocal ground glass opacities. Multiple serologies were all negative. Biopsy revealed both hypersensitivity pneumonitis and sarcoidosis. It was pointed out by Drs. Michael Gotway and David August that the usual presentation of sarcoidosis in the lung is bilateral lymphadenopathy with multiple small nodules in a peribronchovascular distribution along with irregular thickening of the interstitium. Although multifocal ground glass opacities have been reported with sarcoidosis, it is unusual.

Dr. George Parides presented two cases of patients with rheumatoid arthritis receiving biologic therapy. One presented with a positive QuantiFERON test for tuberculosis and the other with a positive PPD. Management was discussed. None were aware of any data but the majority thought that stopping the biologics, if possible, and treating with INH for 9 months was probably appropriate.

Dr. Colby presented a second case of a 52 year old heavy smoker with shortness of breath while playing basketball. Chest CT showed ground glass opacities with minimal fibrosis. A lung biopsy showed various areas consistent with desquamative interstitial pneumonia, respiratory bronchiolitis-associated interstitial lung disease or nonspecific interstitial pneumonitis with scarring.  Dr. Colby stated that smokers with interstitial disease can have different patterns on biopsy. Drs. Gotway and August pointed out that the lung CT pattern is also often heterogenous.

Dr. Lewis Wesselius presented a 49 year old female admitted for hypoxia, lethargy, and an abnormal chest x-ray. She had a prior diagnosis of systemic lupus erythematosis (SLE) with a reported diagnosis of lupus pneumonitis made 3-4 years ago. There was a history of multiple episodes of pneumonia (25 in 5 years), a prior stroke and mitral valve disease with valve replacement. Chest CT showed multiple areas of ground glass opacities and bronchoscopy with bronchoalveolar lavage resulted in a bloody return. Serologies were inconsistent with SLE but anti-phospolipid antibodies were present. Dr. Wesselius reviewed antiphospholipid antibody syndrome (APS) which can occur as a primary condition or in the setting of an underlying systemic autoimmune disease such as SLE. Manifestations include deep venous thrombosis (32%), thrombocytopenia (22%), livedo reticularis (20%), stroke (13%), pulmonary embolus (9%), fetal loss (8%), transient ischemic attack (7%), hemolytic anemia (7%), and rarely alveolar hemorrhage. Treatment includes high dose corticosteroids, cyclophosphamide, mycophenolate, IVIG, and plasmapharesis. A recent report (Lupus 2012, 21:438-40) advocated Rituximab, a chimeric monoclonal antibody against the protein CD20, which is primarily found on the surface of B cells, for recurrent diffuse alveolar hemorrhage in primary APS.

There being no further business, the meeting was adjourned. The next meeting is November 28 at 6:30 PM at Scottsdale Shea.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. October 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:218-9. PDF

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September 2012 Arizona Thoracic Society Notes

A dinner meeting was held on 9/26//2012 at Scottsdale Shea beginning at 6:30 PM. There were 18 in attendance representing the pulmonary, critical care, sleep, pathology, and radiology communities.

A discussion was held on Pending Premium Cigar Legislation HR. 1639 and S.1461, the "Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2011”. This bill would exempt "premium cigars" from FDA oversight.  The definition of premium cigars is so broad that candy flavored cigars, cigarillos and blunts would be exempted from FDA regulation.  Teenage cigar smoking is increasing and this legislation may result in a further increase. The Arizona Thoracic Society is opposed to this bill. Dr. Robbins is to put a link on the Southwest Journal of Pulmonary and Critical Care website linking to the ATS website. This will enable members to contact their Congressmen opposing this legislation.

A discussion was also held on a proposed combined Tucson/Phoenix meeting. George Parides and Ken Knox have been discussing a combined meeting between the Arizona Thoracic members in Tucson and Phoenix in Casa Grande. Dr. William Peppo, chairman of medicine at Midwestern University, made the suggestion that perhaps the University of Arizona video link between the Tucson and Phoenix campus could be used to hold combined meetings. It was decided to pursue this possibility.

Two cases were presented:

  1. Rick Robbins presented a case of a 56 yo man with chronic cough and exertional dyspnea. He had mild restrictive disease and scattered areas of a reticular pattern and ground glass opacities on chest x-ray and CT scan of the chest. Bronchoscopy with bronchoalveolar lavage revealed 60% lymphocytes which were predominately CD8+. VATS was consistent with hypersensitivity pneumonitis. A careful history and hypersensitivity serology did not reveal an etiology of the hypersensitivity pneumonitis. It was pointed out that a pervious series revealed that 25% of chronic hypersensitivity cases had no identifiable etiology. A discussion ensued about how far to investigate the patient’s environment for an etiology. The consensus was that an aggressive, thorough investigation was probably warranted.
  2. Tom Colby presented a case of a 26 year old man with recurrent hemoptysis and pneumothoracies. An open lung biopsy revealed holes in the lung and areas with abnormal scarring. The patient eventually proved to have Ehlers Danlos syndrome characterized by joint hypermobility. None had seen a similar patient but Dr. Colby related he had seen this pattern on lung biopsy previously and since the disease occurs once in every 5000 births, he wondered if the disease was more common than reported.

There being no further business, the meeting was adjourned at 7:45 PM. The next meeting is scheduled for October 24 at Scottsdale Shea 6:30 PM.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. September 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:149-50. (Click here for a PDF version of the notes)

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August 2012 Arizona Thoracic Society Notes

No abstract available. Article truncated at 150 words. A dinner meeting was held on 8/29/2012 at Scottsdale Shea beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, pathology, radiology, and thoracic surgery communities. Four cases were presented: 1. Lewis Wesselius and Thomas Colby presented a 39 yo female with cough and small amounts of hemoptysis for over a year. Chest x-ray was interpreted as perhaps showing some small nodules in the lower lobes which were more easily seen with CT scan. The scattered nodules were lower lobe predominant, non-calcified and surrounded by ground glass haloes. Coccidioidomycosis serology was negative and rheumatologic serologies were negative. Bronchoscopy showed blood in the airway but other than blood, bronchoalveolar lavage was negative. A video-assisted thorascopic (VATS) biopsy showed a hemangioendothelioma, a malignant neoplasm that falls between a hemangioma and angiosarcoma. These vascular tumors can originate in the heart and often metastasize to the lung and pleura…

A dinner meeting was held on 8/29/2012 at Scottsdale Shea beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, pathology, radiology, and thoracic surgery communities.

Four cases were presented:

  1. Lewis Wesselius and Thomas Colby presented a 39 yo female with cough and small amounts of hemoptysis for over a year.  Chest x-ray was interpreted as perhaps showing some small nodules in the lower lobes which were more easily seen with CT scan. The scattered nodules were lower lobe predominant, non-calcified and surrounded by ground glass haloes. Coccidioidomycosis serology was negative and rheumatologic serologies were negative. Bronchoscopy showed blood in the airway but other than blood, bronchoalveolar lavage was negative. A video-assisted thorascopic (VATS) biopsy showed a hemangioendothelioma, a malignant neoplasm that falls between a hemangioma and angiosarcoma. These vascular tumors can originate in the heart and often metastasize to the lung and pleura amongst other sites. Treatment is varied and depends on the site and extent of tumor involvement, site(s) of metastasis, and specific individual factors.
  2. Allen Thomas presented a 78 year old with a history of squamous cell carcinoma and right pneumonectomy done in Florida in 2002. He complained of right-sided chest pain and CT scan revealed a mass in the pneumonectomy space near the stump. Needle biopsy showed only fibrous tissue and hemorrhage. This was followed by a long discussion of what could be done but the patient chose to wait and obtain a follow up CT scan in about 3 months.
  3. Dr. Thomas presented a second case of a 62 yo former smoker with cough and blood-streaked sputum, weight loss, and night sweats. Chest x-ray revealed a large cavity in right middle lobe. Bronchoscopic transbronchial biopsy showed a question of necrotizing granulomas. Two weeks later the lesion had nearly doubled in diameter and he felt worse. This was felt to be most consistent with an infectious process based on doubling times and he was empirically treated with fluconazole pending the results of the cultures obtained at bronchoscopy. Two weeks later the lesion had again nearly doubled in size and he felt worse. Resection of the lesion revealed a poorly differentiated carcinoma. It was felt that the lesion enlarged rapidly because of bleeding into the cavity rather than enlargement of the tumor mass.
  4. Bridgett Ronan presented a 69 year old referred for recurrent hemoptysis. The hemoptysis was severe and the patient had been endotracheal intubated X 3, bronchoscoped X 2 and had bronchial artery embolization X 2 over the past year. The first episode occurred in July 2011 He was treated for presumed sepsis syndrome and improved. However, this sequence of fevers, rigors and hemoptysis recurred twice in Oct 2011 and again in November. In all instances chest x-ray and CT showed dense consolidation in the right upper lobe lung and he improved on antibioitics. After the November episode the patient was empirically treated with corticosteroids. He did well until January when his symptoms recurred while the corticosteroids were being tapered.  A repeat bronchoscopy in March was negative for infection and VATS showed nonspecific pathology with a question of capillaritiis. His rheumatology serologies including anti-nuclear cytoplasmic antibody (ANCA) were negative. He was begun on cyclophosphamide in addition to the corticosteroids. At his last follow up he had done well and the corticosteroids were slowly being tapered. This was felt to possibly be a case of small vessel, ANCA negative, pulmonary vasculitis but questions were raised about the adequacy of the biopsy.

There being no further business, the meeting was adjourned at 8 PM. The next meeting is scheduled for September 26 at Scottsdale Shea 6:30 PM.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. August 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:104-5. (Click here for a PDF version)

August 2012 Arizona Thoracic Society Notes

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August 2012 Special Meeting Arizona Thoracic Society Notes

On the hottest day of the summer to date (reported high 114° F), a special meeting to allow Rep. David Schweikert (R-AZ 5th) to attend the Arizona Thoracic Society meeting was held on 8/8/2012 at Scottsdale Shea beginning at 6:30 PM. There were 27 in attendance representing the pulmonary, critical care, sleep, infectious disease, radiology, and thoracic surgery communities.

Representative Schweikert arrived slightly before his scheduled time of 7 PM and spoke for about 20 minutes predominantly on the budget process. Major points of his remarks included that:

  • Money leads to the disagreements in Congress.
  • If unchanged SGR will result in about a 73% reduction in physician payments in 14 ½ years.
  • There is considerable concern that baby boomers will lead to increased health care consumption as they age.
  • The Independent Payment Advisory Board, or IPAB, will direct medical care to achieve specified savings in Medicare/Medicaid.

This was followed by about a 20 minute question and answer session where questions were asked regarding ACA, healthcare finance and several other issues. Representative Schweikert was presented with handouts from the ATS regarding three issues: SGR, Clean Air Act, and the exemption of cigars from FDA regulation (click on issue to be directed to ATS handout.

After Rep. Schweikert’s question and answer session, 3 cases were presented:

  1. Tim Kuberski, an infectious disease specialist from Maricopa Medical Center, presented a young man who presented with left upper quadrant pain and fever which eventually proved to be disseminated coccidioidomycosis.
  2. George Parides, a pulmonologist from Phoenix, presented a case of a patient with ulcerative colitis and bronchiectasis. Infliximab therapy is planned for the patient’s ulcerative colitis and Dr. Parides raised the question if infliximab would affect the patient’s bronchiectasis. The consensus was that the answer was unknown.
  3. Andrew Goldstein, a thoracic surgeon, presented a case of young man with multiple bullae and a spontaneous pneumothorax. Multiple etiologies were considered but the cause remains unknown.

At the end of the meeting Dr. Steven Farber gave a brief presentation on docs 4 patient care (http://www.docs4patientcare.org). This is an organization of concerned physicians committed to the establishment of a health care system that preserves the sanctity of the doctor-patient relationship, promotes quality of care, supports affordable access to all Americans, and protects patients' freedom of choice.

There being no further business, the meeting was adjourned at 8 PM. The next meeting is scheduled for August 29 at Scottsdale Shea 6:30 PM.

Richard A. Robbins, MD

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. August 2012 special meeting Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;5:82-3. (Click here for a PDF version of the notes)

9/7/12

Addendum: Rep. Schweikert sent the following letter to George Parides thanking him for the opportunity to speak at the Arizona Thoracic Society.

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June 2012 Arizona Thoracic Society Notes

The June 2012 Arizona Thoracic Society meeting was held on 6/27/2012 at Scottsdale Shea beginning at 6:30 PM. There were 23 in attendance representing the pulmonary, critical care, sleep, pathology, infectious disease, radiology, and thoracic surgery communities.

Discussions were held regarding offering CME and partnering with other thoracic societies in the Southwest Journal of Pulmonary and Critical Care. This was endorsed by the membership. There was also discussion regarding what to discuss with Rep. David Schweikert on August 8.

Seven cases were presented:

  1. Thomas Colby, a pulmonary pathologist from the Mayo Clinic, presented a case of a 45 yo woman with a history of asthma and systemic lupus erythematosis who was found to have cysts on CT scanning. The CT scan was considered consistent with lymphangioleiomyomatosis (LAM). A lung biopsy showed only changes consistent with asthma in addition to the cysts. This case was published along with 4 similar cases by Rowan C, et al. Am J of Surg Pathol 2012;36:228–34.
  2. Jonathan Ruzi, a pulmonologist and sleep medicine specialist in Scottsdale showed an unusual flow-volume loop in an asymptomatic patient (Figure 1 below). Figure 1. Flow-volume loop of patient presented in case 2.         The cause of the obstruction was unknown but most thought this represented a type of upper airway obstruction from redundant tissue such as seen in obstructive sleep apnea or an enlarged tongue.
  3. Henry Luedy, a pulmonary fellow, presented a case of an 82 yo with cough who was a former smoker with COPD who presented with a cough. The patient presented with a consolidative process in the lingula and underwent bronchoscopy which revealed bronchial inflammation and a trace of blood in the lingula. Biopsy revealed an adenocarcinoma. Unfortunately, the pathology was not presented due to Dr. Luedy being unable to obtain the slides or images from the VA due to a clerk citing HIPAA regulations as the reason. A discussion was led by Dr. Colby on how the pathology affects the classification of these tumors as bronchoalveolar or adenocarcinoma and how there is much overlap between the classification. It was noted that educational activities are excluded from HIPAA regulations as long as the data is de-identified and there are not identifiers on a pathology slide.
  4. Tonya Whiting, a pulmonary fellow, and Manny Mathew, a pulmonologist based at Good Samaritan, presented a case of a man who developed shortness of breath while camping in the White Mountains. CT scanning revealed dense consolidation especially of the left upper lobe. He was referred for bronchoscopy but both his symptoms and consolidation resolved within 24 hours. It was felt this was a case of high altitude pulmonary edema which was somewhat unusual because high altitude pulmonary edema is unusual below 12000 feet (the patient was camping at about 9000 feet).
  5. Tonya Whiting and Allen Thomas, a pulmonologist at the VA, presented a 61 year old man with a history of polysubstance abuse and multiple lung nodules. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy was negative. Open lung biopsy revealed brochiolcentric inflammation with acute lung injury. The patient was treated with corticosteroids and the nodules resolved in 2-3 weeks. The feeling was that this represented cryptogenic organizing pneumonia (COP) presenting with multiple nodules which is a rare presentation for COP.
  6. Andrew Goldstein, a thoracic surgeon, presented a case of a 50 year old asymptomatic, nonsmoker with a huge, > 10 cm, lung tumor. The lesion was round and smooth and did not invade the chest wall on CT scan. Dr. Goldstein pointed out that pain is sensitive in predicting chest wall invasion. The tumor was resected and proved to be a carcinoid tumor.
  7. Tim Kurberski, an infectious disease specialist from Maricopa Medical Center, presented a 39 year old with a history of systemic lupus erythematosis on corticosteroids who presented with shortness and breath thought to be secondary to pulmonary edema from a cardiomyopathy. The CT scan revealed diffuse ground glass opacities. The patient also had a rash near the buttocks which was thought to be possible shingles and the chest findings possible chickenpox pneumonia. The steroids were increased but the patient failed to improve. She underwent bronchoscopy with bronchoalveolar lavage which revealed larvae consistent with Strongyloidiasis.

There being no further cases, the meeting was adjourned at 8:30 with the next meeting being a special meeting on August 8 when Rep. David Schweikert is scheduled to attend. 

Richard A. Robbins, M.D.

CCR Representative

Arizona Thoracic Society

Reference as: Robbins RA. June 2012 Arizona Thoracic Society notes. Southwest J Pulm Crit Care 2012;4:211-3. (Click here for a PDF version of the Notes)

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May 2012 Council of Chapter Representatives Meeting

The Council of Chapter Representatives met in conjunction with the ATS meeting in San Francisco on May 19, 2012.

The meeting was called to order at 10 AM. Roll call revealed representatives from Arizona, California, Colorado, DC Metro, Michigan, Mississippi, New York, New Mexico, New York, Rhode Island, and by telephone from Oregon.

Information was provided that ATS will not charge for CME. Most state meetings are obtaining CME.

Nuala Moore from ATS Government Relations gave a presentation on 2013 health research and services funding. This included description of the President’s proposed FY 2012 budget, new NIH grants changes, and the formation of a house tuberculosis caucus.

Gary Ewart from ATS Government Relations gave a presentation on Congress, the Courts, and the Administration. Highlights included description of the impact of the SGR, the Affordable Care Act decision, a number of air pollution regulations and a proposal to make many asthma medications over the counter.

Monica Kraft, ATS President 2012-3 encouraged advocacy for research, education and implementation of guidelines. She reviewed ATS efforts for training, advocacy, health disparities, and revenue generation.

Stephen Crane, ATS Executive Director, gave an overview of the finances of the ATS which were mostly positive. Revenues are increasing and attendance is increasing at the annual meeting. Members can now update their information on the ATS website.

Discussion regarding Outstanding Clinician Award occurred and recognizing those who are nominated.

Dean Schraufnagel gave a presentation on the new Proceedings of the American Thoracic Society. The Proceedings is designed to be more of a clinicians’ journal. In addition to original research, it will publish reviews, educational materials, commentary, and meta-analysis. The journal will begin accepting submissions in July, 2012 and plans to publish its first issue February, 2013.

Linda Nici, Incoming CCR Chair, reviewed plans for the upcoming year.

The meeting was adjourned at 1:10 PM.

 

Richard A. Robbins, MD

Arizona CCR Representative

 

Reference as: Robbins RA. May 2012 council of chapter representatives meeting. Southwest J Pulm Crit Care 2012;4:177. (Click here for a PDF version of the meeting notes)

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May 2012 Arizona Thoracic Society Notes

The May 2012 Arizona Thoracic Society meeting was held on 5/16/2012 at Scottsdale Shea beginning at 6:30 PM. Attendees representing the pulmonary, critical care, sleep, infectious disease, radiology, and nursing communities were present.

This was the first meeting on Wednesday. The meetings will usually be held the last Wednesday of every month, pending availability of a meeting room at Shea and conflicts with holidays.

Congressman David Schweikert has accepted an invitation to speak at the Arizona Thoracic Society. Because of the Congressman’s schedule, it was decided to hold a special meeting on 8/8. The August meeting scheduled for 8/29 was to go on as planned.

Six cases were presented:

  1. Dr. Timothy Kuberski: An African-American male presented with knee pain. Chest radiography showed a very subtle opacity over the left upper chest, not clearly intraparenchymal. Thoracic CT showed a fluid collection centered around the left sternoclavicular joint and costomanubrial junction, extending medially into the superior mediastinum, posteriorly into the thorax (but remaining extraparenchymal and extrapleural), into superficially into the left pectoralis musculature. This focus showed low attenuation, consistent with abscess. The abscess was drained, and contrast injection through the catheter showed that all the aforementioned spaces were in communication with one another, with cranial extension into the left lower neck. No organisms could be recovered from this collection, but pneumococcus was recovered from aspiration of the knee fluid and blood. There was speculation that the chest wall lesion could be related to actinomycosis, but testing this far has not revealed this organism.
  2. Gerry Schwartzberg presented two cases of coccidioidomycosis on chest radiography, one of which produced a pleural effusion in a Filipino man. The organism was not isolated from the thoracentesis fluid, but Judd Tillinghast noted he once had similar case that underwent video-assisted thoracoscopic surgery that showed pleural surface plaques containing the organism.
  3. Tom Colby presented two cases: A 39-year-old woman presented with chest pain and lymphadenopathy in the thorax. Reportedly, multiple fine needle aspiration biopsies were non-diagnostic. Evaluation for immunodeficiency and autoimmune disease was unrevealing. Thoracic CT initially showed a mass-like opacity in the right lower lobe, possibly with peribronchial lymphadenopathy and areas of patchy ground-glass opacity. A small pleural effusion was also present, as was smooth interlobular septal thickening. The patient presented later with hemoptysis and pleuritic chest pain. Repeat thoracic CT showed a complex cystic mass in the right lower lobe, arising in the area of mass-like opacity seen previously. The patient underwent right lower lobectomy. The final diagnosis was pulmonary lymphangioma with rupture into a bronchus, allowing the lesion to become air-filled.
  4. Dr. Colby also presented a case of a 28-year-old man presented with a right lower lobe mass and dyspnea. He was a non-smoker, with a history of asthma requiring multiple hospitalizations as a child as well asteroid use. He noted several episodes of “bronchitis” every year as an adult. His pulmonary function testing showed mild reversible obstruction. A PET scan reportedly showed increased uptake (maximum standard uptake value of 8) in the right lower lobe mass. Bronchoscopy was reportedly unrevealing, but sputum cultures did show normal flora and 1 colony of Aspergillus. His thoracic CT showed an area of consolidation in the superior segment of the right lower lobe tracking along the bronchovascular bundle; the superior segment bronchus could not be visualized at all. Review of the pathology showed goblet cell hyperplasia, Charcot-Leyden crystals, allergic mucin, bronchiocentric granulomatosis, and eosinophilic pneumonia. The patient was subsequently diagnosed with allergic bronchopulmonary aspergillosis.
  5. Al Thomas presented a case of a patient who underwent chest radiography and was diagnosed with a “narrowed” trachea, which prompted thoracic CT. The narrowed trachea simply represented a “saber sheath” trachea”, but a focal opacity was noted along the posterior tracheal wall. The patient underwent bronchoscopy, which showed a verrucous lesion along the posterior tracheal wall with a “fish egg” appearance. Biopsies subsequently showed the lesion to represent squamous papilloma.
  6. A case was presented of an older woman presented with a history of aspirating a calcium pill. Due to social factors, she delayed presenting to her physician (she wanted to attend a relative’s wedding). Thoracic CT sowed a high density structure, consistent with a calcium tablet, in the bronchus intermedius. The tablet was easily removed with bronchoscopic retrieval, but review of the coronal images on CT showed two tablets adjacent to one another (the patient did not remember aspirating the first tablet). The second tablet was much more difficult to remove, requiring over one hour. Extensive discussion regarding various methods for bronchoscopic removal of airway foreign bodies took place. Al Thomas concluded that a loop snare provides the best results.

There being no further cases, the meeting was adjourned at 8:00 PM. The next meeting is scheduled for Wednesday, June 27.

Michael B. Gotway, M.D.

Vice President

Arizona Thoracic Society

Reference as: Gotway MB. May 2012 Arizona Thoracic Society notes. Southwest J Pulm Crit Care 2012;4:174-6. (Click here for a PDF version of the Notes)

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April 2012 Arizona Thoracic Society Notes

The April 2012 Arizona Thoracic Society meeting was held on 4/17/2012 at Scottsdale Shea beginning at 6:30 PM. There were 19 in attendance representing the pulmonary, critical care, sleep, infectious disease, radiology, and nursing communities.

Discussions were held regarding moving the meeting to another day of the week to allow the Mayo pathologists to attend. It was decided to try and move the meeting to the third Wednesday of every month, pending availability of a meeting room at Shea.

Because this is an election year and members of Congress made themselves available, it was thought it might be reasonable to invite members of Arizona’s Congressional delegation to an Arizona Thoracic Society meeting in order to discuss issues important to the medical community.

Three cases were presented:

  1. Dr. Timothy Kuberski, who has recently been named chief of infectious disease at Maricopa Medical Center, presented a case of a 52 year old Native American male who complained of cough. He was taking lisinopril for hypertension and type 2 diabetes. Chest x-ray showed multiple small pulmonary nodules. IgM was positive for coccidioidomycosis but IgG and urinary antigen for coccidioidomycosis were negative. HIV was negative. He complained of headache and CT scan revealed hydrocephalus. Because it was unclear if he had coccidioidomycosis or tuberculosis he was treated for both. Eventually he was shown to have tuberculous meningitis. He is now on 5 drugs for tuberculosis including INH, rifampin, PZA, streptomycin and Levaquin. A comment was made that miliary patterns in coccidioidomycosis appeared to only occur in immunocompromised hosts. No one could recall seeing one that was not.
  2. Allen Thomas from the Phoenix VA presented a case of a 61 year old with increasing dyspnea, cough, occasional blood-streaked sputum, night sweats and 30 lb weight loss. He had a history of dipolar disease, diabetes and had recently been evaluated for an abdominal mass that was not identified. Dry crackles were noted on lung exam. Chest x-ray was remarkably similar to the previous presentation with multiple small nodules noted which were new compared to a chest x-ray 2 years previously. He had an elevated WBC with a left shift. Sputum cultures, coccidioidomycosis serology, and a tuberculosis skin test were all negative. Bronchoscopy with BAL and transbronchial biopsies was all nondiagnostic. For this reason a VATS was performed. Cultures and special stains for organisms were all negative. The biopsy slides were sent to the Mayo group and they diagnosed cryptogenic organizing pneumonia (COP). Dr. Thomas presented literature that a miliary pattern in COP had rarely been reported. The patient was improved on oral corticosteroids.
  3. Rick Robbins, retired pulmonologist, presented a case of a 31 yo previously health woman who presented with nonproductive cough, dyspnea, fever and arthralgias over 3 weeks. She had been empirically treated with a course of Levaquin and a course of Biaxin without improvement. She presented to the ER with increasing dyspnea and was found to have a markedly elevated WBC of 49,000 and a platelet count of over 1 million. Her only medication was valproic acid for prevention of migraine headaches. Physical exam revealed a moderately dyspneic woman despite a non-rebreathing mask. Diffuse crackles were heard on auscultation of the lungs. Bronchoscopy with BAL and cultures was negative as were HIV, coccidioidomycosis, Legionella, and Mycoplasma titers. ANA, RF, histoplasma urinary antigen, and blood cultures were also negative. She was transferred to the ICU and required endotracheal intubation. Because her diagnosis was unclear, a VATS was performed which revealed acute inflammation with eosinophils. She was begun on steroids and rapidly improved. She eventually admitted to smoking crack cocaine just prior to her hospital admission. It was noted that the course and presentation of acute eosinophilic pneumonia was variable and has been associated with use of crack cocaine. It was mentioned that a case of acute eosinophilic pneumonia had appeared as the April 2012 Imaging Case of the Month.

There being no further cases, the meeting was adjourned at 8:00 PM. The next meeting is tentatively scheduled for May 15 but may be moved to a Wednesday.

Richard A. Robbins, M.D.

Reference as: Robbins RA. April 2012 Arizona Thoracic Society notes. Southwest J Pulm Crit Care 2012;4:114-5. (Click here for a PDF version of the Notes)

 

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March 2012 “Hill Day” and Council of Chapter Representatives Meeting Notes

As part of “Hill Day” the Council of Chapter Representatives meant on March 28-29, 2012 in Washington, D.C.

The meeting began with a bus trip to the Rayburn House Office Building at 7 AM sharp on Wednesday. A breakfast meeting was held with presentations by one of the ATS lobbyists, Gary Ewart; Rep. Jim McDermott (D, WA), a former psychiatrist, on the Affordable Care Act (ACA); and representatives from the EPA and AMA.

Richard Robbins, Arizona CCR representative, and Ann Schneidman, RN from Hospice of the Valley, along with Dale Dirks from the ATS and Dr. Christine Fukui from Hawaii traveled to the Congressional offices. The group met with several representatives from the Arizona Congressional Delegation including:

  • Rep. Ben Quayle (R-AZ-3) and Rachel Dresen, Rep. Quayle’s legislative director
  • Rep. Raúl Grijalva (D-AZ-7) and Kelsey Mishkin, Rep. Grijalva’s legislative assistant
  • Cassie Sonn, legislative assistant office of Rep. David Schweikert (R-AZ-5)
  • Judith Gheuens, health counsel to the office of Sen. Jon Kyl (R-AZ)
  • Greg Kuhn, legislative correspondent office of Sen. John McCain (R-AZ)

Four issues were discussed and ATS handout on each was presented:

The Council of Chapter Representatives (CCR) met on Thursday, March 29. Nine attendees and 3 ATS staff were in attendance with one representative participating by conference call. The meeting was called to order at 9:00 AM by Dona Upson, Chair CCR.

The ATS President’s address was given by Nick Hill, ATS President 2011-2. His remarks included a discussion of ATS goals including the ATS’ new emphasis on advocacy.

An advocacy update was presented by Gary Ewart, ATS Government Relations.  

Eric Yeager, from Colorado, was selected for the ATS Outstanding Clinician Award for 2012. Our own Al Thomas was one of the finalists along with Mitchell Rashkin from Ohio.

CCR business discussions included:

  • Committee Updates
  • CCR Representatives on Committees for 2012-3
  • A report from Dona Upson on the new requirements for recertification by the American Board of Internal Medicine (not yet announced) which will take effect on January, 2013. ATS is striving to meet those requirements beginning with the ATS 2012 International Meeting.
  • Renaming of Wegner’s granulomatosis
  • An announcement that it will shortly be possible for members to change their identifier information (telephone, address, e-mail, etc.) on the ATS website.

The meeting was adjourned at 11:30 AM.

Richard A. Robbins, MD

Arizona, CCR Representative

Reference as: Robbins RA. March 2012 "Hill Day" and Council of Chapter Representatives meeting notes. Southwest J Pulm Crit Care 2012;4:69-70. (Click here for PDF version)

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March 2012 Arizona Thoracic Society Notes

The March 2012 Arizona Thoracic Society meeting was held on 3/20/2012 at Scottsdale Shea beginning at 6:30 PM. There were 21 in attendance representing the pulmonary, allergy, radiology, and thoracic surgery communities.

Dr. Allen Thomas, the Arizona nominee for ATS Clinician of the Year, was recognized. Voting for will be on 3/29/2012 at the ATS Council of Chapter Representatives meeting in Washington, D.C.

Multiple cases were presented:

1. Dr. George Parides presented a case of 46 year old female who complained of mild shortness of breath. A chest x-ray revealed a large left pleural effusion. Thoracentesis showed that the fluid was an exudate but cytology and cultures were negative. A repeat chest x-ray showed a large left lower lobe mass and a CT scan showed a 24X21 cm mass in the left lower chest. Surgical resection was performed and was a benign fibrous tumor of the pleura on histology. Discussion ensued that there have been several of these reported at the Arizona Thoracic Society and perhaps these are not as rare as commonly thought. Rick Helmers pointed out that these tumors can be associated with hypoglycemia.

2. Gerald Swartzberg presented on diaphragmatic paralysis. The initial sniff test had been negative but a repeat was positive. Discussion ensued about the sensitivity and specificity of the sniff test. Although no one could recall specific numbers, most thought that the sniff test was fairly good. This evolved into a discussion of the usefulness of diaphragmatic placation (render the flaccid hemidiaphragm taut by oversewing the membranous central tendon and the muscular components of the diaphragm) and how long to wait for phrenic nerve generation before performing placation.

3. John Roehrs presented a case of 75 yo rock miner from Globe who had very severe oxygen dependent COPD and pulmonary hypertension. He was found to have a lung nodule which was followed and increased in size after 6 months and was now 2 cm. PET scan showed the nodule to have increased uptake of about 2.8 SUV. Treatment of the patient was extensively discussed. Most thought that an operative intervention was contraindicated because of his COPD and pulmonary hypertension. Obtaining a coccidioidomycosis serology was suggested although most thought this likely a lung cancer. Following the patient without intervention was suggested by most.

4. Dr. Swartzberg presented a second case of a 32 year old Filipino man who was referred by a dermatologist had biopsied a skin lesion on the chest and found coccidioidomycosis. He was treated for 6 months with fluconazole and the coccidioidomycosis complement fixation tests had been 1:2 to 1:4. Al Thomas pointed out that he had seen several patients with apparent direct inoculation into the skin. Discussion ensued about how long to treat coccidioidomycosis in this situation. Although there was agreement that there was no data available, most advocated longer rather than shorter treatment.

There being no further cases, the meeting was adjourned at 8:00 PM. The next meeting is scheduled for April 17.

Richard A. Robbins, M.D.

Reference as: Robbins RA. March 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;4:67-8. (Click here for a PDF version of the Notes)

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February 2012 Arizona Thoracic Society Notes

The February Arizona Thoracic Society meeting was held on 2/21/2012 at Scottsdale Shea beginning at 6:30 PM. There were 25 in attendance representing the pulmonary, radiology, and thoracic surgery communities.

A presentation on elevated IgE was given by Dr. Cristian Jivcu a second year pulmonary fellow at the Good Samarian/VA program to follow up the two cases presented last month Dr. Swartzberg. (Click here for the slides used in the presentation)

Multiple cases were presented:

Dr. Gerald Swartzberg presented two cases. The first was an 86 yo with an enlarging mass in the right lower chest. Biopsy had previously revealed the mass to be a benign spindle cell tumor. There was no invasion of the chest wall or evidence of metastases consistent with the tumor’s benign pathology. Despite the tumor appearing to occupy nearly ¼ of the lower chest, the patient was asymptomatic. Most continued observation although thoracic surgery thought it could be safely debulked.

The second case presented by Dr. Swartzberg was a 58 yo with a pulmonary embolism who had been anticoagulated for 6 years. Unfortunately, the patient had a recurrent embolism after the anticoagulation was stopped. The patient is now back on anticoagulation and asymptomatic but had a removable inferior vena cava filter placed. Discussion centered on whether it was appropriate to remove the filter. None knew of a randomized trial and no consensus could be reached.

Dr. Cristian Jivcu presented a case of a 52 yo patient with ulcerative colitis who initially presented at another VA with shortness of breath and fever. Work up eventually resulted in VATS lung biopsy which revealed organizing pneumonia. The patient was started on corticosteroids and transferred to the Phoenix VA where he was admitted and became increasingly short of breath. CT scan revealed a “reverse halo” sign. A routine blood gas detected 12% methemoglobin. At that time it was discovered the patient had been started on dapsone for PCP prophylaxis. The symptoms improved when the dapsone was stopped.

Dr. Syed Zaidi presented two cases from Maricopa Medical Center. The first was a 36 yo with a 2 week history of cough and fever. Chest X-ray was thought to be abnormal in the right lower chest and for this reason a CT scan was ordered. An interlobar pulmonary sequestration was discovered with the blood supply arising from below the diaphragm. Discussion centered on whether the sequestered lung should be removed.

Dr. Zaidi’s second case as a 23 yo with AIDS and a past medical history of pneumocystis pneumonia, Kaposi’s sarcoma and Candida infection who presented with severe cough. CT scan showed adenopathy in the mediastinum and scattered groundglass opacities. Bronchoscopy showed an ulcerating mass in the right bronchus intermedius. Biopsy revealed Mycobacterium avium-intracellulare. Dr. Zaidi’s literature review revealed that endobronchial lesions secondary to M. avium-intracellulare had previously been reported in AIDS and other immunocompromised patients.  

There being no further business the meeting adjourned at 8:00 PM. The next meeting will be on Tuesday, March 20, 6:30 PM at Scottsdale Shea.

Richard A. Robbins, M.D.

Reference as: Robbins RA. February 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;4:40-1. (Click here for a PDF version of the Notes)

 

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January 2012 Arizona Thoracic Society Notes

The January Arizona Thoracic Society meeting was held on 1/11/2012 at Scottsdale Shea beginning at 6:30 PM. There were 30 in attendance representing the pulmonary, radiology, thoracic surgery and allergy communities.

Al Thomas was voted to be clinician of the year nominee from Arizona.

A progress report for 2011 was given by Rick Robbins on the Southwest Journal of Pulmonary and Critical Care (for a summary of the presentation click here).

Multiple cases were presented:

  1. George Parides presented a 64 year old with a second PPD which was positive. A discussion regarding interpretation of PPDs ensued.
  2. Gerald Swartzberg presented two cases-both had in common a markedly elevated IgE level. These cases created a discussion of the differential diagnosis of an elevated IgE and how to approach patients with this laboratory abnormality.
  3. Paul Conomos presented 2 cases. One was a patient with a pericardial cyst and the other a subcarinal mass. Discussion centered on how to manage patients with asymptomatic subcarinal masses.
  4. Cristian Jivcu presented a case of a left upper lobe 7 cm mass. Bronchoscopy with bronchoalveolar lavage was negative. The patient was followed with complete resolution.
  5. Henry Luedy presented a 79 yo with an interstitial lung disease probably secondary to chronic aspiration for 5 years with complete radiologic resolution.
  6. Joshua Jewell presented a case of pneumonia with empyema. Rather than decoritcation the patient was treated with thoracostomy drainage and TPA and DNAase with complete resolution over several weeks.
  7. Manny Mathew followed with a similar case of a pleural effusion treated with TPA which also resolved. Discussion occurred on when it was appropriate to treat patients conservatively with chest tube drainage compared to aggressively with decortication.

There being no further business the meeting adjourned at 8:00 PM. The next meeting will be on Tuesday, February 21, 6:30 PM at Scottsdale Shea.

Richard A. Robbins, M.D.

Reference as: Robbins RA. January 2012 Arizona thoracic society notes. Southwest J Pulm Crit Care 2012;4:4. (Click here for a PDF version of the Notes)

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November 2011 Arizona Thoracic Society Notes

The November Arizona Thoracic Society meeting was held on 11/8/2011 at Scottsdale Shea beginning at 6:30 PM. There were 22 in attendance representing the pulmonary and radiology communities.

Three cases were presented:

1. Henry Luedy, a pulmonary fellow from Good Samaritan/VA, presented a case of Lemiere’s disease. Lemierre's disease is a form of thrombophlebitis usually caused by Fusobacterium and usually affects young, healthy adults. Lemierre's disease develops most often after a sore throat caused by some bacterium of the Streptococcus genus has created a peritonsillar abscess. Deep in the abscess, anaerobic bacteria which are part of the normal oral flora such as Fusobacterium can flourish. These anaerobic bacteria penetrate from the abscess into the neighboring jugular vein in the neck and there they cause sepsis or septic emboli.

2. Alexis Christie, a pulmonary fellow at the Mayo Clinic, presented an unusual case of pulmonary embolism. Discussion centered on unusual presentations of pulmonary embolism.

3. Rick Robbins presented a case of lymphocytic interstitial pneumonia developing in a man with long standing systemic lupus erythematosis.

At the end of the case presentations, George Parides was elected the new Arizona Thoracic Society president. He thanked the outgoing president, Rick Helmers, for his service. Rick will be leaving for Chicago at the end of November.

A discussion of the goals and objectives of the Arizona thoracic society ensued. Jud Tillinghast raised the possibility of an educational meeting involving physicians with interest in pulmonary, critical care and sleep medicine throughout the Southwest. Many thought such a meeting might be valuable. Dr. Robbins will contact members of the pulmonary community and determine if there is any interest.

There being no being further business the meeting was adjourned at 7:45. The next meeting is scheduled for Wednesday, January 11, 2012, at Scottsdale Shea. Meetings are scheduled for 10 months of 2012 as follows:

Wednesday, January 11

Tuesday, February 21

Tuesday, March 20

Tuesday, April 17

Tuesday, May 15

Tuesday, June 19

No meeting in July

Tuesday, August 21

Tuesday, September 18

Tuesday, October 16

Tuesday, November 20

No meeting in December.

 

Richard A. Robbins, M.D.

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October 2011 Arizona Thoracic Society Notes

The October Arizona Thoracic Society meeting was held on 10/18/2011 at Scottsdale Shea beginning at 6:45 PM. There were 17 in attendance representing the pulmonary and radiology communities.

Prior to the case presentations, a discussion was initiated by Ewa Lupa-Laskus regarding the usefulness of procalcitonin, particularly in the ICU. The consensus of the group was that, although it was of moderate sensitivity and specificity, it added to the armamentarium for clinical decision-making, particularly regarding continuing or stopping antibiotics. Numerous physicians reported difficulty in getting laboratories to run the test. Strategies were discussed regarding how to obtain this test sufficiently quickly to be clinically useful.

It was discussed why the attendance was low. Part of this was attributed to cancellation of the September meeting because of a last moment loss of sponsorship. However, we now have sponsorship through 2012. It was felt that an e-mail reminder, either the day before or the day of the meeting, might improve attendance. Also, a newsletter summarizing the meeting, publications in the Southwest Journal of Pulmonary and Critical Care, appropriate announcements, etc were thought to be good ideas. This will be distributed by e-mail through Mary Kurth.

Two cases were presented by Lewis Wesselius from the Mayo Clinic:

A 22-year-old woman was referred after developing respiratory failure over 2 weeks. She was intubated because of respiratory failure. Thoracic CT revealed “crazy paving,” which is characteristic finding in pulmonary alveolar proteinosis (PAP). It consists of patchy, bilateral geographic areas of ground-glass opacity associated with interlobular septal thickening. Although the CT scan was suggestive, it was not diagnostic of PAP but a prior lung biopsy was consistent with the diagnosis. For this reason the patient underwent whole lung lavage and was begun on GM-CSF. She improved, was extubated and discharged from the hospital. A serum anti-GM-CSF antibody returned positive. Although she improved, she was unable to continue the GM-CSF therapy because for financial reasons.  She had recurrence of her disease requiring lung lavage but did not improve to the extent she had previously. Discussion centered on diagnosis and management of PAP.

2.   A late middle-aged man with an incidental finding on chest x-ray

A 61-year-old man was seen in the ER because of chest pain. This was not cardiac in origin and spontaneously resolved. Pulmonary function testing revealed a reduction in the DLCO and a thoracic CT for pulmonary embolism showed typical crazy paving. Lung biopsy was typical of PAP.  Although GM-CSF therapy was offered, the patient refused because he was asymptomatic. His DLCO spontaneously improved, follow up thoracic CT showed improvement in ground-glass opacity and associated interlobular septal thickening, and he remains well without therapy.

At the end of the case presentations, George Parides presented a plaque to the president of the Arizona Thoracic Society, Rick Helmers, thanking him for his service. Rick will be leaving for Chicago at the end of November.

There being no being further business the meeting was adjourned at 7:45. The next meeting is scheduled for Tuesday, November 8, at Scottsdale Shea.

Richard A. Robbins, M.D.

Michael B. Gotway, M.D.

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August 2011 Arizona Thoracic Society Notes

The August Arizona Thoracic Society was held on 8/16/2011 at Scottsdale Shea beginning at 6:55 PM. There were 25 in attendance representing the pulmonary, radiology, and surgery communities.

Nine cases were presented:

1. Spontaneous Pneumothorax Secondary to Aspergilloma

Jud Tillinghast and Michael Caskey presented a case of a 65-year-old man with right upper lobe pneumonia on chest x-ray who was asymptomatic. Repeat chest x-ray showed resolution of the pneumonia, however, shortly afterwards he presented with a large right pneumothorax. CT scan of the chest showed right apical cystic changes and some areas of ground glass densities in the right upper lobe. A video-assisted thoracotomy was performed and a whitish fibrotic mass was viewed at the right apex. This was resected. Pathology revealed Aspergillus species. The patient was placed on voriconazole and made an uneventful recovery.  Drs. Tillinghast and Caskey hypothesized that one of the cystic lesions at the right apex developed an Aspergilloma and eventually ruptured causing the pneumothorax. A discussion of how long to continue the voriconazole ensued.

2. Young Woman with Hypoxemia and Hemoptysis.

Paul Conomos presented a second case of a 21-year-old woman who presented with shortness of breath, cough and hemoptysis. Her SpO2 was 87% and a CXR revealed a left lung tubular-shaped density with an enlarged left pulmonary artery. CT angiography showed several large arteriovenous (AV) malformations in the left lower lobe with several smaller lesions. The lesion was successfully embolized by coiling and the patient’s SpO2 improved to 98%.

3. Chest Masses in Identical Twins.

Dr. Conomos presented a second case of a 71-year-old woman found to have an approximate 5 cm right upper lobe mass with smaller right upper and left lower lobe nodules Biopsies of the larger right upper lobe mass and the left lower lobe nodule both revealed adenocarcinoma. Shortly thereafter, the patient’s identical twin also presented with a right middle lobe nodule- also adenocarcinoma (with bronchioloalveolar features), as well as several other suspicious-appearing pulmonary nodules, 

4. Slowly Growing Lung Mass.

Dr. Conomos presented a third case of a right lower lobe mass which was slightly enlarged compared to a previous chest x-ray in 2006. Positron emission tomography (PET) scanning showed a standardized uptake value (SUV) of 26. Needle biopsies were twice nondiagnostic. Resection revealed inflammatory  myofibroblastic tumor, also known as an inflammatory pseudotumor or plasma cell granuloma.

5. Severe Bronchiolitis Obliterans (Swyer-James Syndrome) in a 33-Year-Old.

David August presented the case of a 33-year-old man who complained of cough and had localized left upper lobe cystic bronchiectasis on chest x-ray. CT scanning also revealed left lower pulmonary artery atresia or obliteration. Discussion focused on the association of the pulmonary artery atresia / obliteration and the focal bronchiectasis.

6. Innumerable Pulmonary Cysts.

Henry Leudy and Allen Thomas presented a 63-year-old pipe smoker with a previous history of anal carcinoma who became short of breath after borrowing some bad tobacco from a friend. Chest x-ray revealed innumerable pulmonary cysts, as did thoracic CT. Images of the lung bases obtained from an abdominal CT performed in 2007 when the patient underwent resection of a 9 cm anal adenocarcinoma was unremarkable. Transbronchial biopsy showed adenocarcinoma consistent with metastatic disease. Most felt this was a very unusual radiographic appearance for metastatic disease.

7. Calcification Within a Carcinoid Tumor.

Dr. Thomas presented a second case of a 57-year-old with a tubular mass with calcification Bronchoscopy revealed a fleshy tumor in the right lower lobe bronchus which proved to be carcinoid on histological examination. Dr. Thomas presented a series that calcification was not unusual in carcinoid tumors.

8. Anti-Inflammatory Therapy for Radiation Pneumonitis.

Thomas Ardiles presented a case of a 72-year-old man who developed cough while receiving radiation therapy for mesothelioma.  His chest x-ray was compatible with radiation pneumonitis and he was begun on high dose prednisone. However, he developed mental status changes and was begun on azathioprine as the steroids were tapered without improvement. He was subsequently begun on azithromycin because of the drug’s anti-inflammatory effects with resolution of his symptoms.

9. Multiple Lung, Soft Tissue and Brain Lesions in a Patient Receiving Interferon for Hepatitis B.

Dr. Ardiles presented a second case of a 31-year-old that developed multiple bilateral small lung nodules and some scattered cutaneous and subcutaneous nodules which were noted on CT scanning. Two months later a follow up CT showed some resolution of the nodules, but most were unchanged. However, because he was complaining of headaches, brain MRI was performed and showed multiple small lesions also. Biopsy of one of the soft tissue lesions revealed cysticercosis which is due to the eggs of Taenia solium, the pork tapeworm.

The meeting adjourned at 8:30 PM.

Richard A. Robbins, MD

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Rick Robbins, M.D. Rick Robbins, M.D.

June 2011 Arizona Thoracic Society Notes

The June Arizona Thoracic Society was held on 6/21/2011 at Scottsdale Shea beginning at 6:55 PM. There were thirteen in attendance representing the pulmonary, radiology, and surgery communities.

Five cases were presented:

1. Jon Ruzi presented a case of an intravascular foreign body detected at chest radiography, found to represent a fractured strut from an inferior vena cava filter. The patient presented with a linear metallic foreign body on a chest radiograph, new from 2 years earlier. The dictated report suggested and airway foreign body, but the patient’s complex hospitalization at St. Joseph’s Medical Center, between time of the radiograph showing the abnormality and the prior showing nothing raised the possibility of an intravascular foreign body. Retrieval undertaken at St. Joseph’s confirmed an embolized strut from a fractured inferior vena cava filter. Much discussion ensued regarding this occurrence, with Judd Tillinghast indicating a recent paper showed a 10% incidence of such of an event, but the group concurring that the real life frequency must be substantially less.

2. Dr. Ruzi also presented an adenocarcinoma of the right lower lobe in a patient with scleroderma. A patient with scleroderma and lung involvement presented with persistent cough and non-resolving right lower lobe consolidation. CT showed findings consistent with non-specific interstitial pneumonia, with more focal right lower lobe opacity consisting of smooth interlobular septal thickening and intralobular interstitial thickening. The focal nature of the process is inconsistent with scleroderma-related lung disease. Bronchoscopy showed adenocarcinoma. The group noted that the pattern of carcinoma in this case is consistent with what has been previously referred to as bronchoalveolar carcinoma, particularly when the latter presents as a pneumonia-like process. The CT findings suggest that the disease is localized and potentially amenable to resection. The patient has been referred to oncology.

3. Dr. Ruzi presented a third case of an infection with coccidioidomycosis and actinomycosis, presenting as a complex cavitary lesion associated with nodules. A 39-year-old man with diabetes and untreated sleep apnea presented with a slowly enlarging right apical opacity on chest radiography. CT was performed and showed that the cavity had significantly complex internal architecture, suggesting a tissue invasive process. Small nodules in the right upper lobe suggested additional foci of granulomatous infection; the process appeared suggestive of an invasive fungal infection. Serologies indicate recent coccidioidomycosis infection, and bronchoscopy also recovered Actinomyces. Much discussion ensued regarding the accuracy of serologies and optical density testing for coccidioidomycosis infection among the various facilities that perform such testing. The group seemed to include that both infections may be at play in this patient.

4. Ewa Lupa-laskus presented older woman presented with a history of aspirating a calcium pill. Due to social factors, she delayed presenting to her physician (she wanted to attend a relative’s wedding). Thoracic CT sowed a high density structure, consistent with a calcium tablet, in the bronchus intermedius. The tablet was easily removed with bronchoscopic retrieval, but review of the coronal images on CT showed two tablets adjacent to one another (the patient did not remember aspirating the first tablet). The second tablet was much more difficult to remove, requiring over one hour. Extensive discussion regarding various methods for bronchoscopic removal of airway foreign bodies took place. Al Thomas concluded that a loop snare provides the best results.

5. Andy Goldstein presented an older woman with ovarian carcinoma and a large left pleural effusion presented for a clinical trial for chemotherapy. Prior to study, the patient underwent chest-abdomen-pelvis CT scanning, which showed that the large left pleural effusion now contained pockets of gas. Thoracentesis had been performed recently, but not between the scan showing pleural fluid only and the follow up scan showing hydropneumothorax. The patient’s enrollment in the clinical trial was put on hold, pending investigation. The group postulated that infection could have been introduced at the time of first thoracentesis but not taken hold until the time of the second scan. The patient remains asymptomatic. This raised the question that how likely is it that a patient could be comparatively asymptomatic but be harboring an anaerobic infection? The group concluded that such patients have been seen and further investigation with sampling / pleural fluid drainage is warranted

The meeting adjourned at 8:05 PM.

Michael B. Gotway, MD

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