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Arizona Thoracic Society Notes

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November 2018 Arizona Thoracic Society Notes
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December 2013 Arizona Thoracic Society Notes
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October 2013 Arizona Thoracic Society Notes
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August 2013 Arizona Thoracic Society Notes
July 2013 Arizona Thoracic Society Notes
June 2013 Arizona Thoracic Society Notes
May 2013 Council of Chapter Representatives Notes
May 2013 Arizona Thoracic Society Notes
April 2013 Arizona Thoracic Society Notes 
March 2013 Arizona Thoracic Society Notes
March 2013 Council of Chapter Representatives Meeting 
and “Hill Day” Notes
February 2013 Arizona Thoracic Society Notes
January 2013 Arizona Thoracic Society Notes
November 2012 Arizona Thoracic Society Notes
October 2012 Arizona Thoracic Society Notes
September 2012 Arizona Thoracic Society Notes
August 2012 Arizona Thoracic Society Notes
August 2012 Special Meeting Arizona Thoracic Society Notes
June 2012 Arizona Thoracic Society Notes
May 2012 Council of Chapter Representatives Meeting
May 2012 Arizona Thoracic Society Notes

 

For a complete list of the Arizona Thoracic Society notes click here.

The Arizona Thoracic Society meets every other month in Phoenix, usually on the fourth Wednesday of odd numbered months, from 6:30-8:00  PM at Scottsdale Healthcare Shea Hospital located at Shea and 90th Street in Phoenix. During these meetings dinner and case presentations occur.

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Thursday
Aug092012

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.

Thursday
Jun282012

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)

Sunday
May202012

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)

Friday
May182012

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)

Wednesday
Apr182012

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)