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Arizona Thoracic Society Notes

Last 50 Postings

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November 2018 Arizona Thoracic Society Notes
September 2018 Arizona Thoracic Society Notes 
July 2018 Arizona Thoracic Society Notes
March 2018 Arizona Thoracic Society Notes
January 2018 Arizona Thoracic Society Notes
November 2017 Arizona Thoracic Society Notes
September 2017 Arizona Thoracic Society Notes
March 2017 Arizona Thoracic Society Notes
January 2017 Arizona Thoracic Society Notes
November 2016 Arizona Thoracic Society Notes
July 2016 Arizona Thoracic Society Notes
March 2016 Arizona Thoracic Society Notes
November 2015 Arizona Thoracic Society Notes
September 2015 Arizona Thoracic Society Notes
July 2015 Arizona Thoracic Society Notes
May 2015 Arizona Thoracic Society Notes
March 2015 Arizona Thoracic Society Notes
January 2015 Arizona Thoracic Society Notes
November 2014 Arizona Thoracic Society Notes
September 2014 Arizona Thoracic Society Notes
August 2014 Arizona Thoracic Society Notes
June 2014 Arizona Thoracic Society Notes
May 2014 Arizona Thoracic Society Notes
April 2014 Arizona Thoracic Society Notes
March 2014 Arizona Thoracic Society Notes
February 2014 Arizona Thoracic Society Notes
January 2014 Arizona Thoracic Society Notes
December 2013 Arizona Thoracic Society Notes
November 2013 Arizona Thoracic Society Notes
October 2013 Arizona Thoracic Society Notes
September 2013 Arizona Thoracic Society Notes
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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Friday
Jul292016

July 2016 Arizona Thoracic Society Notes

The July 2016 Arizona Thoracic Society meeting was held on Wednesday, July 27, 2016 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 14 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

Prior to the case presentations, a discussion was held on 4 issues. First, Dr. Rick Robbins  gave a summary of ATS Hill Day. During Hill Day a presentation was given by a representative from the Campaign for Tobacco-Free Kids. Their web site lists tobacco company contributions to members of Congress on their web site. Dr. Gary Ewart from the ATS office in Washington gave a presentation on the Traditional Cigar Manufacturing and Small Business Jobs Preservation Act before Congress (aka the Cigar Bill) which the ATS opposes. He noted that cosponsors for the bill included several Congressmen from Southwestern states. Dr. Robbins combined the two sets of data to see if there was a correlation between the tobacco company contributions and cosponsorship of the Cigar Bill. There was a highly significant correlation and Dr. Robbins asked the group if they felt this data was worthy of publication in the SWJPCC. The consensus was that Dr. Robbins should write an article and send it out for review.

Second, the Arizona Hospital Executive Compensation Act 2016 was discussed. This is an Arizona state proposition to limit hospital executive pay to $450,000/year which was circulated by Service Employees International Union and submitted to the Arizona Secretary of State to include on the November ballot. Although the required number of signatures were present, the validity of those signatures is being challenged by Arizona Chamber of Commerce. The Arizona Hospital and Healthcare Association said a cap on executive pay would "harm healthcare and hurt patients.“ Dr. Robbins asked if a survey through the SWJPCC should be conducted to determine whether the act would harm patients. After discussion, the Arizona Thoracic Society asked Dr. Robbins to conduct the survey the report on the results.  

Third, a discussion was held on Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The ATS along with other groups has been asked for input for quality measures. However, Rep. Kevin Brady (R-Texas), chairman of the House Ways and Means Committee, was recently quoted by Medpage Today as saying “MACRA is a good law, but I'm frustrated with the implementation…The heart of this [was supposed to be] how do you measure quality? Should we measure it from Washington, or measure the best practice of what is occurring in that region or in those physician practices?” (1). After discussion and noting that many previous quality measures are not evidence based, the Arizona Thoracic Society thought that local input was important. Dr. Robbins is to ATS CCR representatives from the Southwest and to report to a committee consisting of Dr. Wesselius, Parides and Robbins to determine how best to voice the Arizona Thoracic Society's input into determining quality measures.

Lastly, Dr. Parides moved to name Dr. Lewis Wesselius as the Arizona Thoracic Society clinician of the year. This was unanimously approved.

Dr. Lewis Wesselius presented a 52-year-old woman with a past renal transplant for eclampsia and hypertension who presented with a low grade fever 38.2º C and a right upper lobe mass. Her coccidioidomycosis serology was negative. Bronchoscopy with bronchoalveolar lavage was performed but was initially non-diagnostic.

After bronchoscopy, the mass markedly enlarged but the patient refused further diagnostic studies since despite her worsening radiologic appearance, she felt somewhat better. Her Legionella serology subsequently returned positive as did her Legionella culture from her bronchoscopy. She was treated with levofloxacin and markedly improved.

Dr. Gerry Swartzberg presented two cases of positive Gold Quantiferons in an asymptomatic 76 year old woman whose father had tuberculosis and a 35 year drug addict. After discussion, the consensus was not to treat the elderly woman but treat the younger drug addict.

Dr. George Parides again asked for input on bringing more young people into the Arizona Thoracic Society. Several suggestions were given and several members said they would contact the local fellowship directors.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, September 28, 2016 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

Cite as: Robbins RA. July 2016 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2016;13(1):38-9. doi: http://dx.doi.org/10.13175/swjpcc071-16 PDF

Thursday
Mar242016

March 2016 Arizona Thoracic Society Notes

The March 2016 Arizona Thoracic Society meeting was held on Wednesday, March 23, 2016 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 17 in attendance representing the pulmonary, critical care, sleep, and radiology communities. Of note, Dr. Elijah Poulos drove from Flagstaff to attend the meeting.

Dr. Rick Robbins gave a summary of ATS Hill Day and the possibility of collecting dues for the Arizona Thoracic Society along with American Thoracic Society dues. Dr. Robbins also presented the results of emailing the Table of Contents of the Southwest Journal of Pulmonary and Critical Care to the ATS members in Arizona, New Mexico, Colorado, and Nevada along with listing the contents in Inspirations the California Thoracic Society newsletter. The number of page views doubled over usual the following day.

Dr. George Parides presented a short presentation on whether coccidioidomycosis nodules in the setting of biologics for rheumatoid arthritis should receive fluconazole and the new coccidioidomycosis skin test under development.

Dr. Lewis Wesselius presented a plaque to Dr. Robbins who was voted 2016 Arizona Thoracic Society clinician of the year (Figure 1).

Figure 1. Dr. Lewis Wesselius (left) presenting a plaque to Dr. Rick Robbins.

There were 5 case presentations:

  1. Dr. George Parides presented a 67-year-old man with a thin walled cavity and positive coccidioidomycosis serology who was unable to tolerate fluconazole and voriconazole. There were several possible therapies suggested including posaconazole or resection of the cavity.
  2. Dr. Elijah Poulos presented a case of 44-year-old woman who had occupational exposure to mineral spirits and presented with a chronic dry cough. Chest x-ray showed bilateral apical infiltrates. Thoracic CT scan confirmed the presence of the infiltrates which appeared lobular. Physical examination and laboratory evaluation including induced sputum specimens were unrevealing. A bronchoscopy with bronchoalveolar lavage and transbronchial biopsy were performed. The biopsy was consistent with acute eosinophilic pneumonia. Because her cough and CT scan were improving no therapy was given. A follow-up CT scan showed resolution of the apical consolidations but a new rounded 4 cm area of consolidation but her cough has resolved and she is now asymptomatic. The group suggested several possibilities including possible lipoid pneumonia or possible cryptogenic organizing pneumonia. The majority felt that following the patient was the most appropriate course of action.
  3. Dr. Paul Conomos presented a case of a 43-year-old man who had an incidental finding of a vessel in the left lower lung originating from the abdominal aorta.  The abdominal CT scan was performed for abdominal pain which quickly resolved. He had no respiratory symptoms. It was that this was likely a pulmonary sequestration and discussions with invasive radiology to better define the vascular supply and thoracic surgery for possible resection  might be useful.
  4. Dr. Lewis Wesselius presented a case of an 65-year-old woman who presented to her gastroenterologist with anemia and some weight loss. A thoracic CT scan was performed which suggested a tracheal abnormality, possibly a tracheal wall lesion. Bronchoscopy showed a smooth indentation in the trachea with a yellowish discoloration. A similar yellowish area was seen near the main carina. Biopsies were performed. Congo red stain was positive consistent with amyloidosis.
  5. Dr. Allen Thomas presented a 62-year-old man with symptoms of an upper respiratory infection beginning in January who improved sufficiently that he rode his motorcycle near Bagdad, AZ this month. He rode through a dust storm and subsequently developed dyspnea, cough and gray sputum production. Laboratory evaluation in an emergency department showed a pO2 of 60 on room air but was otherwise unremarkable. He was seen in pulmonary consolidation a few days later. Thoracic CT scan showed subpleural areas of ground glass and consolidation. The patient was asymptomatic by this time and declined biopsy. The group suggested following the patient with a repeat thoracic CT scan. It was suggested that this could possibly be a case of acute eosinophilic pneumonia.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, May 25,2016 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

Cite as: Robbins RA. March 2016 Arizona thoracic society ntoes. Southwest J Pulm Crit Care. 2016 Mar;12(3):112-3. doi: http://dx.doi.org/10.13175/swjpcc029-16 PDF

Thursday
Nov192015

November 2015 Arizona Thoracic Society Notes

The November 2015 Arizona Thoracic Society meeting was held on Wednesday, November 18, 2015 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 14 in attendance representing the pulmonary, critical care, sleep, and radiology communities. 

There were 3 case presentations:

  1. Dr. Gerald Schwartzberg presented a case of a 56-year-old man with a history of diabetes, alcoholism and tobacco abuse who has a history of Mycobacterium avium-intracellulare (MAI) with a residual thin-walled cavity in his right upper lobe (RUL). After quitting drinking and smoking and years of being asymptomatic, he presented with hemoptysis. Chest x-ray showed increasing density in the RUL. CT scan showed an intracavitary density in his previous cavity presumably a fungus ball. Sputum cultures are pending. Discussion followed on management of fungus balls. Bronchoscopy was recommended to view the bronchial anatomy to exclude other diagnosis as well as obtaining additional cultures. The consensus of the group was operative intervention if possible. If not, bronchial artery embolization was offered as an alternative.
  2. Dr. Schwartzberg presented a second case of a middle-aged woman with a past history of Valley Fever who was treated and left with a negative serology and a pulmonary nodule. She has developed rheumatoid arthritis and is being considered for biological therapy. The question was whether she should received fluconazole during therapy. No one knew of any data but the group advised caution and suggested fluconazole during immunosuppressive therapy.
  3. Dr. Lewis Wesselius presented a case of an 18-year-old with a prior diagnosis of Ehlers-Danlos syndrome. CT scan revealed multiple lung cysts. Dr. Wesselius reviewed Ehlers-Danlos syndrome and congenital pulmonary airway malformations (CPAM) (1,2). CPAM, previously known as congenital cystic adenomatoid malformation, is a developmental lesion of the lung comprising single or multiple cysts of uniform or varying sizes arising from anomalous growth of airways. Most of the cases are identified in infants and neonates with respiratory distress. Rarely, CPAM can present in adulthood with recurrent chest infections, pneumothorax, hemoptysis, or dyspnea. Dr. Michael Gotway showed CT scans of several additional patients.

There being no further business, the meeting was adjourned about 7:45 PM. The next meeting will be in Phoenix on Wednesday, January 27,2016 at 6:30 PM. A change of venue was discussed and will be announced prior to the meeting.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Dowton SB, Pincott S, Demmer L. Respiratory complications of Ehlers-Danlos syndrome type IV. Clin Genet. 1996;50(6):510-4. [CrossRef] [PubMed]
  2. Baral D, Adhikari B, Zaccarini D, Dongol RM, Sah B. Congenital pulmonary airway malformation in an adult male: a case report with literature review. Case Rep Pulmonol. 2015;2015:743452. [CrossRef] [PubMed] 

Cite as: Robbins RA. November 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;11(5):233-4. doi: http://dx.doi.org/10.13175/swjpcc143-15 PDF

Thursday
Sep242015

September 2015 Arizona Thoracic Society Notes

The September 2015 Arizona Thoracic Society meeting was held on Wednesday, September 23, 2015 at the Scottsdale Shea Hospital beginning at 6:00 PM. This was a dinner meeting with case presentations. There were 13 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

There were 6 case presentations:

  1. Dr. Gerald Schwartzberg presented a case of a 58-year-old woman with a history of Mycobacterium avium presented with cough and malaise. CT revealed a history of lower love centrilobular nodules and scattered ground glass opacities and some bronchiectasis. Sputum revealed Aspergillus fumigatus. IgE was normal but IgA was deficient at 20 mg/dl (normal 80-350 mg/dl). She was started on itraconazole and clinically improved. Many questioned whether the Aspergillus was the cause of her pneumonia and some questioned the association of the IgA deficiency with her overall clinical picture.
  2. Dr. Schwartzberg presented a second case of a 92-year-old former opera singer who had a past diagnosis of asthma but without airflow obstruction, gastroesophageal reflux disease, and myelodysplastic syndrome. CT scan revealed mosaic areas most consistent with hypoperfusion secondary to air trapping. Complete pulmonary function testing revealed only a markedly decreased DLco. She had oxygen desaturation with exercise. Clinically she did not respond to a bronchodilator. Most were perplexed as the cause of her overall clinical picture.
  3. Dr. Schwartzberg presented a third case of a morbidly obese 61-year-old woman who presented with shortness of breath. CT scan showed some scattered lung nodules in her lower lobes. Laboratory evaluation including cocci serologies were negative. A needle biopsy of one of the lung nodules was nondiagnostic and she was empirically begun on fluconazole. She clinically improved. Many thought this could be possibly Valley fever and she should be followed.
  4. Dr. Alan Thomas presented a 66-year-old man with a history of lymphoma about 10 years earlier who presented with some enlarging lymph nodes. Thoracic CT scan was performed as part of his evaluation and showed some areas of emphysema with scattered ground glass opacities. It was felt the radiologic pattern was most consistent with respiratory bronchiolitis with fibrosis (2).
  5. Dr. Thomas also presented a case of an 82-year-old former smoker who quit about a year ago who presented with weight loss and minimal cough. Thoracic CT scan showed a large pleural mass with pleural effusion surrounding the right lung as well as pleural plaques. He did have a history of asbestos exposure in the Navy. Thoracentesis showed a nondiagnostic exudative effusion. A biopsy was performed which was consistent with a large cell neuroendocrine tumor.
  6. Dr. Lewis Wesselius presented a 65-year-old man with exertional dyspnea and possible interstitial lung disease. He has a history of a Ross procedure (replacement of a bicuspid aortic valve with the pulmonic valve) and obstructive sleep apnea. Chest x-ray was unremarkable. Complete pulmonary function testing was normal. Thoracic CT scan showed peripheral reticulations especially in the lower lobes. A video-assisted thorascopic biopsy (VATS) was performed. Histology showed scattered fibroblast foci with scattered fibrosis with airway centricity. It was unclear whether this was usual interstitial fibrosis or chronic hypersensitivity pneumonitis. He was started on prednisone because his picture was felt to be most consistent with chronic hypersensitivity pneumonitis (1). Unfortunately, chronic hypersensitivity pneumonitis with features of UIP appears to carry a worse prognosis.

There being no further business, the meeting was adjourned about 7:30 PM. The next meeting will be in Phoenix at Scottsdale Shea on Wednesday, November 18 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Reddy TL, Mayo J, Churg A. Respiratory bronchiolitis with fibrosis. High-resolution computed tomography findings and correlation with pathology. Ann Am Thorac Soc. 2013;10(6):590-601. [CrossRef] [PubMed]
  2. Myers JL. Hypersensitivity pneumonia: the role of lung biopsy in diagnosis and management. Mod Pathol. 2012;25 Suppl 1:S58-67. [CrossRef] [PubMed]

Cite as: Robbins RA. September 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;11(3):117-8. doi: http://dx.doi.org/10.13175/swjpcc124-15 PDF

Thursday
Jul232015

July 2015 Arizona Thoracic Society Notes

The July 2015 Arizona Thoracic Society meeting was held on Wednesday, July 23, 2015 at the Scottsdale Shea Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 16 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

It was decided to continue holding the meeting on the fourth Wednesday of the odd numbered months.

Lewis Wesselius relayed a request from the Mayo Clinic regarding a survey on how physicians in Arizona treat Valley Fever. There were no objections to using our mailing list to send out the survey.

Dr. Parides formed a committee to encourage younger clinicians to attend the Arizona Thoracic Society meetings.

Richard A. Robbins was chose as the Arizona Thoracic Society's nominee for clinician of the year.

There were 3 case presentations:

  1. George Parides presented a 58-year-old woman with a past medical history of cavitating coccidioidomycosis in both upper lobes from which she had recovered. However, on thoracic CT scan she had traction bronchiectasis as well as narrowing of the inferior vena cava. It had been recommended that a vena cava filter be placed to prevent pulmonary embolism. She had no history of deep venous thrombosis. None in the audience knew of any data suggesting placement of a filter was indicated.
  2. Lewis Wesselius presented a case of a 19-year-old man who presented with dyspnea and bilateral large pulmonary nodules. He had a history of smoking about 5 cigarettes per day and use of medical marijuana for sinusitis. Laboratory workup showed an elevated white blood cell count but a cANCA and cultures was negative. Bronchoscopy with bronchoalveolar lavage demonstrated alveolar hemorrhage. Open biopsy was consistent with pulmonary pyoderma gangrenosum. The patient was begun on corticosteroids and had resolution of both his symptoms and nodules.
  3. Rick Robbins presented Drs. Ling and Boivin's case of a 40 year old man with a history of opioid abuse who was mechanically ventilated but failed an extubation trial (1). The videos of the diaphragm were presented along with a discussion of the diaphragm thickening fraction (DTF) assessed by ultrasound as a predictor for the success of extubation. DTF is calculated using the following formula: Thickness at end inspiration - Thickness at end expiration / Thickness at end expiration. Based on the study published by Ferarri and associates (2), they found that a DTF > 36% would provide a sensitivity of 0.82, a specificity of 0.88, a positive predictive value (PPV) of 0.92 and a negative predictive value (NPV) of 0.75.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix at Scottsdale Shea on Wednesday, September 28 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Ling D, Boivin M. Ultrasound for critical care physicians: take a deep breath. Southwest J Pulm Crit Care. 2015;11(1):38-41. [CrossRef]
  2. Ferrari G, De Filippi G, Elia F, Panero F, Volpicelli G, Aprà F. Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. Crit Ultrasound J. 2014;6(1):8. [CrossRef] [PubMed]

Reference as: Robbins RA. July 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;11(1):49-50. doi: http://dx.doi.org/10.13175/swjpcc098-15 PDF