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)

August 2012 Arizona Thoracic Society Notes

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

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 5^th) 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.

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)

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)