January 2017 Arizona Thoracic Society Notes

The January 2017 Arizona Thoracic Society meeting was held on Wednesday, January 25, 2017 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting (prime rib) with case presentations. There was a good attendance representing the pulmonary, critical care, sleep, and radiology communities.

There was a discussion of supporting the Tobacco 21 bill which has been introduced into the Arizona State Legislature. There was unanimous support for this bill. Another bill to allow school nurses to administer an albuterol inhaler without a doctor’s prescription was also discussed but the members wanted more information.

The new CDC Ventilator-Associated Events (VAE) criteria were also discussed. Before endorsing or opposing the this as a measure, the members wished more information.

It was decided that a decision on both would be postponed until discussed at the next meeting.

Three cases were presented:

1. Dr. Lewis Wesselius from the Mayo Clinic presented a case of a 53-year-old woman who presented with hemoptysis. The hemoptysis was eventually shown to be secondary to mitral stenosis. There were some dramatic photographs from the bronchoscopy of hyperemic airways with dilated submucosal veins. This case was also presented as the January 2017 Pulmonary Case of the Month in the SWJPCC.
2. Dr. Kyle Henry from Banner University Phoenix/VA presented a case of combined emphysema and pulmonary fibrosis. The pros and cons of establishing a diagnosis were discussed. Although a biopsy would be considered ideal, the patient was severely hypoxemic.
3. Dr. Gerald Swartzberg presented several cases of cavitary coccidioidomycosis. A discussion followed regarding management of cavitary cocci ensued.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix on Wednesday, March 22, 2017 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Lewis J. Wesselius, MD

President, Arizona Thoracic Society

Cite as: Wesselius LJ. January 2017 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2017;14(1):42. doi: https://doi.org/10.13175/swjpcc010-17 PDF

November 2016 Arizona Thoracic Society Notes

The November 2016 Arizona Thoracic Society meeting was held on Wednesday, November 17, 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.

Two cases were presented:

1. Dr. Lewis Wesselius presented a case of a 29-year-old man from India on a work visa who complained of right pleuritic pain. Chest x-ray showed a large right pleural effusion. CT scan confirmed the presence of effusion with minimal lung parenchyma changes or mediastinal adenopathy. Gold quantiferon was positive and coccidioidomycosis serology was negative. Thoracentesis showed a lymphocytic predominant effusion and adenosine deaminase was borderline high. No acid-fast bacilli (AFB) were seen in the fluid. PCR for M. tuberculosis was negative. The pleural biopsy did show AFB and eventually grew M. tuberculosis. The patient was started on a 4 drug regimen. Dr. Wesselius gave a short presentation on the sensitivity of the various diagnostic tests for M. tuberculosis.
2. Dr. Richard Robbins presented the case of a 45-year-old Iraqi war veteran who was referred for COPD based on abnormal blood gases. The arterial blood gases showed a PaO2 40 mm Hg, PaCO2 82 mm Hg, pH 7.12, HCO3 34 mEq/L, and SaO2 76. The patient was diagnosed with hypoventilation probably secondary to narcotic abuse which he took for chronic back pain. He was admitted to the ICU but unfortunately administered high flow oxygen and was intubated. He was subsequently given naloxone but became awake and combative. After sedation and small doses of morphine, he was quickly liberated from mechanical ventilation, transferred to the floor and discharged. He did complain to the patient advocate on discharge about the smaller doses of narcotics he was give. A discussion followed regarding narcotic abuse, patient satisfaction, and mortality.

Dr. Parides has been approached regarding having the Arizona Thoracic Society meetings at Select Hospital in Scottsdale. In addition, he has been in contact with Dr. Rajeev Saggar at Banner University Medical Center Phoenix regarding having Arizona Thoracic Society meetings with a video link to Tucson.

Dr. Parides presented a plaque to Dr. Lewis Wesselius who is the Arizona Thoracic Society clinician of the year (Figure 1).

Figure 1. Dr. George Parides (left) presented a plaque to Dr. Lewis Wesselius as Arizona Thoracic Society Clinician of the Year.

A discussion was held regarding the recent American College of Graduate Medical Education (ACGME) decision to allow first year house officers to work 28 hours while on call rather than 16 (1). This is based on a study published in the New England Journal of Medicine in February, 2016 (2). After much discussion, a motion was made by Dr. Parides and seconded by Dr. Alp Umar to draft a letter to the ACGME during this public comment period favoring that ACGME decisions on resident work hours being made on data rather than emotion or politics.

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

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Robbins RA. ACGME proposes dropping the 16 hour resident shift limit. Southwest J Pulm Crit Care. 2016;13(5):216-7. [CrossRef]
2. Bilimoria KY, Chung JW, Hedges LV, et al. National cluster-randomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016 Feb 25;374(8):713-27.  [CrossRef] [PubMed]

Cite as: Robbins RA. November 2016 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2016;13(5):246-7. doi: https://doi.org/10.13175/swjpcc119-16 PDF 

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

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

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