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)

• Opposition to the “Cigar Bill” (H.R. 792)
• Repeal and replacement of the Medicare Sustainable Growth Rate Factor (SGR)
• Urging Congress to provide $32 billion for the National Institutes of Health for fiscal year 2014

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

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

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

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

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