March 2018 Arizona Thoracic Society Notes

The March 2018 Arizona Thoracic Society meeting was held on Wednesday, March 28, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 12 in attendance representing the pulmonary, critical care, sleep, infectious disease and radiology communities.

At the beginning of the meeting several issues were discussed:

1. The Tobacco 21 which had been introduced into the Arizona House was killed in committee by Rep. Jeff Weninger, Chairman of the Commerce Committee.
2. Council of Chapter Representatives (CCR) Meeting and “Hill Day” was cancelled due to inclement weather. It will probably be rescheduled for the summer.

An update on pirfenidone in IPF was presented by Jessica Castle, PhD, Medical Science Liaison with Genentech. Dr. Castle discussed the antifibrotic, anti-inflammatory, and anti-oxidant effects of pirfenidone.

Data was also presented from post-hoc analysis from pirfenidone trials.

• Overall no difference in morality data
• Reduction in respiratory hospitalizations
• Reduction in deaths after respiratory hospitalizations
• Quantitative Image Analysis showed a decrease in fibrosis with pirfenidone

Lastly, Dr. Castle introduced several ongoing trials with combination therapy for IPF.

There were 3 case presentations:

1. Dr. Tim Kuberski, Chief of Infectious Disease at Maricopa, presented a 45-year-old Caucasian man who collapsed in the market and was brought to Maricopa Medical Center. He had evolving gangrene of his distal extremities which proved to be secondary to Yersinia pestis. He received continuous sympathetic blockade to treat his gangrene (1). The patient’s gangrene of his toes resolved but he did require amputation of his fingers and reconstruction of his ears and nose.
2. Dr. Richard Robbins presented a 54-year-old man with triad asthma, eosinophilia and coronary artery spasm. He was begun on montelukast and was doing well. He presented a series from New Zealand of 15 patients with eosinophilia and coronary artery spasm (2). Four of the patients were noted to have asthma. No one could recall a similar case.
3. Dr. Lewis Wesselius presented an 72-year-old woman who was a life-long nonsmoker with progressive dyspnea over 3-4 years. She had bibasilar crackles on physical examination and a low DLco on pulmonary function testing. Thoracic CT scan showed subtle changes of bibasilar reticulation. This did not appear to be UIP. Biopsy showed rather uniform changes with alveolar wall thickening but not areas characteristic for a definitive diagnosis. The consensus was that her case was most likely chronic hypersensitivity pneumonitis.

There being no further business, the meeting was adjourned about 8:30 PM. The next meeting will be in Phoenix on May 23 at 6:30 PM at HonorHealth Rehabilitation Hospital. This will be a planning meeting to structure Arizona Thoracic Society meetings and activities.

Richard A. Robbins MD

Editor, SWJPCC

References

1. Kuberski T, Robinson L, Schurgin A. A case of plague successfully treated with ciprofloxacin and sympathetic blockade for treatment of gangrene. Clin Infect Dis. 2003 Feb 15;36(4):521-3. [CrossRef] [PubMed]
2. Wong CW, Luis S, Zeng I, Stewart RA. Eosinophilia and coronary artery vasospasm. Heart Lung Circ. 2008 Dec;17(6):488-96. [CrossRef] [PubMed]

Cite as: Robbins RA. March 2018 Arizona Thoracic Society notes. Southwest J Pulm Crit Care. 2018;16(3):170-1. doi: https://doi.org/10.13175/swjpcc051-18 PDF 

January 2018 Arizona Thoracic Society Notes

The January 2018 Arizona Thoracic Society meeting was held on Wednesday, January 24, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were 11 in attendance representing the pulmonary, critical care, sleep, and radiology communities.

At the beginning of the meeting several issues were discussed:

1. CME for Arizona Thoracic Society Meetings. Dr. Robbins will be going to Washington and will meet with the ATS concerning obtaining CME for the Arizona Thoracic Society meetings.
2. Tobacco 21. It was unclear if any action was occurring. Dr. Parides said he would check.
3. Council of Chapter Representatives (CCR) Meeting and “Hill Day”. Dr. Robbins will be attending the CCR meeting March 21-22 for Dr. Schwartzberg. This includes meeting with the Arizona Congressional representatives. Those that have issues they wish presented to either the ATS leadership or their legislators should contact Dr. Robbins at rickrobbins@cox.net. 

There were 4 case presentations:

1. Dr. Gerry Swartzberg presented a follow-up of a now 74-year-old who was presented in 2014 who was asymptomatic but with a CT scan showing cysts.  No diagnosis was made at that time. She has been followed for the last 3 years. She now has some shortness of breath with exertion. It was discovered that she had cockatiels. A complete “bird” hypersensitivity was recommended but the patient declined because of cost. A repeat CT in late 2017 showed that the cysts had enlarged. A pigeon serum serologic test was positive. Dr. Gotway pointed out that lung cysts can occur with hypersensitivity pneumonitis (1). A biopsy was performed which showed necrotizing granulomas without any organisms. Although she got rid of her cockatiels, further history reveals that the patient still feeds pigeons.  The consensus (although by no means unanimous) was this was likely hypersensitivity pneumonitis with an unusual presentation. It was thought that a trial of steroids might be beneficial.
2. Dr. Lewis Wesselius presented a 75-year-old woman with a thymic carcinoid tumor diagnosed in 2015. She was treated with resection and radiation therapy. CT scan showed changes consistent with radiation pneumonitis. Bronchoscopy with transbronchial biopsy showed “organizing pneumonitis”. She was treated with corticosteroids for 1 month. CT scan showed some improvement and the steroids were tapered. Her symptoms recurred and she was again started on corticosteroids with improvement but after tapering her steroids, her symptoms again recurred. CT scan showed marked worsening of the lung infiltrates. A bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsy was performed. The BAL showed 12% eosinophils and the biopsy was consistent with chronic eosinophilic pneumonia.
3. Dr. Wesselius also presented a 79-year-old woman who had a right upper lobe resection for non-small cell lung cancer. A follow-up CT scan sometime later showed ground glass opacities (GGOs). A decision was made to follow the GGO’s but a year later CT scan showed worsening of the lesions. Navigational bronchoscopy was nondiagnostic. After a tumor board conference, she received radiation therapy for presumed carcinoma. She was followed but again had increasing shortness of breath. CT scan showed changes consistent with radiation pneumonitis. A long discussion ensued about empiric radiation therapy.
4. Dr. George Parides presented a woman with a clinical history consistent with idiopathic pulmonary fibrosis (IPF) and a CT scan which showed ground glass opacities. Most felt that this was IPF. Pirfenidone was started. A discussion about therapies, including experimental therapies for IPF ensued.

There being no further business, the meeting was adjourned about 8:30 PM. The next meeting will be in Phoenix on March 28 at 6:30 PM at HonorHealth Rehabilitation Hospital.

Richard A. Robbins MD

Editor, SWJPCC

Reference

1. Franquet T, Hansell DM, Senbanjo T, Remy-Jardin M, Müller NL. Lung cysts in subacute hypersensitivity pneumonitis. J Comput Assist Tomogr. 2003 Jul-Aug;27(4):475-8.[CrossRef] [PubMed]

Cite as: Robbins RA. January 2018 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2018;16(1):51-2. doi: https://doi.org/10.13175/swjpcc018-18 PDF 

May 2015 Arizona Thoracic Society Notes

The May 2015 Arizona Thoracic Society meeting was held on Wednesday, May 27, 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.

Ms. Georgann VanderJagt, RN, MSN gave an update on clinical trials at Dignity Health including idiopathic pulmonary fibrosis and alpha-1 antitrypsin deficiency. To contact Ms. VanderJagt call her office at 602-406-3825, her cell at 602-615-2377 or by email at georgann.vaderjagt@digniftyhealth.org.  

Dr. Michael Smith, the surgical director for the lung transplant program at Dignity Health, gave an overview of their lung transplant program. They are currently the fifth busiest transplant program in the US.  They have done 46 lung transplants so far this year. They are on a par with UCLA in number of transplants and survival has been at the National average. Average wait time is only abut 2 weeks. He also discussed recent and ongoing transplant protocols. To contact Dr. Smith call 602-406-7564.

There were 4 case presentations:

1. Jud Tillinghast presented a case of a large man who was short of breath. His CT scan showed multiple calcifications in the lower lobes. It was felt that clinically he was most likely aspirating as a cause of the calcifications.
2. Gerald Swartzberg presented a case of a large man who had some minimal dyspnea and an elevated right hemidiaphragm. His chest x-ray showed consolidation in this right lower lung. He had been seen at the Mayo Clinic and Dr. Lewis Wesselius reviewed his pathology from a needle biopsy of a right lower lobe nodule which was nonspecific. Reviewing his case he also had a biopsy from Sloan Kettering in 2006 which was also nonspecific. Further history was obtained and the patient admitted he was using Vick's Vaporub in his nose since he was 7 years old. It was unclear if this was the cause of his right lower lobe consolidation.
3. Dr. Swartzberg presented a second case of a 70-year-old woman with multiple medical problems. She has a cockatiel but is remarkably asymptomatic. A chest x-ray was taken showed nonspecific lower lobe changes. Pulmonary function tests showed a reduced vital capacity but a normal to high total lung capacity. A DLCO was not able to be obtained. CT scan showed small nodules with ground glass in her lower lobes. It was felt that most likely this was a hypersensitivity pneumonitis secondary to her bird. She got rid of the bird but did not improve.  The cause of her abnormal pulmonary radiology remains unclear.
4. Dr. Wesselius presented a case of a patient with a chronic cough which had been treated with antibiotics and corticosteroids. When he as on oral corticosteroids he was perhaps somewhat better. He was seen at the University of Massachusetts without a diagnosis being made. He subsequently moved to the Phoenix area and was evaluated at the Mayo Clinic. Chest x-ray showed consolidation in his right upper lobe. On bronchoscopy he had some whitish plaques along his trachea and main bronchi. Bronchoalveolar lavage showed 89% eosinophils and his transbronchial biopsy was consistent with chronic eosinophilic pneumonia. Apparently, this association has previously been sporadically reported. He was started on prednisone and improved.

Dr. Jud Tillinghast was acknowledged as the Arizona Thoracic Society Clinician of the Year and one of the four finalists as ATS Clinician of the Year.

After a brief discussion, the membership agreed to encourage and help Nevada form a state thoracic society.

There being no further business, the meeting was adjourned about 8 PM. The next meeting will be in Phoenix at Scottsdale Shea on Wednesday, July 22 at 6:30 PM.

Richard A. Robbins, MD

Editor, SWJPCC

Reference as: Robbins RA. May 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;10(5):304-5. doi: http://dx.doi.org/10.13175/swjpcc075-15 PDF

January 2015 Arizona Thoracic Society Notes

Dr. Judd Tillinghast was presented a plaque in recognition of being chosen by his colleagues as the Arizona Thoracic Society Physician of the Year In 2014.  

Dr. Rajeev Saggar made a presentation entitled "Pulmonary fibrosis-associated pulmonary hypertension: a unique phenotype".  This presentation focused on new echocardiographic methods of assessing right ventricular (RV) function and the pathophysiology of RV dysfunction. Dr. Saggar presented data from a paper he authored on parenteral treprostinil in patients with idiopathic pulmonary fibrosis and pulmonary artery hypertension which was published in Thorax (1).

There were 2 case presentations, both from the Phoenix VA by Dr. Elijah Poulos:

1. A 65 year-old man presented with cough and chills.  His past medical history included multiple myeloma treated with chemotherapy, radiation therapy to spine and bone marrow transplant.  He had a prior vertebroplasty. His symptoms did not improve with doxycycline.  Computerized tomography angiography was done and showed areas of unusual abnormalities in lung that were very high density.  This was determined to be cement emboli from the prior vertebroplasty (pulmonary cement emboli, PCE) which has been previously reported as a complication of this procedure.  The appropriate treatment options in this case were discussed.
2. A 69 year-old man presented with dyspnea on exertion over past couple of years.  Chest radiography showed abnormal areas of central fibrosis with sparing of the lung periphery.  A thoracic CT scan also demonstrated central fibrotic/cystic changes.  The patient subsequently admitted to use of crack cocaine which started at age 59.  There are reports of similar pulmonary fibrosis associated with use of crack cocaine (2).  The possible pathophysiologic mechanisms were discussed.

The next meeting in Phoenix will be at Scottsdale Shea on Wednesday, March 25 at 6:30 PM.

Lewis J. Wesselius, MD

President, Arizona Thoracic Society

References

1. Saggar R, Khanna D, Vaidya A, et al. Changes in right heart haemodynamics and echocardiographic function in an advanced phenotype of pulmonary hypertension and right heart dysfunction associated with pulmonary fibrosis. Thorax. 2014;69(2):123-9. [CrossRef] [PubMed]
2. O'Donnell AE, Mappin FG, Sebo TJ, Tazelaar H. Interstitial pneumonitis associated with "crack" cocaine abuse. Chest. 1991;100(4):1155-7. [CrossRef] [PubMed] 

Reference as: Wesselius LJ. January 2015 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2015;10(1):56. doi: http://dx.doi.org/10.13175/swjpcc012-15 PDF 

May 2014 Arizona Thoracic Society Notes

The May 2014 Arizona Thoracic Society meeting was held on Wednesday, 5/28/2014 at Scottsdale Shea Hospital beginning at 6:30 PM. There were 13 in attendance representing the pulmonary, critical care, sleep and radiology communities.

A discussion was held regarding the Arizona Thoracic Society relationship with the American Lung Association. Several members volunteered to talk to the lung association regarding common ground to strengthen the relationship.

The wine tasting with the California, New Mexico and Colorado Thoracic Societies at the American Thoracic Society International Meeting was a big success. There were about 55 at the meeting. The tasting will probably be held again next year.

At the ATS meeting data was presented that pirfenidone was effective in reducing the progression of idiopathic pulmonary fibrosis (IPF). The data was published in the New England Journal of Medicine on 8/29/14 (1). Lewis Wesselius is one of the investigators enrolling patients in a phase 3 trial while InterMune reapplies to the FDA for approval of pirfenidone in IPF.

Two cases were presented:

1. Lewis Wesselius from the Mayo Clinic Arizona presented a 53 year old woman with a chronic, nonproductive accompanied by malaise and a modest weight loss. She was treated for asthma without improvement.  She was a nonsmoker and had a SpO2 of 98% on room air. Her lungs were clear to auscultation.  Routine laboratory evaluation was unremarkable and exhaled nitric oxide was normal. Thoracic CT scan showed a subtle broncholitis. She was empirically treated for gastroesophageal reflux disease (GERD) without improvement. Bronchoalveolar lavage was performed and showed Nocardia asteroides. She had no evidence of immunocompromise. She was treated with sulfamethoxazole and trimethoprim which produced a rash and then minocycline for 4 months. Her cough resolved. However, when the minocycline was stopped her cough returned. She is currently receiving an additional course of minocycline planned for 6 months.
2. Suresh Uppalapu presented a 58 year old fireman with a complaint of dyspnea on exertion. He has a history of obstructive sleep apnea and lives at an elevation of 7000 feet. The patient had significant desaturation with exercise. Chest x-ray showed borderline cardiomegaly but was otherwise normal. Thoracic CT scan showed pulmonary artery enlargement and borderline right ventricular (RV) enlargement. Ultrasound of the hear showed an enlarged RV but it was difficult to measure PA pressure.  Right-sided heart catherization showed a mean pulmonary artery pressure of 35 cm H2O with a  step up in the oxygen saturation at the right atrium. Transesophageal echocardiogram (TEE) showed a patent foramen ovale (PFO).  Insertion of a balloon stopped the right to left shunting but resulted in a significant increase in the pulmonary artery pressure. He was referred for percutaneous closure of the PFO along with treatment of his pulmonary artery hypertension.

There being no further business the meeting was adjourned about 8:15 PM. The June meeting is scheduled for Tucson. There will be no meeting in July. The next meeting in Phoenix will be a case presentation conference on August 27, 6:30 PM at Scottsdale Shea Hospital.

Richard A. Robbins, MD

Reference

1. King TE Jr, Bradford WZ, Castro-Bernardini S, et al. A phase 3 trial of pirfenidone in patients with idiopathic pulmonary fibrosis. N Engl J Med 2014;370:2083-92. [CrossRef] [PubMed] 

Reference as: Robbins RA. May 2014 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2014;8(6): 297-8. doi: http://dx.doi.org/10.13175/swjpcc072-14 PDF

December 2013 Arizona Thoracic Society Notes

A breakfast meeting of the Arizona Thoracic Society and the Tucson winter lung series was held on Saturday, 12/14/2013 at Kiewit Auditorium on the University of Arizona Medical Center Campus beginning at 8:30 AM. There were 31 in attendance.

A lecture was presented by Joe G. N. "Skip" Garcia, MD, the senior vice president for health sciences at the University of Arizona (Figure 1).

Figure 1. Joe G. N. “Skip” Garcia, MD

The title of Garcia’s talk was “Personalizing Medicine in Cardiopulmonary Disorders: The Post ACA Landscape”.

Garcia began with reiterating that the Affordable Care Act (ACA, Obamacare) is fact and could pose a threat to academic medical centers. However, he views the ACA as an opportunity to develop personalized medicine which grew from the human genome project. Examples cited included the genetic variability among patients in determining the dose of warfarin and bronchodilator response to beta agonists in asthma (1,2).

Garcia’s laboratory has studied predominately 6 diseases including the adult respiratory distress syndrome (ARDS), idiopathic pulmonary fibrosis (IPF), sarcoidosis, asthma, pulmonary artery hypertension and sickle cell disease. Each has in common that there has been minimal progress made in the past generation and each has been shown to have racial or ethnic disparities in outcomes. He cited examples of how molecular testing could improve care.

Black and Hispanic patients with ARDS have a significantly higher risk of death compared with white patients (3). Garcia noted that the ventilator is not necessarily a friend and use of higher tidal volumes has been associated with increased mortality (4). He reasoned that the variation in susceptibility to ventilator induced lung injury could potentially explain the racial differences in mortality. Beginning with a dog model of ARDS, highly significant regional differences in gene expression were observed between lung apex/base regions. One of these potential targets was pre-B-cell colony enhancing factor (PBEF), a gene not previously associated with lung pathophysiology (5). Further work showed PBEF could induce changes seen in ARDS including a neutrophil alveolitis and increases in nuclear factor-κβ (NFKB) expression (6).

Few would question that there is a need for validated biomarkers in idiopathic pulmonary fibrosis. Using a similar approach to the investigation of PBEF in ARDS, peripheral blood mononuclear cell (PBMC) gene expression profiles predictive of poor outcomes in idiopathic pulmonary fibrosis (IPF) were examined by microarray. Microarray analyses suggest that 4 genes (CD28, ICOS, LCK, and ITK) are potential outcome biomarkers in IPF and should be further evaluated for patient prioritization for lung transplantation and stratification in drug studies (7). PBMC gene expression profiles were also examined in sarcoidosis.  There was a significant association of single nucleotide polymorphisms (SNPs) in signature genes with sarcoidosis susceptibility and severity (8). Further examples were presented on sickle cell disease.

Garcia concluded that molecular techniques represent powerful tools to investigate potential therapeutic approaches in respiratory diseases where little progress has been made.

Richard A. Robbins, MD

References

1. International Warfarin Pharmacogenetics Consortium, Klein TE, Altman RB, Eriksson N, Gage BF, Kimmel SE, Lee MT, Limdi NA, Page D, Roden DM, Wagner MJ, Caldwell MD, Johnson JA. Estimation of the warfarin dose with clinical and pharmacogenetic data. N Engl J Med. 2009;360(8):753-64. [CrossRef] [PubMed]
2. Duan QL, Lasky-Su J, Himes BE, Qiu W, Litonjua AA, Damask A, Lazarus R, Klanderman B, Irvin CG, Peters SP, Hanrahan JP, Lima JJ, Martinez FD, Mauger D, Chinchilli VM, Soto-Quiros M, Avila L, Celedón JC, Lange C, Weiss ST, Tantisira KG. A genome-wide association study of bronchodilator response in asthmatics. Pharmacogenomics J. 2013 Mar 19. [Epub ahead of print] [CrossRef] [PubMed]
3. Erickson SE, Shlipak MG, Martin GS, Wheeler AP, Ancukiewicz M, Matthay MA, Eisner MD; National Institutes of Health National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network. Racial and ethnic disparities in mortality from acute lung injury. Crit Care Med. 2009 Jan;37(1):1-6. [CrossRef] [PubMed]
4. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-8. [CrossRef] [PubMed]
5. Simon BA, Easley RB, Grigoryev DN, Ma SF, Ye SQ, Lavoie T, Tuder RM, Garcia JG. Microarray analysis of regional cellular responses to local mechanical stress in acute lung injury. Am J Physiol Lung Cell Mol Physiol. 2006;291(5):L851-61. Herazo-Maya JD, Noth I, Duncan SR, Kim S, Ma SF, Tseng GC, Feingold E, Juan-Guardela BM, Richards TJ, Lussier Y, Huang Y, Vij R, Lindell KO, Xue J, Gibson KF, Shapiro SD, Garcia JG, Kaminski N. Peripheral blood mononuclear cell gene expression profiles predict poor outcome in idiopathic pulmonary fibrosis. Sci Transl Med. 2013 Oct 2;5(205):205ra136.
6. Hong SB, Huang Y, Moreno-Vinasco L, Sammani S, Moitra J, Barnard JW, Ma SF, Mirzapoiazova T, Evenoski C, Reeves RR, Chiang ET, Lang GD, Husain AN, Dudek SM, Jacobson JR, Ye SQ, Lussier YA, Garcia JG. Essential role of pre-B-cell colony enhancing factor in ventilator-induced lung injury. Am J Respir Crit Care Med. 2008;178(6):605-17. [CrossRef] [PubMed]  
7. Zhou T, Zhang W, Sweiss NJ, Chen ES, Moller DR, Knox KS, Ma SF, Wade MS, Noth I, Machado RF, Garcia JG. Peripheral blood gene expression as a novel genomic biomarker in complicated sarcoidosis. PLoS One. 2012;7(9):e44818. [CrossRef] [PubMed] 

Reference as: Robbins RA. December 2013 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2013;7(6):360-2. doi: http://dx.doi.org/10.13175/swjpcc175-13 PDF

April 2011 Arizona Thoracic Society Notes

A dinner meeting was held at Scottsdale Shea Medical Center on April 12, 2011 from 6:30-8:00 PM. Twenty-seven were in attendance including representatives from the pulmonary and chest radiology communities. Six cases were presented and discussed:

1. Alexis Christie and Rick Helmers presented a case of acute respiratory failure in a 51 year old woman who had an “ARDS”-like picture, an initially negative bronchoscopy with bronchoalveolar lavage and a non-specific open lung biopsy. The bronchoalveolar lavage eventually cultured influenza A. Discussion centered on whether the patient should have received corticosteroids.

2. Lew Wesselius presented a 55 year old man evaluated for renal transplant secondary to chronic renal failure from polycystic kidney disease. The patient was asymptomatic but found to have lower lung nodules on CT which were thought to be pulmonary arteriovenous malformations. The patient was referred for embolization. The invasive radiologist identified these as pulmonary varices. No therapy was given. A brief review of pulmonary varices was done by Dr. Wesselius and Mike Gotway discussed the radiographic appearance.

3. Gerald Swartzberg presented a case of a 64 year old woman with a rash on her palms, fever and multiple pulmonary nodules. Cultures and coccidiomycosis serology were negative. The patient was found to have coccidiomycosis on video-assisted thoracic surgery. Discussion centered on the 70% sensitivity of coccidiomycosis serology.

4. Gerald Swartzberg presented a second case of a 55 year old man with dyspnea, a 20 pack-year smoking history, and lower lobe fibrosis. The PFTs were presented which demonstrated a mixed obstructive and restrictive disease with a diffusing capacity of 47% of predicted. Most thought this was a case of COPD with idiopathic pulmonary fibrosis. Management was discussed.

5. John Roehrs presented a case of 52 year old woman with dyspnea with a normal chest x-ray and spirometry. However, on echocardiogram pulmonary hypertension was found with right atrial and ventricular enlargement. A bubble study demonstrated an atrial septal defect. Right-sided cardiac catherization confirmed the elevated pulmonary artery pressure and demonstrated an O2 step up at the atrial level. Discussion centered on therapy with most suggesting cardiology evaluation for a percutaneous closure of the ASD.

6. Christian Jivcu and Manny Mathew presented a case dyspnea of a man who had Hodgkin’s disease in 1987 who had received radiation therapy. CXR revealed bilateral pleural effusions which were exudative. A chest CT scan revealed mediastinal lymphadenopathy. At operation he was found to have mesothelioma which even in retrospect was not recognizable on his CT scan. The patient had no known asbestos exposure. Discussion focused on the association between prior radiation therapy and mesothelioma.

Richard A. Robbins, MD