No abstract available. Article truncated after 150 words. History of Present Illness A 78-year-old man presented to the emergency Department on April 7 for shortness of breath and weakness over the last 2 weeks. He was in good health prior to an outside hospitalization March 29-April 3 for pneumonia and possible a non-ST-elevation myocardial infarction (elevated troponins). He had a bronchoscopy during his recent outside hospitalization without specific pathogen identified but treated with antibiotics, discharged on levofloxacin. Since his hospital discharge 4 days previously he feels weaker and increasingly short of breath. SOB even walking around in his home. He denies fever or a productive cough. Past Medical History, Family History and Social History Atrial fibrillation, s/p ablation. On Eliquis. Prior renal cell carcinoma, s/p resection, no recurrence DM Type 2 GERD OSA Essential tremor Never smoked Medications Apixaban Aspirin Atorvastatin Flecanide Insulin Levofloxacin Lisinopril Pantoprazole Tamsulosin Physical Examination General: The patient looks comfortable and is in no …

No abstract available. Article truncated after 150 words. History of Present Illness A 53-year-old woman from presented with a 3-year history of shortness of breath. She was diagnosed with pneumonia in 2016, but even after treatment with antibiotics, continued to require supplemental oxygen. A CT-guided biopsy of a lung nodule was performed but there were no diagnostic findings. A surgical lung biopsy at another hospital was done but the report is unavailable. She had been diagnosed with possible scleroderma and treated with mycophenolate for 3 months and then azathioprine. Past Medical History, Social History and Family History Aside from her history as in the HPI she has a remarkably negative past medical history. She does not smoke. Family history is noncontributory. Physical Examination • HEENT: negative • Chest: Fine crackles at both lung bases • Cardiovascular: regular rhythm, no murmur • Skin: skin thickening on fingers and distal forearms, but not elsewhere. No pitting, ulcerations or calcinosis Radiology A chest x-ray was …

STUDY OBJECTIVES:Scleroderma is associated with abnormal skin thickening, interstitial lung disease, pulmonary hypertension, and abnormalities of the upper airway. These changes can cause cardiopulmonary complications, potentially including sleep-disordered breathing. The objective of this study is to examine the risk of sleep-disordered breathing in patients with scleroderma. METHODS:We retrospectively identified patients with documented scleroderma. We abstracted data from their electronic health records, including findings from antibody tests, serial pulmonary function tests, transthoracic echocardiography, high-resolution computed tomography, and overnight forehead oximetry. RESULTS:We identified 171 patients with scleroderma. Mean age at the time of initial consult was 56.5 years (range, 18-96 years), and 150 (86.7%) were women. Scleroderma was categorized as limited disease for 108 (62.4%), diffuse disease for 59 (34.1%), and mixed connective tissue disease for 6 (3.5%). Fifty-four patients (31.2%) had abnormal overnight forehead oximetry results, defined as an oxygen desaturation index greater than 5 or a baseline mean arterial oxygen saturation level less than 90%. CONCLUSIONS:Cardiopulmonary complications are common in patients with scleroderma, one of which may be sleep-disordered breathing. In our cohort, approximately one-third of individuals with scleroderma had evidence of sleep-disordered breathing. Moreover, the rate of sleep-disordered breathing in our population of scleroderma patients was twice the rate of pulmonary hypertension and was approximately the same as the rate of interstitial lung disease. Future prospective studies are needed to further assess the role of sleep-disordered breathing in scleroderma clinical outcomes.

No abstract available. Article truncated after 150 words. The September 2018 Arizona Thoracic Society meeting was held on Wednesday, September 28, 2018 at the HonorHealth Rehabilitation Hospital beginning at 6:30 PM. This was a dinner meeting with case presentations. There were representatives in attendance from the pulmonary, critical care, sleep, and radiology communities. At the beginning of the meeting attendance was again discussed. There were 3 case presentations: 1. Dr. Gerry Schwartzberg presented a case of a woman in her 70’s with diffuse cystic lung disease. She had a monoclonal gammopathy of undetermined significance due to light chain disease and the possibility of amyloidosis causing cystic lung disease was discussed. 2. Dr. Lewis Wesselius presented a 28-year-old man from Tennessee with enlarging lung nodules who had been treated for presumed histoplasmosis, but was having hemoptysis and clinically worsening. Lung biopsy demonstrated metastatic angiosarcoma. 3. Dr. Wesselius also presented a 44-year-old woman with diabetes and cavitary pulmonary coccidioidomycosis which …

No abstract available. Article truncated after first page. History of Present Illness: A 75-year-old woman was diagnosed with a thymic carcinoid tumor in April, 2015 (Figure 1). This was treated with surgical resection followed by radiation therapy. She began having cough and dyspnea 1 to 2 months later and in August, 2015 had a thoracic CT scan of her chest (Figure 2). Which of the following are true? 1. Bronchoscopy should be performed; 2. She should be given an empiric course of antibiotics; 3. The most like diagnosis is radiation pneumonitis. 4. 1 and 3; 5. All of the above. …

Submitted March 9, 2018; revision received May 10, 2018; accepted May 25, 2018. C hronic obstructive pulmonary disease (COPD) is an irreversible lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing. It affects roughly 14% of the male and 7% of the female population globally, and it is the third-leading cause of death in the United States. The cost of COPD in the United States was projected to be $50 billion in 2010. Among patients with COPD in the United States, approximately 800,000 receive long-term oxygen therapy (LTOT). Long-term oxygen therapy has been widely accepted as a means to lower the mortality rate in patients with COPD, particularly in patients with severe hypoxemia. However, the mortality benefit of this therapy in patients with COPD with mild to moderate hypoxemia is unclear, with limited evidence for its use in the literature. In this review, we analyzed the available data and addressed the clinical question of whether LTOT increases the survival rate of patients with stable COPD and moderate hypoxemia. For the purposes of this review, moderate hypoxemia is defined as a Po2 value of 56 to 59 mm Hg or oxygen saturation as measured by pulse oximetry (Spo2) of 88% to 90%, with the ability to concurrently maintain oxygen saturations greater than 80% on a 6-minute walk test and 88% at rest.

No abstract available. Article truncated after the first page. History of Present Illness: The patient is a 60-year-old woman with dyspnea on exertion when she had a pulmonary embolism following knee surgery 3 years earlier. She smoked 1 pack per day for the past 40 years. She was seen at another hospital and had pulmonary function testing which showed only a DLco which was 66% of predicted. Serologic studies were negative for a rheumatologic disorder. A CT scan was also performed (Figure 1). The CT scan was interpreted as showing a few small nodules and possible very early interstitial lung disease. Which of the following are true? 1. A pulmonary embolism can reduce the DLco; 2. Her CT scan is characteristic of Langerhans cell histiocytosis; 3. Smoking can reduce the DLco; 4. 1 and 3; 5. All of the above …

Stem cell transplant (SCT) recipients commonly undergo bronchoalveolar lavage (BAL) collection as an infectious pulmonary work‐up. Previous studies report the utility and overall diagnostic yield of fiberoptic bronchoscopy with BAL in this vulnerable population, though none focused purely on microbiologic yield or made comparisons with less invasive means of pathogen detection. We sought to determine and elaborate on the microbiologic yield of BAL in SCT recipients, assess a correlation between BAL studies and less invasive means of pathogen detection, and assess the utility of repeating a BAL within 30 days.

OBJECTIVE We sought to evaluate specific CT criteria for the diagnosis of usual interstitial pneumonitis (UIP) in the absence of honeycombing. These criteria included peripheral reticulation and lobular distortion; some upper lobe involvement, but a lower zone predominance; a heterogeneous appearance with areas of normal lung, minimal reticulation, and substantial distortion alternating throughout the study and often on an individual image; a nonsegmental distribution; and traction bronchiectasis. MATERIALS AND METHODS We searched reports of CT studies performed between January 1, 2009, and January 1, 2012, to identify patients for whom UIP was a likely or probable diagnosis and reviewed the CT study for each case (n = 106). There were 38 patients who met all CT criteria and who also had a clinical diagnosis of idiopathic UIP (also known as idiopathic pulmonary fibrosis [IPF]) and follow-up of at least 6 months, as determined from the electronic medical record. We reviewed prior and subsequent CT examinations in this cohort. RESULTS The median age of our patients was 80 years, and the duration of clinical follow-up was 6-104 months (mean, 38 months; median, 37 months). For all patients, a pulmonary medicine physician made a working diagnosis of IPF. Fifteen patients died from pulmonary complications, and 16 of the surviving patients had clinical or functional progression of disease. There were no instances in which the initial diagnosis was revised or reversed. CONCLUSION Strict application of specific CT criteria may allow a specific diagnosis of UIP in the proper clinical setting in the absence of honeycombing.

No abstract available. Article truncated at 150 words. Dr. Jud 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 ...

The objective of the study was to compare nasal, pharyngeal, and sputum eosinophil peroxidase (EPX) levels with induced sputum eosinophil percentage in 10 adults with poorly controlled asthma and 10 normal controls. EPX was measured using an ELISA and normalized for grams of protein for nasal and pharynx specimens and for mL-gram of protein for sputum. Sputum EPX levels were statistically different between asthma and control subjects (P = 0.024). EPX levels measured in the nasal and pharyngeal swab samples derived from the same patients were also different between asthma and control subjects, each displaying a high degree of significance (P = 0.002). Spearman's correlation coefficients for nasal EPX and pharyngeal EPX levels compared to induced sputum eosinophil percentage were 0.81 (P = 0.0007) and 0.78 (P = 0.0017), respectively. Thus, there is a strong association in a given patient between both nasal and pharyngeal EPX levels and the eosinophil percentage of induced sputum.

History of Present IllnessA 53 year old woman from Indiana was seen who had a history of nonproductive cough for several years.She had a prior diagnosis of asthma but continued to have cough despite asthma treatment.She was also treated for gastroesophageal reflux and had a Nissen fundoplication.This resolved in some improvement in the cough.In May 2013 she noted increasing dyspnea on exertion.An echocardiogram was performed which was notable for a 16% left ventricular ejection fraction.A thoracic CT demonstrated some nodules and a question was raised of sarcoidosis.She was admitted to a hospital in Indiana and had a biventricular pacemaker placed.Bronchoscopy with transbronchial biopsy was performed with no diagnostic findings.No granulomas were seen on the biopsy.Bronchoalveolar lavage showed a CD4/CD8 ration of 0.84.Optic nerve swelling was noted at that time.Due to the cardiac, pulmonary, and optic nerve findings a clinical diagnosis of sarcoidosis with a dilated cardiomyopathy was made and she was treated with prednisone initially, then a combination of prednisone and methotrexate. PMH, FH, SHHer past medical history was as above and family history was noncontributory.She does not smoke or drink. Medications Methotrexate 15 mg weekly  Prednisone 5 mg daily  Furosemide 40 mg daily  Potassium chloride 20 meq daily Physical ExaminationAfebrile.SpO2 96% on room air.The physical exam was unremarkable.