 Good evening and thank you for joining us on behalf of the panel and the organizer I'm pleased to welcome you to our cafe. There will be some coffee later and it will be a real cafe right now you just have to wait for it. And it's hosted by the Lung Association with the support of the Canadian Longitudinal Study on Aging as we call it CLSA. I know many of you are the participants of the CLSA and you're here. And also this event is supported and by the Labarge Optimal Aging Initiative and the newly approved McMaster Institute of Gerro Science. So what this highlights is that McMaster is becoming an important player in the area of research on aging and we are going to be showcasing many of those not only today but in the future events as well. My name is Perminda Reina. I'm the lead principal investigator of Canadian Longitudinal Study on Aging and a professor in clinical epidemiology and biostatistics here at McMaster and I'm going to be your moderator today. I will be the David Letterman. And you will get a chance to hear some of the leaders in the area of lung health and talk about where the research is, what kind of treatments and management issues in relation to lung health they have been working on and what there is to share with all of you here today. And the idea is that they will share the latest knowledge on the topic and how it can help those of you here or people in general in relation to in relation to the lung health. Thinking about pneumonia, lung cancer, asthma or COPD. We appreciate all of you taking the time to come out and take part in what we hope will be an informative session. We are in the virtual world tonight and we have some people through the webcast online. I think the last number I heard they were around 20 to 30 people online already and hopefully those people will be able to hear what our experts have to say and if you any one of you have access to Twitter you can tweet it to you. What is the Twitter address from CLSA? We can use that one. What is it? Yeah it's at CLSA hashtag. Yeah it's at CLSA underscore ELCV. So if you can send your question through Twitter we'll make sure that our panelists are able to address any of your questions. Today's event is also intended to inform you about the lung associations breathing as one campaign for lung research. I wanted to also mention here that this event is actually supported entirely by the lung association through their through their breathing as one campaign. Lung association is one of Canada's oldest and most respected health charities with a focus on education, advocacy, support for patients, caregivers and healthcare providers and of course research. It is the focus on the research that is behind breathing as one campaign for lung research. Those of us here on the stage tonight especially four of my colleagues here and I'm sure many of those in the audience as well know firsthand the challenges and impact on the quality of life for Canadians suffering from respiratory illnesses and statistics are actually quite daunting with one in five Canadians affected by lung disease chronic obstructive pulmonary disease or COPD is becoming number one cause of hospitalization and lung cancer and lung cancer kills more people than breast ovarian and breast prostate cancer combined and thinking about these statistics and also thinking about COPD and the aging of our population and the influence of environment and the air pollution you can see these some of these issues are going to be magnified in the in the coming years and it's also important to mention that November is a long month so there is no better time to introduce this important new campaign to you here today by our colleagues and by the lung association as well and as I mentioned the CLSA is also part of today's event and and we would like to extend special thanks and welcome and thanks to the study participants who are here today and it's kind of fun to see those people come out again again different events that we have hosted here and see their interest in research and evidence and science and how that will not only impact their own health but the future generations as well and how they become ambassadors for some of this research as well and those of you who are not part of the CLSA and don't know CLSA probably saw the promo that we had earlier on going in the loop form CLSA is a 20 year longitudinal study which is recruiting 50,000 men and women between the ages of 45 and 85 across Canada and so far we have already recruited almost 45,000 people so we have 5,000 more to go and we are looking at a science of aging from cell to society we're trying to understand what the biological aspects of aging are as well as to the social aspects of aging and respiratory health actually is an important part of part of the CLSA and keeping in mind what the breathing one campaign is trying to achieve that one of the challenges in the lung health research is getting attention given to research in this area many of the other areas of health get a lot of funding to do research and this area actually hasn't received that attention in relation to how the different research the financial resources be given to conduct research in this area and we hope Canadian longitudinal study on aging is one such platform to enhance research in this area so rather than me taking up a longer time and describing what CLSA is you can go to our website and there are brochures and other information here that you can pick up tonight you will hear from some excellent researchers whose work is helping Canadians live longer and live healthier lives and and Hamilton has long been a leader in the field of research into lung disease and his treatment and tonight's guests are an example of the cutting edge work that happens in this area here breathing as one campaign will help these investigators and many more like them across Canada get the support and funding they need to create the breathing breakthroughs we all desperately need and I guess one of the roles as you community member is to make sure you talk to your members of Parliament saying that how important this area of research is that the what the federal government or the provincial government should be doing in this area from the perspective of research dollars you'll also hear about some of the programs the lung association offers to help those with respiratory illnesses today's event will consist of 10 minute presentation from each one of our four panelists after which we will open up to questions from the floor so you have the opportunity to ask questions and hopefully we sort of have an interactive dialogue around different areas you can pose your question in general terms or you can ask a specific questions to one of the speakers and then we will wrap up the official part of the program just before 7 p.m. after which you're invited to stay and enjoy some of the light refreshments and perhaps mingle with some of the speakers and ask more questions if some of you are shy and don't want to ask the question in public so I don't want to take up too much more time and I'd like to introduce our panelists here what I will do is I'll introduce all four of them now and then they will come to the podium and start presenting first we have Dr. Don Bodish an associate professor in the Department of Pathology and Molecular Medicine at McMaster Don is a holder of the Canada research chair in aging and immunity she earned her PhD at the University of British Columbia and her work there led to a patent and the formation of a small biotech company which I didn't know Don great job she joined McMaster in 2009 and her laboratory here conducts research into some of the major causes of pneumonia in the aging population and and she has greatly benefited through lung association in getting funding for her work in her laboratory so Don will be one of our first speakers our second speaker will be Carol Maddley and director of respiratory health programs from Ontario lung association she is responsible for the delivery of several asthma programs funded by Ontario ministries of health and long-term care as well as as well as Breed Works program funded by the lung association and other respiratory programs that are offered across the province welcome Carol next we have Dr. Carl Richards a professor in at McMaster University as part of the McMaster immunological research center he studies tissue remodeling which is a feature of many lung diseases and how the lung copes with chronic inflammation he's a he has also developed a mouse model of a lung cancer and is using this to develop no novel therapeutics for difficult to treat lung cancers welcome Carl and our final presenter of the evening is Dr. Gerard Gerard Cox a physician for more than 25 years who has we joined McMaster in 1992 trained both in internal medicine and respiratory medicine and is a former head of clinical services at the Firestone Institute for Inspiratory Health at St. Joseph's Hospital here in Hamilton in addition to providing clinical care from respiratory illnesses Dr. Cox is also active in research on the mechanisms and management of pulmonary inflammation so welcome Gerard and and you can see that we have people here that range from what happens in the laboratory side to what happens from the programming side to what happens when a physician interacts with a patient who's suffering from a particular lung health issue and you will hear all their perspective so without wasting any more time I will turn the podium over to Dawn Dawn it's all yours thank you thank you so much for coming I've been working with the Lung Association in their breathing as one campaign and it's been such a thrill for me to be able to speak and help to raise awareness and to raise money for a cause that's both professionally very important to me because obviously it's my research interest but also is personally very important to me because I have a number of older adults in my life who I care deeply about and I want them to remain healthy for a long time in fact you may even recognize me from some of the promotional materials from the Lung Association my lab's vision is that keeping older adults infection free would provide them with more years of independence improve the quality of life and reduce the cost of care and it is very common to blame aging for driving up the cost of our health care system so on the left what you're looking at here is a common bar chart that says how many dollars per year each age group costs and you can see that that increases as you get older but in fact it's not aging that's expensive it's aging and ill health so on the right hand side what you're looking at is a graph from the province of Alberta where they've looked at individuals who are over 65 and how much they cost the health care system and you can see that people in green who have no chronic inflammatory diseases no real medical conditions cost very little in fact they cost less than a pregnant woman no one ever blames them for driving up health care costs even if you have a few risk factors maybe a family history or obesity or smoking if you're not currently sick you're in that yellow bar there and again you don't cost very much but this is what becomes expensive if you have a chronic inflammatory condition like diabetes COPD heart disease or God forbid more than one of them this is what is expensive aging isn't an expensive aging and ill health is and so my lab really wants to prevent or delay or stop or slow down the onset of these chronic inflammatory diseases and something that you might not be aware of is that pneumonia can actually be a driver of some of these things that cause us to have ill health as we get older and so I'll give you an example this is some data that's been collected from American HMOs and their Medicaid system they know that if two older adults go to the hospital for any of the things that an older adult might go to the hospital for let's say they go for a heart attack if one of those people acquires a pneumonia around the time of their stay that person is going to cost an additional fifteen thousand dollars in the next year for health care costs and those health care costs aren't going to be related to the pneumonia and they're not going to be related to whatever they originally went to the hospital for this is because having a pneumonia in mid to late life can sort of accelerate or exacerbate the development of other chronic inflammatory conditions that might seem quite unrelated and to me this is a terrifying graph so these HMOs have tracked people for a few years after they've left the hospital and they've grouped them into two groups people who acquired a pneumonia at the same time that they were ill and people who didn't acquire a pneumonia everyone leaves the hospital healthy in the study but over time what happens is they're looking at the death rate and so if you didn't have a pneumonia the death rate is showing there in gray if you are unfortunate enough to have a pneumonia during your time to stay in hospital the death rate is much steeper these people die a lot and this is all cause mortality this isn't because of pneumonia nobody dies of pneumonia in Canada anymore unless they're very very ill and frail this is because this pneumonia can precipitate or accelerate other chronic inflammatory diseases cardiovascular disease diabetes and dementia being the big ones so preventing pneumonia in mid to late life will hopefully slow down or stop the progression to some of these diseases and what my lab is studying is the strange cyclical relationship between chronic inflammation and chronic inflammatory diseases pneumonia and having acute inflammatory response so for reasons that we don't really understand very well if you've already got a chronic inflammatory disease dementia diabetes and cardiovascular being the big ones you're more predisposed to getting a pneumonia and then if you get a pneumonia the natural immune response that you have the natural inflammatory response that you have that gives you the fever and makes you feel sick and and is actually a very beneficial part to cure to getting better from that pneumonia doesn't seem to go away the way it should be and so that acute inflammatory response that comes around the time that you're ill seems to build up or raise these levels of inflammation that we have in our body and might cause this acceleration or exacerbation of other chronic inflammatory diseases so what my lab's really doing is we're trying to find breaks in the cycle we're trying to find places where we can stop this terrible progression now inflammation which you may or may not know is actually a natural part of aging so on the left here what we're looking at is some blood donors who came to our lab and gave blood and I would encourage all you to do that as well if you're not tapped out from being in the CLA say and and what we are looking at here are a number of pro inflammatory cytokines doesn't matter what they are but basically these are just measures of inflammation in the blood of the volunteers who come to our lab and these are young people old people young people old people young people old people and what you can see no matter what measure of inflammation we look at and there's a lot older adults always have more than younger adults and in fact this happens in a very linear and predictable way so if you were to come and donate your blood for me and I were to ask you what your age is I could actually without if you lied say or maybe you were a little bit subtle about how old you actually were I could actually predict your age within three years just by measuring the levels of inflammation in your blood that's how linear and protective is but if I were to do this study and you were to come and give me your blood you would want to be someone who looks young for their age you would want to be someone who falls below that line and you would want to be someone who is lower than average you'd want me to guess you were young and not just for vanity because having lower than age average levels of information tends to mean you're going to have a longer healthier life and be less plagued by some of these chronic inflammatory diseases and as it turns out you'd be protected from pneumonia as well so like I said we're trying to really figure out why there's a strange relationship between chronic inflammatory diseases inflammation and pneumonia and what we do is we take a certain kind of white blood cell out of the blood or we use aged mice so we use mice that are about two years old which are about an 80 80 year old equivalent and we take a certain kind of white blood cell out of their our blood or their blood called a macrophage and the macrophages job is basically it's the pac man of the immune system it goes in it chomps the bacteria and it destroys it and so what we found and unfortunately the the screen isn't very clear here but the macrophages is yellow and the bacteria is red and what happens is the macrophage throws out its arms engulfs that bacteria and blows it to smithereens so you can't actually see a bacteria in there anymore you just see a red haze now this is a macrophage from an older individual and what's happened here unfortunately is the bacteria the macrophage has been able to eat the bacteria but it can't kill it and so what we found is that old macrophages essentially lose their appetite for bacteria they're not very good at eating and killing them anymore but if we experimentally in our mouse models if we lower that age associated inflammation using drugs or genetics what we can actually do is restore that appetite so they keep their killing capacity so we've been able to use this as a way of studying how reducing inflammation helps the other thing we've noticed is that when we take these macrophages out they have they produce way more inflammation than they need so in the pink bar what we're doing is we're measuring the difference between the pink which are old macrophages and orange which are young macrophages and we see that those old macrophages produce way too much inflammation for what they need and for reasons that we don't understand it's not really very well resolved and so we think that's what contributes to this cycle so in our lab we're trying three basic approaches to make old people have long older adults have longer healthier lives we're developing new drugs for example we just identified that this compound here can restore the appetites of macrophages and we're really interested in bringing that to animal models we're actually trying to use drugs that are natural anti-inflammatories to see if we can reduce inflammation in our mouse models and if we can bring those levels back down to what they were when the mice were young and see if all of a sudden that can repair their their macrophage function and we're also trying to use probiotics and other tools to sort of strengthen the microbial communities that will prevent the bacteria that causes pneumonia from really seeding hold so that's what i'm doing and here's what you can do so the first and most important thing is always managing any chronic inflammatory conditions the better health you have the less chance of getting a pneumonia you have the second thing is to be aware of the symptoms so pneumonia is a bit of a strange infection to have in young adults or kids raging fevers in older adults sometimes those fevers are absent and so people will often complain of being run down or having tightness of chest but they might not have a really really strong fever response so if for any reason you suspect that you're just feeling a little under the weather or feeling that tightness in the chest it's important to get that looked at pneumonia is a serious infection and it doesn't go away and we have two vaccinations that can help prevent this we have the pneumococcal vaccine or the pneumonia vaccine and we have an influenza vaccine because pneumonia often comes with influenza but it's important not just to get yourselves vaccinated in my family we make vaccination a family affair because the number one risk factor for older adults for getting pneumonia is contact with children so those little angels look very sweet but in fact what they are are breeding grounds for the pneumonia that will infect their their grandparents so for dollar for dollar vaccination actually works better in children if you were to only vaccinate two of the people in this picture the under five proud would be the one to do it with nevertheless in my family we're all vaccinated and so essentially this is why my work is important to me on a personal level it's not only because keeping older adults healthy and infection free would provide them with more years of independence improve the quality of life and reduce the cost of care but more importantly it's because it will give them more years of playing with their grandkids and really that's what we all want um so I'd just like to acknowledge the hard work of my team at the McMaster Immunology Research Center and our collaborators who help us do this and I'm really looking forward to entertaining your questions during the question period and meeting you at the coffee break thank you very much thank you very much for joining us this evening my name is Carol Maitley and I work for the Ontario Lung Association I'm going to be speaking you tonight about chronic obstructive pulmonary disease COPD COPD includes chronic bronchitis and emphysema it's a lung disease that takes your breath away and the main symptoms are cough shortness of breath and sputum production approximately 13 percent of Canadians have COPD and its prevalence is increasing especially in women so approximately 13 percent of Canadians have COPD that's millions of Canadians it's a major cause of death and disability it's the fourth leading cause of death in Canada and it's expected to be the third leading cause of death by 2020 it causes more hospitalizations than any other chronic illness this is a serious disease doesn't usually affect people under the age of 40 so it's commonly an older person's lung disease it affects more women than men women are more susceptible to the harmful effects of tobacco smoke and women develop COPD earlier than men so why do people get COPD what are the causes well 80 to 90 percent of the cause is from cigarette smoking but there are about 10 or 20 percent that are caused from other factors like a genetic factor called alpha one antitrypsin deficiency it could be due to your occupation maybe you're exposed to different chemicals at work it could be due to long-term secondhand smoke exposure and a child that had several lung infections so here's a quick self-assessment test if you're over the age of 40 and you smoke or you used to smoke you may have COPD but take this quick test do you cough regularly do you cough up phlegm regularly do even simple chores make you short of breath do you wheeze when you exert yourself or at night do you get frequent calls that persist longer than those of other people you know if you answered yes to one or more of these questions ask your health care provider about a spirometry test now a spirometry test is a simple breathing test you can often get it at a doctor's office a hospital lab a clinic what they'll ask you to do is take a really really big breath in and blow the air out hard and fast and keep blowing and blowing until your lungs feel like they're empty it's the test that we use to help confirm a diagnosis of COPD or asthma i just want to add one thing about that spirometry test some of you may have been told you have COPD but you may have been told you have COPD based on your smoking history and your symptoms however to be sure you have COPD ask for spirometry and having that spirometry test will also help your health care provider to make sure that you're on the proper medications you need for your COPD so how do we manage this lung disease called COPD well if you're smoking find a way to quit and it's not i know it's very very tough and there's many many ways that out there to help you quit and sometimes you need more than one you might need nicotine replacement therapy and some support find a way to quit quitting smoking is the best way to slow down the progression of this lung disease the other thing you want to do is stay away from things that make your lung disease that make your symptoms worse so for instance as Don mentioned if your children or grandchildren are suffering with a cold if they've got the flu don't visit at that time say sorry don't come don't come see me this week also air pollution can make your symptoms worse and if you are prescribed medications it's important to take them as prescribed i can't tell you the number of times i'll say to somebody are you using that medication and they'll and they'll tell me what they're doing with it and i'll say now pick it up and read to me what it says and they're often not doing what it says take your medications as prescribed and in the treatment of COPD the medication is often inhalers exercise is really important for all of us regular exercise is very beneficial for people that have COPD you might want to do mall walking you might have stationary cycle it's important to keep to keep healthy to control your breathlessness and reduce fatigue you need to learn strategies and for instance there's breathing techniques like per slip breathing you also want to prevent and treat flare-ups flare-ups are what makes your symptoms worse so work with your healthcare provider and what we call the COPD action plan so that you understand what to do what kind of action to take when your symptoms are worse you might have heard of pulmonary rehabilitation it's a program that helps with energy conservation exercise training nutrition counseling and it'll also help you manage your lung disease it's extremely important to avoid getting infections so as Don mentioned get the flu shot everyone should get the flu shot and the pneumonia vaccine is very important for people who are at high risk people with lung disease are at high risk so talk to your family doctor or your healthcare provider about the pneumonia vaccine some people require long-term oxygen therapy not everyone but some do and again i have to stress get that action plan to help you manage your disease so what's new in COPD well this year several new medications and devices have come out for the treatment of COPD we haven't seen a new inhaled device sorry a new inhaled medication for COPD in over 10 years so this is really exciting there's a lot of new medications that have come out and you'll notice a lot of these new medications are called bronchodilator bronchodilator bronchodilator you'll see that along this list some of them are combination therapies some of them are long acting why bronchodilators that's because it's the main state therapy of for COPD people need bronchodilators to help with their breathlessness so as you'll see there's also new devices that have come out this year new devices we've never heard about before breeze hail or ellipta, genuera, respomat for the combi-vent so new devices new medications extremely important that if you're placed on one of these new medications that you are in get the instruction on how to use this new medication speak to your pharmacist your healthcare provider taking medications the right way and as prescribed is very important in the management of COPD what else is new well are the there's recently been released new guidelines for the treatment of what we call AECOPD acute exacerbation of COPD what is that word acute exacerbation it's an acute worsening of your symptoms beyond what you have day to day increased shortness of breath increased cough and sputum production and you have an increased need to be taking your medications it's also referred to as a lung attack because sorry it's also referred to as a lung attack because like a heart attack a lung attack is very serious so these new guidelines for managing acute exacerbations of COPD are now available they've come out recently and this will help your doctors your healthcare providers with the management of an acute exacerbation and with the medications and the antibiotics that are needed i'd like to take a few seconds here to speak to you about our breathworks program breathworks is a national program across this country that all the lung associations have resources free resources for people with COPD we also have certified respiratory educators on a helpline the number that you see here is our national helpline number 1-866-717-COPD or you can also email us at info at on dot lung dot ca if you get on a new medication a new device you've been newly diagnosed or you have questions about COPD contact the lung association and speak to a certified respiratory educator thank you well thank you very much for this opportunity to speak to the cafe scientific tonight as part of the breathing as one initiative my name is Carl Richards and i'm going to be speaking to you today today about lung cancer now there's no question that lung cancer is a big killer so on the left of your screen is a big pie chart here 30 percent of people in Canada will die of cancer of that 30 percent in the purple pie chart 27 percent will actually die of lung cancer so it's a really big killer it's caused by a rapid growth of these lung tumors in the lungs there's very few treatments that actually exist for lung cancer and it's got a very very low survival rate on the right hand side of your screen i show a CT scan i'm sure many of you have seen these before this is a very fancy x-ray showing a cross-section of the thorax with two dark sections there of course of lung and you can see i think with a purple line a tumor actually being detected by CT scans generally speaking it's very difficult to detect lung cancer that's one of the main reasons why in fact it's very difficult to treat because it progresses so far before in fact it's actually detected cancer lung cancer like all cancers are actually caused by mutations and these mutations in cells cause cancer cells to grow uncontrollably if in fact they are not held in check by the immune system then those cancer cells will develop into a tumor take over the actual organ and then of course metastasize to other parts of the body where they destroy tissue and take up nutrients there is increasing evidence to suggest that inflammation not only is caused by cancer but actually helps cancer develop and this inflammation can come in all different sorts of shapes and flavors so for example the inflammation that you get from a broken arm or trauma a heat swelling and pain is different than the inflammation that you get for example if you have allergic airway disease where you have coughing and wheezing and it's different than the actual inflammation that you get an autoimmune disease where you get destruction for example of bones and cartilage there is also a cancer-provoking inflammation and that's what we in our lab are trying to actually study in more detail so quickly about lung cancer mortality I'm sure some of you have actually seen these data before but I want to point out to you the actual blue line up top here which shows lung cancer so on the top is males lung cancer mortality over the last 30 years so this is now from 1985 through to 2014 is very high in comparison to the two lower lines there which are colorectal and prostate cancer on the bottom are female rates of mortality and you can see in the green line actually that female lung cancer is increasing over the last 20 or 30 years so now that in fact it is actually the highest killer of women twice as high at least as opposed to breast cancer or lung cancer and some of these numbers here are actually to me quite remarkable 26,000 Canadians will be diagnosed this year with lung cancer 20 will actually 20,000 will die from it and for me as I go throughout my baby boomer years longitudinally these numbers for me were remarkable one in 12 of my Canadian men on the hockey team are actually going to develop lung cancer and 85 percent of those will actually die and the similar numbers in women one in 14 Canadian women are expected to develop lung cancer during their lifetime so it's very very common and the other thing associated with that it is very low survival rate so I hope you can see it but these yellow line right at the bottom here is the survival rate for lung cancer at one three five and 10 years after diagnosis and you can see that even after one year only 40 percent of people survive lung cancer at five years 17 percent survive and at 10 years only 13 percent of people diagnosed with lung cancer survive at 10 years you can see these other cancers prostate cancer at the top blue much higher percentage survival rate female breast cancer 82 survival rate at the 10-year mark despite this major killer activity of lung cancer the funding that goes into lung cancer research is two to three times lower than it is for example in breast cancer and that's the same in the U.S. as it is in Canada deurity detection is very difficult as you can imagine you don't really have feelings in your lungs so in fact things can grow in your lungs without any detection for a very long period of time and that's part of the reason why in fact lung cancer is so advanced by the time it's detected risk factors as Carol pointed out same as COPD smoking is is related to 85 percent of lung cancers so there's 15 percent of lung cancers that are not related to smoking but no question he carols advice if in fact you are a smoker the other the current treatments are of course surgery chemotherapy radiotherapy and more recently these biologic therapies called targeted therapy where they actually target specific molecules and i'll talk about that in just a second and even more recently our immunotherapy approaches where in fact the approach is to jack up the activity of the immune system in order to attack cancer but i won't have time to talk to you about that today so how does cancer grow in the lungs this is a schematic diagram on your right showing a cell a cell is actually activated by growth factors and those growth factors interact at cell surface receptors for example this one is called the egf receptor and what happens after that is a whole series of events inside the cell that tells the cell to grow if in fact these proteins here are mutated so that they're constantly turned on the cell gets the message to continue to proliferate at forever so this is the problem with most cancers and that there is mutations in these molecules and these growth factor receptors that cause the cell to turn on its proliferation and here you can see a couple of tumor cells here dividing in two so there's mutations that cause the lung cancer but also in the lung is a very rich environment for the actual tumors to grow and those mutations have actually been looked at over time this is examples from 1984 through to the present time of trying to define those those particular mutations and the reason is is that you can actually develop medications to target individual mutations that's the goal but you can see in 1984 for example on top left hand side there was only one mutation that was identified it was called KRAS through 2004 2009 and on the bottom right in 2013 in lung cancer now we know what the mutations are in 65 percent of individuals and that helps with us trying to decide particularly med oncologists trying to decide which medications that patients might be more responsive to compared to others so that's the mutation side of things i'm i'm not a mutational biologist i am an inflamologist and i'm really interested in how the inflammation actually causes the cancer to grow and the cancer cells don't actually grow in a vacuum there's other cells macrophages and fibroblasts and immune cells that are all actually intermixed into the tumor so that 50 percent of the tumor is actually non-tumor cells and those cells i believe are instrumental in developing the actual cancer growth and they can be controlled by different stimulus of inflammation so here's an example i'll only show you two data slides this is one of them this is one of my most favorite and these are mouse lungs so i work in mouse like dawn i work in mouse and on the left hand slide are mouse lungs that have been treated with the tumor and on the bottom there is a what's called a histological slide where you can actually see under the microscope where the tumors are the next slide over is where we change and skew the environment with this growth factor it's called osm it's a growth factor that actually skews the inflammatory environment to increase the tumors they're 50 to 100 full okay we can also follow these by ct scans and if you look at that on the far right hand side you can see those what we call heat maps identifying tumors there that are shown in red we can follow this system in animals over time using these ct scans analysis the other thing that we've done and this is only the second data slide that i'll show you is we've looked at a model of k-ras mutations in mice because in fact k-ras here represents 25 percent of the of the mutations in lung cancer and when we take a mouse and we activate a mutant k-ras gene in the mouse and follow it by ct scans you can see in the middle here that you can see in two different mice dramatic increases in these tumors if you combine that mouse with one that has reduced function of this growth factor that i'm talking about you can get a dramatic decrease in amount of tumors so that is what we're trying to understand how is this working and this growth factor we here is actually called osm maybe affecting immune system or maybe affecting the regulation of these non-tumor cells and that we we believe will be a new approach to tackling these very very difficult to handle human tumors and with that i'd like to finish and make sure i recognize the work of one individual shawn labir here is a student who is primarily responsible for some of this work and thank you for your attention so i'm jerry cox i'm going to talk to you about another lung disease this is pulmonary fibrosis this is an illness that doesn't affect as many people as the illnesses you've heard about already today but it is a rather devastating illness almost as bad as lung cancer in its outlook and unfortunately it's an illness that becomes more common as we age so that while i started in this condition 30 odd years ago studying it and then it was rather uncommon nowadays it's not that uncommon at all because people are living longer and surviving many other insults and they're getting this so this is a disease of the lung tissue you heard about COPD which has been bronchitis and which is predominantly a nilness of the airway or the breathing tubes but pulmonary fibrosis is a nilness of the lung tissue where the gas exchange occurs and so it affects all around the outside of the lung not the breathing tubes so we know about breathing tube disease asthma bronchitis which can be caused by a variety of different factors here COPD that we've heard presented already and bronchitis this might be another one the interstitial lung diseases are a lot less common and they've got much longer names and they're not in the least bit intuitive when you hear the names apart from pulmonary fibrosis the first one with the commonest form of that being of unknown cause so we call it idiopathic pulmonary fibrosis which basically means we don't know what's caused your lung scarring it can be caused by radiation exposure and of course we use a lot of radiation treatment for other cancers and we are all exposed to radiation as long as we live around anywhere and if you go up in an airplane you're exposed to more and if you live in the city you're exposed to more than you live in the country and the interstitial lung diseases can be caused by drugs that are used to treat other conditions so quite a number of our patients are people who have survived in other conditions but unfortunately the treatments have caused lung injury and lung fibrosis and we're left treating with that just to make the counterpoint the opposite emphysema which is also a nilness of of the lung tissue is actually destruction of it so you've got absence of lung tissue and emphysema and big holes in the lung and big spaces where lung tissue used to exist whereas lung fibrosis is a nilness where the tissue becomes denser and stronger and there's a normal scaffolding in the lung to give it some structure and to give it some flexibility and there so there is normal fibrous tissue but not so much of it and it's loosely connected so it's flexible unfortunately when we get an over accumulation of fibrous tissue in scarring diseases it gets stiffer and you can imagine that if these walls get get bigger and stronger and thicker there's going to be less space between them and that's exactly what happens the lungs become stiff and the spaces become smaller so there's less room for air we can detect this on the chest x-ray on the left we can see a normal chest x-ray where as Carl said the lung fields are all black the big white blob in the center is your heart shadow contrast that with the x-ray on the right where you see all these markings all these extra white blobs and blebs in the lungs and this represents an excess of lung tissue getting in the way of gas so it impedes gas exchange making the lung stiffer so it becomes harder to take it be a full breath in again the CT scan is a more sensitive technique for demonstrating this and we have a horizontal or transverse section of the thorax with the heart shadow at the front the spine at the back and we can see a normal study on your left where there are some lines and some blobs for blood vessels in the normal lungs in contrast on the right hand side there's quite a lot of extra white markings and we see that things are not quite even and dispersed there's clumps of things in places around the edges there's a bit of a nice black space here and on the other side on the right lung field over there there's quite a lot of disease when we talk about these changes we use a term honeycombing so a honeycomb is shown on the right nice regular walls with spaces and we think that that term is a good way of describing what happens in this disease where we see over here these little little black spaces with white walls representing the characteristic manifestation of this disease on a CT scan so honeycombing is something we often talk about to describe it on the right we see lung cancer survival rates and the red line is for 50 survival and as Carl pointed out that unless you've got very early stage cancer which would be stage 1a you really have very poor outlook with lung cancer pulmonary fibrosis isn't a whole lot better the 50 survival for pulmonary fibrosis is less than four years so it's a modest improvement over having cancer and yet people don't treat fibrosis with the same respect and fear that we have for lung cancer so where is this coming from and this is going to bring together in fact a number of things you've heard about already so what happens in pulmonary fibrosis is really determined by the individual and their journey what we think happens is that the lining of the lung which is epithelium so the lining of the lung gets damaged by a whole variety of things and this happens always we're damaging the lining of our lung right now by breathing there are particles there are there's things in the atmosphere there are little infecting organisms there's pollution there's smoke and we deal with it it's not a problem but sooner or later you've had too many little insults or you may have a little sensitivity or you may get two or three of them all at the same time so what we think happens is that there's just a build-up of these micro injuries or a little sensitivity on the person's part to them which leads then to too much damage occurring and when there's too much damning and failure to repair you get this chronic ongoing effort to to heal and that's where we get too much scar tissue scar tissue is a normal part of healing and we're seeing too much of it so it's over enthusiastic efforts to heal and it can be provoked by infection like dawn talked about it can be provoked by cigarette smoking like carol talked about it can be provoked by by inflammation some inflammatory injury that's either spontaneous in the body or provoked by some other stimulus any of these can cause excessive healing and that's where we come to this idea about how there's a genetic defect or mutation so that's what carl talked about a lot where there's a a fault in the recipe so the genes are basically the recipes that your cells follow and if there's a fault in the recipe it's making bad stuff and that causes stress and unfortunately the lung is has to open and close every time you breathe and that mechanical stress itself can over years build up and create some damage that leads to more need for injury and more fibrosis and these wonderful terms that other people understand telomere shortening mitochondrial fatigue cells in essence what that basically means these are some of the processes that we all look forward to as we get old these are some of the events going on in cells that are getting just a bit tired and getting a bit knocked up from being around for a few decades and that's sort of inevitable for most of us but there are events that occur in cells as they get older we can identify and hopefully like Don talked about be able to modify by using either new drugs our old drugs our food our goodness knows what to try and interrupt this cycle of build up of damage as it occurs as cells get older unfortunately as a result of this injury this genetic tendency these cell processes that are disturbed we get in fibrosis remodeling with excess enzymes provoking things to be made and in particular in excess of matrix or fibrous tissue being put down so this is just a probably well you probably could read it but it doesn't really matter what this is this is some of the excitement this is when we talk about some of these cell processes that are getting upset as we get old and getting upset as a result of repeated injury there are now examples of different of different types of factors so there's six different things here epigenetic changes signaling pathways doesn't matter what they are but within these groups there are specific examples being identified which will become targets for intervention and that's what's tremendously exciting that we may be able in time to stop this consequence of aging and the accumulation this this this two sided process cells are getting older they're getting hurt and we can stop some of the accumulated damage that occurs so just to talk a little bit about pulmonary fibrosis this is a slide that shows that the the lung function deteriorates progressively as this illness carries on and there are two red arrows there and this is where we might be able to intervene one is at the gradual decline that occurs that's arrow number one and number two is to try and reduce the frequency which people get acute deteriorations or exacerbations you've heard about the importance of avoiding infection because infections can provoke these illnesses as well as treating reflux which causes aspiration and where necessary oxygen as carol said and the exciting part of pulmonary fibrosis now is that there are two drugs available to us that will reduce the fibrotic process these one is approved in Canada perfenedone or esbriate the other nintedinib has been approved in the in the states and in Europe and will come to Canada sometime soon very briefly perfenedone is not an inhibitor of inflammation but it is an inhibitor of fibrosis and we know that in the placebo treated arm of this study we saw exactly what we expected which is that there was a decline in the vital capacity a decline in the breathing capacity and that's in the white bar the blue bar shows that that decline was cut in half by drug treatment this was the first time ever that we showed an effective treatment for fibrosis to prevent deterioration there's also a small but detectable improvement in the mortality rates so this is very exciting going forward the other drug which is an inhibitor of some of the signaling pathways that carl referred to so how does the cell respond to a growth factor well it has an internal signaling system and those internal signals can be inhibited by this drug and we see in the far right that the rate of decline the yellow bar on the right the rate of decline in patients treated with the highest dose of this compound that rate of decline again was less than half of what happened in the placebo group or control group shown in white and nicely too the incidence of acute exacerbations can be cut in half or even reduced further by successful treatment with this drug so while ipf is a potentially deadly disease we now have drugs that can slow progression however we're not finished we need treatments that might actually improve people who have lung fibrosis not just stop them from deteriorating and we need new ideas or we have lots of new ideas we need the opportunity to test these ideas to show how we can reduce the interaction between aging and the consequences of of the general deterioration that occurs because of living and prevent those two coming together to cause this disease thank you yeah my name is Mike McQ i participated in the longitudinal study and i think i done extremely well except when it came to the breathing test well you have to breathe in the i think it looked about a three inch tube you know and you mentioned that well i couldn't do it i tried but you know it's i wondered why it's so big i really never gave any mind until i listened to the four speakers and now i'm get concerned about it you know so is there anything you can do you know to improve your breathing health i mean i'm not too active i must say i must admit that so the result of your breathing test will be of substantial interest because we heard from carol that without a spirometry or breathing test we don't know if a person has got obstructive airways disease or COPD and the symptoms of COPD cough and shortness of breath are very similar to the ones they're the symptoms of lung fibrosis which is a very different disease and has very different treatments so without an accurate measurement that's spirometry or breathing test we wouldn't begin to know is there actually something wrong and be what that is and how we might manage it so my advice to you would be to get a breathing test done properly in a proper facility and let's see what the results are that's not an expensive test actually it's a cheaper than a chest x-ray which lots of people have for investigating lung conditions there are however very innocent technical reasons why you may not have had a good performance on the breathing test a certain percentage of people can't do breathing test just because of the coordination that's required to get the test done it's necessary to form a proper seal with whatever it is you're blowing into and it's important to coordinate what you're what you're doing and when you're doing it and as i say a number of people who don't have any breathing problems at all can have a poor result in a breathing test for technical concerns so it's important to exclude those before we get too worried about illnesses i was just going to add in relation to your experience with a canadian lung adrenal study and aging it might be that you might have taken a few tries to get the reading if we were able to get the reading there is a summary result that we give you saying whether you're normal or abnormal you try it but three or four times and if you don't do it in the three or four times you know then you just move on we stop because in that case you were not able to perform and i think as dr cox said that it might be helpful for you to see your physician to see if there is an issue thanks for harrell you wanted well i just wanted to add that oftentimes we ask people to not take their medications they're inhaled medications before the breathing test and maybe you're in a position where you really do need to take your breathing medications and we may have to you take your medications but then you let the person know that yes i did have to take my medications and maybe that will help you get through the test because we do say to people well stop taking your inhaled medications for the test and maybe that could be the case i really had no breathing problems before you know i i feel i can walk out ten miles without any difficulty yeah but just surprised me i just thought it was the the method you know you breathe in your tube very awkward as most people can yeah thank you you want to add something no i want to ask dawn a question when you were talking about modifying the body's capacity or potential to for inflammation and having too much inflammation going on and getting bad bad outcomes from that um we also we hear a lot about uh eating foods with three omega or something or uh different types of fats in it that are supposed to be good for this is there potential for the food we eat to be good or bad for the body's inflammation potential yes unfortunately it would be nicer if there was a drug we could take or a pill we could take to lower inflammation but actually the two best things you can do to lower your inflammation are actually regular exercise and the Mediterranean type diet so a diet high in uh plant oils and uh fish and lots of fruits and vegetables and low in uh processed meat and all the things that taste good um are actually the best the only ways to show into lower basal levels of inflammation uh reliably although there's a number of clinical trials going on to test different diet interventions and that sort of thing oh a hearty dose it is the Mediterranean diet after all no red wine is can is can still good for us thank god there's another question here um hello i was just wondering where um sarcoidosis fits in with what you've been discussing tonight and if it doesn't how one would learn about um sarcoidosis actually fits into the family of lung tissue diseases um traditionally however it can also affect the airway and it can affect parts of the body outside the chest in about 15 to 20 percent of of patients so sarcoidosis is actually quite a it's a commoner condition than the ones i was talking about it also is a more benign condition uh 80 percent of people sarcoidosis have a benign illness that does not require treatment and of those who do require treatment we actually have very effective therapies to offer so sarcoidosis while let's say cousin of pulmonary fibrosis is a completely different uh condition it's caused by overactivity of the immune system so this inflammation that Don and and Carl are talking about where there's problems with overactivity in the immune system causing tissue damage that's what happens in sarcoidosis we actually have very good treatments because we know what the inflammation is doing and we know what's organizing it and we're able to intervene and prevent it uh quite well so i would say that uh i would expect uh 90 95 percent of our patients with sarcoidosis to actually have a good outcome whereas i wouldn't have any optimism like that for our patients with lung cancer or for our patients with lung fibrosis okay thank you when you talk about treatments are the steroid not based or there are other we usually started steroids because they're the one of the most powerful um anti-inflammatory drugs that we have and prednisone also has i mean the list of how it works is as long as your arm which is great so you don't know exactly which of its actions is useful in every in the patient's using but you know something's working from prednisone and then we work our way through a list of probably four second line drugs to help the prednisone do its job and if they don't work we have a third line drug which is a very specific but powerful inhibitor of one of the substances that Carl knows about tumor necrosis factor uh that's a key mediator in causing sarcoid related inflammation and anti-tnf drugs can be very effective if the other drugs don't work thank you i see there's another couple of questions coming yes thank you and good to see you again yeah i'm in that study too i'm not doing too well um there were four enlightening presentations ever they were really riveting thank you very much and i'm sorry i don't write fast enough so i've got a couple questions to clarify and dr boddish when you had one slide you said recognizing the symptoms and one was run down but the next one says it was lack of fever i didn't make sense how can a lack of fear be a symptom yes that's true it's that's challenging so i guess what i'm trying to say is with infectious disease if you go to your family doctor or whatever the higher your fever is the more seriously they take that as an infection that's a standard marker um for an infection but for reasons we don't entirely understand as we get older our fever response gets less and less so if you had a raging fever for three days you'd probably understand that you were sick and you needed some medical help and you'd go to the doctor but the problem is as we get older we don't have good fever responses so instead of you know having that really obvious knowing that you're sick feeling instead it's more of a creeping unwellness and so that's one of the reasons people often don't get diagnosed quickly enough just because they don't have that sort of glaring obvious sign of illness as we get older okay thank you and dr ritchards again i was i was trying to write down fast and you said 30 percent of all Canadians will die of cancer that's correct yes and then and then the next stat was 27 percent of Canadians will die of is it 27 percent of Canadians will die or 27 percent of the cancer will be low no it's 27 percent of those with cancer not of Canadian 27 percent of Canadians would be an awful lot of people right yeah yeah so 27 percent of those people with cancer will die of lung cancer yeah okay thank you and 30 percent of people in Canada who die will die of a cancer of some sort and then it's 27 percent of that so it works out to be about whatever you know 30 times 30 it's about eight to nine percent of Canadians will be dying no sorry eight percent of those people who do die die of lung cancer okay thank you thank you and just to confirm what we were saying before and i'm an asthma victim for years and years did i just hear you say that you know it really good exercise and good diet are are essential to cope with that too that's good yes well i sadly those are the only things that have been proven to be helped for a good diet and good exercise but this is one of the reasons why managing chronic inflammatory conditions is so important because sometimes that can be something that prevents people from getting the exercise they need so for example someone who's got COPD is going to have to deal with different challenges and finding ways of still being active so it's important if we do have any of the any conditions that prevent us from getting exercise to really have a good health care plan or a practitioner who can help us work around whatever our obstacles are for that i was actually just curious in relation to that question i saw a doctor cox smiling so i'd like to get his view on it why he was smiling or not well if i understand correctly the question said something to it as you mentioned asthma okay so when there is a restriction on lung function when there's a lung disease that stops your lungs from doing what you would like them to do we can't really increase lung capacity we'd like it if we could but we can't that's a hope that's not a reality and the programs that carol was talking about breath works pulmonary rehabilitation that are very effective in helping people become more active and to feel better i think probably the simplest way to describe is a bit like bringing your car for a tune up your car isn't doing very well it's not getting very good gas mileage doesn't have much pickup you bring it to the garage the guy fixes things cleans out the pipes or whatever redos the spark plugs and that the your engine isn't any bigger the capacity is no bigger but your car runs much more efficiently much more effectively and more like it should have been before and that's what exercise does with your lungs it doesn't increase their capacity but it gives you much more bang for your buck so that each breath goes further you go further with each breath by being more efficient as a result of exercising i also want to add about the importance of exercise related to muscle wasting because when you have a muscle and you don't use that muscle it just gets worse so it's really important to keep active and to keep so if you can walk today continue to walk forever anyways i'm not sure how many of you were here a couple of weeks ago sir mir gre was here talking about the fitness gap there's a normal curve for aging and then there is a fitness gap that puts you at risk for developing many chronic conditions so and i think that's the same concept we are talking about here as well next question please my name is dorin johnson and i've started to have shortest of breath um i don't have c o p d and as a matter of fact i don't know what i have but these symptoms are um something that just started i recall that in the month of may i did have some shortest of breath and was asked to do that breathing um tests um i don't recall that my physician had given me anything uh any medication or anything at all what has brought this on again i am going overseas and i had the pneumonia um vaccine and i noticed that i'm sort of having some chills sometimes and um and this shortness of breath i do i've never been told that i have asthma or any of those kinds of things and i'm really not sure what it is now i'm going tomorrow to take the test again the i don't remember the name that you call yeah and um to take the test so i'm really concerned when i saw this was sent to me i was really concerned as to i thought it maybe it's my medication even though i only take two medications and um that is causing this um so and i don't smoke i'm not the wrong people who smokes so i'm at a loss to know what is causing the breathing test i exercise i just came today from i'm a member of the ywca and i just came today and i noticed as was said when i exercise i can walk i can breathe a little better i don't have as much shortness but um i i don't know i don't know what is really happening with me uh i just wondered from telling you that where are you going to have the breathing test done um i don't remember it's a place on james street in hamilton okay well i work in st jose's hospital in the firestone institute for spirituality health so if you're going there tomorrow i'll be in clinic all day and you can ask me and i'll tell you the results of your breathing test because i'm reporting the breathing test this week so i'll be looking at it if it's on st jose so that's just just a possible so you'll get a special care to benefit if you happen to come to st jose your breathing test tomorrow i'll be there looking at them so this is the challenge that um you know family doctors face every day which is trying to pick out of all the different conditions and you heard this evening about three different things all of which could cause you to be short of breath um and you know which one is it or is it any of those or something completely different and in the app without having testing it's very difficult to know which chapter the book we should be reading to find out what's wrong and what to do and um of people who have shortness of breath in general a half or maybe a little more than half actually have a longer airway condition quite a lot of people don't have an airway condition or a long condition at all they have something else that's making them short or breath and there's a whole list of things that can do it you mentioned medications they can do it taking too much aspirin can do it because it changes acid levels having other conditions other illnesses of some kind can do it having weakness of the muscles will make you an effort and tolerant to which your brain will say it's shorter shortness of breath so it gets complicated if it isn't simple which it sounds like it's not because you've had it for a while you talked to your doctor about it and it hasn't been easy to tell from talking when it isn't simple it gets complicated fairly quickly and that's why the way out of that complication or the way the way to get through that complication is to testing the breathing which is what you've got lined up and then a chest x-ray that's a very simple easily accessible test and those two things plus a conversation with somebody who knows about breathlessness gets to the bottom of most of the situations so that's how i'd think i'd see how this works out get the breathing test done if it shows a breathing problem well then that can be pursued investigated and managed and if it shows nothing wrong with your lungs well then we have to go to a different chapter to book all together from lung disease and look for other things that can make people feel uncomfortable with their breathing the only difficulty with this is that i'm due to leave the country i'm going away for a month and here it is um i can breathe properly so i suppose i don't know that is a challenge thank you unless you come to say joes we'll fix you tomorrow we will take maybe okay there's another question hi i'm kathy this is a fantastic session and i thank you very much for it my question is how important is it for every householder to have a radon test in the basement radon is the second second leading cause of lung cancer uh is from radon therefore i would encourage you to um go pick up a radon kit you can get them at hardware stores like canadian tire and those other hardware stores and and check check for check your home i it's definitely worth worth it carl you want to answer yeah i think i think i read statistics a little while ago talking about us homes one in 15 apparently and us homes have above the recommended levels of radon so it's it's something to think about radon is a decompotion product from uranium and and and it's in the natural earth's crusts but it can actually accumulate in certain spots and others so that's why there's certain geographical areas that are higher in radon and others so it might be worth considering radon is the second leading cause of lung cancer far lower of course than smoking but but is the second rate and there's a lot of other lung risks for lung cancer uh that are really a very low risk but they are somewhat of a risk so uh but radon is the second most right so we'll take two more questions before we sort of mingle and chat so please hi i'm heather yoll i've been doing a cat allergy test at mac and through it i was recently diagnosed with asthma and i've always considered myself very healthy but i've always recognized that my lungs were my weakest point i've never been treated for asthma i didn't know previously that i had it but i'm wondering given all this talk about inflammation whether now that i know that i've got very mild asthma should i be treating it to prevent further inflammation um maybe uh so asthma is a common condition it has certain elements that are recognized by us and measured by us but people have different amounts of those factors in their asthma so we know there are people who can have a lot of inflammation and a little breathing problem or people can have a big breathing problem and a little amount of inflammation that even though they go together they're not tightly bound so if you wanted to know about your levels of inflammation well then they would need to be measured i don't think you can make you can't make a confident connection between a diagnosis of asthma and having inflammation in your body that's bad from dr bodice's point of view bad inflammation so and there are ways to measure it okay so i do i approach my family doctor do i go see you after bodice just bring your arm yeah i mean like dr cox said that the link between the age-associated inflammation and asthma is actually very weak and actually asthmatics generally have a long and healthy prognosis especially if they're treated so i would say you know i'm not a physician so i can't recommend this but i would say you would talk to someone like dr cox about the asthma and make sure that wasn't impeding your life but your age-associated inflammation and aging trajectory is probably completely independent of your asthma but if you want to come and give blood by all means we'll uh we we're always taking new donors okay we'll take one more question recruiting for you um could uh medication diagnosed prescribed for a totally unrelated medical issue cause an underlying undiagnosed respiratory problems come to the forefront to the point of being in intensive care for several weeks the lungs completely hardened and nothing more that the doctors could could do yes and this drug this drug was prescribed for a bladder infection and it was macrobit and afterwards finding all the the information from the drug store it does clearly state that it can cause respiratory problems in rare circumstances respiratory problems to the point of death and that's well and we also suspect that she did have an undiagnosed underlying lung problems because it has been brought it's it's we've found out that it's in our family so so somewhere on one of the slides i had was something that referred to that that type of problem drug related that we prescribed medications to do good in one part and unfortunately there's a sting in the tail that they have a this occasional happily rare but we reckon we see it every year the capacity to cause lung injury usually when there's something else going on in the lung and the two things together vault into disease and yes it does happen and happily it's rare and you can't tell who is going to get it we do suspect that but but it wasn't diagnosed but you know that's what that you know her daughters are convinced that it was strictly the drug but we we think that it was underlying issues so great thank you very much i want to take opportunity to thank our panelists for wonderful stimulating discussion here and to all of you for participating in this good discussion and asking some really wonderful questions and hopefully this was a enlightening and informative session for all of you and it was for me especially because i don't know anything about this area of health and i also wanted to take opportunity to thank lung association for sponsoring this event and and there are some of the people here don actually played a major role in organizing this so i like to say special thanks to don and carol yourself as well and sue and laura loson who's gone on to have a new baby who's not here she was very instrumental in organizing and some of the staff from the from the lung association who are at the back thank you very much so we are coming at the end of this session at this point we are going to wrap up the formal part and we would like to ask you to hang out have some snacks that are on the back of the room and if you have any further questions that you didn't get a chance to ask or were shy coming to them mike some of the speakers will be hanging around for a few minutes so with that thank you very much enjoy your evening