{"version":"1.0.0","segments":[{"startTime":0.29,"endTime":3.2,"body":"[upbeat intro music]"},{"startTime":3.2,"endTime":5.58,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.2,"endTime":5.58,"body":"to Harrison's Podclass"},{"startTime":5.58,"endTime":8.74,"body":"where we discuss important"},{"startTime":5.58,"endTime":8.74,"body":"concepts in internal medicine."},{"startTime":8.74,"endTime":9.89,"body":"I'm Cathy Handy."},{"startTime":9.89,"endTime":11.733,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.89,"endTime":11.733,"body":"Wiener, and we're coming to you"},{"startTime":11.733,"endTime":13.74,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.81,"endTime":17.313,"body":"[Dr. Handy] Welcome to episode 70,"},{"startTime":17.313,"endTime":19.99,"body":"a 48-year-old with worsening cough."},{"startTime":19.99,"endTime":23.009,"body":"[Dr. Wiener] Hi Cathy, so"},{"startTime":19.99,"endTime":23.009,"body":"the question begins today,"},{"startTime":23.009,"endTime":25.957,"body":"a 48-year-old man presents"},{"startTime":23.009,"endTime":25.957,"body":"with worsening cough"},{"startTime":25.957,"endTime":29.012,"body":"and exertional dyspnea"},{"startTime":25.957,"endTime":29.012,"body":"over the past two months."},{"startTime":29.012,"endTime":30.73,"body":"He currently smokes one and a half packs"},{"startTime":30.73,"endTime":32.07,"body":"of cigarettes per day,"},{"startTime":32.07,"endTime":34.01,"body":"and he's done so for 30 years."},{"startTime":34.01,"endTime":36.23,"body":"[Dr. Handy] So he started"},{"startTime":34.01,"endTime":36.23,"body":"early and has smoked a lot."},{"startTime":36.23,"endTime":38.22,"body":"It's a heavy smoking history."},{"startTime":38.22,"endTime":40.95,"body":"[Dr. Wiener] Yeah, he attains PFTs"},{"startTime":40.95,"endTime":44.69,"body":"and they show a normal"},{"startTime":40.95,"endTime":44.69,"body":"ratio of FEV1 to FVC,"},{"startTime":44.69,"endTime":48.17,"body":"a total lung capacity"},{"startTime":44.69,"endTime":48.17,"body":"that is 75% of predicted,"},{"startTime":48.17,"endTime":51.28,"body":"and diffusing capacity"},{"startTime":48.17,"endTime":51.28,"body":"that is 60% predicted."},{"startTime":51.28,"endTime":52.76,"body":"What do you think of those results?"},{"startTime":52.76,"endTime":54.38,"body":"[Dr. Handy] Well, we'll"},{"startTime":52.76,"endTime":54.38,"body":"talk about those in a minute"},{"startTime":54.38,"endTime":56.25,"body":"but how about a physical examination?"},{"startTime":56.25,"endTime":57.83,"body":"That would be helpful in this case."},{"startTime":57.83,"endTime":59.43,"body":"- [Dr. Wiener] How so?"},{"startTime":57.83,"endTime":59.43,"body":"- [Dr. Handy] Well, in a smoker"},{"startTime":59.43,"endTime":62.34,"body":"with cough, I'm definitely"},{"startTime":59.43,"endTime":62.34,"body":"interested in oxygen saturation"},{"startTime":62.34,"endTime":64.54,"body":"and JVP looking for hypoxemia"},{"startTime":64.54,"endTime":66.63,"body":"and any signs of right heart dysfunction."},{"startTime":66.63,"endTime":67.68,"body":"[Dr. Wiener] What about the lung exam?"},{"startTime":67.68,"endTime":68.56,"body":"Are you going to include that?"},{"startTime":68.56,"endTime":69.87,"body":"[Dr. Handy] Absolutely, I'd want to look"},{"startTime":69.87,"endTime":72.83,"body":"for a prolonged expiratory"},{"startTime":69.87,"endTime":72.83,"body":"phase, expiratory wheezes,"},{"startTime":72.83,"endTime":74.25,"body":"and inspiratory crackles"},{"startTime":74.25,"endTime":75.47,"body":"because all of those could be helpful"},{"startTime":75.47,"endTime":77.347,"body":"in understanding what's going on."},{"startTime":77.347,"endTime":79.205,"body":"[Dr. Wiener] All right,"},{"startTime":77.347,"endTime":79.205,"body":"well, I'll give you that"},{"startTime":79.205,"endTime":81.264,"body":"in a minute, but what do"},{"startTime":79.205,"endTime":81.264,"body":"you think of his PFTs?"},{"startTime":81.264,"endTime":82.55,"body":"[Dr. Handy] All right, well first off"},{"startTime":82.55,"endTime":85.16,"body":"with his normal FEV1 to FVC ratio"},{"startTime":85.16,"endTime":87.95,"body":"he does not have an"},{"startTime":85.16,"endTime":87.95,"body":"obstructive ventilatory defect,"},{"startTime":87.95,"endTime":89.63,"body":"and therefore I'm less suspicious"},{"startTime":89.63,"endTime":91.93,"body":"that COPD will explain his symptoms."},{"startTime":91.93,"endTime":96.25,"body":"But I will note that his TLC"},{"startTime":91.93,"endTime":96.25,"body":"is less than 80% predictive,"},{"startTime":96.25,"endTime":99.31,"body":"indicating a mild restrictive"},{"startTime":96.25,"endTime":99.31,"body":"ventilatory defect"},{"startTime":99.31,"endTime":100.71,"body":"and his diffusing capacity"},{"startTime":100.71,"endTime":103.44,"body":"or DLCO is 60% predicted, indicating"},{"startTime":103.44,"endTime":106.38,"body":"that he does have a moderate"},{"startTime":103.44,"endTime":106.38,"body":"gas transfer defect."},{"startTime":106.38,"endTime":108.25,"body":"[Dr. Wiener] And where are"},{"startTime":106.38,"endTime":108.25,"body":"those going to lead you?"},{"startTime":108.25,"endTime":110.46,"body":"You already said, away from COPD."},{"startTime":110.46,"endTime":112.55,"body":"[Dr. Handy] Well, a"},{"startTime":110.46,"endTime":112.55,"body":"restricted ventilatory defect"},{"startTime":112.55,"endTime":114.837,"body":"with a normal DLCO would make me think of"},{"startTime":114.837,"endTime":118.154,"body":"neuromuscular diseases, so"},{"startTime":114.837,"endTime":118.154,"body":"on that list would be ALS"},{"startTime":118.154,"endTime":121.45,"body":"or chest wall diseases,"},{"startTime":118.154,"endTime":121.45,"body":"like kyphoscoliosis."},{"startTime":121.45,"endTime":124.55,"body":"His DLCO is actually more"},{"startTime":121.45,"endTime":124.55,"body":"reduced than his TLC,"},{"startTime":124.55,"endTime":126.278,"body":"and that makes me think that he may have"},{"startTime":126.278,"endTime":128.19,"body":"an interstitial lung disease."},{"startTime":128.19,"endTime":130.63,"body":"A CT is often times helpful in this case."},{"startTime":130.63,"endTime":132.35,"body":"[Dr. Wiener] All right, and"},{"startTime":130.63,"endTime":132.35,"body":"you wanted a physical exam"},{"startTime":132.35,"endTime":133.83,"body":"and I promised I'd give you that."},{"startTime":133.83,"endTime":137.439,"body":"So his resting oxygen saturation is"},{"startTime":137.439,"endTime":142.16,"body":"91% on room air, his jugular"},{"startTime":137.439,"endTime":142.16,"body":"venous pressure is normal,"},{"startTime":142.16,"endTime":143.66,"body":"his cardiac exam is normal."},{"startTime":143.66,"endTime":146.04,"body":"You do hear inspiratory fine crackles"},{"startTime":146.04,"endTime":149.66,"body":"on both sides, bilaterally,"},{"startTime":146.04,"endTime":149.66,"body":"and there's a little bit"},{"startTime":149.66,"endTime":152.06,"body":"of a basal predominance but nothing else."},{"startTime":152.06,"endTime":153.5,"body":"He has no peripheral edema"},{"startTime":153.5,"endTime":156.38,"body":"or any other signs"},{"startTime":153.5,"endTime":156.38,"body":"suggesting cardiac failure."},{"startTime":156.38,"endTime":157.9,"body":"[Dr. Handy] And the CT scan?"},{"startTime":157.9,"endTime":159.4,"body":"[Dr. Wiener] A high resolution CT scan"},{"startTime":159.4,"endTime":162.01,"body":"of the chest shows diffuse"},{"startTime":159.4,"endTime":162.01,"body":"centrilobular nodules,"},{"startTime":162.01,"endTime":164.43,"body":"and scattered ground-glass opacities."},{"startTime":164.43,"endTime":166.79,"body":"There's no emphysema,"},{"startTime":164.43,"endTime":166.79,"body":"the pulmonary arteries"},{"startTime":166.79,"endTime":168.62,"body":"and the right heart appear normal."},{"startTime":168.62,"endTime":171.76,"body":"There is no evidence of any emphysema."},{"startTime":171.76,"endTime":173.88,"body":"Sound like interstitial"},{"startTime":171.76,"endTime":173.88,"body":"lung disease to you?"},{"startTime":173.88,"endTime":176.697,"body":"[Dr. Handy] Yeah, it does and"},{"startTime":173.88,"endTime":176.697,"body":"like you mentioned already, too"},{"startTime":176.697,"endTime":179.458,"body":"we've sort of ruled out"},{"startTime":176.697,"endTime":179.458,"body":"a lot of heart disease"},{"startTime":179.458,"endTime":182.18,"body":"as a potential cause of his symptoms."},{"startTime":182.18,"endTime":183.33,"body":"[Dr. Wiener] Okay, how do you think"},{"startTime":183.33,"endTime":184.58,"body":"of the interstitial lung disease?"},{"startTime":184.58,"endTime":186.62,"body":"They have a bunch of confusing acronyms."},{"startTime":186.62,"endTime":189.05,"body":"[Dr. Handy] Yeah, there"},{"startTime":186.62,"endTime":189.05,"body":"are some known causes"},{"startTime":189.05,"endTime":191.74,"body":"so for example, based"},{"startTime":189.05,"endTime":191.74,"body":"on exposures associated"},{"startTime":191.74,"endTime":194.82,"body":"with systemic diseases,"},{"startTime":191.74,"endTime":194.82,"body":"again a more thorough history"},{"startTime":194.82,"endTime":196.59,"body":"and physical will help with those."},{"startTime":196.59,"endTime":198.95,"body":"[Dr. Wiener] What are some of"},{"startTime":196.59,"endTime":198.95,"body":"the examples in those categories?"},{"startTime":198.95,"endTime":201.01,"body":"[Dr. Handy] Well, occupational"},{"startTime":198.95,"endTime":201.01,"body":"exposures would include"},{"startTime":201.01,"endTime":204.108,"body":"asbestosis or silicosis, some therapies,"},{"startTime":204.108,"endTime":206.91,"body":"such as radiation or drugs like Amiodarone"},{"startTime":206.91,"endTime":210.01,"body":"or nitrofurantoin are"},{"startTime":206.91,"endTime":210.01,"body":"also known associations"},{"startTime":210.01,"endTime":211.89,"body":"with interstitial lung diseases,"},{"startTime":211.89,"endTime":213.35,"body":"and of the systemic diseases,"},{"startTime":213.35,"endTime":215.34,"body":"I think mostly of autoimmune diseases,"},{"startTime":215.34,"endTime":217.47,"body":"so for example, scleroderma or lupus"},{"startTime":217.47,"endTime":220.12,"body":"or the ANCA-associated vasculitides."},{"startTime":220.12,"endTime":221.41,"body":"[Dr. Wiener] Well, let's"},{"startTime":220.12,"endTime":221.41,"body":"assume for this case"},{"startTime":221.41,"endTime":224.57,"body":"that he has no occupational"},{"startTime":221.41,"endTime":224.57,"body":"or medication exposures,"},{"startTime":224.57,"endTime":227.44,"body":"and he has no signs or symptoms"},{"startTime":224.57,"endTime":227.44,"body":"of an autoimmune disease."},{"startTime":227.44,"endTime":228.62,"body":"Where do you go next?"},{"startTime":228.62,"endTime":230.76,"body":"[Dr. Handy] Risk factors"},{"startTime":228.62,"endTime":230.76,"body":"also help, for example,"},{"startTime":230.76,"endTime":233.64,"body":"interstitial pulmonary"},{"startTime":230.76,"endTime":233.64,"body":"fibrosis or IPF is rare"},{"startTime":233.64,"endTime":236.08,"body":"among patients who are"},{"startTime":233.64,"endTime":236.08,"body":"less than 50 years old."},{"startTime":236.08,"endTime":237.9,"body":"So it would seem that"},{"startTime":236.08,"endTime":237.9,"body":"that's less likely here"},{"startTime":237.9,"endTime":239.63,"body":"given the patient's age."},{"startTime":239.63,"endTime":241.72,"body":"A history of smoking is"},{"startTime":239.63,"endTime":241.72,"body":"nearly always present"},{"startTime":241.72,"endTime":243.68,"body":"in some forms of ILD."},{"startTime":243.68,"endTime":246.78,"body":"For example, this would include"},{"startTime":243.68,"endTime":246.78,"body":"respiratory bronchiolitis"},{"startTime":246.78,"endTime":249.987,"body":"and desquamative interstitial"},{"startTime":246.78,"endTime":249.987,"body":"pneumonia or DIP,"},{"startTime":249.987,"endTime":251.545,"body":"sometimes referred by pathologists"},{"startTime":251.545,"endTime":253.73,"body":"jointly as smoking-related ILD,"},{"startTime":253.73,"endTime":256.34,"body":"where smoking is really"},{"startTime":253.73,"endTime":256.34,"body":"thought to be causative."},{"startTime":256.34,"endTime":258.42,"body":"And a history of smoking is also noted"},{"startTime":258.42,"endTime":261.54,"body":"in approximately three"},{"startTime":258.42,"endTime":261.54,"body":"quarters of IPF patients."},{"startTime":261.54,"endTime":262.743,"body":"[Dr. Wiener] Does the CT help"},{"startTime":262.743,"endTime":264.293,"body":"narrow things down a little bit?"},{"startTime":264.293,"endTime":266.47,"body":"[Dr. Handy] In some cases"},{"startTime":264.293,"endTime":266.47,"body":"it can. So for example,"},{"startTime":266.47,"endTime":268.47,"body":"a lower lobe subpleural predominance"},{"startTime":268.47,"endTime":270.58,"body":"is characteristic of IPF."},{"startTime":270.58,"endTime":273.1,"body":"Some of the other potentially"},{"startTime":270.58,"endTime":273.1,"body":"more reversible disorders"},{"startTime":273.1,"endTime":274.55,"body":"have inflammatory nodules"},{"startTime":274.55,"endTime":277.05,"body":"and ground-glass"},{"startTime":274.55,"endTime":277.05,"body":"infiltrates, as in this case,"},{"startTime":277.05,"endTime":279.181,"body":"and these changes are non-specific though."},{"startTime":279.181,"endTime":281.737,"body":"[Dr. Wiener] Again, these"},{"startTime":279.181,"endTime":281.737,"body":"disorders are very confusing."},{"startTime":281.737,"endTime":283.331,"body":"[Dr. Handy] Yeah, and"},{"startTime":281.737,"endTime":283.331,"body":"owing to a variety of"},{"startTime":283.331,"endTime":286.5,"body":"clinical presentations as"},{"startTime":283.331,"endTime":286.5,"body":"well as overlapping imaging"},{"startTime":286.5,"endTime":288.35,"body":"and histopathologic findings,"},{"startTime":288.35,"endTime":290.95,"body":"ILDs can be difficult to diagnose."},{"startTime":290.95,"endTime":294.613,"body":"A generally accepted central"},{"startTime":290.95,"endTime":294.613,"body":"tenant of ILD diagnosis"},{"startTime":294.613,"endTime":297.82,"body":"is that the combined weight"},{"startTime":294.613,"endTime":297.82,"body":"of clinical data, laboratory"},{"startTime":297.82,"endTime":300.85,"body":"studies, pulmonary function"},{"startTime":297.82,"endTime":300.85,"body":"testing, imaging findings,"},{"startTime":300.85,"endTime":303.43,"body":"and histopathology if"},{"startTime":300.85,"endTime":303.43,"body":"you're able to obtain it,"},{"startTime":303.43,"endTime":306.35,"body":"are jointly required to"},{"startTime":303.43,"endTime":306.35,"body":"make a confident diagnosis."},{"startTime":306.35,"endTime":307.91,"body":"But there isn't one single piece"},{"startTime":307.91,"endTime":310.56,"body":"of data that confirms the diagnosis alone."},{"startTime":310.56,"endTime":312.54,"body":"[Dr. Wiener] So what do"},{"startTime":310.56,"endTime":312.54,"body":"you think of this patient?"},{"startTime":312.54,"endTime":314.323,"body":"[Dr. Handy] Well, I don't think he has IPF"},{"startTime":314.323,"endTime":315.84,"body":"given his age and CT,"},{"startTime":315.84,"endTime":319.03,"body":"but given his extensive smoking,"},{"startTime":315.84,"endTime":319.03,"body":"I'm thinking he likely has"},{"startTime":319.03,"endTime":321.93,"body":"either respiratory bronchiolitis ILD,"},{"startTime":321.93,"endTime":324.45,"body":"or the desquamative"},{"startTime":321.93,"endTime":324.45,"body":"interstitial pneumonitis"},{"startTime":324.45,"endTime":327.8,"body":"or perhaps a pulmonary"},{"startTime":324.45,"endTime":327.8,"body":"Langerhans cell histiocytosis,"},{"startTime":327.8,"endTime":330.48,"body":"which used to be known as"},{"startTime":327.8,"endTime":330.48,"body":"eosinophilic granuloma."},{"startTime":330.48,"endTime":333.21,"body":"All of these disorders are"},{"startTime":330.48,"endTime":333.21,"body":"directly tied to smoking."},{"startTime":333.21,"endTime":334.6,"body":"[Dr. Wiener] Okay, that's great."},{"startTime":334.6,"endTime":337.692,"body":"Let's get to the question"},{"startTime":334.6,"endTime":337.692,"body":"now, so the question asks,"},{"startTime":337.692,"endTime":340.687,"body":"which of the following"},{"startTime":337.692,"endTime":340.687,"body":"treatments would be most likely"},{"startTime":340.687,"endTime":343.64,"body":"effective for his"},{"startTime":340.687,"endTime":343.64,"body":"interstitial lung disease?"},{"startTime":343.64,"endTime":346.701,"body":"And the options are, A. azathioprine;"},{"startTime":346.701,"endTime":349.103,"body":"B. nintedanib;"},{"startTime":349.103,"endTime":351.186,"body":"C. prednisone;"},{"startTime":351.186,"endTime":353.16,"body":"D. sirolimus;"},{"startTime":353.16,"endTime":355.52,"body":"or E. smoking cessation."},{"startTime":355.52,"endTime":356.785,"body":"[Dr. Handy] So based on our discussion,"},{"startTime":356.785,"endTime":358.443,"body":"the answer in this case is E."},{"startTime":358.443,"endTime":360.118,"body":"Smoking cessation is often times"},{"startTime":360.118,"endTime":361.67,"body":"the only treatment that's required"},{"startTime":361.67,"endTime":363.61,"body":"to reverse the inflammatory process"},{"startTime":363.61,"endTime":366.56,"body":"and the smoking-related"},{"startTime":363.61,"endTime":366.56,"body":"interstitial lung diseases."},{"startTime":366.56,"endTime":368.55,"body":"And patients can often start to improve"},{"startTime":368.55,"endTime":370.408,"body":"within weeks of stopping smoking."},{"startTime":370.408,"endTime":371.901,"body":"[Dr. Wiener] What about"},{"startTime":370.408,"endTime":371.901,"body":"the other therapies listed"},{"startTime":371.901,"endTime":373.84,"body":"in the question? Do they have utility?"},{"startTime":373.84,"endTime":375.181,"body":"[Dr. Handy] Well, at this"},{"startTime":373.84,"endTime":375.181,"body":"point I would say that"},{"startTime":375.181,"endTime":377.01,"body":"before resorting to the other therapies"},{"startTime":377.01,"endTime":379.42,"body":"I'd give this patient a"},{"startTime":377.01,"endTime":379.42,"body":"trial of smoking cessation,"},{"startTime":379.42,"endTime":382.12,"body":"and if he doesn't improve in"},{"startTime":379.42,"endTime":382.12,"body":"the next few weeks to months,"},{"startTime":382.12,"endTime":383.917,"body":"I'd refer the patient to a specialist"},{"startTime":383.917,"endTime":385.9,"body":"who's familiar with ILDs."},{"startTime":385.9,"endTime":387.26,"body":"They're very difficult to treat"},{"startTime":387.26,"endTime":390.44,"body":"and that being said,"},{"startTime":387.26,"endTime":390.44,"body":"azathioprine is sometimes used"},{"startTime":390.44,"endTime":394.11,"body":"for autoimmune diseases"},{"startTime":390.44,"endTime":394.11,"body":"with associated ILD."},{"startTime":394.11,"endTime":397.77,"body":"Nintedanib is an anti-fibrotic"},{"startTime":394.11,"endTime":397.77,"body":"tyrosine kinase inhibitor"},{"startTime":397.77,"endTime":400.08,"body":"that has been shown in"},{"startTime":397.77,"endTime":400.08,"body":"randomized clinical trials"},{"startTime":400.08,"endTime":402.37,"body":"to reduce the rate of decline of FEC,"},{"startTime":402.37,"endTime":404.03,"body":"and it can slow down the progression"},{"startTime":404.03,"endTime":406.64,"body":"of idiopathic pulmonary fibrosis."},{"startTime":406.64,"endTime":408.11,"body":"And while it's currently being studied"},{"startTime":408.11,"endTime":409.56,"body":"in a number of different ILDs,"},{"startTime":409.56,"endTime":412.9,"body":"it is not yet shown to be"},{"startTime":409.56,"endTime":412.9,"body":"effective in other disorders."},{"startTime":412.9,"endTime":415.19,"body":"Prednisone is still used"},{"startTime":412.9,"endTime":415.19,"body":"in some cases of ILD"},{"startTime":415.19,"endTime":417.0,"body":"but certainly would not"},{"startTime":415.19,"endTime":417.0,"body":"be first line treatment"},{"startTime":417.0,"endTime":420.342,"body":"for this patient, and sirolimus"},{"startTime":417.0,"endTime":420.342,"body":"has been used to treat LAM,"},{"startTime":420.342,"endTime":422.36,"body":"but this disease is exceedingly uncommon"},{"startTime":422.36,"endTime":424.78,"body":"in males and his chest"},{"startTime":422.36,"endTime":424.78,"body":"CT is not consistent"},{"startTime":424.78,"endTime":426.14,"body":"with that diagnosis."},{"startTime":426.14,"endTime":429.52,"body":"[Dr. Wiener] You mean, LAM"},{"startTime":426.14,"endTime":429.52,"body":"being lymphangioleiomyomatosis?"},{"startTime":429.52,"endTime":430.417,"body":"[Dr. Handy] Exactly."},{"startTime":430.417,"endTime":431.903,"body":"[Dr. Wiener] Yeah, that's"},{"startTime":430.417,"endTime":431.903,"body":"a tough one to say."},{"startTime":431.903,"endTime":432.945,"body":"[both chuckle]"},{"startTime":432.945,"endTime":435.07,"body":"[Dr. Wiener] Okay, so the"},{"startTime":432.945,"endTime":435.07,"body":"teaching point in this case"},{"startTime":435.07,"endTime":438.68,"body":"is that the combination of"},{"startTime":435.07,"endTime":438.68,"body":"reduced total lung capacity,"},{"startTime":438.68,"endTime":441.09,"body":"and reduced DLCO is consistent"},{"startTime":441.09,"endTime":442.86,"body":"with interstitial lung diseases."},{"startTime":442.86,"endTime":446.04,"body":"In this case, the history and"},{"startTime":442.86,"endTime":446.04,"body":"the CT scan was suggestive"},{"startTime":446.04,"endTime":448.71,"body":"of a smoking-related"},{"startTime":446.04,"endTime":448.71,"body":"interstitial lung disease."},{"startTime":448.71,"endTime":450.93,"body":"And the mainstay of"},{"startTime":448.71,"endTime":450.93,"body":"treatment in these cases"},{"startTime":450.93,"endTime":453.672,"body":"is at least a trial of smoking cessation."},{"startTime":453.672,"endTime":455.6,"body":"[Dr. Handy] And to learn more"},{"startTime":453.672,"endTime":455.6,"body":"about this, you can check out"},{"startTime":455.6,"endTime":458.537,"body":"the Harrison's chapter on"},{"startTime":455.6,"endTime":458.537,"body":"interstitial lung disease."},{"startTime":458.537,"endTime":461.337,"body":"[outro music]"},{"startTime":462.778,"endTime":465.59,"body":"[Mr. Shanahan] This is Jim"},{"startTime":462.778,"endTime":465.59,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":465.59,"endTime":467.22,"body":"Harrison's Podclass is brought to you"},{"startTime":467.22,"endTime":469.2,"body":"by McGraw Hill's Access Medicine,"},{"startTime":469.2,"endTime":471.3,"body":"the online medical resource that delivers"},{"startTime":471.3,"endTime":474.52,"body":"the latest trusted content from"},{"startTime":471.3,"endTime":474.52,"body":"the best minds in medicine."},{"startTime":474.52,"endTime":477.073,"body":"Go to accessmedicine.com to learn more."}]}