Rheumatology Republic: Recent Episodes
Felicity Nelson
Rheumatology Republic is a group of like minded rheumatologists, allied health professionals and patient advocates who would like to jazz up communication more for the rheumatology sector as we move into a mobile social universe. Things are changing for rheumatology professionals, change is hard, and we’d like to help. Sometimes that help is by poking and prodding in places people would prefer we wouldn’t. But that’s how things change sometimes. Ultimately, we’d love to make things better for community health by supporting ‘connected’ primary care givers and empowering patients.
The number of spinal fusions performed in Australia has skyrocketed over the past few decades, with the number of privately funded procedures far outstripping those done in the public system.
Spinal fusions, which help stabilise the spine by surgically joining two or more vertebrae together, can be used following traumatic injury, or to help correct scoliosis in children. But the most common use for spinal fusions is in degenerative conditions of the spine.
This episode of The Medical Republic Podcast explores when this procedure should be considered, and why we are seeing such a large increase in the number of these procedures being performed.
Dr Ashish Diwan, director of the Spine Service at St George Hospital in New South Wales, says there are several considerations to be weighed before undertaking a spinal fusion, including the duration, intensity and frequency of back pain; whether other treatment options have been tried; and what the patient wants.
Dr Diwan has sympathy for GPs with patients who are considering undergoing a spinal fusion, which is far from a straightforward decision: “It’s like trying to get married. If you’re in doubt, don’t do it.”
The decision not to do surgery can be equally challenging, according to Dr Diwan.
“There is also an incredible lack of evidence as to what you do for a person who continues to suffer. The alternatives [drugs, spinal cord stimulators or radiofrequency ablations] are not very clear … none of them stack up when you start dealing with people who have pain of a chronic nature.”
There are many reasons for the spike in the number of spinal fusions being performed, according to Professor Ian Harris, an orthopaedic surgeon and researcher from the University of NSW.
“There is an aging of the population, but [now] there are more so called ‘indications’ for spine surgery,” he tells the podcast. “The techniques of doing them have developed in a way that there’s now lots of different ways you can do spine fusions.”
Several reasons also exist for why more privately, rather than publicly, funded procedures are being done. But Professor Harris feels the inclusion of MRI scans on the MBS is glaringly obvious one.
This presents a fine line to walk between using imaging to rule out potential pathologies and jumping at shadows and operating unnecessarily on age-related changes. This reinforces the need for clear discussions with patients about any imaging findings.
“Just having a scan doesn’t hurt anyone. It’s what you do with the results that can harm people.”
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Voluntourism is an enticing form of travel: exotic locales, cultural immersion, serving needy populations with your skills – all wrapped up in your four weeks’ annual leave.
Not so fast. Before packing your passport and mosquito net, tune in to Rheumatology Republic podcast to hear from two guests who might make you reconsider.
Sydney rheumatologist Dr Rob Baume says he considered Médecins Sans Frontières after a bout of professional burnout, but ended up staying put.
“When I did a bit of more research, I found that unless you have a specific specialty such as anesthetist or an obstetrician, you need to sign up for nine months. The other part of the equation is that I don't speak the language. Then there’s also the cost, the health risks and the risk to your life,” he said.
Instead of volunteering himself, Dr Baume has just reached a milestone: raising $1 million for healthcare in developing nations through his charity, Twice the Doctor.
The idea is that you “volunteer” in your own practice for one day per year (or more if you wish), see your own patients and donate the income from that day. Twice the Doctor, in partnership with UNICEF and The Fred Hollows Foundation, uses those funds for doctors and primary healthcare workers in Africa.
One day of your wages is around the same as one month’s wages for a doctor in Africa or six months for a nurse.
Dr Baume says research shows that if a doctor wants to make maximum impact on the world, it doesn't matter which specialisation they have.
“What matters is that you give a fair bit of your income to third world causes,” Dr Baume said.
Our second guest, Dr Andrew Browning, has been doing fistula surgery in Africa through the Barbara May Foundation for around 25 years. He says it’s life-changing for patients who start to live normal lives again after the deeply distressing injury caused by obstructed labour. However, Dr Browning says a donation that funds local health workers may better support outcomes than a short-term volunteering stint.
Short-term volunteers often teach local staff new clinicial approaches. However, the volunteer’s lack of relationship and cultural understanding can stymie the uptake of Western ways.
“You don't know the culture, you don't know the way things work or don't work.
“The people [healthcare staff] there are very polite, very long-suffering, and will put up with you for the time that you're there. Then as soon as you leave, they just go back to their normal ways.”
There are some spaces for shorter-term volunteers if you have specialised in obstetrics, gynaecology or midwifery, he says.
“Around 40% of these girls [with fistulas] have been suicidal or attempted suicide with this injury, 100% of them are depressed. And when you treat them they just turn back to normal, happy citizens,” Dr Browning says.
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When the choice is between writing a script for pain killers and a 45 consultation about weight management, which one do you choose?
Associate Professor Kade Paterson, University of Melbourne, is a guest this episode of In Conversation podcast. He says scripts for pain killers and referrals to orthopaedic surgeons are unnecessarily common for patients with osteoarthritis (OA).
Professor Paterson says everyone who has osteoarthritis should be offered some sort of therapeutic exercise that suits them, and his fitness focus is backed by evidence.
“We see very positive outcomes from the three approaches - exercise, weight management and education. All have been shown to be clinically effective at reducing both pain and function,” Professor Paterson says.
Professor Kim Bennell is director of the Centre for Health, Exercise and Sports Medicine at University of Melbourne. She also joins In Conversation podcast and says that the kind of language clinicians use with osteoarthritis patients is important. Focusing on the person, rather than the joint, is shown to be clinically effective in improving a patient’s willingness to take up exercise, she says.
“Using language that talks with optimism about the effective, different treatments out there,” is a small change that is relatively easy to make says Professor Bennell.
This episode also delves into the latest research into foot OA, when ACL surgery is best, why young girls are at risk and what gets in the way of a doctor trying non-drug treatments first.
Resources:
OA treatment resources from the Centre for Health, Exercise and Sports Medicine.
Handbook of Non-drug Interventions (HANDI)
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Patients with covid-related hair loss are benefiting from rheumatologists and dermatologists working together on its treatment, says Irish dermatologist Dr Dmitri Wall.
In June year, the JAK inhibitor baricitinib won US FDA approval for patients with severe alopecia areata.and is now being used for hair loss more broadly.
In this podcast episode, Dr Wall talks about the discussions he’s been having with rheumatologists when treating patients with severe hair loss associated with long covid.
“I have a number of patients back in Ireland who are seeing me and they're also seeing a rheumatologist. There's back and forth communication between me and the rheumatologists saying ‘Look, maybe we can alter the dose in this way to best cover both’,” he said.
Dr Wall said that for patients who have a more rapid trajectory and more extensive disease, one of the big, currentdiscussions \is the use of JAK inhibitors. .
“It’s making a huge difference to patients with more severe or more progressive alopecia areata,” he said
Dr Wall also talks about his recently published paper which includes a case report on a patient with Crohn’s disease and severe hair loss. Dr Wall encouraged the patient to speak with his gastroenterologist about looking for clinical trials where both conditions could possibly be treated.
“I didn't hear anything for a year but then I got an email that said, ‘I just want to thank you. I got on that clinical trial and all my hair grew back’. As it turned out, he was treated with filgotinib, which has never been described in the area of alopecia areata before,” Dr Wall said.
Dr Wall provides some research insights from the UK–Irish Atopic eczema Systemic Therapy Registry (A-STAR) and reveals what showed up as a result of covid.
“We had this really strange but interesting collection of data suggesting that while some of the immunosuppressants could be beneficial with covid, some of them may actually be more damaging. And that's what the registry started to define as giving people a degree of awareness of the circumstances, the patients where they should or shouldn't be prescribed,” he said.
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It wasn’t the conventional path to becoming a rheumatologist, but Professor Catherine Hill has found her career journey extremely rewarding.
The immediate past president of the ARA joins In Conversation podcast this month and shares candid insights about her life, career and what it meant to win the 2022 Parr Prize.
“I was delighted to be the recipient, but it's a body of work over many years. And it's also not just my efforts, it's really a team effort. I have a fantastic team that I work with, the radiology research group at the Basil Hetzel Institute,” Professor Hill says.
A strong advocate of mentoring, Professor Hill also provides some coaching tips on how to handle giving feedback.
“If I've agreed to take on a PhD student, I enter a pact to be open and supportive to them, also asking them what I could do better if they are struggling - asking what could we, as a team, do to help them if things are starting to fall behind,” she says.
Professor Hill says mentors are necessary even for mid or later-career rheumatologists who might be reflecting on the next stages in their career.
“Maybe sit down and think about where your priorities are for both your career and your life and what you really want to concentrate on. Find a colleague who you can have an honest conversation with. I still have some mentoring myself some time,” she says.
You can listen and subscribe to the show by searching for “The Tea Room Medical Republic” in your favourite podcast player.
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AI in healthcare is only going to get bigger and new Macquaire University research reveals how to do it better.In this super short podcast we hear from Associate Professor Paul Formosa from Macquarie University. He’s been researching how patients respond to AI making their medical decisions compared to how they respond if a human is involved.Professor Formosa says that patients see humans as appropriate decision makers and that AI is perceived as dehumanizing even when the decision outcome is identical.“There's this dual aspect to people's relationship with data. They want decisions based on data and they don't like it when data is missing. However, they also don't like themselves to be reduced merely to a number,” Professor Formosa says.Study scenarios included use of imaging AI to diagnose of skin cancers and to allocate organ donations. Professor Formasa poses a key question for both technology designers and specialists to ask.“If AI technology is used, is it being used in ways that promote good health care interactions between patients and healthcare providers? Or is it just automatically relied on in a way that interferes with that relationship?” he says.
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After a year of lockdowns and border closures the Australian rheumatology community has come together again at ARA 2022.Rheumatology Republic captured the spirit of the conference in conversation with speakers including Professor Lyn March, Professor Paul Bird and Dr Mona Marabani.Popular sessions included the covid update which one delegate heralded as a timely “masterclass”. Other delegates lauded the sessions on sleep disorders, autoinflammation and paediatric papers.The overall sentiment in the face-to-face hubs was one of celebration at coming together again.
Physical examinations are hampered by telehealth, but after an extensive literature review, experts have curated the best workarounds to optimise diagnosis.In this episode of In conversation we introduce Tele-Presence 5 – a guideline for doctors to coach patients through self-examinations via telehealth. We are joined by Professor Stephen W. Russell, physician and researcher from the University of Alabama at Birmingham.Using long-term shoulder pain as an example, Professor Russell demonstrates how to talk a patient through a physical self-examination and touches on new technology emerging to support telehealth. He also explains the five key tenements of Tele-Presence 5 which are validated ways to increase connection and communication between patient and doctor.
Beyond ‘brain fog’ – the real penalty of cognitive dysfunction in lupus and what to do about it.
Prevention is better than cure when it comes to cybersecurity. Data security expert Troy Hunt discusses how to protect yourself, your practice and your patient’s privacy.The health care sector is number one again in 2021 for reporting the highest number of data breaches in Australia. It’s a consistent track record that reflects a concerted targeting by hackers because health data can fetch a lot more than other personal information on the black market.According to cyber-security expert Troy Hunt, sophisticated cyber hackers are trying to trip up your systems and your staff “every hour, every day”.Mr Hunt spoke to In Conversation podcast and outlined practical actions that can be taken take protect doctors, businesses and patient privacy.
Dr Jessica Leung and Dr Georgia Harris find PMR is not as self-limiting as generally thought and often misdiagnosed for months.
It’s as complex and difficult as losing weight but Ayano Kelly is getting to the bottom of adherence.
Professor Flavia Cicuttini AM talks about her early research career, key research moments and her passion for helping today’s early and mid-career researchers to create a better future.
The chair of Doctors for the Environment Australia, rheumatologist Dr John Van Der Kallen, is calling for a national body to reduce healthcare emissions.
Living guidelines could soon be the gold standard for treating inflammatory diseases. Here’s how they work.
With COVID-19 raging through the United States like wildfire, and the controversial US election whipping up rage and spreading misinformation far and wide, Seth Ginsberg is very happy with his decision to move from New York to the relative calm and safety of Australia – his wife’s home country. Felicity Nelson and Karina Bray chatted to Seth Ginsberg on the Rheumatology Republic podcast.
As Australia’s first ever wellness officer, rheumatologist Dr Bethan Richards has focused on meeting the basic needs of hospital staff – offering protected lunch breaks, access to water, functioning rest areas and moments of human connection. It all sounds tragically obvious but has required deep changes in governance, organisational structure and culture.
The FAST study that pitted febuxostat against allopurinol for patients with gout and CVD risk factors has released its results in a late breaking abstract at ACR. Thomas MacDonald, the senior author and a professor of medicine at the University of Dundee in the UK, came on the Rheumatology Republic podcast to discuss the study.
With COVID-19 cases climbing in Victoria, some rheumatologists are being called up to help with frontline care of sick patients.Today, we're interviewing Dr Mueed Mian, a rheumatologist at Austin Health and Northern Health, who’s been working with patients who have coronavirus.
The absence of any data on the risk that SARS-Cov 2 poses to patients with rheumatic disease has been unsettling for the entire rheumatology community. It feels like we’re all fumbling around in the dark...This week, I’m joined by Dr David Liew, the COVID-19 Global Rheumatology Alliance's regional lead for Australia. I’m hoping he has some updates for us on how this pandemic is panning out for patients for rheumatic disease.
At the ACR annual meeting in Atlanta, Rheumatology Republic reporter Penny Durham caught up with Patricia Davidson and Karin Tse from the Lupus Foundation of America, which is trialling two self-management programs for lupus patients.
Associate Professor Mark Arnold works as a rheumatologist in Dubbo and Orange in NSW.There's a significant need for rheumatologists in the bush, but it comes with its own unique challenges.There are vast distances to travel and wildlife to avoid. You learn not to schedule patient appointments around peak times for emu and kangaroo strikes, and to watch out for blocks of concrete on the road, otherwise known as wombats.Rheumatology Republic reporter Penny Durham met with Associate Professor Arnold at the ACR annual meeting in Atlanta.
Rheumatologists don’t always ask their female patients this question, but, according to US rheumatologist Dr Bonnie Bermas from UT Southwestern in Dallas, it’s really quite important.The ‘One Key Question’ is: “Are you planning on becoming pregnant in the next year?”The conversations about contraception and pregnancy planning are often out of the “comfort zone” of rheumatologists, says Dr Bermas.But this is a topic that rheumatologists should bring up with their patients to kickstart a conversation about disease control during pregnancy.Rheumatoid arthritis patients are at a greater risk for pregnancy complications if their disease is more active, says Dr Bermas.“We have a lot of data that show that pregnancies do best when they are planned and disease is under good control,” she says.
Dr David Liew, a rheumatologist at Austin Hospital in Victoria, is at ‘Disneyland’ for rheumatologists – the annual meeting for ACR in Atlanta, Georgia.“The kind of conversations that you have here are the kind of conversations that are hard to have elsewhere,” he tells Rheumatology Republic reporter Penny Durham.Australia is “leading the field or certainly up there” in terms of using PET CT in polymyalgia rheumatica, he says.Another positive development from Australia reported at the conference was the success of the EVOLVE guidelines.In ANA-negative patients, doctors shouldn’t order anti dsDNA antibody tests unless there were features consistent with lupus, says Dr Liew.“It’s something that we’ve really been trying to emphasise to our generalist colleagues,” he says. “And our data show the campaign worked. In our centre, at least, there was an incredible drop off in inappropriate double stranded DNA ordering.”
Dutch research presented at EULAR has shown that low-dose prednisolone improves symptoms in patients with painful hand osteoarthritis.Here's presenting author Dr Féline Kroon, a researcher at Leiden University Medical Center in The Netherlands, explaining the implications of her team's research.
Patients with rheumatic conditions often report being unable to get out of bed, having countless nights of restless sleep and being weighed down by relentless exhaustion.Rheumatology Republic caught up with Dr James Galloway, an epidemiologist and rheumatologist at King’s College London in the UK, at EULAR in Madrid to chat about why fatigue is an often-ignored burden of rheumatic disease.
What has stroke got to do with diabetes? Are asthma and eczema related? How come a smoking cessation drug seems to work for obesity treatment?Presenting at EULAR in Madrid on the topic ‘The end of medicine as we know it’, Professor Harald Schmidt explained how big data is breaking down traditional ideas about disease.
The study results we've all been waiting for – part 2 of the GiACTA trial – have been announced at EULAR, but there were still a few “unanswered questions”, an Australian rheumatologist says.
Dr Luke Williamson, a rheumatology registrar from Canberra, sums up his EULAR experience in three words: exciting, extensive and inspirational.
Dr Williamson has been to a few international conferences, but EULAR is “like nothing else I've been to before”, he tells Rheumatology Republic.
What makes EULAR different? And why are rheumatologists so infatuated with Twitter?Rheumatology Republic editor Dr Irwin Lim shares a few thoughts from EULAR in Madrid.
Have you ever wondered whether it’s worth repeating an ANA test? Australian data presented at EULAR in Madrid has finally provided an answer to this clinical conundrum.
What will the next decade of RA treatment bring? Iain McInnes, a professor of experimental medicine at the University of Glasgow, has some answers.
It's difficult to know when to start tapering off high-dose steroids for patients with takayasu arteritis, but novel biomarkers discovered in India could help guide the decision.Professor Debashish Danda, a rheumatologist at Christian Medical College Vellore in India, spoke about his research with Rheumatology Republic reporter Felicity Nelson at APLAR-ARA 2019 in Brisbane.
Rheumatologist Dr Helen Benham has been running a "hub and spoke" telehealth model of care for 200 patients annually at Princess Alexandra Hospital in Brisbane.The telehealth patients still have to see their rheumatologists once a year face-to-face, and Dr Benham "universally get groans" from patients at that time of the year."It really demonstrates, as the research did, that patients generally do prefer telehealth for lots of different reasons," she says in conversation with Rheumatology Republic reporter Felicity Nelson.
Victorian rheumatologist Peter Ryan has been offering telehealth for years using "simple Skype"."Teleheath is something I can't live without," he says. "I started telehealth 16 years ago with the help of Medicare and various medical indemnity societies. Now, I could not practice without it. I could not deliver what I do to country patients in a way that they've come to love."Speaking with Rheumatology Republic reporter Felicity Nelson at APLAR this week, Associate Professor Ryan shared his experiences in telerheumatology in Victoria.
"If people learn why they hurt, they hurt less."Rheumatology Republic reporter Felicity Nelson caught up with Professor Lorimer Moseley at APLAR in Brisbane this week to chat about how educating patients about pain science can actually reduce their pain levels in the long term.