‘Rheum to improve’ the image of rheumatology
Dr Emily Pender won the Irish Society for Rheumatology (ISR) Bernard Connor Medal 2017 at the recent ISR Autumn Meeting for a thought-provoking essay on the image of rheumatology as a speciality.
Dr Pender, who is an intern in the Mater Hospital, Dublin, received praise for her piece, entitled ‘Rheum to improve? A reflection on medical student attitudes to rheumatology as a specialty’.
Outgoing ISR President Dr Alexander Fraser recommended the audience read her essay published in the meeting’s booklet, describing it as an “excellent piece of writing”.
“I think we’re all aware that rheumatology, not being organ specific as in dermatology – skin, cardiology – heart, has an image problem. And Dr Pender goes into great detail from the student and newly qualified doctor’s view in her essay,” Dr Fraser said.
“It’s quite chastening and it is something that we often think about – how do we improve our image out there for patients and our colleagues as to what we do?”
After receiving a strong round of applause, Dr Pender took to the stage and explained the reasons for her essay.
During her time as a student, she realised that rheumatology was either “dismissed or people reacted with some confusion” as to her interest in the specialty.
“So I decided to write the essay to address the issue and look at possible solutions,” she said.
After extensive research, Dr Pender discovered that many of her peers believed that chronic pain was an issue that could not really be resolved.
She said that as it was presently mainly an outpatient specialty, students were not being exposed to rheumatology enough. This, the essay stated, had contributed to the perception that rheumatology was at best mystifying or at worst “an uninteresting or unfulfilling specialty”.
“However, rheumatology as a specialty is evolving and dynamic,” she said.
In her essay, Dr Pender concluded that the solution to rheumatology’s image problem was “multifactorial” and there was no “quick fix”.
“However, modification of the current approach to teaching rheumatology at all stages, in a simple manner that does not require significantly increased resources, is possible and may go towards ensuring rheumatology joins the list of in-demand specialties, continuing to attract the brightest trainees,” she wrote.
“Throughout my student training, the rheumatology consultants and NCHDs I have met have been interested, engaging and eager to teach. To share this enthusiasm with a wider range of students through lectures, talks and mentoring, would go a long way to ensuring the future of rheumatology as a specialty that continues to attract the best and brightest of medical students and reform its image as a new and exciting specialty.”
Over 300 delegates attended the ISR meeting, which took place in the Radisson Blu Hotel, Galway, on 21 and 22 September.
The Arthritis Research Coalition was officially launched at the recent ISR Autumn Meeting in Galway. It is hoped that the Coalition will improve research opportunities in Ireland and outgoing ISR President Dr Alexander Fraser described the initiative as an exciting and important development.
The primary aim of the Coalition is to recruit patients with common rheumatic diseases and obtain bio samples that will underpin clinical research. A secondary aim is to increase national involvement in clinical trials of novel therapeutic agents, and to “make Ireland a great place to do further studies”, Coalition Lead Prof Gerry Wilson explained.
Addressing ISR delegates in Galway, he pointed out that he spoke at an ISR meeting three year ago when the idea of establishing a research coalition working across Ireland was first mooted and it was great to see it now becoming a reality.
The development of national rheumatology research networks in many European countries, including Sweden and the Netherlands, highlights their value. The benefits of collecting data from well-characterised populations is now firmly established, Prof Wilson added. While an attempt in the UK to set up a similar register failed, Prof Wilson is confident that the Arthritis Research Coalition will be a success.
“I think in Ireland we are the right sized country. We have the interest and expertise,” he said. “The Coalition hopes to develop cohort populations to underpin translational clinical medical research across many areas of rheumatology.”
Ireland’s rheumatology research excellence was acknowledged in a recent study, ‘Worldwide research productivity in the field of rheumatology from 1996 to 2010: A bibliometric analysis’, the meeting heard.
This study found that Ireland was first out of 35 countries in the number of citations for papers on rheumatology, despite being been reliant on a fragmented and poorly funded infrastructure.
This is a key metric, said Prof Wilson, and put Ireland ahead of countries like Belgium and the Netherlands in terms of research.
How it works
The establishment of Arthritis Ireland chairs and the development of a Dublin Centre of Excellence, will form the foundation of a national rheumatology research strategy. The development of a research nurse network will seek to engage all clinicians, co-ordinate all research activities and ensure that Ireland remains on top, under the new Coalition.
The Coalition will be based on the HSE’s Hospital Group structure, with the initial disease areas including RA (led by Prof Doug Veale), spondyloarthropathies (led by Dr Barry O’Shea), osteoarthritis and crystal arthritis (led by Prof Geraldine McCarthy), connective tissues diseases (led by Dr Grainne Murphy), paediatrics (led by Dr Orla Killeen), and metabolic bone (led by Dr John Carey).
“But there will be other areas, I hope, being developed,” Prof Wilson said, and he encouraged those attending the ISR meeting to join the Coalition.
In the first year the Coalition aims to recruit a 100 patients per disease area and these patients will be followed up regularly. Depending on resources, it is hoped that they will be seen four times over a 12-month period and that clinical data and bio material will be collected as appropriate at each of those four time-points.
The Coalition is also working closely with Clinical Research Coordination Ireland centres around the issue of recruitment and ethics, Prof Wilson said.
“To date, we have got ethics approval for the study from most of the centres. We’re just waiting for two of the seven to come through,” he said. An online data capture system has also been agreed for the rheumatoid, paediatrics and lupus areas.
He added that the Coalition is hoping to start recruiting staff shortly and that for governance and other reasons, these staff will be situated in the clinical research centres in each of the Hospital Groups.
Prof Wilson also confirmed that ownership of the samples would remain with the local consultants who can opt in and out of studies, an aspect that was welcomed by Dr Fraser.
Access to study data will require approval by a steering committee and a publication policy outlining guidelines for publication and data use is also in place.
In terms of funding, Arthritis Ireland had agreed to support the Coalition for three years, and it is also funded by the Health Research Board Clinical Research Coordination Ireland (HRB CRCI). Pfizer and Novartis are also funding the development. Prof Wilson hopes that more funding sources can be located so that the Coalition can carry out longer longitudinal studies and achieve greater collection of bio material.
Other metrics of success identified are involvement in international collaborative studies, presentations and publications, as well as increasing the research opportunities for trainees.
“It’s taken a while, but we are very close to starting what I hope will be a great underpinning resource for translational research, involving as many people in this room as possible,” concluded Prof Wilson.
Welcoming the development, Dr Fraser said the Coalition’s underpinning message is “stronger together”.
“We have some incredibly successful units, however, trying to compete in an international market with major research centres, it is so difficult,” he said, adding that Ireland is perfectly suited to produce very important data.
For more information on the Arthritis Research Coalition visit www.molecularmedicineireland.ie/research/arthritis-research-coalition/.
Rheumatology teaching for GP trainees would be beneficial and help GPs manage rheumatologic conditions in primary care, the ISR Autumn Meeting heard.
Dr Shama Khan made an oral presentation at the meeting on formal rheumatology teaching for GPs in training. She presented the findings of a study that compared the ability and confidence of trainees who had received rheumatology teaching with those who had not.
The study was carried out by the rheumatology department at the Midlands Regional Hospital, Tullamore, and covered two centres, Tullamore and University Hospital Waterford (UHW).
“Up to 20 per cent of primary care consultations involve muscoskeletal (MSK)-related disorders but given the fact that there is little teaching about MSK in medical school and minimum exposure in the GP training field, these practitioners find it hard to meet the demand of patients with MSK disorders,” she said, adding that the rhuematology waiting lists in Ireland and internationally are long.
However, GPs can be trained to manage these conditions in order to break the disconnect between the flow of knowledge and the burden of care in the rheumatic conditions.
The rheumatology departments at Tullamore and UHW facilitate GP teaching in their outpatient clinics and every year six trainees are trained by a consultant rheumatologist. This involves one-on-one teaching in managing rheumatic conditions including joints and soft tissue injections.
The cross sectional study evaluated whether the doctors benefited from the training in diagnosing and treating rheumatology diseases when compared to non rheumatology trainees.
GP trainees who received rheumatology training as part of their hospital rotation were included as ‘cases’, and compared to those who did not have any formal rheumatology exposure during their training (controls). There were 60 participants in the study with 30 in both the case and control categories.
The case GPs attended supervised rheumatology training with the consultant for one year. Initially they were in the same room as the rheumatologist but after a few weeks they were able to see patients independently and discuss them.
Both groups filled in a questionnaire on their ability and comfort level in diagnosing, assessing and managing inflammatory and non-inflammatory conditions, along with joint and soft tissue injections.
The vast majority (94 per cent) of surveyed GP trainees did not have formal rheumatology teaching in medical school, a figure which surprised the ISR audience, but had rheumatology experience post graduation. The GP trainees had an average seven months exposure to rheumatology and those who attended the clinics were confident in examining joints, and differentiating musculosketal/mechanical disorders from inflammatory conditions. They were also confident in interpreting serological tests and managing conditions such as osteoarthritis, tennis elbow, as well as soft tissue and intra-articular knee and shoulder injections.
“The results are quite promising,” Dr Khan said, adding that even the control group was confident in dealing with osteoarthritis.
However, there was a difference in dealing with other conditions. The control group was able to inject large joints like knees but not small joints, and carpel tunnel was a challenge for both groups. Dealing with fibromyalgia was also identified as a challenge for both groups, with only some feeling confident in dealing with it.
In terms of training, GPs preferred workshops where they could participate and receive feedback, and she also suggested establishing a primary care rheumatology society in Ireland to help train those with an interest in the specialty.
Rheumatology training for GPs is beneficial and would help minimise or reduce referrals to tertiary care, she concluded.
Eminent surgeon Prof John McCabe explained some of the challenges facing surgeons in terms of treating osteoarthritis and other illnesses at the recent ISR 2017 Autumn Meeting in Galway.
Prof McCabe is a Consultant Orthopaedic Surgeon at University Hospital Galway and is heavily involved in ongoing research and teaching, particularly in the area of spinal surgery.
As well as experiencing considerable technological advances in the last 30 years, Prof McCabe told colleagues, “spinal surgery in Ireland is probably the most litigious area you can practice in”.
“There is no doubt that we can do better,” he added. “The challenge is to do it in a structured fashion with limited resources.”
However, the enduring tenet of surgery is to treat pathology with minimal disturbance, he explained, but immobilising the spine is essentially no longer considered a tenet of proper spinal practice.
“We (surgeons) have gone small to achieve big things and nowhere is this more obvious than in the spine,” he said. Majorly invasive spinal surgery is still being carried out, but is performed now with millimetre incisions with the aim of achieving stabilisation, decompression or a combination of both.
“Surgery is increasingly small cuts, small morbidity, low rate of infection, rapid rehabilitation and rapidly out of hospital,” he said. Minimally invasive procedures and technologies can be broadly characterised, the meeting heard, as: Traditional open procedures through small incisions, endoscopy, tubular retractor-muscle dilation, fine needle procedures and miscellaneous technologies such as laser-assisted percutaneous discectomy.
Minimally invasive spine surgery (MISS) results in less blood, less post-operative pain, decreased intensive care needs and decreased length of hospitalisation, Prof McCabe said.
MISS operative times are comparable to those of traditional surgical procedures and the techniques are applicable to many different clinical scenarios. The costs are also reasonable, the surgical objective is achievable and the complication rate is comparable, he noted.
While the milestones have continued apace at a phenomenal rate, the problem is that the “technology needed to support it (advances) costs serious money”.
Prof McCabe explained that he started performing kyphoplasty in 2000, two years after it was introduced in clinical practice. The goal of this surgical procedure is to stop the pain caused by spinal fracture, to stabilise the bone and to restore some or all of the lost vertebral body height due to the compression fracture.
He said it is important to remember that new developments have to keep the complication rate at least comparable to open surgery. However, whether the cause of the problem is trauma, tumour, infection, etc, to some extent the response is the same issue – achieve stability, protect the neural structures and mobilise the patient.
Selecting the right patient can be difficult for this surgery, he said, as is making sure that the right diagnosis has been reached. An elderly patient presenting with a painful spine could be a candidate for osteoarthritis but also cancer and he stressed the need of taking thorough patient histories and also the use of scans.
However, Prof McCabe acknowledged that the average waiting times for MRIs in his public clinic is two years. In terms of how to select a patient with osteoporosis who may need percutaneous stabilisation, a situation that is clearly going to be an “increasing epidemic”, he suggested criteria where pain was present for a month or longer and where simple analgesics were not improving the pain.
The Professor again stressed that a correct diagnosis is key. “There is literature out there showing that upwards of 10-15 per cent of patients undergoing kyphoplasty actually have some other pathology,” he warned.
“So it is important to realise that our capacity to be absolutely certain in an ageing population is not by any means perfect.”
Kyphoplasty, he said, reduces pain in about 90 per cent of patients, stabilises the area and it is safe, something that is acknowledged by the UK’s National Institute for Health and Care Excellence (NICE), which has accepted it as a valid technique.
“The overall incident of causing neurologic harm for kyphoplasty is less than 1.5 million,” he added. The technique is done under general anaesthesia and mini incisions are used to stabilise the bone.
Comparing balloon kyphoplasty and vertebroplasty, Prof McCabe said both achieve pain relief and stabilise fractures. However, the latter resulted in no deformity correction above postural reduction, while balloon kyphoplasty can achieve deformity correction to maximise clinical benefit.
Vertebroplasty involves a high-pressure cement injection and a higher risk of leak. However, in balloon kyphoplasty creating a bone void lowers the risk of a leak.
Catastrophising’ one’s condition may contribute to greater pain intensity, anxiety and depression, one of Ireland’s leading pain researchers told delegates attending the ISR 2017 Autumn Meeting.
Prof Brian McGuire, Professor of Clinical Psychology, School of Psychology and Centre for Pain Research, NUI Galway, said studies have shown that people who are more accepting and at ease with their pain have a better response to treatment.
He said that there was an enormous raft of literature on the risk factors for developing pain after surgery. One of these factors is patients ‘catastrophising’ their condition. He explained that this is common and is made up of three components – rumination, magnification and sense of helplessness, all of which help increase the levels of pain and emotional and physical distress.
Another study has found that somatisation, depression, anxiety and poor coping are most predictive of a poor response to both lumbar and spinal cord surgery.
“However, if you can identify people you can do something about it. You can help people change how they think about their symptoms,” he said.
Conversely, dispositional optimism, psychological ‘robustness’, expectation of pain control and function recovery were associated with reduced risk of post-operative pain and chronic pain, regardless of the procedure and medication, the meeting heard.
“These are psychological factors and personality traits that appear to influence the outcomes of your treatment,” Prof McGuire added.
He asked as we move into the era of personalised medicine, whether healthcare professionals should now sweep for these psychological factors in order to identify the right patients for the right treatments.
Working to help people with chronic pain (CP) to cope and function is a particular area of interest for Prof McGuire. Mindfulness is now being used commonly for the treatment of pain as is cognitive behavioural therapy (CBT), he said.
Prof McGuire told the meeting that he hopes an online resource developed in NUI Galway could be expanded to help reach a wider number of people.
International studies have found that about 20 per cent of the population in Europe has chronic pain, defined as pain that lasts more than three months and is always present, he added. Moreover, 80 per cent of people with CP have pain in more than one site.
“Almost half of the people we surveyed had pain in four or more sites. The majority of people with CP manage to work full-time, which is remarkable, but about 12 per cent were unable to work or could only work part-time because of pain.”
Concluding his talk, Prof McGuire said that the Irish Pain Research Network, which was established in 2015 and he Chairs, is hopefully going to be a preparatory step for a clinical trials network focused on chronic musculoskeletal pain.
Dr Richard Conway has been awarded the ISR Young Investigator Award 2017.
The Consultant Rheumatologist in St James’s Hospital, Dublin, won the prestigious prize for his study, ‘Giant cell arteritis (CTA): Diagnostic tools, treatment targets and pathogenic pathway’.
His study found that temporal arthritis, ultrasound and CTA scans were useful tools in the diagnosis of GCA, the most common form of systemic vasculitis. Il-12 and l-23 also play central and distinct roles in stimulating inflammatory and proliferative pathways in GCA, the researchers stated.
Dr Conway thanked the ISR for the award and his many co-authors, while outgoing Society President Dr Alexander Fraser congratulated Dr Conway on his achievement.
The Society also awarded first prize to Dr Leigh Rooney for her oral clinical presentation on ‘The impact of radiology reporting of vertebral fractures on treatment of fracture risk’. The second oral clinical prize was given to Dr Gillian Fitzgerald for her presentation, ‘Obesity predicts worse disease outcomes in axial spondyloarthropathy patients’.
In the first time in the competition’s history, there was a four way tie with the third clinical prize going to Megan Hanlon, Sarah Wade, Dr Trudy McGarry and Dr Mary Canavan.
For the case presentation awards category, the first prize went to Dr Cathy Donaghy, with the first poster prize going to Dr Aine Gorman. The second poster prize went to Dr Bernie McGowan, and third prize was awarded to Dr Wan Lin Ng.
The meeting was then closed with Dr Fraser thanking the Society’s many supporters and members. He also thanked everyone who had submitted research studies and posters.
The National Centre for Paediatric Rheumatology’s (NCPR) experience with tocilizumab (TCZ) has been positive, an oral presentation at the ISR Autumn Meeting stated.
TCZ is a recombinant-humanised-monoclonal-antibody that acts as an interleukin-6-receptor antagonist. It is approved for the treatment of children aged over two years diagnosed with systemic-onset juvenile idiopathic arthritis (SoJIA), and polyarticular JIA (PJIA).
According to the investigating team from Crumlin, TCZ use saw high rates of remission and improved outcomes, with good tolerability with most patients remaining on the drug, and was steroid sparing in refractory cases.
“Rather than using multiple biologics this encourages consideration of the drug earlier,” the study stated.
Dr Charlene Foley, Paediatric Rheumatology Research Fellow, gave the presentation at the meeting entitled ‘The NCPR experience of the use of tocilizumab in the treatment of JIA: A seven year story?’ and explained how the team carried out a retrospective chart review of all children with JIA who have received TCZ since the drug’s NCPR introduction in 2010.
As part of the study, baseline demographics were recorded, as were prior and adjunctive treatments, particularly oral steroid use. Completion of pre-TCZ biologic workup was also reviewed. TCZ dose and infusion frequency were also documented.
The researchers defined active disease as active joint count (AJC), and/or the presence of raised acute phase reactants (APR). At TCZ commencement, initial AJC and raised APR were documented. Clinical remission was defined as zero AJC, while laboratory remission was defined as normalisation of APR. Hospitalisation rates due to serious side effects were also looked at, said Dr Foley.
“It has allowed for another treatment option, especially in those patients who are refractory or steroid dependent,” she commented.
A total of 32 JIA patients, 81 per cent of whom were female, have been treated with TCZ over the seven years of the study.
The majority of patients, 41 per cent, had a diagnosis of SoJIA, 34 per cent had PJIA (3/11 RF-positive), 12.5 per cent had extended oligo-JIA (EoJIA), 6.25 per cent had enthesitis-related arthritis (ERA) and 6.25 per cent had psoriatic JIA (PsJIA). The median patient age at diagnosis was 5.7 years, the median age for TCZ commencement was 10 years and median time to commencing TCZ was 4.3 years.
Prior to TCZ commencement, 97 per cent of the children received methotrexate (MTX) monotherapy and 91 per cent received at least two biologics prior to starting TCZ.
“Some 60 per cent received a total of four biologics, meaning that TCZ was a fifth-line agent. None had received TCZ as a first-line agent to date,” said Dr Foley.
Following MTX, the vast majority of children, 97 per cent, were varicella immune. As per the guidelines all received TCZ fortnightly at the outset with a dose of 12mg/kg if their weight was less than 30kgs and 8mg/kg if their weight was greater than 30kgs.
The researchers found that all the children had full biologic work up before commencing on TCZ.
Escalation to weekly infusions were required in 28 per cent (9/32) of the patients with the majority of these, 56 per cent, diagnosed with SoJIA.
“We managed to reduce infusion frequency in 44 per cent of the cohort to three- to eight-week gaps between their infusions,” she explained.
Adjuvant steroids were required in 56 per cent at commencement of TCZ and complete steroid wean was achieved in 83 per cent of these children.
“We have to date no serious adverse events,” she said, adding that one area the researchers wished to look further into was neutropaenia. “Prior to TCZ, the children will have their bloods done and if they have neutropaenia we will just move the dose out for a week.”
Average initial AJC was found to be nine (3-23 joints) on starting TCZ and APR were raised in 56 per cent prior to starting TCZ. Clinical remission was achieved in 83 per cent (25/30) and the average time to remission was five months (0.5-16 months).
“Some 47 per cent of the cohort achieved this by the first three months on TCZ and the majority, 73 per cent, by the first six months,” she said. APR was normalised in 78 per cent of patients after one infusion, and 100 per cent after three.
The outcome of TCZ was found to be variable in different JIA subtypes. “The most successful group treated with TCZ were those diagnosed with PJIA, where remission was achieved in 100 per cent,” Dr Foley said. Patients with EoJIA also saw 100 per cent remission.
As long-term outcomes, TCZ was continued in 78 per cent (25/32) of the cohort, of these 36 per cent (9/25) achieved and maintained reduced infusion frequency of three to eight weeks.
TCZ was discontinued in 22 per cent (7/32), three of these children had primary loss of response and all of these have now undergone a stem cell transplant (HSCT), the meeting heard.
The remaining four patients had secondary loss of response and were switched to another biologic, such as rituximab, ustekinumab, adalimumab,and golimumab.
“In the future we would like to further assess the laboratory and clinical remission and look at the differences,” Dr Foley concluded.
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