Rheumatology Republic Felicity Nelson

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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