Transcript Rheumatology - Auckland Chinese Medical Association

Rheumatology
Dr Kristine Ng
Rheumatologist (WDHB)
Honorary Senior Clinical Lecturer,
University of Auckland
Case 1
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81 year old Chinese man
Gout for 35 years
Referred by GP for management
Initial symptoms – podagra
Tophi deposits – last 2 years
Deforming joints last 3 years
Limited hand & feet function
Picture
Case 1
• Naproxen last 40 years
• Renal impairment Cr 165µmol/L, eGFR
33ml/min
• Allopurinol – blister type rash
• Benzbromarone (6 months) – ineffective
• Probenecid – ‘uncomfortable sensation’
• Colchicine – ‘uncomfortable sensation’
Case 1
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Urate 0.63 mmol/L
Erosions on hand XR
Meds: prednisone 5mg daily
“Prednisone and naproxen are the only
medications that help”
• How would you manage his gout?
ULT Algorithm
• 1st line – allopurinol
• 2nd line – probenecid
– benzbromarone
• 3rd line – febuxostat
Allopurinol Myth 1
You can’t start allopurinol during an acute attack
– WRONG- YOU CAN, start low (50-100mg)
Taylor et al. Am J Med 2012 Nov; 125(11):1126-1134
Allopurinol Myth 2
You can’t use allopurinol if there is renal
impairment
– WRONG- YOU CAN, with dose modification (start
at 50mg daily, and dose increments of 50mg until
target achieved)
Stamp et al. Arthritis Rheum. 2011 Feb; 63(2):412-21
Allopurinol Myth 3
You should stop allopurinol during an acute
attack
– WRONG- YOU ONLY stop allopurinol if the patient
develops adverse events due to allopurinol,
mainly a rash
Allopurinol Myth 4
The maximal dose of allopurinol is 300mg
– WRONG- you adjust the dose slowly to reach
serum urate of <0.36mmol/L, up to 900mg
Stamp et al. Arthritis Rheum. 2011 Feb; 63(2):412-21
Febuxostat
• Non purine selective inhibitor of xanthine oxidase
• Metabolized by liver
– does not require dose adjustment in renal failure
(unless severe)
– need LFT monitoring (reports of fatal hepatotoxicity)
• Not recommended in those with IHD or CHF
• Dosing: 80 – 120mg daily
• Much more expensive than allopurinol
Case 1
• Started Febuxostat 80mg daily
• Prednisone cover for acute gout flare
• Long discussion on meds and management of
gout
Healthpoint Pathways
Management of acute gout
http://www.healthpointpathways.co.nz/northern/adult-16-az/gout/gout-acute/
Gout prevention
http://www.healthpointpathways.co.nz/gout-prevention/
Case 2
• 71 year old man referred for management of
ankylosing spondylitis
• Recent hospital admission for diverticulitis.
• IV antibiotics, due for OP colonoscopy
• CT abdomen and pelvis
Case 2
• Diagnosed with Ankylosing Spondylitis 1995
whilst in hospital for pneumonia
• Told nothing much could be done
• Last 10 years, increasing back pain
• Affecting sleep
• EMS 3-4 hours
Case 2
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Prescribed M-Eslon last 6 months
Lives with wife
Functional difficulties
Severe R hip OA – awaiting replacement
LHJR - 2001
Case 2
Examination
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Stooped posture
Loss of lumbar lordosis
Limited lumbar flexion – 1 cm
Lumbar lateral flexion – 4cm
Chest expansion reduced 1.5cm
Neck fixed flexion position -10 degrees
Case 2
• CRP 10mg/L
• HLA B27 positive
• How would you manage this patient?
• Is there any effective therapeutic
intervention?
Ankylosing Spondylitis
• Delay in diagnosis up to 10 years
• Approximately 5% of lower back pain is
attributed to AS
• HLAB27
 90% AS patients are HLAB27
 5-15 % general population HLAB27 +
 (4-8% in Chinese population)
 Only 5% of HLAB27 positive people develop AS
Case 2
• Discussion with patient ? tumour necrosis
factor (TNF) inhibitors
ACMA Mentorship programme
Dr Kristine Ng (ACMA coordinator)
Chen (Eileen) Zhou (YACMA coordinator)
What is a mentor?
• Experienced person who can offer advice on
education, future career and networking
opportunities
ACMA/YACMA mentorship programme
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Started August 2014 – one year
Mentor/mentee matching process
Max ratio 1 mentor: 5 mentees
Introductory email sent
Arrangement of meetings dependent on
mentor
• A few mentors not based in Auckland
Benefits for students
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Wisdom and learning from past experiences
Contacts
Lifeskills
Insight
A sounding board
Reduced feelings of isolation
Improved performance
Why be a mentor?
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Personal satisfaction
Enhance people skills
Increase professional networks
Hear fresh perspectives
Increase your profile
Mentoring 2014-2015
Survey Results
Chen (Eileen) Zhou
Why students wanted a mentoring
programme
RESPONSE:
– Lots of interest
from all year
levels
– 2/3 were preclinical
– ADVICE!!!
– Small groups
and face to
face meetings
were
preferred.
Mentoring begins!
• LOTS OF MENTEES
– 54 signed up last year
– At capacity!!!
– 10 signed up this year
• MENTOR SIGNUPS
– 12 signed up last year,
with 3 more this year
– Mix of specialisations and
GPs
Top 5 most wanted specialties
Over half of students didn’t mind what specialty
their mentor was from.
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Emergency Department
General Medicine
Surgery
Paediatrics
GP
6 month survey
What the mentors said
• 80% response rate!
• Most have done 1-2 meetings
• Face to face meetings taking
1-3 hours
– Some shared a meal!
– May be difficult with number
of students at different stages.
• Most were satisfied with
turnout
• Made suggestions for
programme improvement
What the mentees said
• 22% response rate!
• Very positive feedback
• Most mentors were
approachable and gave
great advice.
• Face to face meetings
were most effective.
Plans for the future
• Changing mentorship groups vs. continuing
current mentoring groups
• Introductory social gathering alongside ACMAYACMA joint events.
• Possibility of clinical students mentoring preclinical students.
• Encourage mentees to not be shy!
• Encourage mentors to sign up
Thank you!
Any suggestion or comments?
Checklist for mentors
• Ask mentee to begin thinking about short and
long term plan
• Ask mentee to send updated CV
• First meeting:
Express interest in mentee career
development
Discuss short and long term goals
Discuss frequency of meetings
Checklist for mentees
• Getting ready
• The first meeting – know what you want?
 Motivation
 Advice
 Listener
 Role model
 Achiever
Cultivating the relationship
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Agree on structure and objectives
Set goals and expectations
Plan and set meeting agendas
Ask questions
Listen actively
Ask for feedback
Be responsive and flexible
Follow up meetings
• Meet in accordance with agreed plan
• Try to maintain relationship for at least 2 years
• Re-evaluate mentoring relationship as needed
after one year
• Agree on confidentiality and no fault
termination