Challenges facing rheumatology

In advance of the Irish Society of Rheumatology’s Autumn Meeting, we speak to President of the Society
Prof Geraldine McCarthy about holding medical conferences during a pandemic and the challenges facing the specialty

The Autumn Meeting of the Irish Society for Rheumatology (ISR) will once again be held virtually because of the continuing Covid-19 pandemic. There is no doubt that the importance of in-person interaction at clinical meetings has become clearer with each passing online meeting. It is hoped the progress of the vaccination campaign may mean 2022 will witness more Society meetings migrating from online to the ‘real world’.

Virtual

“The board of ISR have taken the decision that due to the present climate, the Autumn Meeting taking place on the 30 September and 1 October 2021 will again be virtual,” the Society said in a recent statement.”This is unfortunate, as everybody was anxious for a face-to-face meeting.” Speaking to the Medical Independent (MI) in advance of the meeting, President of the Society and Consultant Rheumatologist at the Mater Misericordiae University Hospital, Dublin, Prof Geraldine McCarthy, said: “We are a relatively small, collegial group and we all really enjoy getting together and we really miss that.

There are people I haven’t seen for two years.” The last ISR meeting back in May was also held virtually. According to the Society, however, one benefit of the virtual format is that a number of presentations from that meeting are still available online on both YouTube and through the ISR’s own website. Prof McCarthy said another benefit of holding meetings online is the ability to attract a greater number of high-quality international speakers.
“You have to take advantage of your situation, and the advantage is we have had amazing speakers for the last few meetings… normally, we only could afford one or two from abroad.”

Agenda

The ISR has succeeded in pulling together an exciting agenda for the meeting.
The agenda was developed by Consultant Rheumatologists at Tallaght University Hospital, Dublin, Prof Ronan Mullan and Prof David Kane. The topics are varied and engaging, grappling with some of the greatest challenges in the speciality and in wider society, with an impressive line-up of domestic and international speakers from as far afield as New Zealand and the US.

Along with the talks, there are also the usual meeting highlights, such as the young investigator award, top eight premier posters, and prizes. Of course, with the ongoing pandemic, it is easy to lose sight of the other major challenges facing healthcare and society in general. For its part, the ISR has given one of the greatest issues of our age a significant role in the upcoming meeting. The final talk on Friday (1 October) will be delivered by Mr James Dixon, Associate Director — Sustainability at the Newcastle Upon Tyne Hospitals NHS Foundation Trust in the UK. The title of his talk is ‘First do no harm — the climate emergency is a health emergency’. With the growth in organisations, such as Irish Doctors for Environment, it is clear that increasing numbers of people working in medicine are convinced that climate change needs to be seen through the prism of health policy and clinical practice.

Even with this wider focus, it is impossible to ignore the main crisis the health service in Ireland and abroad has faced over the last 18 months. Thus, Covid-19 and its relationship with rheumatology does make a significant appearance in the agenda as well. On Thursday (30 September), Prof Kimme Hyrich, Professor of Epidemiology Centre for Musculoskeletal Research, the University of Manchester and Manchester University NHS Trust in the UK, will speak on the topic of ‘Covid-19 and rheumatology: Lessons learned from an international database’. Later that day, Prof Kevin Winthrop, Professor of Infectious Diseases and Ophthalmology at the School of Medicine in Portland, Oregon, US, will deliver a talk titled, ‘Infection, autoimmune disease and 2020 — what we have learned.’ There will be reflections on where rheumatology stands in Ireland historically on Thursday when Prof Gaye Cunnane, Consultant Rheumatologist, St James’s Hospital, Dublin, will give an overview of the history of the ISR itself.

There is also a series of meetings across both days looking into the most recent research and innovation in rheumatology. On Thursday evening Prof Andrew Cope, Versus Arthritis Professor of Rheumatology, and Head, Centre for Rheumatic Diseases, King’s College, London, UK, will give a talk titled, ‘The emerging spectrum of musculoskeletal inflammatory syndromes associated with immune checkpoint inhibitor therapy for cancer.’ In 1990, Prof Cope was awarded a Wellcome Trust Clinical Training Fellowship, studying for a PhD in cytokine biology. Following a postdoctoral fellowship at Stanford University, California, studying transgenic models of autoimmunity, he returned to the Kennedy Institute to set up his own laboratory.

Dr Suzanne O’Sullivan, Consultant Neurologist, University College London Hospitals, UK, will give the final talk of the day. Dr O’Sullivan qualified in medicine in 1991 from Trinity College Dublin and is trained in both neurology and clinical neurophysiology. Her intriguingly-titled presentation is called, ‘It’s all in your head’.
On Friday morning, Prof Nicola Dalbeth, Professor of Rheumatology, University of Auckland, New Zealand, will address new developments in the management of gout. Prof Dalbeth is an academic rheumatologist who leads a clinical and laboratory programme of research in gout, an inflammatory arthritis of major significance to Aotearoa/New Zealand. Prof Oliver Distler, Head of the Department of Rheumatology, University Hospital Zurich, Switzerland, will address treatment strategies in systemic sclerosis-interstitial lung disease. Before lunch-time, Prof Alida Caforio, Professor of Cardiology, University of Padova, Italy, will give a talk titled, ‘Myocardial involvement in systemic immune-mediated diseases’.

Covid-19 impact

Prof McCarthy told MI that the pandemic has had a severe impact on waiting lists for rheumatology clinics. “There are a lot of people on the waiting list now compared to pre-pandemic,” she said. “I would also say, particularly last year, when we were hardly seeing patients at all for about six weeks. There were people who really got into bad shape around that time. We did try to see urgent patients, but no new patients were seen unless it was really urgent. Urgent people are being seen now in a reasonable timely fashion, but the waiting list has extended, unfortunately.”

However, Prof McCarthy said the greater use of telemedicine has been a positive development and one that will continue to be adopted, in some capacity, after the crisis is over. “You might have a frail person over in the West of Ireland, and say they are needing a biologic drug refilled, you can certainly work between utilising telemedicine and the local GP to decide that person doesn’t need to drag themselves all the way to Dublin to be seen,” she said. “For stable patients, it is really useful.”

However, Prof McCarthy did admit to some frustration with remote consultations. “I will say it can be quite frustrating at times; first of all, for all of our clinics in the Mater, it is not video; it is literally telephone. They mightn’t be able to hear you; you might have to call a number of times; there are certain connectivity issues that can arise. Overall, however, we have adapted well to different ways of doing things.” Regarding Covid-19, Prof McCarthy said the use of international registries has been vital in building-up the growing evidence base for how the disease affects rheumatology patients. “We took the view that our patients were immune-suppressed and needed to be extra cautious,” she said, speaking for the speciality as a whole. “There has been a huge international effort and an awful lot of funding into Covid research and as time passes, and as more patients are assessed, we’ll know more. Our knowledge is increasing all the time.”

Vaccination was recommended for all patients. However, specific advice was given to patients on rituximab, which is used treat a variety of conditions, including rheumatoid arthritis, lupus, vasculitis and dermatomyositis, due to its suppression of the body’s ability to generate antibodies. “We tried to have them have their vaccination in advance of their next dose,” Prof McCarthy said. “We did the same thing for methotrexate… we’d have people pause their methotrexate for a short period of time around the time of their vaccine doses.”

Specialty

As for the specialty of rheumatology, Prof McCarthy praised the efforts of HSE Clinical Programme Lead for Rheumatology Prof Kane in his efforts to have more consultant rheumatologists appointed. “He has done a fantastic job in fighting our case for more rheumatologists,” she said. For Prof McCarthy, who has been asked by the ISR board to remain as President until September 2023 as a result of Covid-19 and the lack of face-to-face meetings, a continuing problem is the lack of exposure medical students and NCHDs have to the specialty. “We are not getting enough applicants, in my opinion, to train [in rheumatology]. I think there is a basic problem there,” she said. “And it is a really, really, wonderful speciality, and I just don’t think people know about it.”

However, she said the situation may be improving due to the efforts of rheumatology departments across the country, including at the Mater. “We have had some medical students coming through our department doing electives, and I think this might be the case in other departments,” Prof McCarthy said. “So I am cautiously optimistic it will get better.”

Ireland historically on Thursday when Prof Gaye Cunnane, Consultant Rheumatologist, St James’s Hospital, Dublin, will give an overview of the history of the ISR itself. There is also a series of meetings across both days looking into the most recent research and innovation in rheumatology. On Thursday evening Prof Andrew Cope, Versus Arthritis Professor of Rheumatology, and Head, Centre for Rheumatic Diseases, King’s College, London, UK, will give a talk titled, ‘The emerging spectrum of musculoskeletal inflammatory syndromes associated with immune checkpoint inhibitor therapy for cancer.’ In 1990, Prof Cope was awarded a Wellcome Trust Clinical Training Fellowship, studying for a PhD in cytokine biology.

Following a postdoctoral fellowship at Stanford University, California, studying transgenic models of autoimmunity, he returned to the Kennedy Institute to set up his own laboratory. Dr Suzanne O’Sullivan, Consultant Neurologist, University College London Hospitals, UK, will give the final talk of the day. Dr O’Sullivan qualified in medicine in 1991 from Trinity College Dublin and is trained in both neurology and clinical neurophysiology. Her intriguingly-titled presentation is called, ‘It’s all in your head’.

On Friday morning, Prof Nicola Dalbeth, Professor of Rheumatology, University of Auckland, New Zealand, will address new developments in the management of gout. Prof Dalbeth is an academic rheumatologist who leads a clinicaland laboratory programme of research in gout, an inflammatory arthritis of major significance to Aotearoa/New Zealand. Prof Oliver Distler, Head of the Department of Rheumatology, University Hospital Zurich, Switzerland, will address treatment strategies in systemic sclerosis-interstitial lung disease.

Before lunch-time, Prof Alida Caforio, Professor of Cardiology, University of Padova, Italy, will give a talk titled, ‘Myocardial involvement in systemic immune-mediated diseases’

Covid-19 impact

Prof McCarthy told MI that the pandemic has had a severe impact on waiting lists for rheumatology clinics. “There are a lot of people on the waiting list now compared to pre-pandemic,” she said. “I would also say, particularly last year, when we were hardly seeing patients at all for about six weeks. There were people who really got into bad shape around that time. We did try to see urgent patients, but no new patients were seen unless it was really urgent. Urgent people are being seen now in a reasonable timely fashion, but the waiting list has extended, unfortunately.” However, Prof McCarthy said the greater use of telemedicine has been a positive development and one that will continue to be adopted, in some capacity, after the crisis is over.

“You might have a frail person over in the West of Ireland, and say they are needing a biologic drug refilled, you can certainly work between utilising telemedicine and the local GP to decide that person doesn’t need to drag themselves all the way to Dublin to be seen,” she said. “For stable patients, it is really useful.” However, Prof McCarthy did admit to some frustration with remote consultations. “I will say it can be quite frustrating at times; first of all, for all of our clinics in the Mater, it is not video; it is literally telephone. They mightn’t be able to hear you; you might have to call a number of times; there are certain connectivity issues that can arise. Overall, however, we have adapted well to different ways of doing things.”

Regarding Covid-19, Prof McCarthy said the use of international registries has been vital in building-up the growing evidence base for how the disease affects rheumatology patients. “We took the view that our patients were immune-suppressed and needed to be extra cautious,” she said, speaking for the speciality as a whole. “There has been a huge international effort and an awful lot of funding into Covid research and as time passes, and as more patients are assessed, we’ll know more. Our knowledge is increasing all the time.” Vaccination was recommended for all patients. However, specific advice was given to patients on rituximab, which is used treat a variety of conditions, including rheumatoid arthritis, lupus, vasculitis and dermatomyositis, due to its suppression of the body’s ability to generate antibodies.

“We tried to have them have their vaccination in advance of their next dose,” Prof McCarthy said.
“We did the same thing for methotrexate… we’d have people pause their methotrexate for a short period of time around the time of their vaccine doses.”

Specialty

As for the specialty of rheumatology, Prof McCarthy praised the efforts of HSE Clinical Programme Lead for Rheumatology Prof Kane in his efforts to have more consultant rheumatologists appointed. “He has done a fantastic job in fighting our case for more rheumatologists,” she said. For Prof McCarthy, who has been asked by the ISR board to remain as President until September 2023 as a result of Covid-19 and the lack of face-to-face meetings, a continuing problem is the lack of exposure medical students and NCHDs have to the specialty.

“We are not getting enough applicants, in my opinion, to train [in rheumatology]. I think there is a basic problem there,” she said. “And it is a really, really, wonderful speciality, and I just don’t think people know about it.” However, she said the situation may be improving due to the efforts of rheumatology departments across the country, including at the Mater. “We have had some medical students coming through our department doing electives, and I think this might be the case in other departments,” Prof McCarthy said. “So I am cautiously optimistic it will get better.