Everyday Medicine with Dr Luke

Hypermobile joints were noted by Hippocrates as long ago as 400 BCE and are common, occurring in about 10-25 % of the population. In a minority of patients’ pain and injury results suggest that the clinical findings may reflect a condition referred to as hypermobility spectrum disorder, a polygenic connective tissue syndrome affecting between 1:500 to 1:600 people. This syndrome involves extreme joint flexibility often associated with joint pains, tends to run in families and is more common amongst females. Hypermobility spectrum disorder has been redefined separately from the more stringent diagnostic criteria required for the diagnosis of more extreme hypermobility syndromes such as Ehlers-Danlos syndrome, Marfans disease, Loeys-Dietz or Osteogenesis imperfecta syndromes. In relation to the above-mentioned syndromes in 1901 a Danish doctor, Dr Lauritz-Edvard Ehlers presented a case of hypermobility, and a similar case was subsequently presented by French physician Dr Henri-Alexandre Danlos in 1908. The name Ehlers-Danlos syndrome (EDS) wasn’t proposed until many years later in 1936 by Englishman Dr Parkes-Weber. We now recognize 13 types of Ehlers-Danlos syndrome with hypermobile EDS as the most common and myopathic EDS, Spondylodysplastic classical EDS and brittle cornea syndrome as just some of the others. About 1: 3500 to 1: 5000 people have EDS. Both dominant and recessive inheritance patterns are noted. Frequent joint and ligament injuries including sprains and dislocations may occur and joint stiffness, clumsiness, fatigue dizziness and associated bowel and bladder complaints are often cited. Another well-known hypermobility disorder Marfans syndrome is rare affecting about 1 in 5000 and in three-quarters of cases, inheritance is autosomal dominant with the defective fibrillin gene resulting in tall individuals with slender limbs, fingers and toes, cardiac defects including aortic dissections, aortic root aneurysms and valvular incompetence, lens dislocations as well as the high arched palate, crowded teeth and abnormal sternum development (pectus excavatum or pectus carinatum ). A quarter of cases experience a new gene mutation with no family pedigree identified. These hypermobility conditions have common abnormalities in collagen structure and function. Whilst genetic studies are available in some cases of hypermobility (but not hypermobility spectrum disorder), the criteria for diagnosis referred to as The Beighton criteria are essentially clinical and includes a Beighton score reflecting joint extensibility and mobility combined with arthralgia over 3 months, dislocations and subluxations, soft tissue lesions such as epicondylitis, tenosynovitis and bursitis, Marfanoid habitus and abnormal skin with striae, hyperextensibility, thin skin and papyraceous scarring. No cure is currently known for these syndromes which are managed symptomatically. Fortunately, societies such as the Ehlers-Danlos Society and physicians such as Assoc Professor Chris O’Callaghan from Melbourne’s Austin Health are the most helpful resources and I welcome you to the interview with Chris to expand our understanding of this subject today. References: Assoc Professor Chris O’Callaghan: www.austin.org.au The Ehlers Danlos Society: www.ehlers-danlos.com Ehlers-Danlos syndromes: www.nhs.uk

Acid-Base theory is often considered a difficult subject. As long ago as 1962, Creese et al wrote in the Lancet … “There is a bewildering variety of pseudoscientific jargon in medical writing on this subject “My suspicion is that some degree of confusion and thus avoidance of the subject continues to this day. Hopefully, this podcast conversation will resonate with some of our listeners and smooth out any misunderstandings should they exist. As a background, Bronsted and Lowrys definitions of acids and bases are as follows: A base is a substance that accepts a proton (a hydrogen ion) an acid is a compound that dissociates in water to release a proton. A strong acid is one that readily dissociates in water to release a proton (eg HCL), and a weak acid does not readily dissociate in water (uric acid). pH is the negative logarithm of the hydrogen ion concentration to the base 10. Thus, the negative logarithm of 0.0000001 which may be expressed as 10 to the power of -7 is 7. The reason blood and cellular pH are so important is that their stability is essential to the integrity of enzymes, metabolic processes, and cell membrane potential. Homeostasis holds our blood pH tightly between 7.35 and 7.45 with an intracellular pH of 6.8. Where does the acid come from? Acid production results from the production of CO2 by metabolism of glucose, fatty acids, and amino acids. CO2 combines with water and is converted to carbonic acid -H2CO3 by carbonic anhydrase and then dissociates to H+ and HCO3-. That enzyme carbonic anhydrase pops up everywhere. Acid production also results from anaerobic glucose metabolism whereby glucose is converted to H+ and lactate in ketogenesis as well as from the catabolism of the amino acids: methionine and cysteine. Which organs play a major role in the maintenance of pH? Both the lungs and kidneys play critical roles in acid-base balance. We exhale CO2 from the lungs effectively blowing off acid but may also retain CO 2 by underventilation. The kidneys have the potential to excrete or absorb bicarbonate and to excrete or reabsorb protons (hydrogen ions) influencing and compensating for pH disturbance through an intricate juggling of these two. The excretion of protons is by combination with ammonia from the metabolism of muscle glutamine or in combination with monohydrogen phosphate. These ingenious biological systems may be influenced by multiple disease processes and respiratory forms of acidosis and alkalosis as well as metabolic processes leading to acidosis and alkalosis are well recognised. Whilst arterial blood gas assessment is used in critical care units to determine the degree of oxygenation, adequacy of ventilation, and the presence and severity of acid-base disturbances in the body, arterial puncture may result in complications, and the difficulty in acquiring arterial blood may delay care. Venous blood gas (VBG) is a more accessible alternative to ABG sampling and correlates well with arterial sampling in pH measurement (slightly lower in venous sample) and HCO3 - (1.41 mmol/l higher in venous) with pCO2 approximately 5.6 mmHg higher in venous blood. These differences may be exaggerated however in circulatory failure. In this podcast with ICU physician Associate Professor Adrian Regli, we will explore the subject further, delve into some of the typical metabolic and respiratory disturbances we are likely to encounter as clinicians and also review some handy rules of thumb to draw upon in practical acid-base interpretation. Currently, Adrian works as an ICU consultant at Fiona Stanley Hospital Perth. Please welcome Adrian to the Podcast. References Assoc Professor Adrian Regli - via Google Oh’s Intensive Care Manual, Bersten et al 6 th ED, Butterworth Medical Biochemistry at a Glance, Salway,3rd ED, Wiley-Blackwell Acid-Base Disorders in the Critically Ill Patient, Achanti et al CJASN, Sept 2022

Motor neuron disease (MND) is a rare group of neurodegenerative disorders causing motor nerves in the brain and spine to lose function over time. It affects approximately 2,000 Australians (1 in 11,000), with two new diagnoses daily and a 1:300 lifetime risk. MND is more common in males (60%) than females (40%), particularly those aged 75–84. While 10% of cases have a hereditary cause, the genetic fault is identifiable in only 60% of these cases. Types of MND 1. Amyotrophic Lateral Sclerosis (ALS): The most common form, affecting both upper and lower motor neurons, leads to muscle weakness in the arms, legs, mouth, and respiratory system. ALS patients typically live 3–5 years post-diagnosis, but supportive care can extend survival. Prominent figures such as Stephen Hawking and Lou Gehrig had ALS. In Australia, Neale Daniher's 2013 diagnosis raised significant awareness. ALS is sometimes associated with frontotemporal dementia (10–15% of cases). 2. Primary Lateral Sclerosis (PLS): A rare, non-fatal form that progresses slowly, affecting brain neurons. 3. Progressive Bulbar Palsy (PBP): Involves the brainstem, causing speech, swallowing, and choking difficulties. Often co-occurs with ALS. 4. Progressive Muscular Atrophy: Affects lower motor neurons, leading to gradual muscle wasting in the arms, legs, and mouth. 5. Spinal Muscular Atrophy (SMA): An inherited condition caused by a genetic change (SMA1), mainly affecting children. 6. Kennedy’s Disease: An inherited disorder affecting males, causing muscle weakness, twitching, and other symptoms such as gynecomastia and azoospermia. Causes and Risk Factors While 10% of MND cases are hereditary, the rest arise randomly. The exact causes remain unclear, but factors such as genetics, toxins, viruses, and environmental influences are believed to contribute. Symptoms and Diagnosis Early symptoms, such as muscle twitching, weakness, and slurred speech, may mimic other conditions like multiple sclerosis. Diagnosis is challenging due to the lack of specific biomarkers, though imaging like MRI or CT can help rule out other conditions. Treatment and Management While MND has no cure, various treatments can slow its progression and help manage symptoms. Medications like Riluzole, which reduces glutamate release, can extend short-term survival in ALS, while Edaravone slows disease progression in milder cases. Baclofen helps alleviate muscle stiffness, and Botox provides temporary relief from muscle spasticity. Supportive therapies, including physical therapy, speech therapy, and NSAIDs, can reduce discomfort from cramps, spasms, and mild pain, improving the patient’s quality of life. Guest Expert In this episode, we welcome back Associate Professor Ernie Butler, a consultant neurologist and founding member of Frankston Neurology Group. He specialises in managing multiple sclerosis, myasthenia gravis, and Parkinson’s disease. Prof. Butler holds leadership roles at Peninsula Health, Monash Health, and the Monash MS clinic. He previously joined us on episodes covering multiple sclerosis, myasthenia gravis, and Guillain-Barre syndrome. Join us as we explore MND in-depth with Associate Professor Butler, gaining insights from his extensive expertise in neurology.

Exploring Parkinson's Disease with Associate Professor Ernie Butler In this episode, we dive into Parkinson’s Disease (PD), a progressive neurodegenerative disorder that primarily impacts dopamine-producing neurons in the substantia nigra, leading to motor and non-motor symptoms. Our guest, Associate Professor Ernie Butler, consultant neurologist and founder of Frankston Neurology Group, provides expert insights into PD's complexities. Pathophysiology of Parkinson’s DiseasePD affects dopaminergic neurons in the substantia nigra, leading to a significant drop in dopamine, a neurotransmitter essential for movement. Dopamine loss disrupts communication between the substantia nigra and corpus striatum, impairing motor functions. Additionally, the loss of norepinephrine-producing nerve endings can cause non-motor symptoms like fatigue and blood pressure irregularities. Lewy bodies, protein aggregates containing alpha-synuclein, are also present and may contribute to neuronal death. Global ImpactAs the second most common neurodegenerative disorder, PD affects millions worldwide, with over 200,000 cases in Australia. Around 38 new cases are diagnosed daily, and one in five diagnoses is made before age 50. Core Symptoms of Parkinson’s DiseasePD's four main motor symptoms are: Tremor - Typically a “pill-rolling” tremor noticeable at rest. Rigidity - Muscle stiffness, often evident when limbs are moved. Bradykinesia - Slowed movement, which reduces facial expression and complicates tasks. Postural Instability - Impaired balance, often resulting in a shuffling gait and episodes of “freezing.” Parkinson’s Plus SyndromesSeveral conditions mimic PD but include unique symptoms: Multiple System Atrophy (MSA): Involves autonomic symptoms like poor coordination. Lewy Body Dementia: Features motor symptoms and cognitive impairment with visual hallucinations. Progressive Supranuclear Palsy (PSP): Includes gait instability, eye movement issues, and mood changes. Corticobasal Degeneration (CBD): Causes rigidity, balance problems, and tau protein deposits. Risk FactorsPD risk factors include: Age: Most cases begin around age 70. Biological Sex: More common in men. Genetics: About 25% of patients have a family history, with mutations in genes like GBA and LRRK2. Environmental Exposure: Living in rural areas and exposure to pesticides may increase risk. Diagnosis and TreatmentPD is diagnosed through medical history and neurological exams, as CT and MRI scans often show no abnormalities in early stages. Treatment OptionsWhile PD has no cure, several treatments help manage symptoms: Medications: Dopamine precursors (levodopa and carbidopa) increase dopamine. COMT inhibitors (entacapone) extend the effect of levodopa. Anticholinergics reduce tremors, while amantadine treats dyskinesia. Surgical Intervention: Deep Brain Stimulation (DBS) involves implanting electrodes in the brain to improve motor symptoms in patients unresponsive to medication. With extensive experience in managing PD, MS, and myasthenia gravis, Associate Professor Ernie Butler is a senior neurology specialist at Frankston Neurology Group and Monash Health. He has been featured in prior episodes on Multiple Sclerosis and Myasthenia Gravis, providing valuable insights into complex neurological conditions. References Frankston Neurologyhttps://www.frankstonneurology.com.au › ...Our Neurologists Parkinson's Foundationhttps://www.parkinson.org › what-is...What is Parkinson's? National Institute of Neurological Disorders and Stroke (.gov)https://www.ninds.nih.gov › disordersParkinson's Disease | National Institute of Neurological Disorders ...

It’s difficult to walk through an old-growth natural forest anywhere in the world and not feel awe and a connection to the majesty of our beautifully stunning Earth, however, when these amazing ecosystems burn as forest fires the consequence has devastating outcomes for affected communities. In recent times in Australia the Ash Wednesday fires of 1983 claimed 75 lives, The Black Saturday Fires of 2009 claimed 173 lives, 3500 buildings, and 2000 houses and the Black Summer fires of 2019/2020 claimed 26 lives and 2500 houses. The health consequences in terms of mental health, acute pulmonary disease and socioeconomic effects from these disasters is difficult to comprehend and the loss of life devastating.  The normal response to fire prevention has been to recommend controlled burns and to thin forests through commercial logging. Is this scientifically correct? We talk with Professor David Lindenmayer from the Fenner School of Environment at ANU in this episode to explore this idea further. David is a leading world expert on forest ecology and resource management, conservation science and biodiversity conservation. He has published over 900 peer reviewed scientific papers and written 48 books with his latest book The Forest Wars addressing myths concerning forest management and ecology to be released in the next few weeks. He is frequently consulted by government and has lectured widely on this subject. His scientific work has pointed to the reduced flammability of mature forests, wet or dry, compared to younger forests subject to recent logging or controlled burn offs. Forest disturbance has been found to stimulate flammability; an effect referred to as disturbance-stimulated flammability. Both crown fire -where burn occurs up to 7 times the height of flames, and house loss were more likely in the 2009 tragic Victorian fires if the area within 1 km of houses had been burnt off within the past 5 years. His work highlights the value of reviewing the science on the subject at hand, to be curious and question the evidence and rationale underpinning decision making and to muster the courage and commitment to educate the world despite the resistance and ignorance that exists to hear and understand the truth. As Bill Mollison said, “If we lose the forests, we lose our only teachers”. It was a great privilege to have this conversation with David who I believe is at the vanguard of ecological change and thinking both in Australia and on the world stage. I look forward to reading his new book The Forest Wars and hope you will also. Please welcome David to the podcast References: Professor David Lindenmayer, Professor of Ecology and Conservation Biology at the Australian National University’s Fenner School of Environment and Society Identifying and managing disturbance-stimulated flammability in woody ecosystems. David Lindenmayer and Phil Zylstra, Biological Reviews (2023) The Forest Wars, David Lindenmayer, Allen & Unwin 2024

Globus, a persistent or intermittent sensation of a lump or foreign body in the throat, is a well-defined clinical symptom. Though it is non-painful, it can be long-lasting, difficult to treat, and prone to recurrence. Interestingly, this sensation often improves with eating and typically does not accompany dysphagia (difficulty swallowing) or odynophagia (painful swallowing). Globus is a common condition, accounting for about 4% of new referrals to ear, nose, and throat (ENT) clinics, and is reported by up to 46% of apparently healthy individuals, with peak incidence in middle age. The condition affects men and women equally, though women are more likely to seek medical care for it. The origins of globus pharyngeus trace back to Hippocrates, who noted it around 2,500 years ago. In 1707, Purcell provided the first accurate description, attributing it to pressure on the thyroid cartilage from the contraction of the neck's strap muscles. Historically, the condition was labeled as "globus hystericus" due to its frequent association with menopause or psychological factors. However, in 1968, Malcomson introduced the more accurate term "globus pharyngeus" after discovering that most patients with globus did not have a hysterical personality. The exact cause of globus remains unknown, but it appears to be multifactorial. While data are limited, recent studies suggest that factors such as gastroesophageal reflux disease (GERD), abnormalities of the upper esophageal sphincter (UES), psychological and psychiatric disorders, and stress may contribute to the sensation of globus. The variety of potential causes has made it challenging to establish standard investigation and treatment strategies, requiring an open mind when considering possible causes. Dr. Andrew Martin, a practicing ENT surgeon based in the southeastern suburbs of Melbourne and Northern Tasmania, sheds light on this condition. He completed his MBBS at The University of Queensland in 2008, following a Bachelor of Pharmacy Sciences with Honours from Monash University in 2003. In 2021, he earned his fellowship with the Royal College of Surgeons in Otolaryngology and Head and Neck Surgery in New Zealand and completed an Advanced Fellowship in Head and Neck Surgery at The Royal Melbourne Hospital in 2022. Dr. Martin has special interests in nasal obstruction, obstructive sleep apnea, ear and balance issues, chronic sinus disease, mid-facial pain, pediatric ENT, as well as swallowing, voice, and throat disorders. Beyond his professional achievements, Andrew is a dedicated family man with two young daughters and enjoys hunting and fishing in his free time. It was a privilege to have this insightful conversation with him about globus symptoms. Please welcome Dr. Andrew Martin to the podcast. References: ⁠Dr Andrew Martin "Globus pharyngeus: A review of its etiology, diagnosis and treatment." World Journal of Gastroenterology. 2012 May 28; 18(20): 2462–2471. Published online 2012 May 28. doi: 10.3748/wjg.v18.i20.2462 https://www.uptodate.com/contents/globus-sensation 

Approximately 1 in 10 adults will experience pain or discomfort in the mid-facial region, with a higher prevalence among females and young adults. Understandably, many patients attribute this pain to sinus issues, given the proximity of the sinuses to the face. However, nasal endoscopy and CT scans have shown that chronic sinus infections are not as common a cause of facial pain as one might think. Sinusitis typically causes significant pain only when accompanied by thick nasal drainage, loss of smell, or nasal obstruction. In these cases, nasal endoscopy usually reveals some drainage or inflammation. Facial pain related to sinusitis is generally alleviated, at least partially, by a course of antibiotics. When sinusitis is ruled out, other potential causes of mid-facial pain should be considered, including: Tension Headache: This type of headache may manifest as pressure or tightness across the bridge of the nose, forehead, or the back of the head. The face may feel "swollen," and the nose may seem "blocked," though there is no actual breathing obstruction. Tenderness over the forehead and cheeks is common. A low dose of amitriptyline (10-25mg, up to 75mg) taken at night for six weeks typically relieves this pain. Migraine Headaches: More common in women with a family history of migraines, these headaches can last up to 48 hours and are often associated with nausea. Nasal congestion is also not uncommon. Acute treatment may include antimigraine medications such as sumatriptan (50mg). For frequent episodes, preventative medications like pizotifen or amitriptyline may be effective. Cluster Headache: This condition, more common in men, causes severe unilateral pain around the forehead, eye, and cheek, often lasting over an hour. The affected eye and nose typically water on the side of the pain. Treatment is similar to that for migraines. Temporomandibular Joint Dysfunction (Myofascial Pain): Inflammation around the jaw joints can lead to pain, which may be alleviated by rest and simple analgesia. Neurologic Pain: Conditions such as trigeminal neuralgia, postherpetic neuralgia, and glossopharyngeal neuralgia often cause severe, burning pain and may involve trigger points. Medications like gabapentin can be effective in managing this type of pain. Dr. Andrew Martin is a practicing ENT surgeon based in Melbourne's southeastern suburbs and Northern Tasmania. He earned his MBBS from The University of Queensland in 2008, following a Bachelor of Pharmacy Sciences with honours from Monash University in 2003. In 2021, he completed his fellowship with the Royal College of Surgeons in Otolaryngology and Head and Neck Surgery in New Zealand, followed by an Advanced Fellowship in Head and Neck Surgery at The Royal Melbourne Hospital in 2022. Dr. Martin has a special interest in various conditions, including nasal obstruction, obstructive sleep apnoea, ear and balance problems, chronic sinus disease and mid-facial pain, paediatric ENT, and disorders related to swallowing, voice, and the throat. Beyond his medical practice, he is a dedicated family man with two young daughters and enjoys hunting and fishing. It was a privilege to have Dr. Martin join us for this conversation, where we explored the complexities of mid-facial pain in greater detail. Please join me in welcoming Dr. Andrew Martin to the podcast. References: andrewmartinent.com Nick S. Jones. Midfacial Segment Pain: Implications for Rhinitis and Sinusitis. Curr Allergy Asthma Rep. 2004 May. North Melbourne ENT

Rhinitis, Sinusitis, and Rhinosinusitis are common conditions frequently seen in primary care. Studies indicate that 1.4 out of every 100 general practice encounters involve acute or chronic sinusitis, and over 2 million Australians are estimated to suffer from chronic rhinosinusitis. In some studies, this condition has shown a greater impact on social functioning than chronic heart failure, angina, or back pain. Anatomy and Pathophysiology: The paranasal sinuses—frontal, maxillary, ethmoid, and sphenoid—are lined with ciliated epithelium and goblet cells, forming a mucociliary blanket that traps and moves harmful particles to the nasopharynx. The maxillary sinus, the largest air-filled sinus in the body, has a draining ostium only 2.4 mm in diameter, making it particularly prone to blockage during infection or inflammation. Treatment for sinusitis focuses on restoring mucociliary clearance and drainage while addressing underlying inflammation. Acute Rhinosinusitis: The spectrum of acute rhinosinusitis (ARS) includes the common cold, post-viral ARS, and acute bacterial rhinosinusitis. Though less than 2% of viral upper respiratory infections progress to bacterial infections, antibiotics are prescribed in over 85% of sinusitis cases. Symptoms of ARS include nasal obstruction, discharge, changes in smell, facial pain or pressure, and cough. Facial pain may worsen when bending forward and can radiate to the teeth. Diagnosis requires the sudden onset of two or more symptoms, with at least one being nasal blockage, congestion, obstruction, or discharge, accompanied by facial pain or pressure and/or a reduction in smell. Nasal examination should assess for discharge (clear or purulent), polyposis, swelling, and erythema. Chronic Rhinosinusitis (CRS): CRS presents in two forms, distinguished by the presence or absence of nasal polyps. It is defined by the persistence of symptoms for more than 12 weeks, including nasal congestion, discharge, facial pain or pressure, and reduced smell. Viral and bacterial infections are the most common causes, with Streptococcus, Pneumococcus, Haemophilus, and Moraxella being the usual bacterial suspects. Other factors such as allergies, structural abnormalities, ciliary dysfunction, immunodeficiencies, and fungal infections should also be considered. Allergic Rhinitis: Allergic rhinitis, commonly known as hay fever, affects around 18% of Australians. Despite its name, allergic rhinitis is not caused by hay and does not result in fever. It typically presents with sneezing, itching, rhinorrhoea, nasal congestion, and lacrimation, triggered by allergen exposure. These allergens can often be identified through patient history, but RAST serology may be required when clear precipitants are not evident. To deepen our understanding of these conditions, we welcome Dr. Andrew Martin, a practicing ENT surgeon in Melbourne's Southeastern suburbs and Northern Tasmania. Dr. Martin completed his MBBS at The University of Queensland in 2008 after earning a Bachelor of Pharmacy Sciences with Honours from Monash University in 2003. He completed his fellowship with the Royal College of Surgeons in Otolaryngology and Head and Neck Surgery in New Zealand in 2021, followed by an Advanced Fellowship in Head and Neck Surgery at The Royal Melbourne Hospital in 2022. Dr. Martin’s specialties include nasal obstruction, obstructive sleep apnoea, ear and balance disorders, chronic sinus disease, mid-facial pain, paediatric ENT, and disorders affecting swallowing, voice, and throat. Outside of his medical practice, he is a devoted family man with two young daughters and enjoys hunting and fishing. It was a privilege to have this conversation with him as we explored rhinitis and rhinosinusitis in more detail. Please join me in welcoming Dr. Andrew Martin to the podcast. References: ⁠Dr Andrew Martin⁠ ⁠National Institutes of Health - Rhinitis and Sinusitis⁠ ⁠Journal of Allergy and Clinical Immunology - Rhinitis and Sinusitis⁠

In an earlier episode titled Breathing we had the privilege to explore heathy breathing patterns and the Bohr effect which governs oxygen delivery to tissues with physiotherapist and breathing expert Allan Abbott, if you haven’t had an opportunity to listen to that podcast, I recommend it as an introduction to the subject we are covering today. Allan has been exploring breathing techniques to enhance exercise performance and improved health for many years and has created a dynamic company called Health Innovations that can be found at healthinnovations.net.au in order to bring this important knowledge into public forum. Although most of us pay little attention to breathing technique in our busy world, many cultures and alternative health practises such as YOGA and Ayurveda have focused on this for centuries and the recent excellent book Breath by James Nestor explores the importance of breathing technique in detail including the influence on facial structure and disease brought about by mouth breathing and poor execution of this seemingly automatic task. Allan takes us further in this podcast episode in which we explore functional breathing, breathing during exercise and how we can utilise breathing techniques to replicate high altitude training at sea level to improve performance and stamina in ways you may not have considered possible. Allan was generous enough to give up a good deal of his spare time taking me on a deep dive through these breath training techniques one on one. We focused first on nasal breathing light, slow and deep utilising the diaphragm rather than purely chest muscles and aiming for a 4 second nasal inhalation followed by a slow nasal exhalation over 6 seconds. This develops the habit of six breaths per minute. We then worked on the breath oxygen level test - the so-called BOLT with the objective of building CO2 tolerance to reduce the ‘gassing out’ feeling that can occur when one trains at a moderate exercise intensity. Subsequently Allan took me to ‘altitude’ with some strong breath holds during exercise simulating the reduced partial pressure of oxygen experienced as we venture 2000 metres above sea level and more, slowly resetting central CO2 chemoreceptors, increasing our haematocrit, erythropoietin and 2-3 DPG levels as well as enhancing myoglobin production, mitochondrial density, and cardiac output. Allan is meticulous about this training and on establishing correct technique noting this would not be appropriate for those with advanced lung disease. I really enjoyed learning from him and have implemented these exercises into my daily routine. I hope this conversation will pique your interest as it did mine as we share the art of functional breathing. Please welcome Allan to the conversation. References: Allan Abbott at: healthinnovations.net.au (+61) 0419379371 Buteyko.com Acute Effects of Repeated Cycling Sprints in Hypoxia Induced by Voluntary Hypoventilation. Woorens/ European Journal of Applied Physiology. September 2017 Repeated Sprint Training in Hypoxia Rugby. Woorens . European Journal of Sport Science. 2018. Intermittent Hypoxia Training. Sohagatay et al. Journal of Human Kinetics Vol32/2012 197-210 Hypercapnic Hypoxic Training. Bakovic et al. Journal of Applied Physiology 2003, Vol 95 No 4 1460-1466 Breathing Pattern Disorders and Functional Movement. Bradley et Al. International Journal of Physiotherapy Feb 2014,9(1),28-39 James Nestor- Breath - The New Science of a Lost Art. Riverhead Books, 2020

In an earlier episode titled 'Breathing' we had the privilege to explore heathy breathing patterns and the Bohr effect which governs oxygen delivery to tissues with physiotherapist and breathing expert Allan Abbott, if you haven’t had an opportunity to listen to that podcast, I recommend it as an introduction to the subject we are covering today.  Allan has been exploring breathing techniques to enhance exercise performance and improved health for many years and has created a dynamic company called Health Innovations that can be found at healthinnovations.net.au in order to bring this important knowledge into public forum. Although most of us pay little attention to breathing technique in our busy world, many cultures and alternative health practises such as YOGA and Ayurveda have focused on this for centuries and the recent excellent book Breath by James Nestor explores the importance of breathing technique in detail including the influence on facial structure and disease brought about by mouth breathing and poor execution of this seemingly automatic task.  Allan takes us further in this podcast episode in which we explore functional breathing, breathing during exercise and how we can utilise breathing techniques to replicate high altitude training at sea level to improve performance and stamina in ways you may not have considered possible. Allan was generous enough to give up a good deal of his spare time taking me on a deep dive through these breath training techniques one on one. We focused first on nasal breathing light, slow and deep utilising the diaphragm rather than purely chest muscles and aiming for a 4 second nasal inhalation followed by a slow nasal exhalation over 6 seconds. This develops the habit of six breaths per minute.  We then worked on the breath oxygen level test - the so-called BOLT with the objective of building CO2 tolerance to reduce the ‘gassing out’ feeling that can occur when one trains at a moderate exercise intensity. Subsequently Allan took me to ‘altitude’ with some strong breath holds during exercise simulating the reduced partial pressure of oxygen experienced as we venture 2000 metres above sea level and more, slowly resetting central CO2 chemoreceptors, increasing our haematocrit, erythropoietin and 2-3 DPG levels as well as enhancing myoglobin production, mitochondrial density, and cardiac output.  Allan is meticulous about this training and on establishing correct technique noting this would not be appropriate for those with advanced lung disease. I really enjoyed learning from him and have implemented these exercises into my daily routine. I hope this conversation will pique your interest as it did mine as we share the art of functional breathing. Please welcome Allan to the conversation. References: Allan Abbott at: healthinnovations.net.au (+61) 0419379371 Buteyko.com Acute Effects of Repeated Cycling Sprints in Hypoxia Induced by Voluntary Hypoventilation. Woorens/ European Journal of Applied Physiology. September 2017 Repeated Sprint Training in Hypoxia Rugby. Woorens . European Journal of Sport Science. 2018. Intermittent Hypoxia Training. Sohagatay et al. Journal of Human Kinetics Vol32/2012 197-210 Hypercapnic Hypoxic Training. Bakovic et al. Journal of Applied Physiology 2003, Vol 95 No 4 1460-1466 Breathing Pattern Disorders and Functional Movement. Bradley et Al. International Journal of Physiotherapy Feb 2014,9(1),28-39 James Nestor- Breath - The New Science of a Lost Art. Riverhead Books, 2020

Amyloidosis is a group of diseases in which abnormal proteins known as amyloid fibrils build up in various tissues including the kidney, heart, liver, skin, and nervous system resulting in a variety of clinical sequelae including organ dysfunction and death. There are over 23 unrelated proteins known to form amyloid fibrils, many of which are aggregates of misfolded proteins that are neither biodegradable nor can be recycled by our bodies.  Abnormal Immunoglobulin light chains known as AL (amyloid light chain), transport protein transthyretin (ATTR) which normally transports retinol and thyroxine, and amyloid A (AA) are some of the better recognised examples of amyloid proteins.  It is important to note however that hereditary, dialysis associated, localised and ocular forms also exist, and Beta protein precursor is implicated in Alzheimer syndrome as are other amyloid fibrils in different dementia diagnoses. The quoted incidence of amyloid disease is 12 per million and it is estimated that over 20 000 cases of amyloid are undiagnosed and untreated in Australia alone. It is noteworthy that 13-17% of patients with heart failure and degenerative aortic stenosis have amyloidosis and that up to 50 % of patients with amyloid see five doctors before a diagnosis is made. Up until recently only a four-year life expectancy was anticipated, fortunately pharmacological breakthroughs are expanding this horizon.  Although the term amyloid was originally coined by German botanist Mathias Schleiden to describe the normal amylaceous of plants, it was Rudolf Virchow in 1854 who adopted the term to describe abnormal extracellular material seen in the liver during autopsy.  As we will explore in this podcast we now think of amyloid disease in terms of primary systemic amyloid (AL) where a clone of abnormal plasma cells secretes excess immunoglobulin light chains that misfold and aggregate as non-biodegradable non-recyclable amyloid fibrils. Such a clone is also observed in about 5 % of myeloma diagnoses and about 12% of MGUS (monoclonal gammopathy of uncertain significance).  Additionally, age associated amyloid transport transthyretin protein ATTR is an acute phase reactant produced predominantly in the liver in response to multiple cytokines which may become amyloid in form with senescence depositing in the heart and kidneys where diastolic dysfunction and renal impairment develop. In this podcast I was curious to explore how we can improve our surveillance for this condition and to raise our awareness. I was also keen to understand how to confirm the diagnosis and to explore treatment options. To explore this interesting area further please welcome to the podcast Dr Simon Gibbs from Precision Haematology who is a clinical haematologist and amyloidosis specialist, and a Senior adjunct lecturer at Monash University. After attaining his medical degrees from the University of Melbourne he moved to Cambridge in the United Kingdom to gain further experience in autologous and allogeneic bone marrow transplantation as treatment for myeloma and leukaemia and completed a four-year fellowship at the National Amyloidosis Centre at University College London, focusing on novel therapies for AL amyloidosis.  Upon returning to Australia, he was appointed the Myeloma Lead at Eastern Health and established the Victorian and Tasmanian Amyloidosis Service (VTAS).  He is the Chair of the Australian Amyloidosis Network (www.amyloidosis.net.au), and a member of the Haematology Society of Australian and New Zealand (HSANZ). He serves on both the Educational Subcommittee for the International Society of Amyloidosis, and the Medical and Scientific Advisory Committee (MSAG) for Myeloma Australia and is the author of over 40 publications in international medical literature.  References : Dr Simon Gibbs: https://precisionhaematology.com.au/doctor/dr-simon-gibbs/ Australian Amyloidosis Network: https://aan.org.au/

The use of faecal microbiota transplantation (FMT) to treat severe C. Difficile enterocolitis was visited in episode 14 of Everyday Medicine with Dr Darcy Holt as our guest. If you haven’t had an opportunity to listen to that conversation, please do and hopefully it will pique your interest. In this episode we invite a guest involved in active research at Melbourne’s St Vincent’s Hospital to discuss FMT in IBD broadly then more specifically as it applies to her current research project evaluating its efficacy in Crohn’s disease. FMT is defined as the infusion of faeces from healthy donors into the gastrointestinal tract of recipients to treat disease associated with gut dysbiosis. Noting that the precise aetiology of IBD is unknown, a multifactorial pathogenesis is proposed influenced by genetic susceptibility, host mucosal immune responses and the environment including diet, the gut microbiome and smoking history. Particularly with both ulcerative colitis and Crohn’s disease a deficiency in Faecal bacterium prausnitzii recognised for its potential anti- inflammatory properties has raised interest in the FMT space. To date FMT has been investigated in patients with inflammatory bowel disease (IBD) both in non- randomised and subsequently randomised controlled trials showing promising results although with significant differences in FMT protocols and procedures. The adoption of FMT for the treatment of IBD is compromised by recruitment of donors, preparation of faecal material, determination of the optimal route of administration and lack of established regulatory framework. Establishing an optimal framework is essential for the future management of IBD should the merits of this therapy stand up to scrutiny. The first international Rome consensus conference on gut microbiota and faecal microbiota transplantation in inflammatory bowel disease, published in Gut.bmj this year has attempted to set this framework and is a very helpful publication. In this episode we introduce Dr Sasha Fehily who is actively engaged in the MIRO study looking at FMT in Crohn’s IBD. The MIRO Study is a randomised, double-blind placebo-controlled trial where all recruited patients receive active standard IBD treatment and those on placebo who don't respond are administered active FMT therapy. This is an excellent study with greatly anticipated results, and I was curious to learn more about the research directly from Sasha. Please welcome her to the podcast. References : Dr Sasha Fehily - St Vincent’s Hospital Melbourne  miro.study@svha.org.au Guideline: The first international Rome consensus conference on gut microbiota and faecal microbiota transplantation in inflammatory bowel disease. Lopetuso et al. https://gut.bmj.com/content/72/9/1642

Primitive single-celled organisms had patches of photoreceptor proteins to detect light. The first eyes, developed over 550 million years ago, are now the second most complex organ after the brain, with over two million working parts and more than a million nerve fibres connecting each eye to the brain via the optic nerves. Unfortunately, many Australians suffer from chronic eye conditions, with over 13 million affected. Chronic eye disorders impact up to 93% of people aged 65 and over, with a higher prevalence in females. These conditions include refractory disorders like hyperopia, myopia, presbyopia, and astigmatism, as well as colour blindness (affecting about 550,000 Australians), cataracts, macular degeneration, diabetic retinopathy, strabismus, amblyopia, venous occlusions, and retinal detachment. Noteworthy conditions include: - Age-related macular degeneration (AMD): The most common cause of irreversible vision loss in Australia, affecting 1 in 7 people over 50. AMD impairs tasks requiring central vision like reading and driving. - Cataracts: Lens opacities impacting vision and the leading cause of visual impairment. Cataract surgery is the most common elective procedure in Australian public hospitals. - Glaucoma: The world's leading cause of blindness, affecting about 300,000 Australians. It is often asymptomatic early on and significantly increases in prevalence after 50. In this episode, Dr Rogan Fraser, completing his fellowship in ophthalmology, discusses common eye problems. Topics include managing red eye, ophthalmic complications from shingles, giant cell arteritis, and semaglutide (Ozempic), as well as glaucoma, retinal vein occlusion, and macular degeneration. Welcome Dr Rogan Fraser to the podcast for a focused tour of key ophthalmology topics. References: LinkedIn - https://www.linkedin.com/in/rogan-fraser-7a9855b8/ National Eye Institute https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases https://www.aao.org/eye-health/news/can-ozempic-affect-eye-health-here-s-what-ophthalm

An estimated 20% of Australians have an allergic disease, with Melbourne as a hotspot where one in three people experience hay fever and thunderstorm asthma. Allergies can affect the skin, sinuses, airways, gastrointestinal tract, or other organs. Allergies are immune reactions to foreign antigens, causing tissue inflammation and organ dysfunction. Symptoms depend on prior immune response, antigen exposure, and genetic factors. Atopic individuals have a genetic predisposition to conditions like allergic rhinitis, atopic dermatitis, allergic asthma, and IgE-mediated food allergies. Reactions can be immediate (within 60 minutes) or delayed (hours, days, or weeks). In 1963, Gell and Coombs classified hypersensitivity reactions into four types based on the immune response. Type 1: Immediate hypersensitivity: IgE antibodies on mast cells bind to antigens, causing cell degranulation. This leads to vasodilation, smooth muscle contraction, mucous secretion, and inflammation. Anaphylaxis is a severe form needing adrenaline intervention. Food allergies affect 4-7% of children, often involving milk, eggs, peanuts, tree nuts, shellfish, wheat, and soy. Type 2: Antibody-mediated hypersensitivity: IgG or IgM antibodies, with complement or phagocytic cells, cause reactions seen in blood transfusions, rheumatic fever, and autoimmune diseases. Type 3: Immune complex-mediated hypersensitivity: Antigen-antibody complexes cause inflammation, as seen in chronic glomerulonephritis, SLE, and rheumatoid arthritis. Type 4: Delayed hypersensitivity: T cells and persistent antigens trigger cytokine secretion and monocyte activation. This occurs in conditions like tuberculosis and leprosy, with reactions peaking 48-72 hours after exposure. In this podcast, we explore the prevalence of allergies, their signs and symptoms, and common diagnostic tests. We also discuss non-allergic sensitivities like reactions to nitrates, sulphites, and food additives. Dr Colin Little, a Melbourne-based immunologist and allergist with over 40 years of experience, provides insights on treating common and rare allergic conditions. References: Dr Colin Little: 1/324 Stephensons Rd Mt Waverley 3149 "Hypersensitivity - an overview," Science Direct "Immediate Hypersensitivity Reactions," AAJ Vaillant, 2022, www.ncbi.nlm.nih.gov "Hypersensitivity Reactions," April 2009, Rutgers New Jersey Medical School

Barrett’s oesophagus is a common condition, named after the Australian born thoracic surgeon Norman Barrett who practised in England and laid the foundation descriptions of this condition but incorrectly concluded the abnormal columnar tissue lining was embryonic in origin due to the presence of a congenitally shortened oesophagus leading to a tubular portion of stomach being trapped in the chest.  We now recognise that between 5-10 % of patients with chronic reflux disease develop columnar metaplasia as a response to repeated oesophageal acid exposure. Long segment disease extends for more than 3 cm, short segment less than 3 cm and metaplasia at the OG junction (less than 1 cm in length) is not considered to be pathological.  Its presence informs us that our patient has GORD and alerts to the possibility of dysplastic change and malignant transformation. Although the latter is relatively unlikely in any individual the risk is real. Estimates quote 0.33 to 0.5 % risk per year, that is 1: 200 per year which is 30-125 times the average population risk. Malignant risk increases with longer lengths of Barrett’s, Caucasian males and smokers but is probably not influenced by alcohol history. In the absence of invasive malignancy, nodular areas are removed by a mucosal stripping technique described as endoscopic mucosal resection (EMR) and remaining lengths of Barrett’s mucosa may be removed using radio frequency ablation (RFA). This ablative technique involves the use of radiofrequency energy delivered with balloon-based catheters that heats the oesophageal mucosa and destroys non dysplastic and dysplastic tissue. Randomised control trials have demonstrated superiority over sham ablation in limiting dysplasia and metaplasia at one year. The technique is associated with a lower stricture rate and decreased post procedure morbidity than other techniques sometimes utilised in this situation such as photodynamic therapy or cryotherapy. I was keen to have a conversation with Professor Finlay Macrae on this important subject exploring the topic of Barrett’s in more length as well as the techniques of EMR and RFA. Professor Macrae is a gastroenterology mentor, head of colorectal medicine and genetics at the Royal Melbourne Hospital and has public and private practices focusing on the management of Barrett’s oesophagus, inflammatory bowel disease and familial bowel cancer. He trained both in Melbourne and at St Marks Hospital in London. In 2016 he was awarded the Order of Australia for his work in genetics and genomics. Professor Macrae has been delivering advanced therapeutic solutions for patients with complex Barrett’s disease for over 30 years and was therefore, an obvious choice of expert guest to discuss this topic today, it was a great privilege to have this conversation with him. References: Professorfinlaymacrae.com Spechler S.et al. Barrett’s Esophagus. N ENG J Med 2014; 371:836-45 Whiteman et al. Journal of Gastroenterology and Hepatology 30 (2015) 804-820 Cancer Council Australia Barrett’s Oesophagus Guidelines Working Party. Clinical Practice Guidelines for the Diagnosis and Management of Barrett’s Oesophagus and Early Oesophageal Adenocarcinoma. Feb 12.2015

The advent of complex therapies including biologics and small molecules has provided a new paradigm for the treatment of many immune mediated inflammatory conditions notably in rheumatology, gastroenterology (Inflammatory Bowel Disease) and also in dermatology. New dimensions of treatment can now be applied from this amazing therapeutic armamentarium at our disposal. In this podcast we will turn our attention to how this relates to management strategies in dermatology. The term ‘biologic’ refers to agents synthesised from the products of living organisms and includes monoclonal antibodies raised against cytokines including Tumour Necrosis Factor (TNF) or some of the interleukins. Contrasting these small molecules are laboratory produced and directed to inhibit the so-called JAK- STAT messaging system which was discovered to link the external world of cells with the transcription of proteins from the genetic code held within DNA. These complex molecules as a group inhibit cytokines, and thus modulate immune mediated inflammation. As they are specific in terms of their immune system action their safety profile is generally considered to be more favourable than that of traditional systemic immuno-suppressive drugs. In this conversation we talk with Associate Professor Peter Foley to expand our understanding of the place of these complex molecules in dermatologic management. In particular we will focus on psoriasis which affects 2-4 % of the world’s population with a higher prevalence in northern countries. Plaque psoriasis is the most common type encountered with its prominent feature being sharply demarcated erythrosquamous plaques. Hyperproliferation and abnormal differentiation of keratinocytes is the hallmark of psoriasis which may also manifest with arthritis in up to 30% of patients and be preceded by nail changes characterised by small but definite pits in 50-80 % of cases. Associate Professor Peter Foley graduated from Monash University in 1987 after completing a BMedSc thesis which was the first National Skin Cancer Survey. He later obtained a fellowship in dermatology in 1997 and completed an MD exploring the effects of Vitamin D on the skin. He is actively involved in research and has been principal investigator for numerous clinical trials which include more than 70 on subjects such as psoriasis, eczema, seborrheic dermatitis, rosacea and many more. He has an appointment as an Associate professor in the Department of Medicine -Dermatology at The University of Medicine and is director of research and immediate Past-President of the Skin and Cancer Foundation. He is Australia’s only councillor on the International Psoriasis Council and sits on the Board of the Photomedicine Society. Clearly, he is well credentialed to discuss current approaches to using Biologics and Small molecules in dermatologic practice and we welcome him to the podcast. References: Assoc Professor peter Foley: Foley Dermatology and associates. www.foleydermatology.com.au Biologics in Dermatology: An Integrated Review, Seghal et al. ncbi.nlm. nih.gov The Australian College of Dermatologists, Biologic Treatments Used in Dermatology www.dermoll.edu.au

Neurosurgeon Rondhir Jithoo has led an extraordinary life, growing up in South Africa with a medical father and deeply thinking anthropologist mother. He obtained his medical degree from the Nelson Mandela School of Medicine at the University of Natal and trained in neurosurgery at South Africa’s Wentworth Hospital where he received the Registrars Prize from the South African Society of Neurosurgeons and obtained his neurosurgery fellowship in 2000.  After relocating to Australia, he was awarded the Australasian Fellowship in Neurosurgery in 2004 and worked at Royal Melbourne Hospital where he developed an interest in spinal trauma, anterior spinal surgery and cranial surgery. This interest in cranial surgery took him to Frances’ famous neurosurgical epicentre in Montpellier to further his study and skills in the art of awake craniotomy.  At Montpellier Rondhir was able to develop skills reflecting the modern connectionist approach to neurosurgery which has revolutionised treatment of brain tumours. The traditional concept proposed by Paul Broca, and still taught, is that the brain is organised into different areas controlling specific functions. This localisation theory has now been disproven, and work with contributions from Montpellier has shown that the brain is organised in dynamic interactive networks capable of constantly readapting. This connectionist approach explains why some patients can lead a perfectly normal life despite having a large tumour affecting an area of the brain previously considered crucial for brain function. The brain is able to compensate for lesions and its incredible plasticity allows it to reorganise itself to continue functioning normally. In awake craniotomy, providing lesions have not caused disability, tumours may be safely removed in real time using cortical mapping. By keeping the patient awake to verbal commands the impact of surgical resection can be carefully assessed and damage minimised. After returning to Australia with this skill Rondhir served with the Australian armed forces in Iraq, assessing and providing acute neurosurgical assistance for battlefield traumas and is now intrinsically involved in contributing his skill and expertise to establishing and independent neurosurgical service in Darwin where he travels at repeat intervals throughout the year. He is a head and clinic consultant of Neurosurgery at Alfred Health in Melbourne and is a member of the Victorian Audit of Surgical Mortality Committee as well as a postgraduate examiner for the Royal Australasian College of Surgeons. I found Ron to be deeply philosophical and spiritual in his approach to the art of medicine and I’m sure you will enjoy this conversation with him. References : Mr Rondhir Jithoo: www.healthshare.com.au  www.alfredhealth.org.au

The health and welfare workforces deliver diverse services through many private and public organisations. Combined these services employ more than 1 million people of which there were more than 642 000 health practitioners working in their registered professions in Australia in 2020. This included 105 300 medical practitioners, 350,000 nurses and midwives, 21,500 dental practitioners and 166,000 allied health professionals. In this podcast we will consider more generally the positions of nursing and medical practitioners and a possible future landscape.  In the five years to 2021 only the equivalent of 4200 full-time General Practitioners were added to the workforce and on average both male and female GP’s have been trending towards fewer hours per worker. The AMA’s Plan to Modernize Medicare campaign reported: 1. Australia faces a shortage of more than 10,600 GP’s by 2031-32 and the supply of GP’s falling behind growing community demand.    2. The demand for doctors’ services increased by 58% in the decade to 2019. 3. That the most cost-effective method with the best outcomes for patients is GP led primary care. GP’s provide twice the number of episodes of care as hospitals per year for one sixth the expense. Away from doctors the nursing and midwifery sector represent the largest workforce in the healthcare system accounting for 55% of total workforce however in a recent McKinsey survey one fifth of Australia’s registered nurses said they intended to leave the current role in the next year. Even before the pandemic a shrinking supply of nursing-school graduates and a decline in nurses migrating from other countries to Australia brought about nursing shortages. These short-term demands are superimposed on longer-term demands caused by Australia’s population growth and aging demographic. The McKinsey 2021 Future of Work in Nursing Survey found that in addition to the figure above 41% of nurses surveyed said they were planning to move countries or leave direct-care roles entirely, leading to a calculated deficit of between 20,000 and 40,000 unfilled nursing positions. Similar results have been documented in the United Kingdom, France, Japan, USA, Singapore and Brazil.  In this podcast I was keen to pursue the workforce conditions and future strategies to manage them with Mr Murray Bruce, a young and energetic Lawyer with a welcomingly fresh set of ideas who is Director of Latrobe Community Health Service. Murray has extensive board and governance experience with expertise in strategic planning, risk management, commissioning, change management and policy development. Please welcome Murray to the Podcast. REFERENCES:  Mr Murray Bruce.Board Directors -Gippsland Primary Health Network.gphn.org.au  McKinsey and Company, Should I stay or should I go? Australia’s nurse retention dilemma, Sep 23rd, 2022 AMA report projects “staggering” GP shortage, Nov 25,2022 Health Workforce, Updated July 7, 2022 aihw.gov.au RACGP-Health of the Nation, 2022 racgp.org.au

Clinical problems related to the integument are very common and contribute up to 15% of all general practitioner presentations. Humans are predisposed to a multitude of skin diseases ranging from acne and atopic dermatitis to psoriasis, autoimmune diseases such as SLE, vasculitis, skin cancers, viral exanthems, drug eruptions and external manifestations of internal disease - which in the gastroenterology world have erythema nodosum and pyoderma gangrenosum as interesting examples of these. Given our love affair with the sun it’s not surprising to learn that skin cancer will affect 2 in 3 Australians in their lifetime. About 2000 Australians die each year from melanoma and non-melanoma skin cancer - 800 more than the number of people dying from car accidents annually in Australia bringing into perspective the impact of this disease alone. Inflammatory skin diseases such as acne and eczema are also very common. They are a cause of serious morbidity, both physical as well as psychological – a child with severe eczema has a burden of disease that is worse than a child with diabetes. Have you ever had itchy skin? This is one of the most distressing symptoms one may experience.The mental health issues of patients with skin disease can be severe. A recent meta-analysis of patients with alopecia areata for example found that up to 17% of those patients required professional help for symptoms of anxiety and depression. A skin problem is very visible and yet, in the hierarchy of “medical student teaching” – dermatology is treated almost as an optional extra. In recent years advances in skin management have been significant especially following the discovery of TNF inhibitors such as Adalimumab used in dermatology for moderate to severe psoriasis as well as in both rheumatology and gastroenterology. In this podcast I was curious to learn more about dermatological management, the new horizons of treatment, possible role for AI in assisting diagnosis as well as to be reminded of key tips that would be useful in primary care. It was a real honour to discover Melbourne dermatologist Dr Alvin Chong, founder of an internationally acclaimed podcast called Spot Diagnosis that has been ground-breaking in bringing the specialty of dermatology to general practice and medical students. Alvin has established himself as a key educator in this field and has received accolades from the RACGP recognising his achievements and contribution to education. Alvin has public appointments as Visiting Dermatologist and Director of Dermatological Education at St Vincent’s Hospital Melbourne and Head of Transplant Dermatology Clinic at Skin Health Institute. He is Adjunct Associate Professor at the University of Melbourne. Please welcome Alvin to the Podcast. References: Dr Alvin Chong ⁠http://spotdiagnosis.org.au/⁠ ⁠https://www.skinhealthinstitute.org.au/page/370/spotdiagnosis⁠

Clinical problems related to the integument are very common and contribute up to 15% of all general practitioner presentations. Humans are predisposed to a multitude of skin diseases ranging from acne and atopic dermatitis to psoriasis, autoimmune diseases such as SLE, vasculitis, skin cancers, viral exanthems, drug eruptions and external manifestations of internal disease - which in the gastroenterology world have erythema nodosum and pyoderma gangrenosum as interesting examples of these.  Given our love affair with the sun it’s not surprising to learn that skin cancer will affect 2 in 3 Australians in their lifetime. About 2000 Australians die each year from melanoma and non-melanoma skin cancer - 800 more than the number of people dying from car accidents annually in Australia bringing into perspective the impact of this disease alone. Inflammatory skin diseases such as acne and eczema are also very common. They are a cause of serious morbidity, both physical as well as psychological – a child with severe eczema has a burden of disease that is worse than a child with diabetes. Have you ever had itchy skin? This is one of the most distressing symptoms one may experience.The mental health issues of patients with skin disease can be severe. A recent meta-analysis of patients with alopecia areata for example found that up to 17% of those patients required professional help for symptoms of anxiety and depression. A skin problem is very visible and yet, in the hierarchy of “medical student teaching” – dermatology is treated almost as an optional extra.  In recent years advances in skin management have been significant especially following the discovery of TNF inhibitors such as Adalimumab used in dermatology for moderate to severe psoriasis as well as in both rheumatology and gastroenterology.  In this podcast I was curious to learn more about dermatological management, the new horizons of treatment, possible role for AI in assisting diagnosis as well as to be reminded of key tips that would be useful in primary care. It was a real honour to discover Melbourne dermatologist Dr Alvin Chong, founder of an internationally acclaimed podcast called Spot Diagnosis that has been ground-breaking in bringing the specialty of dermatology to general practice and medical students. Alvin has established himself as a key educator in this field and has received accolades from the RACGP recognising his achievements and contribution to education. Alvin has public appointments as Visiting Dermatologist and Director of Dermatological Education at St Vincent’s Hospital Melbourne and Head of Transplant Dermatology Clinic at Skin Health Institute. He is Adjunct Associate Professor at the University of Melbourne.  Please welcome Alvin to the Podcast.   References: Dr Alvin Chong http://spotdiagnosis.org.au/ https://www.skinhealthinstitute.org.au/page/370/spotdiagnosis