ACR2019 Panels Group B Save
ACR2019 Panels Group B by Dr. Cush
Transcription
Hi. I'm doctor Jack Cush, and this is the ACR two thousand nineteen podcast. We're coming to you from the annual meeting in Atlanta, Georgia. This episode is a collection of our faculty reports, interviews, and panel discussions recorded live from the RheumNow booth. I hope you enjoy and learn.
Hi. I'm doctor Rachael Tate coming to you from Atlanta for ACR twenty nineteen and I am presenting the first ever X Factor with some of my closest friends. So our hashtag for this is going to be ACR unfiltered because this is a really great group of women who have some really interesting perspectives on some fun and very important topics. So I'm gonna let you guys introduce yourselves and tell us something fun.
So my name is Kanika Manga and I am actually a second year fellow at UT Houston. Something fun about me is I like to dance, specifically Bollywood music Awesome. In my free time.
I'm Courtney Crane. I'm a pediatric rheumatologist from Alabama, and I am the proud mama to two baby boys ages five and two My
name is a bruni jayatilica. I am a rheumatologist at temple in Philadelphia, and I actually participated in a drumline that opened a conference in Philadelphia. It was on a much smaller scale Awesome.
Katherine Dow. I'm from Dallas at UT Southwestern and many of you know me as Jack Cush's partner, the nicer one. Anyways, things that you may not know about me is that when Jack first started RheumNow, I mean like all great things, it started on a paper napkin. And we have one more guest, Rachel. I want to bring into this women in rheumatology panel.
Come on in. This is our best female advocate, Doctor. Ruterman. Yep. Doctor.
Eric Rueberman. Who needs no introduction?
Eric Rueberman from Chicago. Tell Tell somebody fun. I I I have a menagerie at home. My my youngest daughter is an animal lover, so we have cats, chickens, rabbits, dogs, you name it. And I'm in charge of all animal cleanup at the house.
Oh, wow. That's a big job. Well, we're a little bit of a menagerie, I think, ourselves. So you guys, I just want your perspective on what have been your experiences for being a female rheumatologist or mentoring female rheumatologists.
So for me, just to give you a little bit of my background. So I graduated medical school twenty years ago and I, you know, I've been so lucky to have such good mentors in my life. Mean, and a lot of the mentors, I mean, they didn't even realize they were my mentors. It's people in medicine as well as people outside of medicine. And I would say Jack Cush is probably one of my biggest mentors.
And when people ask me why did I choose rheumatology, I actually say it's not me choosing rheumatology, it's rheumatology who chose me. And it was actually Doctor. Wayne Yokoyama who actually had the idea that I should be a rheumatologist. And at that point I was thinking about being a GI doctor. So I just wanted to give you a little perspective there.
So there's a lot of different things that being a woman, that you encounter, some of that is what many of us have actually experienced, is the imposter syndrome. And you can talk a little bit more about that. She presented this beautiful research study with regards to women in rheumatology.
You Thank so much for
you. Yes. I'm honored and so excited to be able to talk about our research nationally at conferences after a really huge study. They actually showed the overall proportion of women to male speakers was actually only thirty four percent women. And so Doctor.
Liu and I decided to look at what that percentage was at our ACR annual meeting. So what we actually found is overall, we're doing significantly better, especially than surgical and even other medical specialties, which is great. So our average was about 45% of the overall proportion were women. So that's amazing. And actually from 2017 to 2018, we've actually increased by 4%.
And I'm proud to say that in 2019, we're now at forty nine point one So it would be really naive of me not to mention that I know for this to happen it took the effort of amazing men and women and the American College of Rheumatology making it an active and conscious part of our mission to promote equal representation. So I'm so fortunate to be in our field and to be surrounded by all of
you guys. So thank you. Well speaking about kind of the transition with everything, Doctor. Crane was talking to us about her experiences with balancing work and life. And I think you have a really great perspective.
Would you mind sharing that with us?
Yes. So I had both of my my sons during medical training. So the first one during my intern year of residency, where my husband and I were separated geographically, so I was raising a son mostly as a single mom. And then I had my second son during and I had a very different experience so fellowship allowed me the opportunity to have more flexibility because of the research schedule and the less clinic time and then the no inpatient call and so I think Rheumatology has a great potential for work life balance if you have supportive mentors and supportive division who understands that you don't always have to be at the office because the schools are closed, know kids get sick, they can't go back to school for two days. And so if you have the opportunity to kinda cater your schedule with the advent of the medical record, the electronic medical record is a mom's best friend.
Yeah. Like and same with, like, the online journals. Like, you can do a lot of your stuff after the kids get tucked away to bed, and so you don't necessarily have to physically be at the hospital all the time like you did during residency. So Well,
I think that's a unique perspective. The electronical medical record actually being a tool that we can use for our day to day life to survive. What are your thoughts
on that? On the electronic medical record, I think.
Or in life balance. That
is an excellent question. So I also have two children and my first child was born at the end of my fellowship. And it was not something that I really understood how it would impact my professional life. And I had maybe six weeks at the end of the fellowship, and I had to start my job as an attending two weeks later. And so I had total of eight weeks off, which didn't seem like a big deal to me before I had a child.
And then it ended up that, you know, it was quite a big deal. And thankfully, with some better maternity leave policies at my institution, my second child was a bit easier than I had during my career.
Well, of the things that I think is so important as a mom is that you didn't introduce the factor of breastfeeding. My god. I used that word. Yes. And lactation.
What? Yes.
There's How did you handle this? No.
But it but it it is I mean, we've we've struggled. It's a big issue in clinic. Right? It's like if you're having a clinic and okay. You're gonna carve out some time.
Even if baby's not there, you're pumping. Right? And what do you do? And you carve out the time, but then where do you go? A lot of hospitals don't have places to go, and they're like, well, use the bathroom.
Bathroom. You know? So so we we would actually close some of the clinic exam rooms for for some of our doctors as they've come through because you gotta do what you gotta do.
Yeah. So I'm actually in a pediatric hospital that's very breast friend breastfeeding friendly, and there's still no good place to go to go home. But that that's the you kinda hit the the nail on the head. I think to be successful as a parent, whether you're female or male Yeah. You have to have a schedule.
There has to be structure, and so, like, you have to preplan, and I think that's the, the that like, that's the way to be successful as a parent and be a physician. So
Yeah. I it so isolating breastfeeding and pumping, you know, that first year. And instead of being able to interact with my colleagues during lunchtime, had to go back to my office, which was in a different location and pump. And it was difficult. I think I think that gave me a news perspective for my fellows when they came through training and had children, and I understood their needs and encouraged them to do the same thing.
Well, and give us a little bit more about the male perspective. I know that you said Doctor. Ruderman, it's a little bit of a challenge to create an environment that supports everybody. What have you guys done at Northwestern, or what have you seen?
You know, the the first part is recognition and recognizing that it's not like, well, we don't treat you any differently, but sometimes we kind of do because outside of work, it's different. And the the mom thing is it's changing, but it's always like if something if there's a problem, the kids home from school from from school sick, it's mom's job. Right? Mhmm. Way better than it used to be because at least, hopefully, most of the dads now are better partners, but society still expects that.
And then I think it's hard. So we have to we work around that, and we try to make sure that, listen, if you got a childcare problem or whatever, I mean, you're gone. I I I remember and, you know, and and the key for that is not even at work. It's to is to have a partner you can work with on that and make sure that they're all in. But I still remember when I started twenty five years ago, my practice my my nanny left, and our daughter was home from school sick, and I had to cancel my patients for a whole day.
And my senior partner guy looked at me, and he said, well, I don't understand why that's your problem. And that's changing, but it's still a challenge.
It's a problem.
We feel guilty.
You know? We do.
And we do.
I'm guilt factor because we're supposed to be there.
Right? You shouldn't be forced to do that.
But also sorry. But also, it's so whenever you're asked to do something, for example, I was asked as a third year fellow, like, in the second half of my third year fellowship to write a case report, and I politely declined it seven times because it's not career enhancing at that point, and I offered it to a medical student. It was perceived as I can't write the case report because of my kids. And so you get this negative perception, so you're not allowed it's almost like you're not allowed to say no. You're not allowed to miss a day because it's always because of the kids, and that's not necessarily what what the message is.
So we have to be the ones to shift the paradigm and to support each other and I mean I have amazing mentors like this is one of them. Doctor Catherine Dow. Doctor Ruderman is actually another one of them as well and I been really fortunate but I like most women also put my fertility in a little bit of a bind based on wanting to have a family later in life and I think it just goes to show that we have struggles that we aren't expecting. And I think my personal goal is to advocate for each of us. I mean, regardless of if you're male or female, we need to support each other.
There we have a loss of how many people we have in the workforce. And however you make your work schedule work, you're more productive if you have that scheduling ability. So any final thoughts you guys? We could talk about this forever. I mean, literally we we've been off camera for a while.
We've been waiting on some other groups to be done, and I think you guys have a wonderful perspective and sharing it's important.
Can I make a comment on your paper? Because it it was fascinating, and I think that's that it's great news, but it's not enough. Right? So even at 49%, you know, there we have way more women fellows now than men. So that's not even the percentage of rheumatologists.
And then you dig deeper and you will how many of those were moderators? How many of those gave important invited lectures? That's the next step. It's not just showing up. It's we need to make sure that women get to the top of what we're doing.
How do do that? Thank actually, thank you for bringing that up. One of the big things we looked at was clinical versus basic sciences. Even though
the
overall proportion was now forty nine point one percent, as of 2017 and 2018, we do have a discrepancy of about 5% even between clinical versus basic sciences. Wow. So that is something we do need to work on. The ACR's work task force actually had predicted by 2020, there would be our field in adult rheumatology would consist of 57% women versus men. So our goal should not be 50%.
It should be more reflective of the active workforce, which is what you were getting at.
How about we go around the table, Rachel, and then every one of us gives a little bit of advice to especially the female trainees.
To me?
Yeah, we love you.
And you know, you you also need us to give us the medical students advice and people, you know, who are younger than us and who may not have as good of an experience. What what exactly would you what one piece of information would you distill to help others?
I would say the most important thing that my mentors and sponsors have taught me is if you wanna do something and you believe in it, don't let impostor syndrome take over. Be your own advocate, you know. Be proud of what you wanna achieve, what you wanna accomplish, and don't be afraid to reach out to people. In fact, I've realized even at meetings like ACR, I've reached out to people that I've I hadn't really met in real life yet. I'd, you know, been inspired by on Twitter or social media, and I've reached out to them and say, hey, can we meet?
And they've been more than excited to meet and give me advice. And I think that's actually really helped me in developing my skills.
And I'll I'll kinda piggyback on that. I think I think you have a lot of choices about life, whether what career path you choose, whether it's research or clinical, private practice, academics, planning a family, getting married, or traveling. And I think whatever path you choose, just make sure you're confident that that's what you want, that's your passion, that's your desire, that is your choice, and to own it, to own your character, own your your choices.
Yeah. I mean, couldn't have said that better myself. I would say my one pearl for everyone is to find mentors who are supportive and who encourage you and challenge you to be better and you're never gonna fall flat on your face. You have a support team. That's what I believe rheumatology is.
Agreed. And as somebody who tries to be a mentor and a program director, I try to not assume that I know what my female or male fellows want, or when they plan to have families or if they plan to have families during their training, and instead to ask them what their goals are and not assume that their family life goals are necessarily in conflict Yeah. With their professional goals and it's so I try to support them that way. So
for me is the only person you have to impress and you have to think about this is actually your kids because more is caught than taught. So if you're gonna be pushing them aside, they're not gonna treat other people that well. And if you don't put family as a priority, they're not going to put family as a priority. They'll be like, bye, mom. You know?
So to me, I think that when I have my family as as the center of my life here, and everybody else kind of falls into place, it works out. Yeah. It's great.
It's always tough to be the end of the line when you have
to find a
guy and tell me no. It's something new. But but I actually I wanna follow the mentor story because find mentors who advocate for you. That's really critical. So not just it will support you and help you, and you need to advocate yourself.
But when a position opens up or an opportunity opens up, you need somebody who's gonna go in there and and and push for you. And it's it's unfortunate because sometimes it it is it women, they people don't think about, you know, as this is the spot for you. You need somebody who's gonna help you so then you can show what you can do when you're there. But if you can't even get in the role, if you can't even get that opportunity, you can't. You can't show what you can do.
You
guys, you are so sage. This is probably my favorite panel. I've had a really long time. I I really thank you so much for all of your perspectives. You are wonderful.
Keep fighting the good fight, and find someone to mentor on that on that final note. So check us out at roomnow.com, and our Twitter handle is at room now, and stay tuned for more from Atlanta. Hi.
My name is Eric. Ruterman. We're here with RheumNow at the ACR meeting in Atlanta. We have a group of us here together to talk about psoriatic arthritis. Before we begin, let's give you a little more background.
As I said, I'm Eric Ruterman. I'm from North University in Chicago.
Alexis Agde, Rheumatologist, University of Pennsylvania in Philadelphia.
Jesse Walsh, Salt Lake City.
Jose Chair, NYU Langone Health, New York City, New
York. Okay. So, the big news in psoriatic arthritis at this meeting has got to be the two phase three trials with guselkumab. I want to talk about this a little bit but I think it's really going to be helpful to talk what's that going to say about that pathway for psoriatic disease. Alexis, start us off by what did these trials show?
Well, they're the first two phase three studies in the P19 inhibitors, so that's really exciting. There was one trial that was completely treatment naive. The other trial had some TNF non responders or biologic non responders in that trial. So in the trial that was combined, biologic responders and treatment naive, a lot of them There was two doses tested, a Q4 week and a Q8 week compared to placebo. And in that trial, the Q4 week looked numerically a little bit better than the Q8 week, but it wasn't that much different overall.
When they split it out by TNF, versus not TNF experience, they saw actually that the TNF experience people did equally well between either dose, which was a little interesting. And then in the other trial, among all treatment patients, the two doses looked identical. But the one caveat there was that the radiographic progression was statistically significant at the q four week dose, but not at the q eight week dose. So some interesting things to kind of grapple with in terms of dosing and how we'll use that or what what the FDA will think when that's submitted.
And and both both show the drug work.
Yes. Very
effective. And and I wanna get into where that is gonna fit for us. But before we go there, Jesse, the dermatologists are all in on IL-twenty three inhibitors. What's that about?
Well, makes sense. Their outcomes look great. They're achieving good skin clearance with IL-twenty three inhibitors. Dosing wise, they're somewhat easier to give. Patients like the less frequent dosing than with some of the TNF inhibitor alternatives.
I think there are some hints that there may
be
some safety advantages, particularly compared to the IL-seventeen inhibitors, where we don't have to think so much about Candida or inflammatory bowel disease. I think the jury's out serious infection rates, but it may be a little bit more favorable with IL-twenty three inhibitors compared to IL-17s and TNFs.
And before we talk about where these drugs are going to fit, the last thing I want to touch on, and Jose, tell me, so the dermatologists have successfully sort of upped the ante with each round of treatments from TNF to IL-seventeen, IL-twenty three and it doesn't look like that we've achieved the same thing for the arthritis. What's that about?
Biology. It's all about pathophysiology. We have nailed down the pathways for psoriasis. As you go upstream on the molecular pathway, you achieve better and better outcomes. We're jealous.
They get passy one hundreds. Since the year 2004, our metrics have not changed. It's ACR20. Not only they haven't changed, the efficacy of these drugs are about the same. You get a 50 five-sixty percent ACR20 on the drug versus placebo.
What do we do with that information? I think one of the progressive thought approaches or thought processes is that we may be late when we treat psoriatic arthritis patients. Perhaps later in disease process, not in the patient, in the disease process. Is there room to perhaps conceive preventive trials or very, very early psoriatic disease clinical trials.
All right, so now we've got the data, we know what the skin is. I want to open this up. So this is the first. Two phase three trials that are going to get this drug approved for psoriatic arthritis and we have two more drugs waiting in the wings that are likely to follow. We have TNF inhibitors, we have IL-seventeen inhibitors, we have one and eventually more JAK inhibitors, We have a premilast.
Where are these IL-twenty three inhibitors going to fit in our patients?
It's a great question. I think some of the easy things are that in practice, we're still gonna use the drugs that we have first most likely, and then this will be the next drug. So most of our patients that we're gonna prescribe gusakimab for probably are gonna be TNF experienced already because that's where it's gonna come into the line. I would probably use it in a patient with more severe skin disease.
Probably avoid it in anybody who were concerned about axial disease.
What's that about?
It didn't work. The IL-twenty three data are not showing efficacy with axial disease. We haven't really specifically been studied in axial psoriatic disease, but in AS populations it's just not working. That probably again comes back to the biology. Maybe there's something different about Yeah.
These A little bit more synovial involvement
in Look, the these are good drugs. The p nineteens, we're not talking about a lower effect class in terms of efficacy. We've got to be careful now. Now it's about the side effect profile. Now it's about dosing.
Now it's about having a conversation with our patients, which we used to do. We had methotrexate and nothing else, and then we had methotrexate plus minus a DNF, which was an easy conversation. Right now, we open it up and we include the patients in the decision making.
I think we also need more studies that are going to help us differentiate this because right now we just have a bunch of trials in polyarticular patients. We don't actually know anything about how to target therapies. So there's a huge opportunity for this now moving I
think you're specifically referring to patients who may have lower peripheral joint burdens and more diverse phenotypes, is that right?
Yeah, exactly.
Jess, you made an interesting comment, you were like, well we use the drugs we're sort of used to using, and I think that's important. We're creatures of habit. We get used to doing certain things, and the dermatologists have a compelling reason to use the IL-twenty three inhibitors because they're so much better for skin disease. I don't think we have that compelling reason, at least yet, in joint disease. Is that right?
Right. I mean, there's nothing really in terms of joint outcomes that differentiates them well.
All right. Let me shift gears a minute and let's talk about another trial that was presented here at the ACR meeting which I thought was really interesting. It's a question that's come up in rheumatoid arthritis before. We haven't looked at psoriatic arthritis and that is if you have a patient who's doing really, really well, can you back off their medication? So the ixekizumab study which took all these patients, put them on ixekizumab, if they got into minimal disease activity they were randomized to withdraw the ixekizumab and just stay on placebo or stay on the execizumab in a blinded fashion.
What happened?
So I don't know. Yeah. Most almost all of them went back up onto therapy again. So once they withdrew, they, they flared. A median, I think it was about six months or something like that.
They looked at over forty weeks. There were significantly more flares than people who were pulled off the drug from compared to people that were stayed on the drug. But the interesting thing is that once they restarted them on drug, you could recapture most of them, which was also interesting.
I mean, the survival curves were fascinating. Basically, you said if you went on placebo and you waited long enough
You were gonna flare.
Your disease was gonna come back.
Yeah.
Okay. Should we should we not have expected that?
I expected that. We expected
that based on rheumatoid experience with DNF blockers. Right? We've we've seen this before, this behavior. What we haven't seen and it's new is this easy recapture, which may have to do with immunogenicity, where TNFs do create immunogenic responses. And the 17A class is not for that.
So that may be an advantage.
Although seventy percent of them were on methotrexate in the study which is So really interesting to maybe that led to some baseline treatment that you could then make it easier to recapture some of them. I don't know. Interesting.
So one last question. And I look at that study. Wish they had had an arm where they gave placebo every other dose because in RA at least, we've seen you can decrease the biologic, just you're sort of nodding your head. Mean, that's the question. Know, stopping the drug doesn't make any sense.
Wouldn't it be nice if we were able to look at how I think
they just want to do
it that way. They say, I decrease my dose rather than come up at all at once? So I think it's logical and preferred by
To close the circle on that one, going back to P19s, this is a drug that's every two months. But if you leave people off of drug for six months, fifty percent of them will remain with good skin outcome. So you could argue that frequency is one thing we should look at in other targets.
So the message is anybody out there who is involved in trial design, we'd like to see not necessarily withdrawal trials, but maybe spacing trials to give you some of those answers. Alright, think we'll wrap there. Thank you everybody for doing this. Again, for RheumNow coming from ACR in Atlanta in 2019. Thanks for watching.
Hi, I'm Len Calabrese from the Cleveland Clinic, and I'm here on RheumNow with two experts in immune related adverse events from cancer immunotherapy, Laura Capelli from Johns Hopkins, Cassie Calabrese, who I actually know, from Cleveland Clinic. And, you know, four or five years ago, you you had to look for define one or two presentations on this. And by one calculation, there are over 60, abstracts that involve cancer and rheumatic disease at this meeting. So highlights. Laura, give me a couple.
So I think we had a really great oral abstract session yesterday, and there was some very interesting pharmacovigilance data that was presented from the group from the SOAR Bone. So they looked at the World Health Organization database for IRAE, so immune related adverse events secondary to immune checkpoint inhibitors. And they found about six hundred reported cases of arthritis and about four hundred of myositis. But I think the real take home message from that abstract was that in the patients with myositis, those who would have fatal cases typically developed the first symptoms about two weeks before those who would have not fatal cases, which I think is really thought provoking about the pathogenesis that's going on there. Do these people have already
Oh, pre absolutely. Yeah. Great, great, presentation, and, my side is very serious and gotta be picked up early. Cassie, give me one.
Yeah. So many great abstracts. I think I've been told there's 60 some. I'm not sure if that's accurate. But also, yesterday at the oral session, something kind of new and different, from Marie Costine, in Bordeaux looked at the effect of microbiome altering medications, on IRAEs.
And what they did was a retrospective study, I think 600 some patients, looking at administration either within the month before or month after of a handful of different types of drugs, including antibiotics, steroids, some psychotropic medications like statins, ACE inhibitors, and looked at the effect on overall survival and tumor response. Interestingly, something we've kind of suspected is that prednisone equivalent dose of ten milligrams or more daily at baseline had negative effects on overall survival and and tumor response. Also, interestingly, similar negative associations with antibiotics and proton pump inhibitors. That was another one. So I take home point, if we can avoid baseline steroids at a dose of ten milligrams or more daily, that's probably something we should be doing prior to starting immunotherapy.
That's a very provocative study. These immune diseases, as Laura mentioned, some may be pre existing autoimmunity, some may be operating through novel mechanisms of breaches of tolerance, and we have an incomplete understanding of both the genetics, which may be our partial contributor, and environmental factors. And you know the antibiotic story has been out for a long time but geez PPIs and these other drugs and are they operating?
Not so commonly administered people.
So, you know, my actual personal discussion with patients and friends who have undergone this is to try to live as naturally as you can. You know, a healthy diet and do all the type of wellness behaviors you can before doing this and try to clean your system out. We are at the beginning of the beginning of this. I think that one more abstract from Laura and we'll wrap this up.
So I think we're gonna go from big, you know, database studies to small. And so the Mayo group presented also at the oral abstract session some flow cytometry data looking at peripheral T cells in patients who develop new inflammatory arthritis from checkpoint inhibitors as compared to healthy controls, RA controls, and checkpoint inhibitor controls who didn't get arthritis. Bottom line is small number of patients needs more validation, but intriguing that the immunosenescent phenotype seemed to be up and the exhausted T cells seemed to be down in the checkpoint inhibitor patients in a similar way actually to the traditional rheumatoid arthritis patient. So I think that it was provocative, small number of patients, good pilot data for more study.
I agree 100%. There was just a recent roundtable discussion, I think in Nature Immunology, taking the world leading experts on, exhausted T cells, and there's really a lack of uniform definition of how to define these by advanced flow and metabolomics and transgenomics. So again, I think it's a great start. It's telling us something and hopefully we can build upon it with larger studies. I want to thank everybody for coming into the room now.
IRAEs are here to stay. They're only going to get bigger. And next year, we're shooting to maybe have our own abstract category.
Fingers crossed. Yeah.
Thanks.
Hi. I'm doctor Rachael Tate coming to you from Atlanta for ACR twenty nineteen and I am presenting the first ever X Factor with some of my closest friends. So our hashtag for this is going to be ACR unfiltered because this is a really great group of women who have some really interesting perspectives on some fun and very important topics. So I'm gonna let you guys introduce yourselves and tell us something fun.
So my name is Kanika Manga and I am actually a second year fellow at UT Houston. Something fun about me is I like to dance, specifically Bollywood music Awesome. In my free time.
I'm Courtney Crane. I'm a pediatric rheumatologist from Alabama, and I am the proud mama to two baby boys ages five and two My
name is a bruni jayatilica. I am a rheumatologist at temple in Philadelphia, and I actually participated in a drumline that opened a conference in Philadelphia. It was on a much smaller scale Awesome.
Katherine Dow. I'm from Dallas at UT Southwestern and many of you know me as Jack Cush's partner, the nicer one. Anyways, things that you may not know about me is that when Jack first started RheumNow, I mean like all great things, it started on a paper napkin. And we have one more guest, Rachel. I want to bring into this women in rheumatology panel.
Come on in. This is our best female advocate, Doctor. Ruterman. Yep. Doctor.
Eric Rueberman. Who needs no introduction?
Eric Rueberman from Chicago. Tell Tell somebody fun. I I I have a menagerie at home. My my youngest daughter is an animal lover, so we have cats, chickens, rabbits, dogs, you name it. And I'm in charge of all animal cleanup at the house.
Oh, wow. That's a big job. Well, we're a little bit of a menagerie, I think, ourselves. So you guys, I just want your perspective on what have been your experiences for being a female rheumatologist or mentoring female rheumatologists.
So for me, just to give you a little bit of my background. So I graduated medical school twenty years ago and I, you know, I've been so lucky to have such good mentors in my life. Mean, and a lot of the mentors, I mean, they didn't even realize they were my mentors. It's people in medicine as well as people outside of medicine. And I would say Jack Cush is probably one of my biggest mentors.
And when people ask me why did I choose rheumatology, I actually say it's not me choosing rheumatology, it's rheumatology who chose me. And it was actually Doctor. Wayne Yokoyama who actually had the idea that I should be a rheumatologist. And at that point I was thinking about being a GI doctor. So I just wanted to give you a little perspective there.
So there's a lot of different things that being a woman, that you encounter, some of that is what many of us have actually experienced, is the imposter syndrome. And you can talk a little bit more about that. She presented this beautiful research study with regards to women in rheumatology.
You Thank so much for
you. Yes. I'm honored and so excited to be able to talk about our research nationally at conferences after a really huge study. They actually showed the overall proportion of women to male speakers was actually only thirty four percent women. And so Doctor.
Liu and I decided to look at what that percentage was at our ACR annual meeting. So what we actually found is overall, we're doing significantly better, especially than surgical and even other medical specialties, which is great. So our average was about 45% of the overall proportion were women. So that's amazing. And actually from 2017 to 2018, we've actually increased by 4%.
And I'm proud to say that in 2019, we're now at forty nine point one So it would be really naive of me not to mention that I know for this to happen it took the effort of amazing men and women and the American College of Rheumatology making it an active and conscious part of our mission to promote equal representation. So I'm so fortunate to be in our field and to be surrounded by all of
you guys. So thank you. Well speaking about kind of the transition with everything, Doctor. Crane was talking to us about her experiences with balancing work and life. And I think you have a really great perspective.
Would you mind sharing that with us?
Yes. So I had both of my my sons during medical training. So the first one during my intern year of residency, where my husband and I were separated geographically, so I was raising a son mostly as a single mom. And then I had my second son during and I had a very different experience so fellowship allowed me the opportunity to have more flexibility because of the research schedule and the less clinic time and then the no inpatient call and so I think Rheumatology has a great potential for work life balance if you have supportive mentors and supportive division who understands that you don't always have to be at the office because the schools are closed, know kids get sick, they can't go back to school for two days. And so if you have the opportunity to kinda cater your schedule with the advent of the medical record, the electronic medical record is a mom's best friend.
Yeah. Like and same with, like, the online journals. Like, you can do a lot of your stuff after the kids get tucked away to bed, and so you don't necessarily have to physically be at the hospital all the time like you did during residency. So Well,
I think that's a unique perspective. The electronical medical record actually being a tool that we can use for our day to day life to survive. What are your thoughts
on that? On the electronic medical record, I think.
Or in life balance. That
is an excellent question. So I also have two children and my first child was born at the end of my fellowship. And it was not something that I really understood how it would impact my professional life. And I had maybe six weeks at the end of the fellowship, and I had to start my job as an attending two weeks later. And so I had total of eight weeks off, which didn't seem like a big deal to me before I had a child.
And then it ended up that, you know, it was quite a big deal. And thankfully, with some better maternity leave policies at my institution, my second child was a bit easier than I had during my career.
Well, of the things that I think is so important as a mom is that you didn't introduce the factor of breastfeeding. My god. I used that word. Yes. And lactation.
What? Yes.
There's How did you handle this? No.
But it but it it is I mean, we've we've struggled. It's a big issue in clinic. Right? It's like if you're having a clinic and okay. You're gonna carve out some time.
Even if baby's not there, you're pumping. Right? And what do you do? And you carve out the time, but then where do you go? A lot of hospitals don't have places to go, and they're like, well, use the bathroom.
Bathroom. You know? So so we we would actually close some of the clinic exam rooms for for some of our doctors as they've come through because you gotta do what you gotta do.
Yeah. So I'm actually in a pediatric hospital that's very breast friend breastfeeding friendly, and there's still no good place to go to go home. But that that's the you kinda hit the the nail on the head. I think to be successful as a parent, whether you're female or male Yeah. You have to have a schedule.
There has to be structure, and so, like, you have to preplan, and I think that's the, the that like, that's the way to be successful as a parent and be a physician. So
Yeah. I it so isolating breastfeeding and pumping, you know, that first year. And instead of being able to interact with my colleagues during lunchtime, had to go back to my office, which was in a different location and pump. And it was difficult. I think I think that gave me a news perspective for my fellows when they came through training and had children, and I understood their needs and encouraged them to do the same thing.
Well, and give us a little bit more about the male perspective. I know that you said Doctor. Ruderman, it's a little bit of a challenge to create an environment that supports everybody. What have you guys done at Northwestern, or what have you seen?
You know, the the first part is recognition and recognizing that it's not like, well, we don't treat you any differently, but sometimes we kind of do because outside of work, it's different. And the the mom thing is it's changing, but it's always like if something if there's a problem, the kids home from school from from school sick, it's mom's job. Right? Mhmm. Way better than it used to be because at least, hopefully, most of the dads now are better partners, but society still expects that.
And then I think it's hard. So we have to we work around that, and we try to make sure that, listen, if you got a childcare problem or whatever, I mean, you're gone. I I I remember and, you know, and and the key for that is not even at work. It's to is to have a partner you can work with on that and make sure that they're all in. But I still remember when I started twenty five years ago, my practice my my nanny left, and our daughter was home from school sick, and I had to cancel my patients for a whole day.
And my senior partner guy looked at me, and he said, well, I don't understand why that's your problem. And that's changing, but it's still a challenge.
It's a problem.
We feel guilty.
You know? We do.
And we do.
I'm guilt factor because we're supposed to be there.
Right? You shouldn't be forced to do that.
But also sorry. But also, it's so whenever you're asked to do something, for example, I was asked as a third year fellow, like, in the second half of my third year fellowship to write a case report, and I politely declined it seven times because it's not career enhancing at that point, and I offered it to a medical student. It was perceived as I can't write the case report because of my kids. And so you get this negative perception, so you're not allowed it's almost like you're not allowed to say no. You're not allowed to miss a day because it's always because of the kids, and that's not necessarily what what the message is.
So we have to be the ones to shift the paradigm and to support each other and I mean I have amazing mentors like this is one of them. Doctor Catherine Dow. Doctor Ruderman is actually another one of them as well and I been really fortunate but I like most women also put my fertility in a little bit of a bind based on wanting to have a family later in life and I think it just goes to show that we have struggles that we aren't expecting. And I think my personal goal is to advocate for each of us. I mean, regardless of if you're male or female, we need to support each other.
There we have a loss of how many people we have in the workforce. And however you make your work schedule work, you're more productive if you have that scheduling ability. So any final thoughts you guys? We could talk about this forever. I mean, literally we we've been off camera for a while.
We've been waiting on some other groups to be done, and I think you guys have a wonderful perspective and sharing it's important.
Can I make a comment on your paper? Because it it was fascinating, and I think that's that it's great news, but it's not enough. Right? So even at 49%, you know, there we have way more women fellows now than men. So that's not even the percentage of rheumatologists.
And then you dig deeper and you will how many of those were moderators? How many of those gave important invited lectures? That's the next step. It's not just showing up. It's we need to make sure that women get to the top of what we're doing.
How do do that? Thank actually, thank you for bringing that up. One of the big things we looked at was clinical versus basic sciences. Even though
the
overall proportion was now forty nine point one percent, as of 2017 and 2018, we do have a discrepancy of about 5% even between clinical versus basic sciences. Wow. So that is something we do need to work on. The ACR's work task force actually had predicted by 2020, there would be our field in adult rheumatology would consist of 57% women versus men. So our goal should not be 50%.
It should be more reflective of the active workforce, which is what you were getting at.
How about we go around the table, Rachel, and then every one of us gives a little bit of advice to especially the female trainees.
To me?
Yeah, we love you.
And you know, you you also need us to give us the medical students advice and people, you know, who are younger than us and who may not have as good of an experience. What what exactly would you what one piece of information would you distill to help others?
I would say the most important thing that my mentors and sponsors have taught me is if you wanna do something and you believe in it, don't let impostor syndrome take over. Be your own advocate, you know. Be proud of what you wanna achieve, what you wanna accomplish, and don't be afraid to reach out to people. In fact, I've realized even at meetings like ACR, I've reached out to people that I've I hadn't really met in real life yet. I'd, you know, been inspired by on Twitter or social media, and I've reached out to them and say, hey, can we meet?
And they've been more than excited to meet and give me advice. And I think that's actually really helped me in developing my skills.
And I'll I'll kinda piggyback on that. I think I think you have a lot of choices about life, whether what career path you choose, whether it's research or clinical, private practice, academics, planning a family, getting married, or traveling. And I think whatever path you choose, just make sure you're confident that that's what you want, that's your passion, that's your desire, that is your choice, and to own it, to own your character, own your your choices.
Yeah. I mean, couldn't have said that better myself. I would say my one pearl for everyone is to find mentors who are supportive and who encourage you and challenge you to be better and you're never gonna fall flat on your face. You have a support team. That's what I believe rheumatology is.
Agreed. And as somebody who tries to be a mentor and a program director, I try to not assume that I know what my female or male fellows want, or when they plan to have families or if they plan to have families during their training, and instead to ask them what their goals are and not assume that their family life goals are necessarily in conflict Yeah. With their professional goals and it's so I try to support them that way. So
for me is the only person you have to impress and you have to think about this is actually your kids because more is caught than taught. So if you're gonna be pushing them aside, they're not gonna treat other people that well. And if you don't put family as a priority, they're not going to put family as a priority. They'll be like, bye, mom. You know?
So to me, I think that when I have my family as as the center of my life here, and everybody else kind of falls into place, it works out. Yeah. It's great.
It's always tough to be the end of the line when you have
to find a
guy and tell me no. It's something new. But but I actually I wanna follow the mentor story because find mentors who advocate for you. That's really critical. So not just it will support you and help you, and you need to advocate yourself.
But when a position opens up or an opportunity opens up, you need somebody who's gonna go in there and and and push for you. And it's it's unfortunate because sometimes it it is it women, they people don't think about, you know, as this is the spot for you. You need somebody who's gonna help you so then you can show what you can do when you're there. But if you can't even get in the role, if you can't even get that opportunity, you can't. You can't show what you can do.
You
guys, you are so sage. This is probably my favorite panel. I've had a really long time. I I really thank you so much for all of your perspectives. You are wonderful.
Keep fighting the good fight, and find someone to mentor on that on that final note. So check us out at roomnow.com, and our Twitter handle is at room now, and stay tuned for more from Atlanta. Hi.
My name is Eric. Ruterman. We're here with RheumNow at the ACR meeting in Atlanta. We have a group of us here together to talk about psoriatic arthritis. Before we begin, let's give you a little more background.
As I said, I'm Eric Ruterman. I'm from North University in Chicago.
Alexis Agde, Rheumatologist, University of Pennsylvania in Philadelphia.
Jesse Walsh, Salt Lake City.
Jose Chair, NYU Langone Health, New York City, New
York. Okay. So, the big news in psoriatic arthritis at this meeting has got to be the two phase three trials with guselkumab. I want to talk about this a little bit but I think it's really going to be helpful to talk what's that going to say about that pathway for psoriatic disease. Alexis, start us off by what did these trials show?
Well, they're the first two phase three studies in the P19 inhibitors, so that's really exciting. There was one trial that was completely treatment naive. The other trial had some TNF non responders or biologic non responders in that trial. So in the trial that was combined, biologic responders and treatment naive, a lot of them There was two doses tested, a Q4 week and a Q8 week compared to placebo. And in that trial, the Q4 week looked numerically a little bit better than the Q8 week, but it wasn't that much different overall.
When they split it out by TNF, versus not TNF experience, they saw actually that the TNF experience people did equally well between either dose, which was a little interesting. And then in the other trial, among all treatment patients, the two doses looked identical. But the one caveat there was that the radiographic progression was statistically significant at the q four week dose, but not at the q eight week dose. So some interesting things to kind of grapple with in terms of dosing and how we'll use that or what what the FDA will think when that's submitted.
And and both both show the drug work.
Yes. Very
effective. And and I wanna get into where that is gonna fit for us. But before we go there, Jesse, the dermatologists are all in on IL-twenty three inhibitors. What's that about?
Well, makes sense. Their outcomes look great. They're achieving good skin clearance with IL-twenty three inhibitors. Dosing wise, they're somewhat easier to give. Patients like the less frequent dosing than with some of the TNF inhibitor alternatives.
I think there are some hints that there may
be
some safety advantages, particularly compared to the IL-seventeen inhibitors, where we don't have to think so much about Candida or inflammatory bowel disease. I think the jury's out serious infection rates, but it may be a little bit more favorable with IL-twenty three inhibitors compared to IL-17s and TNFs.
And before we talk about where these drugs are going to fit, the last thing I want to touch on, and Jose, tell me, so the dermatologists have successfully sort of upped the ante with each round of treatments from TNF to IL-seventeen, IL-twenty three and it doesn't look like that we've achieved the same thing for the arthritis. What's that about?
Biology. It's all about pathophysiology. We have nailed down the pathways for psoriasis. As you go upstream on the molecular pathway, you achieve better and better outcomes. We're jealous.
They get passy one hundreds. Since the year 2004, our metrics have not changed. It's ACR20. Not only they haven't changed, the efficacy of these drugs are about the same. You get a 50 five-sixty percent ACR20 on the drug versus placebo.
What do we do with that information? I think one of the progressive thought approaches or thought processes is that we may be late when we treat psoriatic arthritis patients. Perhaps later in disease process, not in the patient, in the disease process. Is there room to perhaps conceive preventive trials or very, very early psoriatic disease clinical trials.
All right, so now we've got the data, we know what the skin is. I want to open this up. So this is the first. Two phase three trials that are going to get this drug approved for psoriatic arthritis and we have two more drugs waiting in the wings that are likely to follow. We have TNF inhibitors, we have IL-seventeen inhibitors, we have one and eventually more JAK inhibitors, We have a premilast.
Where are these IL-twenty three inhibitors going to fit in our patients?
It's a great question. I think some of the easy things are that in practice, we're still gonna use the drugs that we have first most likely, and then this will be the next drug. So most of our patients that we're gonna prescribe gusakimab for probably are gonna be TNF experienced already because that's where it's gonna come into the line. I would probably use it in a patient with more severe skin disease.
Probably avoid it in anybody who were concerned about axial disease.
What's that about?
It didn't work. The IL-twenty three data are not showing efficacy with axial disease. We haven't really specifically been studied in axial psoriatic disease, but in AS populations it's just not working. That probably again comes back to the biology. Maybe there's something different about Yeah.
These A little bit more synovial involvement
in Look, the these are good drugs. The p nineteens, we're not talking about a lower effect class in terms of efficacy. We've got to be careful now. Now it's about the side effect profile. Now it's about dosing.
Now it's about having a conversation with our patients, which we used to do. We had methotrexate and nothing else, and then we had methotrexate plus minus a DNF, which was an easy conversation. Right now, we open it up and we include the patients in the decision making.
I think we also need more studies that are going to help us differentiate this because right now we just have a bunch of trials in polyarticular patients. We don't actually know anything about how to target therapies. So there's a huge opportunity for this now moving I
think you're specifically referring to patients who may have lower peripheral joint burdens and more diverse phenotypes, is that right?
Yeah, exactly.
Jess, you made an interesting comment, you were like, well we use the drugs we're sort of used to using, and I think that's important. We're creatures of habit. We get used to doing certain things, and the dermatologists have a compelling reason to use the IL-twenty three inhibitors because they're so much better for skin disease. I don't think we have that compelling reason, at least yet, in joint disease. Is that right?
Right. I mean, there's nothing really in terms of joint outcomes that differentiates them well.
All right. Let me shift gears a minute and let's talk about another trial that was presented here at the ACR meeting which I thought was really interesting. It's a question that's come up in rheumatoid arthritis before. We haven't looked at psoriatic arthritis and that is if you have a patient who's doing really, really well, can you back off their medication? So the ixekizumab study which took all these patients, put them on ixekizumab, if they got into minimal disease activity they were randomized to withdraw the ixekizumab and just stay on placebo or stay on the execizumab in a blinded fashion.
What happened?
So I don't know. Yeah. Most almost all of them went back up onto therapy again. So once they withdrew, they, they flared. A median, I think it was about six months or something like that.
They looked at over forty weeks. There were significantly more flares than people who were pulled off the drug from compared to people that were stayed on the drug. But the interesting thing is that once they restarted them on drug, you could recapture most of them, which was also interesting.
I mean, the survival curves were fascinating. Basically, you said if you went on placebo and you waited long enough
You were gonna flare.
Your disease was gonna come back.
Yeah.
Okay. Should we should we not have expected that?
I expected that. We expected
that based on rheumatoid experience with DNF blockers. Right? We've we've seen this before, this behavior. What we haven't seen and it's new is this easy recapture, which may have to do with immunogenicity, where TNFs do create immunogenic responses. And the 17A class is not for that.
So that may be an advantage.
Although seventy percent of them were on methotrexate in the study which is So really interesting to maybe that led to some baseline treatment that you could then make it easier to recapture some of them. I don't know. Interesting.
So one last question. And I look at that study. Wish they had had an arm where they gave placebo every other dose because in RA at least, we've seen you can decrease the biologic, just you're sort of nodding your head. Mean, that's the question. Know, stopping the drug doesn't make any sense.
Wouldn't it be nice if we were able to look at how I think
they just want to do
it that way. They say, I decrease my dose rather than come up at all at once? So I think it's logical and preferred by
To close the circle on that one, going back to P19s, this is a drug that's every two months. But if you leave people off of drug for six months, fifty percent of them will remain with good skin outcome. So you could argue that frequency is one thing we should look at in other targets.
So the message is anybody out there who is involved in trial design, we'd like to see not necessarily withdrawal trials, but maybe spacing trials to give you some of those answers. Alright, think we'll wrap there. Thank you everybody for doing this. Again, for RheumNow coming from ACR in Atlanta in 2019. Thanks for watching.
Hi, I'm Len Calabrese from the Cleveland Clinic, and I'm here on RheumNow with two experts in immune related adverse events from cancer immunotherapy, Laura Capelli from Johns Hopkins, Cassie Calabrese, who I actually know, from Cleveland Clinic. And, you know, four or five years ago, you you had to look for define one or two presentations on this. And by one calculation, there are over 60, abstracts that involve cancer and rheumatic disease at this meeting. So highlights. Laura, give me a couple.
So I think we had a really great oral abstract session yesterday, and there was some very interesting pharmacovigilance data that was presented from the group from the SOAR Bone. So they looked at the World Health Organization database for IRAE, so immune related adverse events secondary to immune checkpoint inhibitors. And they found about six hundred reported cases of arthritis and about four hundred of myositis. But I think the real take home message from that abstract was that in the patients with myositis, those who would have fatal cases typically developed the first symptoms about two weeks before those who would have not fatal cases, which I think is really thought provoking about the pathogenesis that's going on there. Do these people have already
Oh, pre absolutely. Yeah. Great, great, presentation, and, my side is very serious and gotta be picked up early. Cassie, give me one.
Yeah. So many great abstracts. I think I've been told there's 60 some. I'm not sure if that's accurate. But also, yesterday at the oral session, something kind of new and different, from Marie Costine, in Bordeaux looked at the effect of microbiome altering medications, on IRAEs.
And what they did was a retrospective study, I think 600 some patients, looking at administration either within the month before or month after of a handful of different types of drugs, including antibiotics, steroids, some psychotropic medications like statins, ACE inhibitors, and looked at the effect on overall survival and tumor response. Interestingly, something we've kind of suspected is that prednisone equivalent dose of ten milligrams or more daily at baseline had negative effects on overall survival and and tumor response. Also, interestingly, similar negative associations with antibiotics and proton pump inhibitors. That was another one. So I take home point, if we can avoid baseline steroids at a dose of ten milligrams or more daily, that's probably something we should be doing prior to starting immunotherapy.
That's a very provocative study. These immune diseases, as Laura mentioned, some may be pre existing autoimmunity, some may be operating through novel mechanisms of breaches of tolerance, and we have an incomplete understanding of both the genetics, which may be our partial contributor, and environmental factors. And you know the antibiotic story has been out for a long time but geez PPIs and these other drugs and are they operating?
Not so commonly administered people.
So, you know, my actual personal discussion with patients and friends who have undergone this is to try to live as naturally as you can. You know, a healthy diet and do all the type of wellness behaviors you can before doing this and try to clean your system out. We are at the beginning of the beginning of this. I think that one more abstract from Laura and we'll wrap this up.
So I think we're gonna go from big, you know, database studies to small. And so the Mayo group presented also at the oral abstract session some flow cytometry data looking at peripheral T cells in patients who develop new inflammatory arthritis from checkpoint inhibitors as compared to healthy controls, RA controls, and checkpoint inhibitor controls who didn't get arthritis. Bottom line is small number of patients needs more validation, but intriguing that the immunosenescent phenotype seemed to be up and the exhausted T cells seemed to be down in the checkpoint inhibitor patients in a similar way actually to the traditional rheumatoid arthritis patient. So I think that it was provocative, small number of patients, good pilot data for more study.
I agree 100%. There was just a recent roundtable discussion, I think in Nature Immunology, taking the world leading experts on, exhausted T cells, and there's really a lack of uniform definition of how to define these by advanced flow and metabolomics and transgenomics. So again, I think it's a great start. It's telling us something and hopefully we can build upon it with larger studies. I want to thank everybody for coming into the room now.
IRAEs are here to stay. They're only going to get bigger. And next year, we're shooting to maybe have our own abstract category.
Fingers crossed. Yeah.
Thanks.
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