RheumNow Podcast Rheumatologist Salaries (12.21.18) Save

This is the Room Now podcast for 12/21/2018. This podcast is brought to you by Room Now Live, the next best meeting in rheumatology, March '24 in Fort Worth, Texas. Hi, I'm Doctor. Jack Cush, Executive Editor of RheumNow and Co Chair of RheumNow Live with Artie Cavanaugh. This week in the news, we're going to rehash some things from last week and that might just be enough before the holidays.

We'll also tell you what a rheumatologist is worth. So we'll start with a study from The UK, BSRBR, the British Society of Rheumatology's Biologic Registry, which looked at the risk of cancer and looked at the associations with death, and sort of reaffirmed a lot of the messages that we've passed on before that with TNF inhibitors, and they looked at seven hundred plus patients, followed over a long period of time, they had thirty four cancers and forty one deaths. When we did their comparisons, the SIR, the standardized incidence ratio for malignancies was not higher with a TNF inhibitor was zero point nine four, overlapped one, and that was again in line with what we've seen with a lot of other cancers, and that's the general cancer risk and that's, you know, it's your job to treat arthritis, somebody else's job to treat cancer. If you're being handcuffed by a safety concern and talk of cancer, you need to know the data. So, the interesting thing that also came out of this study was the flip side of the coin which looked at the risk of death and they showed a twofold increase in the standardized mortality ratio in their trial, and especially for non melanoma skin cancer.

The overall SMR was only one point five six or fifty six percent increase, but most of this mortality rate that was increased, in patients on TNF inhibitors was from cardiovascular events. So, you might want to, keep that in mind. I found this interesting, who has more pain and is pain the same between different ethnic and racial groups? I remember having this conversation with Fred Wolf, gosh, about twenty years ago and, only Fred could show you the data that says that Hispanics actually have different pain perceptions than do African Americans and talk to Fred if you want the answer to that question. But in this particular study, a meta analysis of 61 articles looked at pain severity scores and compared Caucasians with African Americans.

The consistent message was that African Americans tended to have higher WOMAC scores and higher pain in non WOMAC studies as well compared to Caucasians. Now, is that just a racist comment or is that the fact Jack? I think it's important when you consider that pain is an important outcome that we look at, especially in clinical trials, and the fact that in clinical trials African Americans are very underrepresented. As has been shown in many other studies by many other people, the people who are left out in the cold in research are African Americans and women and low income people. A lot of clinical trials involve middle and higher income individuals, more men than women and much, much, much more Whites.

Forget about Hispanics and Asians and whatnot. So again, this is an important data, but it's an important call for, better studies and better inclusion. I threw out a link to, what I think is a really interesting, podcast called The Plenary Session. It comes from the Oregon Health Science Center's oncologist, Vinay Prasad, and Vinay actually has a really cool podcast. It's a teaching podcast, he's an oncologist, but he talks about more than oncology.

This particular podcast that I've linked to is a discussion between himself and one of his colleagues, who's a cardiologist, on a lot of different trials in the New England Journal recently including the CERT study, the methotrexate in cardiovascular risk patients. They also looked at, fish oils and vitamin D and comment on those things which I found very, very interesting in this one hour podcast. But, somewhere around minute thirty five in that podcast, you can hear two non rheumatologists discuss this data and critique Paul Ricker's, beliefs that inflammation is involved in this, and they come away with the message that, targeting inflammation in cardiac patients with anti inflammatory drugs like methotrexate, even IL-one inhibitors is probably dead, and maybe only reserved for select situations. And I think that this is followed up by another interesting podcast from Michael Putnam. He has the Evidence Based Rheumatology Podcast which is a nice podcast where he reviews a journal article usually about once a week and you can find these again on iTunes and on SoundCloud or Stitcher if you have an Android phone.

I think there's a lot of good rheumatology podcasts not just through RoomNow podcast, I point you to also Ruminations by Adam Brown from the Cleveland Clinic who does interviews of interesting rheumatologists on some of their work. So anyway also Michael Putman has a discussion of the CIRT and CANTO studies, again sort of saying that these studies have sort of killed the excitement about targeting inflammation. I think it's going to sort of be an ongoing discussion and knowing this data and knowing other viewpoints might make you the smart conversant rheumatologist. I was at the Arthros Georgia State meeting, actually it was the Mars Metropolitan Atlanta meeting last weekend with Sergio Schwarzman and Bing Bingham and Bing gave a fabulous talk on the immune related adverse events and I tweeted two things from there that I thought are bare repeating here. Mainly because a week before, two weeks before, was with Arty and we were at his large meeting at UCSD with about a 100 rheumatologists in the audience and we asked them how many of you have seen these immune related adverse events associated with immune checkpoint inhibitors used for cancer?

And more than half the audience shot his hand up and maybe only about fifteen percent of those or the overall audience said they've seen more than two cases. So we did the same thing with about 40 plus rheumatologists in Atlanta and about a third of the audience have seen these events. If you haven't seen these immune related adverse events, you better keep your eyes open. Again, these are people taking checkpoint inhibitors, and PD-one and PDL-one targeted therapies that are really popular now in very aggressive, cancers including melanoma. Anyway, Bing's lectures talked about there being a three to five percent, risk of these, musculoskeletal side effects associated with these immune checkpoint inhibitors, and that some of the common things that we see are not just arthralgias and arthritis, but also, tendonitis, tenosynovitis, dactylitis, and PMR.

These patients tend to be all seronegative. A lot of them are treated with low dose steroids, it's sort of a no no to use high dose steroids, about twenty milligrams, talk to your oncologist about what can be used, do not use abatacept, that's a bad one, people are using some other biologics to treat inflammatory arthritis. We cover this quite a bit in RheumNow, you can do a search on our webpage to see the things that are out there, some really good articles coming from some really good people. I also want to rehash, an issue I brought up last week which was how would you treat a 27 year old who has four months of bilateral knee effusions, synovial fluid of 22,000, culture negative, MRI showing synovitis only, labs only showing a positive ANA one to one sixty in a speckled pattern, negative tests for parvo, b nineteen, IgM, b 27, rheumatoid factor, CCP, RPR, Hep B, Hep C, sed rate and CRP were not elevated, no response to nonsteroidals, no response to intra articular steroids, and what would you diagnose her as? Well we did a survey on Twitter and the answer was, the most common answer was forty seven percent of you said this is either a cult IBD PSA or SPA.

The next most common answer was seronegative at twenty four percent, the next most common was twenty one percent with adult onset pauci JIA and no one liked the idea of incomplete lupus and obviously don't believe in that. I got a nice and very informative email from Atul Daydar also from Oregon Health Science Center saying, you know, in nomenclature this patient might be referred to as peripheral spondyloarthropathy, meaning that there's no axial disease, this is peripheral spondyloarthritis, and that this happens to be HLA B27 negative peripheral spondylarthropathy. So is that the better term? I tend to like the term because the ANA positivity that this is adult onset postarticular JIA with a positive ANA. The question is, will this patient because of the ANA have a higher risk of uveitis and inflammatory eye disease, but if she did, would she then not qualify for the diagnosis of adult seronegative peripheral spondyloarthritis?

We have a nomenclature issue here, so let's see how this pans out. I think this is an interesting discussion. I have about four of these kind of patients, I think it's what we call them and how we treat them is probably more importantly. Anyways, the patient was treated with steroids, did better, eighty percent better, is going to be started on methotrexate, we'll let you know how it pans out in the future. An interesting survey came from MedPage Today about rheumatologist salaries for $20.18 and that comes up with a grand total of, drum roll please, 214,000 a year is the average salary for rheumatologists making you the fourth lowest salary amongst all the medical disciplines that were covered.

We are fourth behind, only lower than us, is pediatrics, family practice and endocrinology. This sort of jives at least the placement with a earlier report from Medscape, on the salaries of physicians that was issued in April 2018 where our salary was a mean of 257,000, where we were eighth on the list, again, also only lower than us was pediatrics, family practice, endocrinology, physical medicine rehabilitation and a few other things, neurology actually. So that's kind of interesting. Two more reports, nail fold video capillaroscopy and dermatomyositis, an interesting study looking at seventy patients and not just their nail fold capillaroscopy done with video microscopy, but also looked at skin biopsies, serologies and whatnot. Finding, a positive or abnormal, capillaroscopy study was seen in more than half, fifty eight percent of patients, much higher in dermatomyositis patients sixty five versus twenty seven percent, twenty eight percent in polymyositis alone.

Nailfold video, caproscopy abnormalities were associated with more so with antibodies against, TIF-one gamma and also, the NXP-two antibodies or I'm sorry not NXP-two, the MDA-five antibodies, and that was much higher eighty five percent, ninety percent in those people, much lower in the tRNA synthetase syndromes associated with disease. If you had nail fold capillaroscopy abnormalities you were more likely to have more cellular skin biopsies as well. And the interesting thing was that unlike scleroderma where nail fold changes tend to be static and unchanging over time, with one year of therapy, their patients actually showed significant improvement in the nail hole capillaroscopy findings. So I thought that was an interesting and new revelation to me. I'll end with a press release from Lilly on their Spirit head to head H2H ixekizumab versus adalimumab and while I covered this because it's slow news week, I don't think this is a really strong report only because it's a press release and they tell you they met their primary endpoint and showed that ixekizumab was significantly better than adalimumab in treating moderate, active psoriatic arthritis, but they give you no data.

They tell you five fifty six patients treated with ixekizumab or standard doses of adalimumab, and at the end of twenty four weeks, guess what, we're better. But no, you have to go to a meeting to find out. We really shouldn't have press reports like this, I don't think that it helps anybody. I know this is marketing at its best or at its worst, I think this should be left for peer review and for, open forums to have this kind of information released. That's my 2¢.

I'll add 25¢ more and tell you about, RheumNow lives, March '24, starts Friday afternoon, ends Sunday at 12:30 with Artie and I doing a meeting roundup or wrap up. The meeting's in Fort Worth. It's, early registration is on, there's a significant discount on that for both fellows and for faculty. You can go to roomnow.live to look at this meeting, look at the faculty. Next time I talk to you here, we're going to have a full listing of the faculty which I can fully reveal at that time.

For now you're just going to have to be in suspense and look at the titles and the subjects, it's going be really cool. Blocks of lectures on one topic, PSA, vasculitis, lupus, rheumatoid panel discussions and then we're going have TED like talks, we're calling step talks in between from some really cool people. So go to the website www.roomnow.live and see more about this great meeting. It is the December 21, I hope you're going to have a great holiday and a good time off and a good vacation. We'll probably not have a presentation next week, If we do, that means something important happened in rheumatology that I just couldn't help myself, I had to get back on.

So we'll see you in two weeks, enjoy the holiday.