Chicago Arthritis and Regenerative Medicine Weekly Live- 20200617 Replay.
-Medical decision making in uncertainty.
-Imaging negative spondyloarthropathy.
-Antibody testing for covid19.
Hello, everyone, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. Welcome to our weekly live event. Today is June 17th, 2020. I hope everyone is doing well on this Wednesday. It’s been really an extraordinary last few months and I hope everyone is healthy, doing well, and getting stronger and better.
So, a couple things I want to talk about today, but before I do that one notification or update, something new that I’m trying is we are going to be publishing, distributing, a video series ending every week, basically a weekly educational series. It’s actually something I am doing for my own team at work, where I’m talking about some of the basics of what we do at Chicago Arthritis and Regenerative Medicine when it comes to evaluation and treatment of arthritis, tendinitis, injures, back pain, and autoimmune conditions. The focus being on going over basics, principles, details, to get a better sense for what are state of the art ideas of how to treat musculoskeletal issues and what we’re all about here in the office as well. My new sense is that if something is HIPAA compliant, safe, interesting, educational, and if we’re presenting it, or I’m presenting it, to everyone else at work, why don’t we tape it, audio, video, caption it, written, and then put it out for everyone else to read and consume as well. I think it’s a interesting and helpful way for people to get a better sense for, you know, how the field is changing, and how we can learn more so people are more educated and understanding of how to make smart decisions regarding their own health.
Something I wanted to talk about today is decision making in uncertainty. I think the last few months, uncertainty is, that’s our new way of life! And medicine, and physicians in particular, traditionally have had a relatively protected place in society where people really trust us wholeheartedly. And I think the last 20 years, a lot of that infallibility has progressively broken down, and part of that is because of realizing that medicine has limits to where it can fully help people with some of their medical issues. There’s some things that medicine does not naturally do well on its own, that we need to maybe change up. Part of it is realizing that the cost of care in this country is so enormously high, and how there’s flaws associated with that, and not only in terms of access to care but reliability care, and the value of care, if it’s that expensive as well.
So as that process has happened, I think the last three to four months, I think that’s been accentuated. As people start to realize the limits of medicine and public health authorities and plans in this kind of time. And part of that is that the coronavirus COVID-19 is so new that there’s thing that we’re still learning about it in terms of basics, right. Meaning things such as how well do antibodies protect people? How reliable is the testing for this? And how severe is this as well? There’s a lot of things that we’re still learning and sussing out about this condition, and so there’s a lot of uncertainty with that.
The reality is that medicine in general, there’s a ton of uncertainty. And reality as from a physician’s standpoint, we try to take a combination of what is the best evidence and data available regarding condition xyz. What are some big picture principles about some of these conditions and what we already understand. And how do we then that apply to that to the people that we’re actually trying to help, and who we’re seeing in the office or telehealth every single day. And the reality of that is that a lot of medicine is not necessarily based on our highest, highest level of evidence, meaning double-blind, controlled, placebo controlled studies. A lot of medicine has not quite reached that level, and a lot of it is based on layers of evidence that are maybe not quite level one evidence, but they’re still evidence, and based on taking those big picture principles. And when you do that, you can still make smart decisions and guide people in the right way, but making decisions in uncertainty is a big part of what medicine is about, and it’s a big part of what life is about as well. And I think if you, as a patient, look at your health in that same way, meaning you know there’s some things that are just good, solid, reliable things that you should be doing, but then there’s a lot of uncertainty about how that gets expressed and what that means, you can still make smart, risk appropriate decisions.
This past week I thought of kind of a few different things, but I’ll talk about two of them right now. The one is a specific patient case, and this was a young man in his mid to late twenties, he was coming to me for a second opinion. He’s had kind of generalized pains, both elbows, both knees, lower back. And he has some symptoms that sound suspicious for possible inflammatory arthritis, meaning his autoimmune system causing inflammation in the joints, specifically with a condition called spondyloarthropathy, which means inflammation of the spine and tendons basically, and some peripheral joints. So, he’s had a workup for this previous to seeing me, and his workup showed imaging, an MRI, and an x-ray of his lower back and SI joints, that was normal, did not show the classic imaging findings. He also had some basic lab tests that showed no significant inflammation, as well as a negative antibody test.
He came to me for a second opinion, and part of that was because he’d been tried on some other treatments, he’d been tried on a strong anti-inflammatory, prednisone, it’s a steroid, and didn’t get a good response. He was then progressively started on other disease modifying treatments to work on the immune system, including sulfasalazine and methotrexate with limited benefit, and wanting to get a sense for what are the next steps. So, you know, when I evaluated him, we screened for a number of other things that could also cause generalized pains, all that was normal. I also did an ultrasound of his elbows and knees to see if there’s any evidence of inflammation. He has some very mild tendon changes, but no definitive inflammation. And so, he’s someone who has been labeled with a diagnosis of what’s called imaging negative spondyloarthropathy, meaning he doesn’t have the imaging findings on MRI, x-ray, or ultrasound that quite fit this diagnosis, but he has some other symptoms that can give him a diagnosis of spondyloarthropathy. This is a accepted and well known diagnosis in rheumatology.
My take was a little bit different than his traditional rheumatologist, which is, his current rheumatologist had told him, “Well, if you’re not responding to this treatment, then we need to escalate to the next thing, and if that doesn’t work, then escalate to the next thing.” And if you accept that diagnosis, then you can say that that’s the appropriate way to proceed. My take was, “You don’t quite meet the criteria for that diagnosis.” And so you’ve got in this situation two physicians who are looking at the same situation, both of them saying, look, your case is a little bit atypical. One of them is saying proceed one way, and another one is saying maybe that doesn’t quite make sense, maybe proceed a little bit differently. My personal take in this kind of setting is if you don’t meet two a T, that diagnosis, rather than getting onto a progressively aggressive medication regimen, let’s maximize everything else conservatively. Whether that’s physical therapy, over the counter supplements, if that’s not enough, then injection options like platelet rich plasma for some of his tendon related issues. That’s my principle take, right. Meaning my take is that, philosophically, if you don’t quite meet a diagnosis, let’s approach this in as low-risk a way as possible, and see if you can get things better before we start escalating higher. And in his case, because he hasn’t had a good response to some of the traditional treatments we would use that diagnosis, spondyloarthropathy, that’s why I’m suggesting that.
It’s a case where, as I’m trying to explain to him, which is that you really have to philosophically decide where you lay on this spectrum. Are you going to take the approach that maybe you fit this diagnosis, and because of that, let’s now start progressively escalating treatment medication wise. Or do you take the perspective that I am, which is that, look, you don’t quite meet that diagnosis, so let’s start ultra-conservative and slowly start progressing, and if there’s other evidence that suggests we need to go back into that traditional regimen of medication, then get back into that. And that’s probably a hard thing for an individual, a patient who’s not medically sophisticated to really understand. Which is that, at some level as a individual, and as a patient, when it comes to your own care, you have to come to some meeting of the minds with your physician about what philosophically makes sense. And in cases where, especially, there’s some uncertainty, either in diagnosis or in treatment, which happens quite frequently, a lot. It makes a big difference if your values and your perspective aligns very well with your physician’s, because from a not only diagnostic standpoint, but from a treatment standpoint, how aggressive will you want to escalate treatment really depends on how you philosophically think your care should proceed.
So this is one of those where it’s subtle, but the difference in treatment would be pretty significant, meaning I would not recommend aggressively ratcheting up medication in his case, because not only does he quite not meet the diagnostic criteria from my perspective, but he also has failed other traditional treatment options that he should have responded to, and so my take would be, go in a different direction of conservative care, and then if needed, an injection like platelet rich plasma, which will still be low-risk and can be helpful from the tendon standpoint, and maybe a better option in his case at this stage. That’s a subtle one, but it was an important one to me, because it just, it’s so important to understand that, from a physician’s standpoint, how you approach medical care with your first principles and big picture thinking effects the nitty gritty with how you end up then guiding patients in terms of what they need to do, or what you would recommend that they do.
Second one is something that I’m hearing a lot of now, which is antibody testing for COVID-19. So, I’m getting progressively more and more patients asking, “Hey, are you screening for COVID with antibody testing?” Patients, the general public. And it’s an interesting question because COVID-19 antibody testing, in theory, could be very beneficial. Meaning when it comes to antibody testing there are antibodies that indicate if you had a recent exposure, and then there are antibodies that indicate if you’ve had a prior exposure, let’s say three, four week previous, And if you can find someone that has had a previous exposure, you could then, in theory, give them the green light to go into the life if those antibodies are protective.
Now, the reality is that’s not fully accurate. For starters, we’re not exactly sure how protective the antibodies to COVID-19 are. Number two, we’re not sure that if you’ve got the antibodies, you avoid getting reinfected if you’re exposed again, that may not actually be true. There’s some evidence that that might not be the case. In addition, the actual testing itself. We’re still not exactly sure how reliable some of this testing is. It’s so new, in terms of the antibody testing that’s out there, that the problem is that there’s a significant rate of possible false positives and false negatives. And a lot of it depends on the actual test that you’re using, but a lot of it depends also on where in the country and the world you are. If there’s a higher prevalence of COVID-19 where you’re located, then the chance of being, the chance of testing positive is going to be higher, just because there’s a higher prevalence, but the flip side is if you’re in a location where there’s a lower prevalence, not as many cases, then the chance of a false positive is much higher and that can be a problem.
With any kind of testing, you have to sit there and ask yourself, “What am I going to do with this test?” And so for most of my patients that ask, “Hey, should I get routinely tested?” The answer is no, because what are you going to do with this? Are you going to change your behavior or how you’re going to proceed in life? And the vast majority of people, that’s not the case. On the other hand I’ve got two examples where we are actually doing something with this.
The first is for my own team at work, we are testing all of us in the office every single week for antibodies. And the reason why is because we’re doing all the other the basics, whether that is checking daily temperatures, whether that is checking for symptoms to screen us to see if there’s anything. In addition, by checking the antibodies every single week, if we’re all negative at baseline, if somebody’s sero converts along the way, we then have to ask, is something else going on? Have they been exposed? And it’s helpful because we have like a pretty detailed laid out plan in terms of how we handle this. Meaning if you come back with the antibody that is more acutely, acute exposure related, IgM, versus the one that’s more chronic related, IgG, we have like a whole protocol about, “Well, if you come with this, then you do this. If you come with that, then you get additional testing. And if you come with this, then you need to be quarantined.” So, we have a process that is meant to account for every scenario. And the good thing is we’ve had to actually test that out in real time, and for actual staff, so that we’re not only protecting our team at work, but any patients that are coming into the office. But the key here is that this is not just a one-off ticket test, and then do something with that. There’s a process behind it, there’s a plan behind it, and it makes sense to use it then.
The second example is, I had a patient that asked me about getting tested, and again, my initial impulse after talking to her is, well, I’m not sure if it’s going to make any difference. But she had an interesting story, and it made me reconsider my thoughts. The first is she mentioned, you know, she had this really bad upper and lower respiratory illness that required antibiotics back in February. Okay, well that’s interesting, I’ve met a bunch of people who’ve kind of given me similar stories and it’s not clear, is that relevant or not. Then she mentioned she has a baseline history of asthma, she’s a runner as well, and ever since she had this respiratory illness a few months ago, her asthma’s been low-level active persistently. And her pulmonologist had mentioned to her, her lung doctor had mentioned to her that, listen, if you really were exposed to COVID, he would recommend that she re-initiate her running regimen in a gradual, slow format, rather than more aggressive format. That’s interesting. I’m not exactly sure how correct that is, but it’s an interesting concept because this is someone who’s obviously an expert in lung diseases, I’m not. Number two, he’s had some experience patients who’ve had COVID, and sort of figuring out what to do with that. But number three, this is now an appropriate trigger to actually get that kind of testing, because now you’re going to do something with it. It’s not, doesn’t give her the all-clear to run back into life and get exposed to anyone and everyone without a mask or social distancing. But at least the test would have some sensible use that could then help guide additional decisions for her.
To me this is a great example of where in a setting of uncertainty, with a new condition, new infectious process, new testing, new societal changes with all of this COVID-19 business, that you can still make sensible decisions if you have a plan of what you’re going to do with that kind of testing. And to me, living in a world of uncertainty, which we’ve all been, it’s just now we’re more hyper acute to that case, it’s a matter of being thoughtful, understanding what are your own risks, what are your own sort of big principles about how you want to approach life, and then being able to make smart, reasoned decisions for your own self, for your family, for your community, in a way with your trusted physician that can give you the benefit of their experience, and the benefit of your own sort of principles to come to some decisions that’ll make sense. And in some cases, there’s not going to be a 100% correct answer, but there will be an appropriate answer for your situation.
I appreciate your time, thank you very much. I hope everyone’s safe and healthy. Any questions, message me, email, call anytime. Don’t forget, I’ve got a now weekly educational series coming out once per week as well on top of the weekly live event, and have a good day, and until next week, live well, bye-bye!
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***About this video***
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses medical decision making during uncertainty, imaging negative spondyloarthropathy, covid19 antibody testing.