Ernst Michael Shanahan

From a single visiting consultant in 1976 to one of Australia's largest tertiary rheumatology units, a narrative history of how the service developed alongside the medical school, the hospital and the discipline itself.

Rheumatology, as a subspeciality of medicine that involves the diagnosis and management of rheumatic disorders, is relatively new. Indeed, ‘rheumatology’ as a word was only introduced in 1949 by Joseph Hollander, an American physician, in the fourth edition of Comroe’s text book Arthritis & Allied Conditions. The word ‘rheumatology’ means the study of, or a […]

Objective: The impact of GCA and its treatment on an individual’s life is poorly characterised. This research sought to advance existing qualitative literature to tailor better diagnostic frameworks, treatment approaches and therapeutic relationships that focus on outcomes that are important to patients. Methods: A qualitative study using phenomenology was undertaken. Purposive sampling selected recently diagnosed participants with varied experiences, including those with and without a confirmatory diagnostic test, vision loss, prednisolone adverse effects and psychosocial impact. Semi-structured interviews were conducted until saturation. Themes emerged through data interpretation, bringing together common experiences and their variant manifestations to elucidate the lived experience of GCA. Results: Of 34 individuals invited, 20 agreed to participate; 12 (60%) were female, median age at diagnosis 68 years (range 58–86) and mean time since diagnosis 15.7 months (range 1–45). Four main themes emerged: living with uncertainty and fear, change in self-perception and loss of autonomy, adapting to physical symptoms and the critical importance of the healthcare interaction. Conclusion: This study provides unique insights into the lived experiences of individuals with recently diagnosed GCA. Our findings emphasise the profound psychological and functional impact of GCA and recognise the critical importance of patient experience on overall well-being. These insights demand we move towards a patient-centred model of care that goes beyond disease control, prioritising clear communication, tailored patient education, support networks and integrated service provision. Addressing these unmet needs represents a critical opportunity to improve outcomes that are important to people living with GCA.

Observational studies have shown that methotrexate, a conventional synthetic disease-modifying antirheumatic drug (csDMARD), is associated with lower arterial blood pressure (BP) and may reduce cardiovascular risk in rheumatoid arthritis (RA). However, it remains unclear whether a cause-and-effect relationship exists between the use of methotrexate and blood pressure reduction. We conducted a controlled comparative study of treatment-naïve newly diagnosed RA patients commenced on subcutaneous methotrexate (Group 1, n = 31, age 57 ± 15 years, 65% females, Disease Activity Score-28 - C-reactive protein, DAS28-CRP = 4.7 ± 1.2) or the DMARD comparator sulfasalazine (Group 2, n = 31, 54 ± 17 years, 61% females, DAS28-CRP = 5.0 ± 0.8). Clinic systolic (SBP, primary study endpoint) and diastolic BP (DBP) and augmentation index (AIx, a marker of arterial stiffness) were measured at baseline and after one and six months of treatment (ClinicalTrials.gov: NCT03254589). After six months, compared to Group 2, Group 1 patients had significantly lower SBP (-7.4 mmHg, 95% CI -14.0 to -0.8, p = 0.03). By contrast, there were no significant between-group differences in DBP (p = 0.18), AIx (p = 0.85), or DAS28-CRP (p = 0.16). A significant effect of single nucleotide polymorphisms (SNPs) rs1801133 (methyl tetrahydrofolate reductase) and rs2231142 (ATP-binding cassette subfamily G member 2) on BP changes during methotrexate treatment was observed. This is the first comparative study showing that methotrexate significantly reduces SBP in RA. This effect did not coincide with significant changes in arterial stiffness or disease activity. Further research is warranted to investigate the mechanisms underpinning the SBP-lowering effects of methotrexate, the role of specific SNPs, and whether such effects may account for reduced cardiovascular risk in patients with RA.

This article discusses the rationale and design of the study "Methotrexate, blood pressure, and arterial function in rheumatoid arthritis". The recognition that immune activation and excess inflammation favor atherosclerosis has stimulated a significant body of research not only to identify new drugs targeting these pathways but also to repurpose (reposition) existing immunomodulatory medications as atheroprotective agents. Observational studies in patients with rheumatoid arthritis have reported that treatment with methotrexate, a traditional disease-modifying antirheumatic drug, is associated with a significantly lower risk of cardiovascular morbidity and mortality when compared with other disease-modifying antirheumatic drugs. One potential mechanism accounting for the reduced cardiovascular risk associated with methotrexate is the lowering effect on arterial blood pressure. However, such effect has only been observed in cross-sectional and observational studies. Given the established role of hypertension as a leading cardiovascular risk factor, these observations justify an intervention comparison study, the focus of this article, investigating the temporal effects of methotrexate on blood pressure and various surrogate markers of atherosclerosis in patients with rheumatoid arthritis. The results of this study might lead to the repurposing of methotrexate for cardiovascular prevention in patients with and without autoimmune disorders.Clinical Trial Registration: NCT03254589 (ClinicalTrials.gov).

Introduction: Assessment design in health professions education is continuously evolving. There is an increasing desire to better embrace human judgement in assessment. Thus, it is essential to understand what makes this judgement fair. This study builds upon existing literature by studying how assessment leaders conceptualise the characteristics of fair judgement. Methods: Sixteen assessment leaders from 15 medical schools in Australia and New Zealand participated in online focus groups. Data collection and analysis occurred concurrently and iteratively. We used the constant comparison method to identify themes and build on an existing conceptual model of fair judgement in assessment. Results: Fairness is a multi-dimensional construct with components at environment, system and individual levels. Components influencing fairness include articulated and agreed learning outcomes relating to the needs of society, a culture which allows for learner support, stakeholder agency and learning (environmental level), collection, interpretation and combination of evidence, procedural strategies (system level) and appropriate individual assessments and assessor expertise and agility (individual level). Discussion: We observed that within the data at fractal, that is an infinite pattern repeating at different scales, could be seen suggesting fair judgement should be considered a complex adaptive system. Within complex adaptive systems, it is primarily the interaction between the entities which influences the outcome it produces, not simply the components themselves. Viewing fairness in assessment through a lens of complexity rather than as a linear, causal model has significant implications for how we design assessment programs and seek to utilise human judgement in assessment.

Introduction: Workplace-based assessment occurs in authentic, dynamic clinical environments where reproducible, measurement-based assessments can often not be implemented. In these environments, research approaches that respect these multiple dynamic interactions, such as complexity perspectives, are encouraged. Previous research has shown that fairness in assessment is a nonlinear phenomenon that emerges from interactions between its components and behaves like a complex adaptative system. The aim of this study was to understand the external forces on the complex adaptive system which may disrupt fairness from emerging. Methods: We conducted online focus groups with a purposeful sample of nineteen academic leaders in the Netherlands. We used an iterative approach to collection, analysis and coding of the data and interpreted the results using a lens of complexity, focusing on how individual elements of fairness work in concert to create systems with complex behaviour. Results: We identified three themes of forces which can disrupt fairness: forces impairing interactivity, forces impairing adaption and forces impairing embeddedness. Within each of these themes, we identified subthemes: assessor and student forces, tool forces and system forces. Discussion: Consistent with complexity theory, this study suggests there are multiple forces which can hamper the emergence of fairness. Whilst complexity thinking does not reduce the scale of the challenge, viewing forces through this lens provides insight into why and how these forces are disrupting fairness. This allows for more purposeful, meaningful changes to support the use of fair judgement in assessment in dynamic authentic clinical workplaces.

Objective Adhesive capsulitis is a common painful shoulder condition. Treatment for the condition remains unsatisfactory. Suprascapular nerve block (SSNB) shows promise as a treatment option for adhesive capsulitis but there are no randomised controlled trials that examine its effect on pain or duration of the condition. The objective of this study was to examine the efficacy of SSNB for the management of adhesive capsulitis. Methods A randomised double-blind placebo-controlled trial of SSNB and standard therapy versus placebo and standard therapy was performed. In total, 54 patients were enrolled in the study. 27 patients received a glenohumeral joint (GHJ) injection and physiotherapy plus a 3-month SSNB, and 27 patients received a GHJ injection and physiotherapy plus a 3-month placebo injection. Patients were followed to resolution of their symptoms as measured by a combination of range of movement, pain scores, Shoulder Pain and Disability Index (SPADI) scores and perceived recovery scores. The primary outcome measure was time to resolution of symptoms. Results Participants who received the SSNB reduced the duration of their symptoms of adhesive capsulitis by an average of 6 months (mean time to resolution 5.4 (95% CI 4.4 to 6.3) months vs 11.2 (95% CI 9.3 to 13) months) in the placebo group. They also had reduced pain scores, improved range of movement and lower SPADI scores compared with the placebo group across all time points. Conclusion SSNB reduced the duration of adhesive capsulitis and resulted in improved pain and disability experience for patients. Trial registration number Australian New Zealand Clinical Trials Registry (ANCTRN 12615001378516).

Objective: This study was undertaken to determine the efficacy of ultrasound‐guided genicular nerve block (GNB) for the management of knee pain in patients with knee osteoarthritis.Methods: We performed a 12‐week parallel‐group, placebo‐controlled randomized trial of GNB. Within 2 weeks of randomization, patients with knee osteoarthritis in the active arm received 3 injections of 5.7 mg celestone chronodose (1 ml) and 0.5% bupivacaine (3 ml) to the inferomedial, superomedial, and superolateral genicular nerves; patients with knee osteoarthritis in the placebo arm received injections of normal saline. At baseline and at weeks 2, 4, 8, and 12, patients recorded their pain and disability on a 100‐mm visual analog scale (VAS) (the primary outcome measure), the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and the Intermittent and Constant Osteoarthritis Pain scale. Statistical significance was set at a 2‐sided Type I error of α = 0.0125 for comparisons at each of the 4 time points. We used a global perceived effect scale to measure patient satisfaction.Results: The 59 patients (36 female, 23 male) who completed the trial had a mean ± SD age of 68.2 ± 8.6 years. Patients in the active group reported improvements in pain scores at 2, 4, 8, and 12 weeks with a diminution of the effect over time. VAS scores at baseline and at weeks 2, 4, 8, and 12 in the active group (n = 31) versus placebo group (n = 28) were 6.2 versus 5.3 (P = 0.294), 2.7 versus 4.7 (P < 0.001), 3.2 versus 5.1 (P < 0.001), 3.9 versus 4.9 (P < 0.001), and 4.6 versus 5.1 (P = 0.055), respectively. Total WOMAC scores at baseline and at weeks 2, 4, 6, 8, and 12 in the active group versus the placebo group were 54.5 versus 48.1 (P = 0.177), 32.9 versus 44.4 (P < 0.001), 33.7 versus 45.8 (P < 0.001), 39.2 versus 44.8 (P = 0.001), and 42.65 versus 45.1 (P = 0.012), respectively.Conclusion: GNB offers short‐term pain relief for knee osteoarthritis.

Background: Frozen shoulder (adhesive capsulitis) is an inflammatory condition affecting the capsule of the glenohumeral joint. It is characterised by a painful restricted range of passive and active movement in all planes of motion. The impact of frozen shoulder on affected individuals remains poorly characterised. In this study we sought to better understand the lived experience of people suffering from frozen shoulder to characterise the physical, psychological and socioeconomic impact of the condition. Methods: A qualitative study using a phenomenological approach was undertaken. Purposeful sampling was used to identify individuals for interview. Semi-structured interviews were performed and continued until saturation was achieved. A biopsychosocial framework was used during the analysis in order to generate themes which best described the phenomenon and reflected the lived experience of individuals’ suffering from this condition. Results: Ten interviews were conducted, and five main themes emerged including; the severity of the pain experience, a loss of independence, an altered sense of self, the significant psychological impact, and the variable experience with healthcare providers. Conclusions: These findings offer an insight into the lived experience of individuals with frozen shoulder, both on a personal and sociocultural level. The pain endured has profound impacts on physical and mental health, with loss of function resulting in a narrative reconstruction and altered sense of self. Our findings illustrate that frozen shoulder is much more than a benign self-limiting musculoskeletal condition and should be managed accordingly. Trial registration: ANZCTR 12620000677909 Registered 28/04/2020 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379719&isReview=true