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Good afternoon, everybody. My name is Frankie. I'm just going to be introducing our speaker for the rheumatology workshop. So we have a doctor down here with us who is a consultant general pediatrician with an interest in pediatric rheumatology at Mid Yorkshire hospitals, which is Wakefield and Dewsbury. She has been a consultant for 10 years, training in Sheffield and the University of Leads. She's originally a southerner from Oxfordshire, but is an honorary Yorkshire woman after having business. And she was 18 outside of work. She is, um um And enjoying playing cello and 10 a horn in the grass. And so I can't imagine anyone else that we best suited to talk to us about rheumatology. So I'll hand over to your doctor severe whenever you're ready. Okay. Thank you. My my son, who is in the room, would like me to mention him just at the outset. So he's he's in the background, hopefully being very quiet, playing on his switch. No. Right. So forgive me if I get any other interruptions, but I shouldn't do so well, come this afternoon. Um, so I hope that you are all a little bit interested in pediatric rheumatology. and I'm going to make you more interested in pediatric rheumatology. So just to get you woken up and started up, if you can stick in the chat any conditions you think might be seen in pediatric rheumatology and you can think of the common and the obscure. Um, and obviously, I'll give you 10 3 points if you think of one that I haven't thought of. Yeah, I've got a JIA. It's a very good start. And SLE. Yep. Well done. Rheumatoid arthritis. Yeah. Anybody can come with, come up with an obscure one rattling your brains from medical school? No, not looking like Like it. Well, that's okay. I definitely Oh, well done. Vasculitis. Brilliant. So certainly I wouldn't have come up with many when I was, uh, what is now foundation. So don't worry. So these are the ones that I came up with, Um, so as as, uh, the first person came up with juvenile idiopathic arthritis, which is the most common condition that we look after. It's not necessarily the most common reason we see Children, but it's certainly the most common condition we would look after in the longer term. Um, and although we do have young people whose arthritis is similar to rheumatoid arthritis. We would always label it juvenile idiopathic arthritis if it presents before they're 16. The other very common things we see those are Children who have pains in their joints, and these are not inflammatory. So things like growing pains. We would label those mechanical joint pains. And we also see a lot of Children young people who are hyper Mobil, and they get problems from that. Lots of people who are hyper Mobil don't get problems, and they're very successful gymnasts and things. But some young people and adults will struggle because of being hyper Mobil, and then we get these more obscure ones. So Lupus, systemic Lupus erythematosus has mentioned dermatomyositis even rare risk systemic sclerosis. Bechet is something called C. R M O, which you may not have heard of, which is a chronic, recurrent multifocal osteomyelitis, which is not an effective but inflammatory osteomyelitis. There are some very rare and complex autoinflammatory conditions which have genetic basis, but the genetics haven't all been discovered yet, so it's a growing field, and then we're often involved in looking after the young people who have uveitis even if they haven't got associated joint problems because of the the therapies that we can use. And then you may have come across since coded Something that's been labeled as Pimm's in this country, anyway. Has a slightly different name in in America, but it's a pediatric, multi system inflammatory response, which we've seen as a result of cove ID. So that's just giving you an idea of of the wide range of things that we do see which I think. Outside of pediatric rheumatology, people often don't think there are very many conditions that we should be worrying about. So then coming on to who does pediatric rheumatology. So, as I said, I'm a general pediatrician. Uh, and I have an interest in pediatric rheumatology. But in tertiary centers, um, my local tertiary center would be leads. And Sheffield there were. There are full time pediatric rheumatologists, and in a lot of district general hospitals, there are adult rheumatologists who have an interest in Children. Young people. So, um, these we can work together. So how do you get up to that point? So to be somebody like me. I did general pediatric training, and I had a little bit of experience during my training, but not a lot. Um, but it's variable. You could you could have a lot of experience or a little experience. Uh, I've developed most of my expertise since becoming a consultant. We do, at the moment have something called spin training, which you might have heard of mentioned earlier in the day, which is a specialist interest training that you can do alongside your general pediatric training to give you, um, some extra qualifications. Uh, and there's going to be some changes with our new curriculum so that you will have something called credentials in A in a particular specialty and that can be gained either before you become a consultant or afterwards, um, and to become a pediatric rheumatologist who works in a specialist center. For the moment, what our trainees do is something called grid training, and that's usually in the last two years of their training, where they would work solely in a tertiary pediatric rheumatology department, and they will often work in two different units over that time to get the right experience and then the adult rheumatologists. They don't really have any training as part of their adult rheumatology training. It's again something that they might pick up, um, and sort of demonstrate an interest and start to develop that expertise. So what's what's a day in the life of a pediatric rheumatologist? So this is more a day in the life of a tertiary pediatric rheumatologist, and I work alongside my colleagues in lead, So I have an idea of what their day in the life is. This is not particularly my day in the life, so the majority of our work in pediatric rheumatology is without patients, so we have a lot of MG t work going on. There are usually specialist nurses and specialist physiotherapists and occupational therapists working alongside the team. In a lot of units, there will be psychologists. If they're fortunate, they will also have youth workers. And then we work very closely with ophthalmologists, renal physicians, dermatologists, immunologists, orthopedic surgeons. And there is some important transition work because a lot of the Children young people who have our Children's arthritis, all these other conditions will be going on into adulthood with those conditions, and so yeah, so we would be doing outpatient clinics. Most units will only have a few in patients at any one time because the majority of the conditions we look after do not require Children to be in hospital. They are not that sick most of the time, but occasionally there are some. The pediatric dermatologists would also be doing joint injections, and that's a very important part of treatment for Children's arthritis. We also need to prescribe quite complex medications. So disease modifying drugs such as methotrexate, mycophenolate and, uh, azathioprine, and also more and more. There are more and more of these biologic therapies coming on the market. Um, in adult rheumatology, you will see that there are, I don't know, you certainly probably 20 plus of them in pediatrics. We are slower to take these on, but but we still are using probably around 10 different ones nowadays. So and those are becoming more and more tailored, and in the future it's likely that we'll be able to tailor the right person to the right biologic therapy. Because of these rapidly changing therapies. There is quite a lot of research going on in the pediatric dermatology world, and we have registries for these drugs so that we can be monitoring what problems there are and what the outcomes for the for the Children and young people are. The pediatric neurologists in the in the Tertiary Center would be giving spending quite a bit of time giving advice to people like myself in the District General Hospitals, Um, and that there was a sudden increase of that with Pimm's during coated, I think very, uh, something that the pediatric neurologists were very unused to being wrong. I think every single night they were, uh, you know, they would often do an on call week because usually they wouldn't be called very much in the wrong call. And that suddenly changed to being called every night, uh, changed how they had to work as well. So it's although it can be a much more daytime type specialty, things can throw a standard into the works, and then we tend to work in networks. So in in West Yorkshire, we have a network with the leads team, and we can have meetings and share learning from cases and ask questions from each other and also share learning in terms of management because sometimes we run into difficulties with prescribing these drugs and the funding for that. So we need each other's help to arrange that. Um, so that's that's the day in the life, Really? So what do our patients look like? Clearly, they don't all look like these cartoons, but this is really just to show you that they come in all shapes and sizes. So we do look after little babies. Some of these rare auto inflammatory conditions can present in in neonatal in the neonatal period. The majority of our patients are not babies. Um, we do have quite a lot of Children who are present with their first episode of arthritis as a toddler. Uh, and then we have a lot of adolescents, particularly the other rarer things, like Lupus and vasculitis, um are more likely to present from adolescents onwards. So we need to be able to look, look, after all, all types of patients really with in pediatrics. So what skills do we need? Well, as in most things in pediatrics, we need to be able to take history. Well, we need to be able to listen to the the young person and their family, and we need to be able to communicate about treatments. We need to have the family on board because some of the treatments are quite difficult to cope with. A lot of them are injections. Some of the methotrexate injections, some of the biologics are injections, and they often have joint injections several times over there over their childhood. Um, so clearly that can like we can run into difficulties. With that, we need to be able to examine the musculoskeletal system. And I think a lot of us in pediatric rheumatology feel that that's quite neglected in the rest of of medicine, really, people often don't do a musculoskeletal examination unless they're specifically looking for a musculoskeletal problem. Whereas we we would often listen to the heart and lungs of a child no matter what they came with. Um, and there is a move to try and change that, but it's not really getting very far. It's quite an easy thing to examine once you've had practice, Um, so if you are wanting to stand up and move about, it's a good idea just to do your gals and get it, get your body moving. I certainly probably move a lot in my clinics compared to my colleagues, by doing a P gals nine times over in an afternoon, um, practical skills. So I don't personally do joint injections as a general pediatrician with an interest in rheumatology, because I probably wouldn't do enough to maintain those skills. And I haven't I haven't been trained, but the tertiary pediatric dermatologists would be doing those very frequently. And some of the specialist nurses are also trained to do joint injections again, similarly to lots of other specialties. We need to have good management and leadership skills because we're working in teams. Um, and we're communicating with other specialties, and we've often got to organize some investigations and organize meetings. Multidiscipline meetings and things and research skills are useful because, as I said, a lot of these therapies are changing quite rapidly. So just a bit more personally, why did I choose it and why do I enjoy it? So as as I was introduced, I'm primarily a general pediatrician and I didn't go into pediatrics to become a pediatric rheumatologist. I like all aspects of pediatrics, and I'm a little bit rare. I do neonate as well as a general pediatrics, um, as well as rheumatology. So I'm a bit of a jack of all trades but I But I enjoy my rheumatology bit because of the the relationships I can build with Children and families for many years. Most of the time they are relatively well. Um, they obviously do have relapses, and they can be difficulties for all sorts of reasons along the way. But it's it's a really nice you get, really get to know families, and therefore, when the difficulties are, they're usually that's been, you know, it's beneficial to have already developed that relationship. As I said, we look after all ages. I love looking after toddlers. I love looking after babies but equally enjoy it, sort of seeing young people mature, particularly when they transition on to my colleagues, who I work closely alongside in the adult world. It's it's really nice to see, so it's really good variety. From that point of view, we do have very few emergencies, and although I'm a general pediatrician and I cover acute um and neonate, I'm not a great fan of being in recess, so I would always choose to not be with an emergency if I can get away with it. But, um so that's again the benefit, I would say of this specialty, but we occasionally do have some very sick Children. Young people. For me, geography was important as to why I work where I work. So, as I said, I'm a, um, an honorary Yorkshire woman. I was very keen. Just once I come to Yorkshire just to stay here, and I wanted a job in Wakefield because I'd already met the team, and I really liked them. So actually, it happened that there was a job coming up for somebody with an interest in rheumatology. I had a little bit of an interest, but I was willing to take that on and develop more of an interest. So I would say, if you're interested in pediatrics right now, you don't need to know where you're going with in pediatrics. Um, and you don't need to have decided by the end of your training, you can decide that afterwards. Um, a lot of places we have a lot of district hospitals like where I work. We need general pediatrician's who can do a few different things and and take on responsibilities and develop them. You don't need to be fully fledged when you get that consultant job and As I said, I've I've developed some really good relationships with my adult dermatology colleagues. I do clinics with two adult rheumatologists twice do them twice a month, and we can really learn from each other. And I think they have a different view of of kind of medicine than we do in pediatrics. Feel quite protected from the rest of the world. So I was I was really able to sort of hear from them how things were when when coated was was really difficult. They had a whole different, um, you know, set of things I'm sure that you will have many of you would have had to deal with than I did in Pediatrics. And also ophthalmology work quite closely with those as well. So I would say it's outside of my own specialty. I've made some really good, um, relationships, So just summarizing what the good bits and what are the trickier bit? So I would say the variety of types of patients and type of conditions I see makes it a really interesting job. We generally are looking after, well, Children and young people. Um, it's a smaller specialty, so it's easier to know everybody in the sort of network that you're working, there are rapidly changing treatment options, things again of moving quite fast. I think only, say, 30 years ago, when I was yeah, before I became a student. But when I became a student, treatment for Children's arthritis was really very poor. Children were going on to be living with significant deformities for most of your adult life because of Children's arthritis, whereas the majority of Children now will. You will not know that they've got arthritis when you see them in school or in college, and they will not develop deformities. So it has really, really improved. Um, there are National International Conference is that you can attend and and speak at, um and say it's still a small specialty. So you get to know everybody kind of nationally relatively quickly as well, a trigger point of view. And we do use complex medications. Um, certainly for myself working in a district hospital, I'm the only person who's prescribing methotrexate regularly, and and although I don't prescribe the biologic therapies, I think in the next 10 20 years time it's likely that I will do because they will become so much More important, we do have some very complex conditions. So that can mean liaising with centers not just in leads, but often with bigger centers. Say in in London, uh, getting opinions from lots of different people and often, you know, cross with other specialties as well. And sometimes it can be a bit difficult working in a district hospital with a small because it's a smaller specialty. So there's less support. I don't have access to a psychologist. Where is my colleagues in leads would do. And I don't have specialist nurses that my colleagues in leads would do. So it sort of Sometimes it feels like you know, you you could definitely do better if you were working in a bigger center. So just, uh, this is just a brief case of just a very sort of run of the mill, uh, situation that I would come across, but it's quite a memorable for one for me. Um, so this is a case of twins, and, uh, it was one of the first Children that I diagnosed with arthritis as a consultant. So a three year old girl was seen in our assessment unit with a swollen right knee. At the time, she was otherwise well, and it was apyrexia. Well, the team did some bloods, as I would expect them to for blood counts. Er p e s are. And they were all nice and normal. And she was discharged with a diagnosis of a reactive arthritis with a plan to review her in two weeks time in the clinic. So she was brought back to the clinic. Two weeks later, she still had that swelling to her right knee. But now her dad had mentioned that she didn't seem to want to use her left hand hand as much as she would normally. So, you know, on examination, she did have reduced range of movement of her left wrist with swelling and restriction of her right knee. So she was then referred onto me as a likely juvenile idiopathic arthritis. I saw her and then referred her onto the tertiary center that she could have her joints injected and she was commenced on methotrexate. And then three months later, her dad rang me and said her twin sister has got a swollen ankle. Could I have a look? Um, and I agreed. It did look like she had arthritis as well. So she had a joint injection, and it's not. It's definitely not a simple court case, but I'm just summarizing you that eight years later, um, twin l has been, has had a really stormy course with treatment with methotrexate on and off had eliminated one of the biologics on and off. She's now going on to a different biologic tocilizumab, whereas her twin after that first joint injection has been absolutely fine. Um, even even initially, when the twins sort of both had arthritis, I thought that was quite unusual. But the fact that they've then had this very different course has been quite strange. Obviously, there's still at risk that H Will will develop some further arthritis at some point, but so far has been much luckier. But this is a family that I know very well. They've been difficulties with keeping. The blood is being monitored difficulties with injections, um, difficulties with attending appointments. But we still have a good relationship with the family. Um, so it just shows you how you can get to know somebody, and and really, um, keep in touch. And this certainly is likely that I will in another four years time. These these at least at least two in l will be moving onto my adult colleagues. Um, and I would have known her most of her childhood. Okay, so I hope that's given you a bit of a picture of what pediatric rheumatology is like. And has anyone got any questions? Thank you so much stuff to do before giving that talk. Pediatric rheumatology in general, I'm giving a flavor of what it encompasses and what the special specialty is about. Um, does anyone have any questions? Please feel free to drop it in the chat box and we can go through them. Um, I have a quick question. If that's okay, doctor dot How do you find in terms of the transition of those that are that have, like, arthritis in teenagers and transitioning them into adult care? Uh, do you do you continue treating them as they go into a young adult phase and then let them go into the adult world? Or how does that usually work? It's extremely variable throughout the country. Um, so there's, uh, kind of this, I suppose, in an ideal, in an ideal everywhere would have an adolescent rheumatologist who has a separate clinic and, um, Sheffield. There may be other centers that do, but I know very well that that Sheffield is the closest one to me that does. They have a very, very well set up adolescent clinic where young people would transition into the adolescent clinic between 14 and 16. They remain in the adolescent clinic from between sort of 16 to 25 ish, and then they transition into the adult clinic between 24 to 26 ish, Um, and it's a whole different ballgame. The clinics are in the evenings. They can bring parents with them, but they are, You know, they are with their scene alone initially, and then they can bring their parents in. They they have a good team of specific nurses for that link to that clinic who can youth workers and be going on the particular kind of youth type issues. They're very good at making sure when young people are going to university that they're still got links in the right places. But that is an ideal that unfortunately, most places haven't managed to live up to. I we I feel that our unit's works relatively well because the two rheumatologists I work with one in Wakefield and one in juice Berry, um, they they would see all the the the young adults. So when they move from my clinic so that it's that one particular rheumatologist who they've already got to know in in the Children's clinic. Um, but we, unfortunately, our trust maintains that they must move pretty soon after their 16th birthday. So so there, Whether they're ready or not, they have to kind of go. But at least they have got to know that that person, um, I think in other in other places where they haven't got an adult rheumatologist working, they might have one clinic where they have a joint clinic with the adult rheumatologist to get to meet them. And then that's it. And that's that's probably the least ideal or yeah, obviously not meeting at all at least ideal. But that's there is. There is still a lot of variation throughout the country. Oh, okay. Thank you. I think level also asking, Is there an exam you have to do as part of the training to become a rheumatologist? Um, and also as a grid registered there are a lot of out of ours work in rheumatology. Specifically. Okay, so? So there isn't There isn't an exam for grid training for any of the grid training. Um, in pediatrics. So So there are There are grades in most of the specialties, which you have to apply to, um, usually in sort of ST will be S t 45. Uh, so you would apply. And you have to have get through an interview process and and have quite a good CV already if you get onto your grid post. Actually, there's lots of work you have to do to demonstrate that you've got that training with your competencies. But there's no exam in terms of out of ours work. You would, you would most in most places, you're still probably doing out of ours work along on a general pediatric rotor. Um, so it's so it's Yeah, it's not really any different from being a general pediatric training in that. In that sense and how much of your week is spent on rheumatologist, you've asked as well. So that would be again, um slightly variable. Most most places would be completely daytime would be rheumatology. But some But you may well still have to do nights when you're doing general pediatrics. So obviously that takes away from your daytime weeks, but yeah, so probably it's more like 80% in total. In some places, some places might achieve 100% rheumatology. Martha, Martha has a question about how did you specifically develop your special, um, interest post CCT with the opportunities for you to shadow or you learn mostly on the job? Um, yeah. It was mainly learning on the job. I was I sort of I did meet up with the one of the tertiary rheumatologists. Um, and I did go to a couple of their clinics, um, sort of, yeah, separately from from my own. But I had to sort of pretty much start my own clinics at day one as well. So I was just basically discussing far more with the tertiary center than I am now. 10 years later, Um uh, and and and really, I remember feeling very one of my colleagues who is now retired, who was much more senior than me, who I value highly had came to ask my opinion when I was only, you know, had only been there for a year, and I was just sort of how possibly can you ask my opinion on rheumatology? I hardly, you know, whereas at least 10 years down the line, I feel like an offer. A sensible opinion. But yeah, it was very much learning on the job with a bit of with Yes, with help from my colleagues in the in the tertiary center. Thank you so much again, Dr. Oh, that's wonderful. And thank you for answering all those questions. Um oh, I think there's Well, there's another few going through. Uh, I think there's a question on Oh, yeah, yeah, yeah. That would be if you were doing a pediatric rheumatology grid. Know if you were doing general pediatrics with an interest, uh, it would be hugely variable. I would say you would probably manage. Um, well, you probably would manage to do a six month post where you were doing primarily rheumatology in the daytime, but I would I would only be a six month post in the whole of your training rather than rather than every job. And Martha variety. What drew me towards having multiple roles? Um, I just like like everything apart from endocrine, I would say my that, um how does it compare? Uh, well, yeah, I just Yeah, I get a variety there you get. Especially people. People's. You're suited to different things, aren't you? And I I find I'm just suited to doing a bit of everything. Uh, how much impatient work does the pediatric neurologists have? Uh, so it's It's pretty small, I think, Um, they will be only like, between zero and three patients in a in A in a Children's hospital, like a tertiary Children's hospital at any one time. When I certainly was doing my training in Sheffield, I think there was yeah, one or two at the most. I think, um, I think that's that's all for today. At the moment, I think we probably need to go for for a break. But oh, actually, no, that's good. Um, um, he was asking whether there any other specialist that you work closely with you mentioned ophthalmology. Is that right? Yeah. Apology. Um, it's probably the closest because of the uveitis treatment with biologics, and they are not often happy themselves to be prescribing things like methotrexate and biologics. Uh, but I would say Yeah. Children with SLE. Obviously, renal team very involved. The Children with the auto, auto inflammatory conditions and the periodic fevers. The immunologists are usually very involved. So it Yeah, it varies. Um, And then some things, like my I've got a young person with rashes. He sees an awful lot of specialists. So So, yeah, it can be Yeah, with the gastroenterologist. Sometimes Children with inflammatory bowel disease can have joint problems as well. So yeah, I think we Yeah, we mix up a lot. Very multi system. Yeah. Thank you again. That's wonderful. Thanks again dot Okay. I think right now, I'm going to go for a break. But thank you again for that. Answering all our questions of rheumatology. Um, we're just going to go for a break. Now, I think if people want to come back at four o'clock to directly to their sessions, whichever one you want to go to, it's still another through workshops that you have an option to. It's either emergency medicine, intensive care or respiratory. You can join them at four o'clock. And I hope you will have a good break and thank you again for your time.