Everyday Medicine with Dr Luke

Clinical problems related to the integument are very common and contribute up to 15% of all general practitioner presentations. Humans are predisposed to a multitude of skin diseases ranging from acne and atopic dermatitis to psoriasis, autoimmune diseases such as SLE, vasculitis, skin cancers, viral exanthems, drug eruptions and external manifestations of internal disease - which in the gastroenterology world have erythema nodosum and pyoderma gangrenosum as interesting examples of these. Given our love affair with the sun it’s not surprising to learn that skin cancer will affect 2 in 3 Australians in their lifetime. About 2000 Australians die each year from melanoma and non-melanoma skin cancer - 800 more than the number of people dying from car accidents annually in Australia bringing into perspective the impact of this disease alone. Inflammatory skin diseases such as acne and eczema are also very common. They are a cause of serious morbidity, both physical as well as psychological – a child with severe eczema has a burden of disease that is worse than a child with diabetes. Have you ever had itchy skin? This is one of the most distressing symptoms one may experience.The mental health issues of patients with skin disease can be severe. A recent meta-analysis of patients with alopecia areata for example found that up to 17% of those patients required professional help for symptoms of anxiety and depression. A skin problem is very visible and yet, in the hierarchy of “medical student teaching” – dermatology is treated almost as an optional extra. In recent years advances in skin management have been significant especially following the discovery of TNF inhibitors such as Adalimumab used in dermatology for moderate to severe psoriasis as well as in both rheumatology and gastroenterology. In this podcast I was curious to learn more about dermatological management, the new horizons of treatment, possible role for AI in assisting diagnosis as well as to be reminded of key tips that would be useful in primary care. It was a real honour to discover Melbourne dermatologist Dr Alvin Chong, founder of an internationally acclaimed podcast called Spot Diagnosis that has been ground-breaking in bringing the specialty of dermatology to general practice and medical students. Alvin has established himself as a key educator in this field and has received accolades from the RACGP recognising his achievements and contribution to education. Alvin has public appointments as Visiting Dermatologist and Director of Dermatological Education at St Vincent’s Hospital Melbourne and Head of Transplant Dermatology Clinic at Skin Health Institute. He is Adjunct Associate Professor at the University of Melbourne. Please welcome Alvin to the Podcast. References: Dr Alvin Chong ⁠http://spotdiagnosis.org.au/⁠ ⁠https://www.skinhealthinstitute.org.au/page/370/spotdiagnosis⁠

Clinical problems related to the integument are very common and contribute up to 15% of all general practitioner presentations. Humans are predisposed to a multitude of skin diseases ranging from acne and atopic dermatitis to psoriasis, autoimmune diseases such as SLE, vasculitis, skin cancers, viral exanthems, drug eruptions and external manifestations of internal disease - which in the gastroenterology world have erythema nodosum and pyoderma gangrenosum as interesting examples of these.

Given our love affair with the sun it’s not surprising to learn that skin cancer will affect 2 in 3 Australians in their lifetime. About 2000 Australians die each year from melanoma and non-melanoma skin cancer - 800 more than the number of people dying from car accidents annually in Australia bringing into perspective the impact of this disease alone.

Inflammatory skin diseases such as acne and eczema are also very common. They are a cause of serious morbidity, both physical as well as psychological – a child with severe eczema has a burden of disease that is worse than a child with diabetes. Have you ever had itchy skin? This is one of the most distressing symptoms one may experience.The mental health issues of patients with skin disease can be severe. A recent meta-analysis of patients with alopecia areata for example found that up to 17% of those patients required professional help for symptoms of anxiety and depression.

A skin problem is very visible and yet, in the hierarchy of “medical student teaching” – dermatology is treated almost as an optional extra. In recent years advances in skin management have been significant especially following the discovery of TNF inhibitors such as Adalimumab used in dermatology for moderate to severe psoriasis as well as in both rheumatology and gastroenterology.

In this podcast I was curious to learn more about dermatological management, the new horizons of treatment, possible role for AI in assisting diagnosis as well as to be reminded of key tips that would be useful in primary care.

It was a real honour to discover Melbourne dermatologist Dr Alvin Chong, founder of an internationally acclaimed podcast called Spot Diagnosis that has been ground-breaking in bringing the specialty of dermatology to general practice and medical students. Alvin has established himself as a key educator in this field and has received accolades from the RACGP recognising his achievements and contribution to education.

Alvin has public appointments as Visiting Dermatologist and Director of Dermatological Education at St Vincent’s Hospital Melbourne and Head of Transplant Dermatology Clinic at Skin Health Institute. He is Adjunct Associate Professor at the University of Melbourne.

Please welcome Alvin to the Podcast.

References:

Dr Alvin Chong

http://spotdiagnosis.org.au/

https://www.skinhealthinstitute.org.au/page/370/spotdiagnosis

From the RACGP Health of the Nation report; depression, anxiety, and sleep disturbances are amongst the most commonly seen presentations of mental disorders in general practice. About 1 in 8 people in the world live with a mental disorder which often involves significant disturbances in thinking, emotional regulation, or behaviour.

Globally it is estimated that 5% of adults suffer from depression, affecting women a little more than men.

Anxiety disorders affect a similar number of people, characterised by excessive fear, and worry and related behavioural disturbances.

Bipolar disease is characterised by periods of depressive episodes alternating with periods where manic symptoms prevail. Affecting less than 1 % of the population, suicide risk is increased.

Addiction disorders embrace a long list of destructive habits. Post traumatic stress disorder (PTSD), schizophrenia, disruptive behaviour, and dissocial disorders as well as neurodevelopmental disorders are amongst the many conditions presenting clinically and often requiring psychiatric assessment.

I was also interested to discover more about the adverse effects of social media on teenage and young adults’ mental health and in this podcast, and was curious to explore some of the mental health conditions presenting commonly in primary practice and to understand the place of therapies available. It was a privilege to interview psychiatrist Dr Usman Riaz for this episode.

Dr Muhammad Usman Riaz is a fellow of The Royal Australian and New Zealand College of Psychiatrists and has sub-specialised in addiction psychiatry. He Holds a Master of Public Health with a major in Occupational Health and Safety from Monash University and Master of Psychiatry from the University of Melbourne. He is Director of Medical Service at The Langmore Centre in Berwick operated by St John of God Hospital. Please welcome Usman to the conversation.

REFERENCES:

Dr Usman Riaz-www.sjog.org.au

World Health Organization-Mental Disorders. Who.int

Selective Serotonin Reuptake Inhibitors-Stat Pearls www.ncbi.nlm.nih.gov

⁠www.beyondblue.org.au⁠

From the RACGP Health of the Nation report; depression, anxiety, and sleep disturbances are amongst the most commonly seen presentations of mental disorders in general practice. About 1 in 8 people in the world live with a mental disorder which often involves significant disturbances in thinking, emotional regulation, or behaviour.

Globally it is estimated that 5% of adults suffer from depression, affecting women a little more than men.

Anxiety disorders affect a similar number of people, characterised by excessive fear, and worry and related behavioural disturbances.

Bipolar disease is characterised by periods of depressive episodes alternating with periods where manic symptoms prevail. Affecting less than 1 % of the population, suicide risk is increased.

Addiction disorders embrace a long list of destructive habits. Post traumatic stress disorder (PTSD), schizophrenia, disruptive behaviour, and dissocial disorders as well as neurodevelopmental disorders are amongst the many conditions presenting clinically and often requiring psychiatric assessment.

I was also interested to discover more about the adverse effects of social media on teenage and young adults’ mental health and in this podcast, and was curious to explore some of the mental health conditions presenting commonly in primary practice and to understand the place of therapies available. It was a privilege to interview psychiatrist Dr Usman Riaz for this episode.

Dr Muhammad Usman Riaz is a fellow of The Royal Australian and New Zealand College of Psychiatrists and has sub-specialised in addiction psychiatry. He Holds a Master of Public Health with a major in Occupational Health and Safety from Monash University and Master of Psychiatry from the University of Melbourne. He is Director of Medical Service at The Langmore Centre in Berwick operated by St John of God Hospital. Please welcome Usman to the conversation.

REFERENCES:

Dr Usman Riaz-www.sjog.org.au

World Health Organization-Mental Disorders. Who.int

Selective Serotonin Reuptake Inhibitors-Stat Pearls www.ncbi.nlm.nih.gov

www.beyondblue.org.au

Over the past decade there has been an emergence of literature pointing to potential clinical benefits for a range of disease states through the adoption of slow breathing techniques. The popularity worldwide of the Wim Hof method adopted from eastern techniques has done much to pique interest.

Notably the belief and practice of controlling one’s breath to both restore and enhance health is not new however and has been practised for thousands of years amongst Eastern cultures. Pranayama or Yogic breathing as well as Kundalini are well-known ancient practices of controlled breathing and exists in various forms often in conjunction with meditation.

A system of breathing developed in the 1900s by the Ukranian doctor Konstantin Buteyko claimed to successfully treat patients diagnosed with respiratory and circulatory disease possibly through reducing ventilatory dead space, increased tidal volume and by inducing favourable effects on the autonomic nervous system. Practised slow nasal breathing has been shown to extract 20 % more oxygen from each breath enhancing athletic performance.

Slow and controlled breathing through the nose with a respiration rate of between 6 and 10 per minute appears to be optimal for enhancing the Bohr effect. Getting there requires practice and adoption of nasal breathing techniques. The latter also delivers more Nitrous oxide, an important vasodilator which in relation to this subject is produced by the paranasal sinuses. Nasal breathing also filters and humidifies the air we breathe.

In this podcast I was interested to explore this fascinating subject with breathing expert, physiotherapist and snow skier Mr Allan Abbott. Allan has broadened his expertise with qualifications in physical education, ergonomics and acupuncture. He runs numerous seminars on breathing for performance including Athletes Master Classes incorporating high altitude training through his company Health Innovations Australia and has established the “Breathe Light Breathe Right” as well as the ‘Sleep Well be Well” programs.

Allan subscribes to a notion that breathing, sleep, diet, exercise and mindfulness are the major components to optimal health. Please welcome Allan to the podcast.

References:

Mr Allan Abbott.oxygenadvantage.com and ⁠www.healthinnovations⁠ .net.au

Breath- The New Science of a Lost Art. Penguin Books. July 20,2021.James Nestor

The Physiological effects of slow breathing in the health human. Russo et al. ⁠www.ncbi.nlm.nih.gov⁠

How Breath-Control Can Change Your Life : A systematic review on Psycho-Physiological Correlates of Slow Breathing. Zaccaro et al.2018. www.frontiersin.org.

Over the past decade there has been an emergence of literature pointing to potential clinical benefits for a range of disease states through the adoption of slow breathing techniques. The popularity worldwide of the Wim Hof method adopted from eastern techniques has done much to pique interest.

Notably the belief and practice of controlling one’s breath to both restore and enhance health is not new however and has been practised for thousands of years amongst Eastern cultures. Pranayama or Yogic breathing as well as Kundalini are well-known ancient practices of controlled breathing and exists in various forms often in conjunction with meditation.

A system of breathing developed in the 1900s by the Ukranian doctor Konstantin Buteyko claimed to successfully treat patients diagnosed with respiratory and circulatory disease possibly through reducing ventilatory dead space, increased tidal volume and by inducing favourable effects on the autonomic nervous system. Practised slow nasal breathing has been shown to extract 20 % more oxygen from each breath enhancing athletic performance.

Slow and controlled breathing through the nose with a respiration rate of between 6 and 10 per minute appears to be optimal for enhancing the Bohr effect. Getting there requires practice and adoption of nasal breathing techniques. The latter also delivers more Nitrous oxide, an important vasodilator which in relation to this subject is produced by the paranasal sinuses. Nasal breathing also filters and humidifies the air we breathe.

In this podcast I was interested to explore this fascinating subject with breathing expert, physiotherapist and snow skier Mr Allan Abbott. Allan has broadened his expertise with qualifications in physical education, ergonomics and acupuncture. He runs numerous seminars on breathing for performance including Athletes Master Classes incorporating high altitude training through his company Health Innovations Australia and has established the “Breathe Light Breathe Right” as well as the ‘Sleep Well be Well” programs.

Allan subscribes to a notion that breathing, sleep, diet, exercise and mindfulness are the major components to optimal health. Please welcome Allan to the podcast.

References:

Mr Allan Abbott.oxygenadvantage.com and www.healthinnovations .net.au

Breath- The New Science of a Lost Art. Penguin Books. July 20,2021.James Nestor

The Physiological effects of slow breathing in the health human. Russo et al. www.ncbi.nlm.nih.gov

How Breath-Control Can Change Your Life : A systematic review on Psycho-Physiological Correlates of Slow Breathing. Zaccaro et al.2018. www.frontiersin.org.

The first fleet comprised of 11 ships and 1420 people arrived in Australia’s Botany Bay under the command of Captain Arthur Phillip in January 1788 after an 8-month journey from Portsmouth. On the voyage there were 48 deaths and 28 births but no recorded serious illnesses such as smallpox or tuberculosis. The colonists subsequently resettled in port Phillip Bay and quickly had to learn to adapt to an environment that was as foreign to them as it must have been for the local indigenous population of aboriginals who made first contact with these white skinned strangely dressed travellers.

Many of the settlers first crops failed and stock brought with them aboard either died, absconded, or were eaten necessitating an early call for help to replenish dwindling supplies.

This initial lack of nutrition jeopardised the viability and success of the newly forming colony. Second and third fleets arrived in 1790 and 1791.

The illnesses and medical conditions that early colonial Australians faced has interested me for some time and after hearing a very interesting radio conversation with historian and constitutional lawyer Professor Chris Reynolds I was honoured to have him join our conversation exploring this subject further.

Chris has completed an excellent history of early colonised Australia called What a Capital Idea - Australia 1770-1901 available from Reynolds publishing (link in the show notes below). What a Capital Idea is essential reading for anyone interested in this period of Australian settlement, carefully researched, and written in colourful prose it affords an intimate familiarity with many famous characters, explorers, and events over those years.

My curiosity for colonial medicine extended to enquire about the nutritional health concerns encountered by early colonists, how water was purified, and how adequate balanced meals could be provided in a new foreign land. I was also fascinated to learn of the smallpox epidemic of 1789 which was devastating to our indigenous first AUSTRALIANS.

Further diseases such as tuberculosis, measles, influenza, and STD’s all earn mention. Alcoholism was a very significant problem amongst colonists as it remains in some quarters today but to a much lesser extent with our rigorous regulations around brewing and distribution. We discuss the medical problems encountered on our goldfields during the madness of the goldrush days in the 1850’s where dysentery was rife and food hygiene extremely poor. Indeed, William Howitt writing from the goldfields at that time where up to 1000 sheep were being slaughtered each day… “They are in their millions all over the country, they cover your horses, your load and yourselves, at your meals in a moment, myriads come swooping down, cover the dish and the meat on your plates till they are one black moving mass……”. It’s easy to imagine how disease spread quickly in that environment.

Leaving gold fever aside, first nations people had survived in Australian conditions for thousands of years coping with illnesses and climatic hardship so what if anything have, we learned in a medical sense from the indigenous people?

Chris Reynolds completed his PhD and Masters degrees at Americas Claremont Graduate University and has held appointments as Senior Professional Staff with both the United States Senate and House of Representatives. He has held several executive roles with NSW government including Executive Director of the World Trade Centre, Sydney. He has worked as a schoolteacher, University professor and political strategist and has applied his breadth of knowledge and experience to writing What a capital Idea-Australia 1770-1901.

Please welcome Professor Chris Reynolds to the podcast.

References:

What a Capital Idea- Australia 1770-1901. Christpher Reynolds. Reynold Learning. www.Reynoldlearning.com

Medicine in Colonial Australia,1788-1900, MJA,7 July 2014

Illness in Colonial Australia. Smith FB, Melbourne: Australian Scholarly Publishing, 2011

The first fleet comprised of 11 ships and 1420 people arrived in Australia’s Botany Bay under the command of Captain Arthur Phillip in January 1788 after an 8-month journey from Portsmouth. On the voyage there were 48 deaths and 28 births but no recorded serious illnesses such as smallpox or tuberculosis. The colonists subsequently resettled in port Phillip Bay and quickly had to learn to adapt to an environment that was as foreign to them as it must have been for the local indigenous population of aboriginals who made first contact with these white skinned strangely dressed travellers.

Many of the settlers first crops failed and stock brought with them aboard either died, absconded, or were eaten necessitating an early call for help to replenish dwindling supplies.

This initial lack of nutrition jeopardised the viability and success of the newly forming colony. Second and third fleets arrived in 1790 and 1791.

The illnesses and medical conditions that early colonial Australians faced has interested me for some time and after hearing a very interesting radio conversation with historian and constitutional lawyer Professor Chris Reynolds I was honoured to have him join our conversation exploring this subject further.

Chris has completed an excellent history of early colonised Australia called What a Capital Idea - Australia 1770-1901 available from Reynolds publishing (link in the show notes below). What a Capital Idea is essential reading for anyone interested in this period of Australian settlement, carefully researched, and written in colourful prose it affords an intimate familiarity with many famous characters, explorers, and events over those years.

My curiosity for colonial medicine extended to enquire about the nutritional health concerns encountered by early colonists, how water was purified, and how adequate balanced meals could be provided in a new foreign land. I was also fascinated to learn of the smallpox epidemic of 1789 which was devastating to our indigenous first AUSTRALIANS.

Further diseases such as tuberculosis, measles, influenza, and STD’s all earn mention. Alcoholism was a very significant problem amongst colonists as it remains in some quarters today but to a much lesser extent with our rigorous regulations around brewing and distribution. We discuss the medical problems encountered on our goldfields during the madness of the goldrush days in the 1850’s where dysentery was rife and food hygiene extremely poor. Indeed, William Howitt writing from the goldfields at that time where up to 1000 sheep were being slaughtered each day… “They are in their millions all over the country, they cover your horses, your load and yourselves, at your meals in a moment, myriads come swooping down, cover the dish and the meat on your plates till they are one black moving mass……”. It’s easy to imagine how disease spread quickly in that environment.

Leaving gold fever aside, first nations people had survived in Australian conditions for thousands of years coping with illnesses and climatic hardship so what if anything have, we learned in a medical sense from the indigenous people?

Chris Reynolds completed his PhD and Masters degrees at Americas Claremont Graduate University and has held appointments as Senior Professional Staff with both the United States Senate and House of Representatives. He has held several executive roles with NSW government including Executive Director of the World Trade Centre, Sydney. He has worked as a schoolteacher, University professor and political strategist and has applied his breadth of knowledge and experience to writing What a capital Idea-Australia 1770-1901.

Please welcome Professor Chris Reynolds to the podcast.

References:

What a Capital Idea- Australia 1770-1901. Christpher Reynolds. Reynold Learning. www.Reynoldlearning.com

Medicine in Colonial Australia,1788-1900, MJA,7 July 2014

Illness in Colonial Australia. Smith FB, Melbourne: Australian Scholarly Publishing, 2011

Emotional intelligence (EI) also known as EQ, is the ability to perceive, understand and manage emotions in positive ways to communicate effectively, empathise with others, overcome challenges and defuse conflict as well as to relieve stress. Emotional intelligence helps build stronger relationships, achieve personal career goals, and interact more positively at work. It gives us an ability to join intelligence, empathy, and emotions to enhance thought and understanding of interpersonal dynamics, guiding our thinking and behaviour. For as in Shakespeare’s Hamlet - 'there is nothing either good nor bad but thinking makes it so'.

The term EI first appeared in writing in 1964 and was popularised by Daniel Goleman in his book titled Emotional Intelligence published in 1995 in which he applied the concept especially to business defining the term as an array of skills and characteristics that drive leadership and performance. EI is commonly defined by four domains or attributes including:

1. Self-Awareness-Understanding what you are feeling and why and appreciating your strengths and weaknesses.

2. Self-Management- The ability to control impulsive feelings and behaviours, adapt to changing circumstances and manage emotions in healthy ways. This is also referred to as self-regulation and points to a positive outlook and achievement.

3. Social awareness -Including the concept of empathy which helps us understand the emotions, needs and concerns of others. Developing social awareness allows us to recognise the power dynamics in a group or organisation.

4. Relationship management-Which encompasses conflict management, coaching and mentorship and encourages the development of teamwork through inspirational leadership.

There are several excellent books on the subject of emotional intelligence including: Achieving Emotional Literacy by Claude Steiner,

'How Emotions are Made' by Lisa Feldman Barrett, Emotional Agility by Susan David and Daniel Goleman’s Emotional Intelligence.

I was curious to explore this topic in more detail and was privileged recently to meet Shawn Price who is an expert in this field.

Shawn initially trained as a mathematician but was drawn to the study of psychology and especially emotional intelligence recognising its important application to both business, families, and individuals.

Shawn now manages his company Positive Intelligence from where he coaches and consults privately as well as being engaged by industry and large organisations to run workshops and lecture programs on this important subject. Please welcome Shawn to the podcast.

References: Shawn Price: Positive Intelligence. www.positiveintelligence.com.au

Emotional Intelligence, Daniel Goleman.

ISBN:9780553804911 Emotional Intelligence;

www.helpguide.org/ Segal, Robinson and Shubin Emotional Intelligence has 12 Elements.

Which do you need to work on? Harvard Business Review. Feb 06,2017. Goleman and Boyatzis

We are dedicating this podcast to the memory of Professor Lawrie Powell, both a gentleman, mentor and giant in the field of hepatology and whose very significant contributions to our understanding of hemochromatosis laid down a firm foundation of knowledge and insight for everyone practicing internal medicine. It is upon his shoulders that much further research in the field of hemochromatosis and hepatology generally has prospered.

Haemochromatosis is the most common autosomal recessive disorder in Caucasians with an incidence of about 1 :260 and carriage of about 1: 10. Untreated the excess iron storage from hemochromatosis may lead to cirrhosis and hepatocellular carcinoma, diabetes, cardiomyopathy, hypogonadism, arthritis, bronzing of the skin and render some susceptibility to siderophilic bacteria including some vibrio and Yersinia species. The consequences of iron overload are exacerbated by preexisting condition such as NASH and alcohol associated liver disease.

A key breakthrough in the understanding of hemochromatosis came with the discovery of a negative regulatory protein coded for by the HAMP gene on chromosome 19 called Hepcidin. Hepcidin serves as a counterregulatory protein. As iron absorption and stores increase Hepcidin levels in healthy individuals also increase leading to decreased iron absorption and restoration of normal iron levels. Hepcidin appears to work by internalization and degradation of Ferroportin thereby inhibiting iron absorption across the basolateral membrane of enterocytes as serum iron levels climb.

A transferrin receptor on the surface of hepatocytes relays information concerning serum iron concentration as part of this elaborate feedback mechanism.

Mutations of the so-called High Iron -or Hemostatic Iron Regulator -HFE gene on the short arm of chromosome 6 modulate the expression of Hepcidin, effectively blocking the elaborate feedback mechanism that senses serum iron and leading to inappropriately lowered levels of Hepcidin production as iron levels climb. This defect underlies the problem of excess iron absorption in Hemochromatosis with the consequent adverse physiologic effects mentioned above.

The gene mutation responsible for Hemochromatosis is thought to have arisen some 6000 years ago within Viking or Celtic communities possibly protecting against iron deficiency states when resources were scarce.

Treatment by regular phlebotomy remains the preferred method of management and screening for HCC in cases of established cirrhosis is mandatory.

I was honored to further this conversation about hemochromatosis with Professor Darrell Crawford, one of my mentors from Queensland in a previous life. Darrell has both the reputation for being an excellent hepatologist as well as having significant international standing in the field of liver disease and has published widely. He has held leadership positions within the national and international professional societies relevant to his discipline including GESA and the University of Queensland including as the Acting Deputy Executive Dean and Head, School of Medicine where he has played a key role in reshaping the medical program and medical faculty at the University of Queensland. Please welcome Darrell to the podcast.

Treatment by regular phlebotomy remains the preferred method of management and screening for HCC in cases of established cirrhosis is mandatory.

References:

Professor Darrell Crawford-medicine.uq.edu.au,

Queensland Gastroenterology

Greenberger’s Current Diagnosis and Treatment, 4th Ed, Friedman et al, McGraw Hill Lange

Principles of Medical Biochemistry, 3Rd Ed, Meisenberg and Simmons, Elsevier Saunders