Ep 52: IBD, Rheumatology and multispecialty MDTs

Dr Jenny Lemon speaks with Giulia Varnier, a paediatric rheumatology consultant and Loveday Jago, a paediatric gastroenterology consultant, to talk about the joined up working between the specialties. They share tips from running a combined clinic and case examples where shared decision making has been crucial to patient care.

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Transcript

00:00:00 [Speaker 1]

You're listening to the talking rheumatology spotlight podcast brought to you by the British Society for Rheumatology. Hello everybody and welcome to this Talking Rheumatology Spotlight podcast. I'm your host Doctor Jenny Lemon, I'm a rheumatology speaker in Mersey Deanery and I'm delighted to welcome two guests today, who both work at Royal Manchester Children's Hospital, and this is for a podcast focusing on the interplay between paediatric rheumatology and gastroenterology with a focus on IBD. So I'll let you both introduce yourself.

00:00:38 [Speaker 3]

Hi I'm Giulia Varnier, I'm one of the pediatric rheumatology consultant at the Children's Hospital.

00:00:45 [Speaker 4]

Hi I'm Loveday Jago, I'm a pediatric gastroenterology consultant at the Children's Hospital.

00:00:52 [Speaker 2]

Thank you, and I know that you two, the reason why I approached you both to come on this podcast today is that I know that you do a joint clinic, together. So can you please tell us a little bit about, your clinic, how it came about, what type of patients you see, and what are some of the benefits that you've seen from working together in this way?

I think the idea came up a couple of years ago where we noticed in rheumatology to have more and more referral from our you know gastro colleague and all the especially for patients with inflammatory bowel diseases and really all of them had some musculoskeletal issues so at that point in we our team was growing and it was more of us consultant and we were developing others and MDT clinic that were working really nicely in juvenile dermatomyositis, lupus, GIA and kind of on that wave.

00:01:50 [Speaker 3]

I thought we could do the same for IBD you know obviously the benefit of having two consultant in two different same room is massive for the patient first because obviously you know they just need to come once rather than twice and for us to be able to just you know have a chat there and then and then get decision and things happening faster.

00:02:11 [Speaker 3]

So that's how I approached Loveday and then we decided to start this clinic together.

00:02:16 [Speaker 4]

We've been doing it for three years now Giulia.

00:02:20 [Speaker 4]

So I think also we felt that it would allow us to have access to the wider rheumatology, which was really helpful as well because as well as us seeing the patients jointly, they then have access to physio, and, you know, the well set up NDT as part of the rheumatology framework, which perhaps we don't get to use so much in gastroenterology.

00:02:48 [Speaker 4]

We do have psychology support, but, so that was really helpful as well, and just learning from each other really.

00:02:57 [Speaker 3]

Yeah that's very true Loveday, I think I can say that you know the next step of our clinic would be ideally to have the physio with us.

00:03:09 [Speaker 3]

We've not done that yet but this is the idea and I think this is probably one of the next steps that we're going to have in our clinic which worked really well and I guess what I noticed is that you know one would expect mostly inflammatory you know musculoskeletal issue which we have and we had loads but what I learned you know with this clinic is that I think most if not all of the IBD patients have biomechanical issues which sometimes are an issue and obviously you know we you know with our expertise, I mean the physio really you know the physio expertise, we can do a lot for these young people so it was an unmet need that I'm so happy that now we managed to you know to deal with this so I think that's really great.

00:03:58 [Speaker 2]

And when we were talking a little bit beforehand Giulia you were talking about some of the other things that you learned or that were diff a little bit different, between rheumatology and gastro, including, that gastro have some access to some biological medications that we don't necessarily, a little bit about using, more use of drug levels.

00:04:16 [Speaker 2]

Can you talk a little bit more about that and how, how you've learned, more about that side of things through participating in the joint clinic?

 00:04:25 [Speaker 3]

Yes that that's very true.

00:04:27 [Speaker 3]

In rheumatology maybe you know historically we're not used to look at drug level and then and antibiotics which is something that's getting more and more space, and then and a bit of more evidence.

00:04:40 [Speaker 3]

And I guess we're late to the party because gastro friends have been doing it for quite a while.

00:04:45 [Speaker 3]

So it's been quite nice, you know, to use that trick to learn that trick to target approach and be consistent in especially for in this case drug like adalimumab or infliximab, routinely look at antibody level and routinely look at a drug level to guide our treatment, our dosing, this is something I learned and I'm definitely and I definitely brought into my you know purely rheumatological practice and for example it's quite useful in other categories of patients, by a group of patients like uveitis, you know, where  adalimumab or infliximab are still you know very much used, so that's been great learning.

00:05:26 [Speaker 3]

And another example could be also for example the use of medication like ustekinumab or upadacitinib, so these are medication that we don't have straight accent yes to rheumatology but you know our gastrocolic do have and for especially for one, a couple of really difficult patients, it's been really great to you know see this patient together and have access to drugs that you know I haven't used before with quite good results really so it's a good learning and obviously you know it's great for the patient that they can have their access to drugs that we wouldn't have you know straight away let's say yeah in the team in a strictly rheumatological rheumatology practice, rheumatology clinic.

00:06:17 [Speaker 4]

Going back to the NTFs, so we obviously use much higher levels in Crohn's disease where there's sort of penetrating disease, so for example if they've got perianal fistula or very, extensive or severe disease, so, I think, you know, that's been helpful because obviously, some of the patients that we see have penetrating disease, and, so Giulia has sort of seen how we like to get the infliximab levels up higher, you know, giving more intensities every four weeks, 10, etcetera.

00:06:53 [Speaker 4]

So things like that, the dosage is slightly different.

00:06:58 [Speaker 4]

So, yeah, we've learned from each other in that respect.

00:07:02 [Speaker 4]

I've learned about giving extra folic acid to methotrexate patients if they're feeling nauseous and things which you know I I'd learned from my rheumatology colleagues so yeah it's definitely good learning both ways 

00:07:20 [Speaker 2]

That's expanding on something that you said, Lovely.

00:07:22 [Speaker 2]

I think you were talking a little bit about how important aspects of the clinic was about having that access to the, kind of rheumatology MDT in terms of pain management.

00:07:31 [Speaker 2]

What are the particular benefits that you see or how does the approach kind of differ classically and have you been able to take this over, into other areas of your gastroenterology, patient cohort?

00:07:42 [Speaker 4]

I think that, what has been a huge help is how involved they get with the families, the rheumatology physio, and you also have access to OTs etc, and I think the liaising with the school, that side of things, you know, we obviously have our IBD nurse specialists, but, from a just a time constraint they can't get as involved with the families, and I think that's the big difference really is being able to see the families, separately and liaising with school.

00:08:26 [Speaker 4]

I think that those are the big things really, I would say00:08:29 [Speaker 2]

Really interesting to learn a little bit more about how it works.

00:08:31 [Speaker 2]

Did you did you want to say something else Giulia?

00:08:33 [Speaker 3]

Well I was you know I think it's also you know not to you know to take anything off of you know you know your nurses that really worked like really hard and I got a lot of work to do.

00:08:42 [Speaker 3]

I guess also the physio benefit is not just getting back to school, it's also giving them a program you know an exercise program or a time breaks or educate you know the family and the school on what they can do, what they should be doing you know the that are allowed, you know, and the the maybe the gradual return back to school they might need, you know, after a big flare up.

00:09:06 [Speaker 3]

So it's a particular, you know, expertise, that I think the rheumatology physio have, which is not just the exercise, you know, not just, not just you know people getting spitter and stronger but it's the whole holistic view that they have of this for the whole person as a whole being not just the disease so then they need to get stronger but they're able to cope with school with COPD exam.

00:09:26 [Speaker 3]

We I really like that they've got this holistic review view of the patient and they and that's how they can help in a I guess in a different way from you know their perspective so that's great have that that that that was in a sense as I said before it was an unmet need for this for this this group of young people.

00:09:48 [Speaker 2]

Moving on to our next question, you obviously see some complex inflammatory cases in this clinic, how do you balance control gut versus joint involvement in these patients?

00:09:58 [Speaker 2]

I guess thinking more about biological drugs, some drugs might control both but there are somewhere that might favour one versus the other.

00:10:06 [Speaker 2]

So how do you how do you get that balance?

00:10:08 [Speaker 3]

These are you know diseases so obviously we always need to keep you know everything in mind and then some joints or organ involvement obviously are really relevant because obviously for example even if you have axial arthritis you can consider secukinumab for some of these patients.

00:10:28 [Speaker 3]

Obviously you really don't want to because that could cause a flare of their IBD.

00:10:33 [Speaker 3]

I think one of my main frustration as a rheumatologist treating a IBD patient is I can't give them any NSAIDs, can I?

00:10:40 [Speaker 3]

Who is that's really tough.

00:10:43 [Speaker 3]

And there's a lot of this question and I know and please not they correct me if I'm wrong that gastroenterologists, I don't think they I want to say I don't want to say like but they use steroids as much as we do because again that those steroids can, yes they can make you feel better that then there's a risk of relapse and bounce back from the gut disease, so we're always very you know and I know we had this this conversation a long time, many times and this obviously limit us in ways you know the respect with the patient with you know just arthritis or other of the condition that we look after.

00:11:18 [Speaker 3]

This is a very particular group of patient to be looking after.

00:11:23 [Speaker 3]

But I guess I guess the good the good thing is that we've always found a solution, we've always found like a biological or not drug that would you know, suits the patient need and which sometimes prompted us to prompt us to use new drugs, you know, new things and then that's scary but also quite exciting you know to explore new medication, new drugs so that's quite that's quite exciting at least have been you know really good for me so when you think we've reached the end of the line I guess one nice example that I, I've learned a lot you know through this this patient of mine, was this young girl that I'm sure you remember her love day then she started with me as a JIA, like, all good JIA.

00:12:17 [Speaker 3]

And then through the year, she developed psoriasis and you think, oh, well.

00:12:22 [Speaker 3]

And then after another few years, she, she was she was on adalimumab and she couldn't tolerate methotrexate anymore.

00:12:30 [Speaker 3]

And I gave her the choice, you know, which one do you prefer, leflunomide?

00:12:35 [Speaker 3]

There's not much evidence of which is best and she decided leflunomide which is absolutely fine.

00:12:43 [Speaker 3]

And maybe that was a coincidence, maybe not, but a couple of weeks later she, had a massive PR bleeding and she ended up in ICU and that's where our gastro colleague, you know, came in, she had a scope and she was diagnosed with Crohn's disease And she's been very difficult to treat because, obviously, she had the the joints, she had the skin, she had the gut, she did so well, for a few years and then she started flaring again.

00:13:15 [Speaker 3]

So again me and lovely we were back to you know what do we do now kind of a place which is you know tricky, and eventually we started around JAK inhibitor and you know fingers crossed this is doing the trick.

00:13:29 [Speaker 3]

So it's about talking and then considering all options really, I think that's the most the most important thing.

00:13:36 [Speaker 3]

What do you think, Loveday?

00:13:37 [Speaker 4]

I was just thinking as you were saying that there's also other clinicians involved aren't there so dermatology for example you know also have an opinion and, a preference, and I guess ophthalmology as well with some of the cases but yeah that particular young lady was you know she bled quite dramatically didn't she and had quite a significant colitis so but yeah it seemed to work really well for her but then her joints her gut settled down but her joints were mainly the issue towards the end weren't they so it is it's I guess it's always reviewing things and reassessments and again that's why we would bring these young people back to clinic and see them together in in NIC.

00:14:33 [Speaker 3]

Yeah good communication is the key and then and sometimes in our busy you know busy professional life it's hard to sit down and have a chat that's why this you know we know that at least three four times every three four months we meet, we can discuss on this case, we bring them all there and we move forward so that's really nice.

00:14:52 [Speaker 2]

I guess it must help as well, like, within the clinic if you've got these patients the way you're trying to debate which drugs might be, best.

00:14:59 [Speaker 2]

I guess it might must be useful being there both at the same time and being able to have that quite frank in front of the family so that the family are aware of the fact that these aren't easy decisions, and that there are lots of factors to consider.

00:15:11 [Speaker 2]

If you found that that as an additional kind of benefit of the clinic being able to sort of have that discussion there and then rather than in a corridor, you know, at another time when the family aren't there?

00:15:21 [Speaker 4]

I think so yes, I think the families really appreciate us spending the time together, seeing them, saving them another journey on another day, and they've fed that back to us haven't they really on the day they've said how much they appreciate the clinic.

00:15:40 [Speaker 3]

Oh yes absolutely it's you know they you know they come from Greater Manchester so we have patients from you know Blackburn, Black patient that travel for over an hour you know to come on the way so you know saving them an appointment is not it's something you know for this family and also I think it's quite nice not just end the the appointment by oh I need to get back you know I need to have a check with Doctor.

00:16:03 [Speaker 3]

Baker and get back to you just doing that and then you know when they ask their own question they can you know obviously we can address their issue you know which their preference is which obviously really matter for us.

00:16:14 [Speaker 2]

And our next question is for you Giulia

00:16:17 [Speaker 2]

You obviously have good experience with IBD, What types of things might make you suspect this in patients presenting with joint inflammation?

00:16:26 [Speaker 2]

Because obviously abdominal pain is something that's really common in our pediatric population in general, but what specifically would make you kind of would trigger a gastro discussion or referral?

00:16:38 [Speaker 3]

I can answer with an example, I think this this is hopefully would help.

00:16:43 [Speaker 3]

I had this eight nine year old girl in clinic and then she came with a you know with joint pain and on examination she had a swollen knee and a swollen knee like two you know arthritis in two joints which was quite you know fairly straightforward but then when we talked she said that she's lost a lot of weight and mum said the school will be loose now.

00:17:10 [Speaker 3]

She had to go back a size which is really odd, and on the blood test the ESR was really high like seventy-eighty, which if you think for a non oligo GIA that's really unusual.

00:17:24 [Speaker 3]

So I think these two were my main red flags.

00:17:27 [Speaker 3]

She didn't have any tummy pain really luckily and no PR, no the classic you know PR bleeding or mouth ulcer.

00:17:34 [Speaker 3]

She didn't have any of those.

00:17:36 [Speaker 3]

But the significant weight loss, you know, losing size, you know, that age and high ASR, those were my red flag.

00:17:44 [Speaker 3]

So when I brought her in, I asked first for an abdominal scan because obviously with the other differential is malignancy and you really can't miss that one.

00:17:52 [Speaker 3]

So but the but the ultrasound showed some, tick and bowel and that's what from the review with my, you know, gastro colleague.

00:18:02 [Speaker 3]

They organized the scope and she was an IBD, so I didn't have to treat her, they just start they started their own you know treatment the diet and everything and then they'll try to stay.

00:18:13 [Speaker 3]

So I guess my learning point from her were definitely you know, look into weight loss and and high inflammatory marker when they don't match your clinical finding and this was definitely my you know red flag in this case because obviously you know an older patient with the profound bleeding and abdominal pain might probably won't even get to our dose first and it would go straight to gastro so definitely that was my that was my, you know, my experience.

00:18:46 [Speaker 2]

Thank you.

00:18:47 [Speaker 2]

One for yourself, lovely.

00:18:50 [Speaker 2]

Can you please give some advice, for interpreting faecal calprotectin in patients with inflammatory rheumatological disease?

00:18:58 [Speaker 2]

Because we see lots of calprotectin that aren't sky high but kind of in that kind of middle range, and it's then knowing what to do with them.

00:19:06 [Speaker 2]

So how do you how do you approach this?

00:19:09 [Speaker 4]

Yes.

00:19:10 [Speaker 4]

So cow calprotectin's obviously come in in a big way in the last few years and, you know, the advantage of it is it's, more sort of bowel specific if you like, it's a marker of inflammation, it's a protein that is, you know, actively leaked from the inflamed bowel, and, I would say that although it's often used as a kind of screening tool to perhaps, differentiate things like IBS and IBD, it's actually probably better a monitoring tool.

00:19:49 [Speaker 4]

So for, you know, judging when parent when patients are in, clinical remission with their IBD.

00:19:57 [Speaker 4]

So the problem is that, it can have quite a lot of false positives.

00:20:04 [Speaker 4]

So for example younger children sort of children less than five years, it can be sort of falsely raised.

00:20:16 [Speaker 4]

Another group of patients where it can be falsely raised is those on non steroidal.

00:20:23 [Speaker 4]

So you know that's obviously going to be of importance in in rheumatoid disease.

00:20:30 [Speaker 4]

So I would say that for us a significant level would be sort of greater than 200 or two fifty.

00:20:41 [Speaker 4]

It doesn't mean to say I'd necessarily totally ignore that the level's lower than that, but, I think you'd want to have other factors involved like your blood inflammatory markers and GI symptoms really.

00:20:58 [Speaker 4]

So it has been helpful you know I thought that children and young people would be much happier to give a poo sample than to have a blood test but you'd be surprised how many just don't want to hand in a poo sample.

00:21:13 [Speaker 4]

They're quite happy to have a needle, so I was quite surprised by that.

00:21:17 [Speaker 4]

So it it has been helpful, but I would say that, you know, sometimes it's actually better as a as a monitoring tool because we know that, you know, when our IBD patients have calprotectins sort of below teeth that that generally they haven't got active disease.

00:21:37 [Speaker 2]

That's really interesting.

00:21:39 [Speaker 2]

And when you say about the NSAIDs affecting the results, does that tend to give very high levels or will that just elevate it moderately?

00:21:46 [Speaker 4]

Moderately I would say yes rather than very high.

00:21:50 [Speaker 4]

So I think you know if you've got really high levels then you'd obviously want to investigate further.

00:21:56 [Speaker 4]

And just going back to what Giulia said with that example of the child where she said she did an ultrasound we're very lucky at the Children's Hospital because the radiologists now have very good expertise with small bowel ultrasound scans, and they're actually finding that they're equally as good as MR for looking at sort of inflammation of the small intestine and bowel thickening.

00:22:24 [Speaker 4]

So, that's been really helpful because obviously that's much easier to get an ultrasound than an MR.

00:22:30 [Speaker 2]

Just coming on to our next question, this is going slightly off the IBD theme, but just a question around, again about markers.

00:22:39 [Speaker 2]

So about how useful or reliable is TTG antibody, in flare of rheumatological disease.

00:22:46 [Speaker 2]

Because obviously we use it quite a lot for screening, because our patients are at increased risk, of having celiacs.

00:22:54 [Speaker 2]

But do we get lots of false positives by using this as a screening tool?

00:22:58 [Speaker 3]

Well, we, you know, from a in in room as Jenny said, in the rheumatology clinic, it is common to use to do the screening because they because you all know when you have an autoimmune disease you're a bit more likely to have others you'll develop others over time.

00:23:13 [Speaker 3]

So I mean personally my practice is to repeat the celiac and thyroid especially.

00:23:21 [Speaker 3]

Once over twelve, eighteen months or so I'm not aware of any false positivity and kind of the other way around when I had new patient coming in without the diagnosis, with arthritis even clinically, clinically, I had knees, I had hips, but the story again of weight loss and bloating and abdominal discomfort, I at least once a year I that's how I make a diagnosis of celiac disease in my clinic and that's normally when I send it you know to the dietitian and to the gastro team and again the arthritis.

00:24:01 [Speaker 3]

I keep an eye on them because obviously it can be both.

00:24:05 [Speaker 3]

I had one case that actually loved they referred to me new diagnosis, do you remember of the other new diagnosis of celiac disease that could not fully open their mouth and initially there was this discussion you know is it is it the arthritis just a sign of untreated celiac or is this something on top you know together with it and I guess because of the severity of the joints involvement and the type of joint involvement she couldn't open her mouth, she couldn't eat, she lost weight because she couldn't eat and not just maybe for the celiac.

00:24:37 [Speaker 3]

We thought in her case it was JIA and celiac disease and I started to notice it.

00:24:41 [Speaker 3]

So they're intertwined with immune disease, I think we're always we're very switched on now you know I guess on my end to think you know gastro to think celiac and probably and then clearly the other way around too you know we would love to you know spotting that she couldn't open her mouth so yeah that was that was our experience.

00:25:04 [Speaker 2]

So I guess it's again about that pattern recognition isn't it and thinking about things from your experience that just don't quite fit and questioning that.

00:25:11 [Speaker 3]

I guess another thing that once you mentioned you know pattern recognition and like thinking you know not just you know so your speciality but having the broader you know view of things I think we over the years we had few patients that kind of evolved you know from one condition to the other.

00:25:30 [Speaker 3]

So I mentioned one at the start you know the little oligo GIA which became psoriatic GIA which became you know full blown full blown Crohn disease.

00:25:39 [Speaker 3]

But also I guess another example because I think that makes it more memorable, we had a little one, a six year old who started with the systemic onset GIA with several episodes of macrophage activation syndrome which was really tricky to you know to get under control but eventually what you know we got him under remission he was doing really well and I think a couple of years ago he started having significant abdominal pain really out of his, you know, it wasn't typical of him and then he started having PR bleeding and then he started having temperature so that it was like you know is this another MIS or is this something different?

00:26:19 [Speaker 3]

Eventually, again we discussed with our gastro colleague and he had an endoscopy and he and he had the results was about Crohn disease, so although it was very unusual because he still had that, well he had the temperature which obviously could fit poor condition but his ferritin was always high, and he had the rash and he had the abdominal pain and the fear of bleeding.

00:26:42 [Speaker 3]

Again we treated in a non-conventional way for his systemic onset GIA but, so we treated with adalimumab as a you know Crohn disease and he's done really well.

00:26:55 [Speaker 3]

So again I think we really need to be mindful in vaccine change, you know, that there are, you know, our young patient they grow up and disease can reveal themselves and change themselves throughout the year, so just keep thinking you know not just because it's got cis image, IEA that's it, you know stop you know you really should remember not to stop thinking because things can change and this diagnosis completely changed the treatment isn't it?

00:27:21 [Speaker 3]

That that it was going to receive.

00:27:23 [Speaker 3]

So to me that was a very you know another interesting case to to be reminded of us.

00:27:30 [Speaker 2]

And I think we've kind of come into the end, of what we'd planned to talk about.

00:27:34 [Speaker 2]

Is there anything else that we haven't covered, that you'd like to, include or anything else that you've learned from working together that you think we haven't covered in enough detail?

00:27:43 [Speaker 3]

I think if I can again go first and then I'll let lovely I love the reply as well.

00:27:51 [Speaker 3]

What I think I just wanted to mention again how important it is musculoskeletal health you know for young people with the bio inflammatory because it's obvious to think so you know with the 15 year old that come with ankylosing spondylitis or hip arthritis so you know peripheral arthritis so this is obvious but it I think is equally important to consider you know biomechanical health in this patient because most of them are tired, most of them are the condition, most of them don't have much guidance or knowledge about what they can or cannot do.

00:28:28 [Speaker 3]

So just always you know, you know I guess my learning but it was always to happen and check on how they're doing if they have any pain and physio really helped.

00:28:40 [Speaker 3]

And another, you know, another important factor that we learn to address as well is mental health.

00:28:52 [Speaker 3]

We again I guess I like making example, we had this it's a 12 year old girl who was flagged up to our clinic from the I think with the nurses because the they weren't so her IBD didn't sound so bad and then her joints didn't sound so bad, she was in so much pain and she was so unhappy and she was so unwell we couldn't work it out.

00:29:18 [Speaker 3]

So we brought her to clinic and, you know, by just talking to her and her family we realized that she had she had developed chronic idiopathic pain.

00:29:26 [Speaker 3]

So she did have arthritis before, she did, you know, she did have IBD, but she developed chronic pain.

00:29:31 [Speaker 3]

So, you know, the issue weren't, you know, the organic side of things, it was a mental health.

00:29:37 [Speaker 3]

And again, through that clinic, she got access to our pain entity, which, you know, which eventually what she needed.

00:29:45 [Speaker 3]

So it's always about remind, you know, remind ourselves that there's different type of pain and, and there's no one solution fits all kind of thing.

00:29:58 [Speaker 3]

So definitely remember musculoskeletal and mental health in in this young patient because you could really make a difference.

00:30:05 [Speaker 2]

Did you have anything else

00:30:06 [Speaker 3]

you wanted to add, Luke?

00:30:07 [Speaker 4]

I don't think so.

00:30:08 [Speaker 4]

I think Giulia said it all.

00:30:10 [Speaker 4]

I think, you know, like she said, a lot of these children are very tired.

00:30:19 [Speaker 4]

They're also trying to fit in, you know, normal school days, and, you know a lot of them are very unfit.

00:30:28 [Speaker 4]

I think that's one thing I've realized that Giulia you know just always asked them about what sort of activities they're doing in school and you know just trying to support them in any way to get back to being active.

00:30:45 [Speaker 4]

And again access to the physio really helps that.

00:30:48 [Speaker 2]

Yeah.

00:30:49 [Speaker 2]

I think it's part of providing good, like, holistic care which we, I guess, pride ourselves on in paediatrics in general, isn't it?

00:30:55 [Speaker 2]

Looking at the whole person, not just

00:30:57 [Speaker 3]

the disease.

00:30:58 [Speaker 2]

Thank you so much both of you for joining us today.

00:31:01 [Speaker 2]

And to our listeners, we'd just encourage you to check out the rest of this month's spotlight learning resources on the BSR e learning platform.

00:31:08 [Speaker 2]

Thank you very much, everybody.

00:31:13 [Speaker 1]

Thank you for listening to Talking Rheumatology Spotlight, brought to you by BSR.

00:31:17 [Speaker 1]

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