Pomegranate Health – Details, episodes & analysis

A 72-year-old female presents to an Adelaide emergency department with bilateral eye pain and redness lasting several days. She has a history of hypertension, hypercholesterolemia and age-related macular degeneration for which she has received a range of medications. Anterior uveitis is identified as the proximal cause of the ocular pain but there are many possible aetiologies that require careful consideration. Pomegranate [Case Reports] have been developed to help Trainees rehearse diagnostic problem solving and case presentation.
 
Guests
Associate Professor Jagjit Singh Gilhotra ,FRANZCO (Queen Elizabeth Hospital; University of Adelaide)
Dr Yong Min (Shane) Lee FRACP (Royal Adelaide Hospital)
 

Host
Associate Professor Stephen Bacchi FRACP (Lyell McEwin Hospital; University of Adelaide)

Production
Produced by Stephen Bacchi and Mic Cavazzini. Music licenced from Epidemic Sound includes  ‘Desert Whispers’ by Tellsonic  and ‘Brighton Breakdown’ by BDBs. Image created and copyrighted by RACP. 

Key Reference (Spoiler Alert)

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Bilateral occlusive retinal vasculitis secondary to intravitreal faricimab injection: a case report and review of literature [Lee, Eye Vis. 2024]

Please visit the Pomegranate Health web page for a transcript and supporting references.Login to MyCPD to record listening and reading as a prefilled learning activity. Subscribe to new episode email alerts or search for ‘Pomegranate Health’ in Apple Podcasts, Spotify,Castbox or any podcasting app.

Australia has just approved a second amyloid-targeting therapy for patients with incipient Alzheimer’s dementia. Lecanemab (Leqembi) now joins donanemab (Kisunla) on the Australian Registry of Therapeutic Goods but the impact of both has been modest in Phase III trials to date. After 18 months of therapy they delay progression of disease, as quantified on neurocognitive tests, by around 5 months on average. 
 
For some, the prolonged independence and dignity will justify the $60,000 to $80,000 a year price tag for the drugs. But for the Pharmaceutical Benefits Advisory Committee “the high burden of [donanemab] treatment on both patients and the health system, combined with the risks and modest clinical impact, makes the drug unsuitable for PBS subsidy”.
 
This burden includes specialist consults, gene screening, multiple MRI and PET brain scans, and delivery of monthly or fortnightly infusions, adding up to another $20,000 in costs. Even before considering these logistical requirements, Australian memory clinics don’t have anywhere near the capacity to address the 245,000 new cases of early dementia or mild cognitive impairment every year. 

Advocates see these disease-modifying therapies as a turning point for dementia research and argue for further investment in the systems infrastructure needed to roll them out. Sceptics argue that the available evidence instead questions the importance of amyloidosis in the Alzheimer’s disease cascade.

Guests
Professor Michael Woodward AM FRACP FANZSGM FAAG FAWMA (Austin Health, Melbourne; University of Melbourne)
Dr Chrysanth Pulle FRACP (Prince Charles Hospital, Brisbane) 

Chapters
13:16 Time Saved
16:18 Costs of treatment
26:44 IMJ paper on resourcing
39:10 Scepticism and staging

Production
Produced by Mic Cavazzini DPhil. Music licenced from Epidemic Sound ‘RGBA’ and ‘Pulse Voyage’ by Chill Cole, ‘A Forest Melody’ by Tellsonic, ‘Axon Terminal’ by Out to the World, ‘Organic Textures 2’ by Johannes Bornlof and ‘Fugent’ by Lupus Nocte. Image courtesy of Wikimedia Commons and University of Pittsburgh. 

Editorial feedback kindly provided by physicians of the podcast editorial group Ronaldo Piovezan, Aidan Tan, Hugh Murray, Joseph Lee, Rahul Barmanray, Simeon Wong and Sebastian Lambooy. Thanks also to Profs Bruce Campbell, Mike Parsons and Amy Brodtmann and registrars Jamie Bellinge and Karan Singh for additional insights into research methods. 

Please visit the Pomegranate Health web page for a transcript and supporting references. Login to MyCPD to record listening and reading as a prefilled learning activity. Subscribe to new episode email alerts or search for ‘Pomegranate Health’ in Apple Podcasts, Spotify,Castbox or any podcasting app.

ST elevation is clearly a worrying finding that can herald life-threatening conditions, such as ST elevation myocardial infarction. But not all ST-elevations are created equal, and Trainees would benefit from considering a broader number of causes for this presentation. In today’s podcast the team will discuss a case of ST elevation observed in a 65-year-old female during the routine elective procedure of atrial fibrillation ablation. A range of pathophysiologies is discussed that can help listeners work though the differentials in a systematic way. 

Guests
Assoc Prof Pramesh Kovoor FRACP FACC PhD (Westmead Hospital; the University of Sydney)
Dr Neil Warwick FANZCA (Westmead Hospital)
 
Hosts
Associate Professor Stephen Bacchi FRACP (University of Adelaide)
Dr Joshua Kovoor (Ballarat Base Hospital)

Production
Produced by Stephen Bacchi and Mic Cavazzini. Music licenced from Epidemic Sound includes ‘Rockin’ for Decades’ by Blue Texas and ‘Brighton Breakdown’ by BDBs. Game show music courtesy of Waderman. Image created and copyrighted by RACP. 

Editorial feedback kindly provided by RACP physicians Aidan Tan, Aafreen Khalid, Hugh Murray and medical student Nivida Dixit.

Key Reference (Spoiler Alert)

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Metaraminol-induced coronary vasospasm masquerading as ST-elevation myocardial infarction during general anaesthesia [Br J Anaesth. 2024]

Please visit the Pomegranate Health web page for a transcript and supporting references.Login to MyCPD to record listening and reading as a prefilled learning activity. Subscribe to new episode email alerts or search for ‘Pomegranate Health’ in Apple Podcasts, Spotify,Castbox or any podcasting app.

In this episode we put continuing professional development (CPD) under the microscope, particularly the regulatory changes on the horizon. The Medical Board of Australia is emulating shifts already made by the Medical Council of New Zealand and regulators in Canada, the U.S. and the U.K. In some cases, this 'revalidation' movement has been fiercely opposed by doctors. But where did it come from, and why is CPD even necessary after you've already done 10 to 15 years of medical training.

Guests
Professor Richard Doherty FRACP (Dean, RACP; Monash Childrens Hospital and University) 
Dr Craig Campbell, MD FRCPC (Royal College of Physicians and Surgeons of Canada; The Ottawa Hospital)

Production
Written and produced by Mic Cavazzini. Recording assistance in Ottawa from Pop-Up Podcasting. Music courtesy Gunnar Johnsén at Epidemic Sound ('Task at Hand 2', 'Task at Hand 5', 'The Sky Changes 2') and Blue Dot Sessions ('Vittoro'). Image courtesy Neil Turner at Flickr.The production manager was Anne Fredrickson.

Editorial feedback for this episode was provided by RACP members Phillipa Wormald, Michael Herd, Rhiannon Mellor, Joseph Lee, Rachel Williams, Phillipa Wormald, Paul Jauncey, Rebecca Grainger, Philip Gaughwin and Alan Ngo. Thanks also to RACP staff Lianne Beckett, Michael Pooley, Elyce Pyzhov, Amy Nhieu, Shona Black, Abigail Marshall, Kerri Brown, Sandra Dias and Carol Pizzuti.

Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.  

An empathic connection and good communication between physician and patient can promote better outcomes. In this episode of Pomegranate Health, U.S. physician A/Prof Danielle Ofri discusses where breakdowns in doctor-patient communication occur—often in the first 10 or 20 seconds of a consultation. Dr Ofri, author of What Patients Say, What Doctors Hear, suggests ways for physicians to listen better, to be understood and promote adherence.

Some media also report a 'crisis of compassion' in healthcare. Burnout of staff is a major contributor, and palliative care physician Dr Shamsul Shah describes how to mitigate it by convening groups to reflect on the emotional challenges of the job. She recently published an evaluation of Schwartz Center Rounds® (case-based reflections) run at Auckland City Hospital in the College's Internal Medicine Journal.

Guests
A/Professor Danielle Ofri MD PhD (Bellevue Hospital, New York; New York University School of Medicine)
Dr Shamsul Shah FRACP (Auckland City Hospital)

Production
Written and produced by Mic Cavazzini. Music courtesy of Blue Dot Sessions ('Periodicals'), Sergey Cheremisinov ('Old Ally', 'Tavern'), and Loch Lomond ('A String- Instrumental'). Image property of RACP. The production manager was Anne Fredrickson.

Editorial feedback for this episode was provided by RACP members Philip Gaughwin, Michael Herd, Andrea Knox, Paul Jauncey, Rebecca Grainger, Joseph Lee, Rachel Williams, Mahesh Dhakal, and Katrina Gibson.

Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.  

As medicine becomes more sophisticated, discussions about clinical ethics become more common. It is now possible to support life in dire clinical circumstances, but physicians are not always sure if this is the right thing to do. There are questions about quality of life and best interests of the patient, questions about cognitive competence to make such decisions for oneself or questions about equitable distribution of limited resources.

This episode was recorded at the RACP Congress in May and centres around two case studies. The first describes a three-year-old boy with a severe neurodegenerative disorder whose parents are desperate to try an expensive experimental drug. The second is about a man ravaged by bowel cancer who has spent months on life-sustaining care. You'll hear a variety of physicians express their views, and members of the College Ethics Committee describe how clinical ethics services can support decision-making in such cases.

Panellists
Professor David Isaacs FRACP (Children's Hospital Westmead, University of Sydney)
Professor Ian Kerridge FRACP (Royal North Shore Hospital, Sydney Health Ethics)
Professor Paul Komesaroff FRACP (Alfred Hospital, Monash University, Centre for Ethics in Medicine and Society)
Associate Professor Jill Sewell FRACP (Royal Children's Hospital Melbourne, Children's Bioethics Centre, University of Melbourne)
Dr Linda Sheahan FRACP FAChPM (St George Hospital, Sydney Health Ethics)
Professor Cameron Stewart (Sydney Law School, Sydney Health Ethics)

Production
Produced by Mic Cavazzini. Initial interview conducted by Melissah Bell. Music courtesy of Daddy Scrabble ('Tune for Elli'), Jason Shaw ('Namaste'), and Kai Engel ('Highway to the Stars'). Image via Shutterstock. The production manager was Anne Fredrickson.

Editorial feedback for this episode was provided by RACP Fellows Philippa Wormald, Andrea Knox, Rebecca Grainger, Philip Gaughwin and Rhiannon Mellor.

Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.  

This is the second of two episodes about acute coronary syndrome (ACS). In part one, the discussion focused on diagnostic workup of acute coronary events. This episode deals with secondary prevention and adherence to therapy. One-fifth of people discharged with a diagnosis of ACS have another ischaemic event within six months, and the risk of dying increases the second time round.

There is an established strategy for secondary prevention of ACS that includes pharmacotherapy, cardiac rehabilitation and lifestyle management. However, 75 per cent of patients are discharged from hospital without one or more of these tools. A recently published study in the Internal Medicine Journal suggests this sets a trend for care going forward. As Professor David Brieger explains, follow-up visits to the GP are unlikely to ensure best-practice pharmacotherapy if this was not prescribed in hospital.

Cardiac rehabilitation may also not be as effective as it could be in reducing the risk of further ischaemic events. On this episode, Associate Professor Julie Redfern argues that the group exercise model is outdated, and a more personalised approach is needed to keep patients engaged.

Guests
Professor David Brieger FRACP (Concord Repatriation General Hospital, University of Sydney)
Associate Professor Julie Redfern PhD(George Institute for Global Health, University of Sydney).

Production
Written and produced by Mic Cavazzini. Music courtesy of Jason Shaw ('Minstrel'), Lee Rosevere ('Become Death'), Sergey Cheremisinov ('Pulsar') and Loch Lomond ('Listen, Lisbon'). Image courtesy of iStock. The production manager was Anne Fredrickson.

Editorial feedback for this episode was provided by RACP Fellows Joseph Lee, Michael Herd, Marion Leighton, Rachel Williams, and Mahesh Dhakal.

Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.  

Chest pain and other symptoms suggestive of ACS make up the majority of presentations to hospital. 11 to 17 per cent of patients presenting to ED with such symptoms end up having the diagnosis confirmed. But follow-up studies of discharged patients show that up to six per cent of diagnoses are missed, and inappropriately discharged patients have a twofold higher mortality rate than those who are admitted.

The 2016 guidelines of the Cardiac Society of Australia and New Zealand were developed to guide the rapid differentiation of patients presenting with suspected ACS. ACS takes in STEMI and non-STEMI heart attacks, and also unstable angina. This episode outlines the investigations used to distinguish these and other differential diagnoses associated with chest pain. First, electrocardiogram recordings are used to identify the occurrence of a myocardial infarction with ST segment elevation. If STEMI is discounted, the next most important step is to rule out other life-threatening causes of chest pain. Third in the diagnostic hierarchy is to establish whether there has been myocardial infarction without ST elevation, or unstable angina. This is where high sensitivity troponin markers become useful, and can feed into stratification protocols for assessing the risk of patients suffering future acute cardiac events.

Guest
Associate Professor Louise Cullen FACEM (Royal Brisbane and Women's Hospital, University of Queensland

Production
Written and produced by Mic Cavazzini. Additional audio recording from Michelle Ransom-Hughes. Music courtesy of Jason Shaw ('Minstrel, Pioneers'), Lee Rosevere ('Become Death'), Sergey Cheremisinov ('Pulsar') and Loch Lomond ('Listen, Lisbon'). Image courtesy of Science Photo Libary. The production manager was Anne Fredrickson.

Editorial feedback for this episode was provided by RACP members Paul Jauncey, Pavan Chandrala, Rebecca Grainger, Phillip Gaughwin, Rhiannon Mellor, Alan Ngo, and Mahesh Dhakal.

Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.  

In Episode 32  we discussed cognitive error in diagnostic reasoning. On this episode, we take a look at systems pressures that increase the likelihood of medical error, crystallised by the recent prosecution of NHS paediatrician Dr Hadiza Bawa-Garba. Almost half of diagnostic errors are due to a combination of systems errors and individual cognitive error. Obvious systems effects come into play in understaffed acute care units; if a clinician is forced to see too many patients without enough time to make careful examinations or reasoned decisions, errors become more likely. The stepping stones of ordering, receiving and reviewing diagnostic tests and scans also allow much opportunity for error and delay. Guests on this episode discuss mechanisms to improve efficiency

Obvious systems effects come into play in understaffed acute care units. If a clinician is forced to see too many patients without enough time to make careful examinations or reasoned decisions, errors become more likely. And of course, long hours and fatigue will only reduce cognitive capacity. Hospital systems also include the stepping stones of ordering, receiving and reviewing diagnostic tests and scans. Missteps and delays in this cascade contribute to a large proportion of diagnostic errors. Guests on this episode discuss mechanisms to improve efficiency.

Another important step in improving health systems is capturing and reporting error rates accurately. If clinical error is wrapped in culture of blame and punishment, it will make such disclosure more difficult. This concern has been raised in response to the recent prosecution of U.K. National Health Service (NHS) paediatrician Dr Hadiza Bawa-Garba, who had her licence to practice medicine revoked for her role in the death of a young patient. Six-year old Jack Adcock died on a chaotic day in 2011 at the Leicester Royal Infirmary that involved delays in the diagnosis and treatment of his sepsis. Today’s episode examines how widespread systems errors contributed to such mistakes.

Guests
Professor Jeffrey Braithwaite FAIM, FACHSM, FAHMS, FFPH-RCP, FAcSS, Hon FRACMA (Australian Institute for Health Innovation, Macquarie University)
Associate Professor Ian Scott FRACP (Director, Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, University of Queensland)
Associate Professor David Heslop FRACGP (University of New South Wal

Production
Written and produced by Mic Cavazzini. Additional audio recording from James Milson and Jennifer Leake. Music courtesy of Kai Engel ('Memories'), Jahzarr ('Become Death'), Sergey Cheremisinov ('Now You Are Here') and Loch Lomond ('Violins and Tea'). Image courtesy of Max Pixel. The production manager was Anne Fredrickson.

Editorial feedback for this episode was provided by RACP Fellows Paul Jauncey, Phillipa Wormald, Katrina Gibson, Rosalynn Pszczola, Andrea Knox, Philip Gaughwin, Rhiannon Mellor and Richard Doherty. 

Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.  

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Cannabis is a plant rich with potential therapeutic compounds and centuries of cultural resonance. At this moment in Australia, media accounts are full of patient stories and lab data suggesting benefit from cannabis for scores of different conditions, while politicians discuss laxer regulation of the drug and a new lucrative industr

However, only a few of the claimed medical effects of the plant have been proven by rigorous clinical trials in people. Nabiximols is the only medicinal cannabis product currently registered in New Zealand and Australia, and it's indicated only for­­ the treatment of spasticity in patients with multiple sclerosis (MS). Systematic reviews of the research note strong evidence that cannabis can also help with the pain associated with MS, the nausea induced by chemotherapy and some cases of epilepsy. But for many other conditions like post-traumatic stress disorder, irritable bowel syndrome, immune disorders and Parkinsonism, reviewers concluded that meaningful clinical recommendations could not be made—there simply aren't enough studies of good quality. 

Cannabis is complex. The flower bud contains mostly cannabidiol and tetrahydrocannabinol (THC), but there are about 100 other cannabinoid compounds. On this episode, Pomegranate Health guests explain how important it is to separate the effect of these various components in a systematic way, and why well-regulated research and prescribing will be safer for patients. 

Guests
A/Prof Peter Grimison FRACP (Chris O'Brien Lifehouse, University of Sydney)
Prof Meera Agar FRACP (UTS, USNW, IMPACCT)
A/Prof Carolyn Arnold FRACP (Monash University Alfred Health)
Prof Samuel Berkovic AC FRACP (Epilepsy Research Centre, University of Melbourne)
Prof Jennifer Martin FRACP (Australian Centre for Cannabinoid Research Excellence, University of Newcastle, John Hunter Hospital).

Production
Written and produced by Mic Cavazzini. Additional audio recording from James Milson. Music courtesy of Blue Dot Sessions (“Cloud Line”), 4T Thieves (“New Times”), Mystery Mammal (“Asylum”) and Jahzarr (“Please Listen Carefully”). Image courtesy of iStock. The production manager was Anne Fredrickson.

Editorial feedback for this episode was provided by RACP members Dr Michael Herd, Dr Pavan Chandrala, Dr Marion Leighton, Dr Rosalynn Pszczola, Dr Mahesh Dhakal, Dr Rhiannon Mellor, Dr Rebecca Grainger, Dr Philip Gaughwin and Dr Paul Jauncey, as well as Louise Hardy (Manager, RACP Policy and Advocacy) and Ms Joanna Harrison (Senior Adviser, ACRE).

Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.