The field of regenerative medicine is receiving significant interest with the objective of restoring damaged tissues to health using biological products, as well as influencing age-related decay.

The use of pluripotent stem cells has been studied for some years now with the hope of nurturing their undifferentiated state into specific cell types reflecting the target tissues requiring repair. Another approach has been to harness the biological properties of exosomes. Exosomes are nano-sized biovesicles released by all nucleated cells into surrounding body fluids upon fusion of tiny intracellular multivesicular bodies and the plasma membrane.

These small vesicles, measuring between 40 and 160 nanometers, were first identified in the late 1980s and initially were proposed as cellular waste resulting from cell damage or by-products of cell homeostasis with little or no effect on neighboring cells. This initial simple interpretation of their function has now been supplanted by new insights into their physiological roles. Exosomes carry a complex cargo of proteins, lipids, and nucleic acids and are now recognized as functional vesicles capable of delivering very important cargoes of information to target cells they encounter. This chemical messaging may ultimately reprogram the recipient cells remotely from their release and represent a novel mode of intercellular communication as well as playing a major role in many cellular processes such as immune response, signal transduction, and antigen presentation.

It is likely that the cargo of exosomes may differ significantly depending upon the function of the originating cell type and its current physiological state, including states of transformation, differentiation, stimulation, or stress.

A current line of study aims to determine whether active exosome cargo may offer prognostic information on a range of diseases such as chronic inflammation, cardiovascular and renal disease, neurodegenerative diseases, lipid metabolic disease, and tumors. Additionally, as exosomes are not immunogenic, they are being examined for their potential to actively deliver biological therapeutics across different biological barriers to target cells, including across the blood-brain barrier.

References:

Dr. Jeffrey Gross:www.ReCELLebrate.com

Stem Cells and Regenerative Medicine: From Molecular Biology to Clinical Applications. Academic Press. 2021.

Exosomes in Cell-to-Cell Communication and Regenerative Medicine. Theranostics. 2020.www.ncbi.nlm.nih.gov

The Role of Exosomes in Regenerative Medicine and Tissue Engineering. Frontiers in Bioengineering. 2019.www.frontiersin.org

In this episode, we delve into the critical issue of obesity and the transformative potential of bariatric surgery with Dr. Jason Winnett, a leading expert in weight loss treatments and Director of the Winnett Specialist Group in Melbourne. With obesity affecting 67% of Australians and posing severe health risks such as type 2 diabetes, heart disease, and cancer, Dr. Winnett explores how modern surgical techniques are offering hope to those struggling to achieve sustainable weight loss through traditional methods.

Dr. Winnett provides insights into the latest bariatric procedures, including gastric sleeve and mini-gastric bypass surgeries, highlighting their effectiveness in achieving long-term weight loss and managing chronic conditions. We also discuss pre-surgical pharmacological approaches, the role of multidisciplinary care, and the importance of managing potential nutritional deficiencies.

This episode offers a comprehensive overview of the advancements in bariatric surgery and its critical role in combating obesity. Tune in to learn from Dr. Winnett's decades of expertise and discover how these treatments are transforming lives.

Resources and References:

* Winnett Specialist Group: winnettspecialistgroup.com.au
* Australian Institute of Health and Welfare: Impact of Overweight and Obesity as a Risk Factor for Chronic Conditions, 2017
* Australian Bariatric Surgery Registry, 2019
* Swedish Obesity Study: J Internal Medicine, 2013
* British Obesity and Metabolic Surgery Society Guidelines, 2020 Update
* RACGP Guide to Bariatric Metabolic Surgery, 2017

As a background to this podcast in 2021 there were 15 200 Australians with kidney failure receiving dialysis, a doubling of the number receiving dialysis from 2000 with a male-to-female ratio of approximately 2 to 1. 

82% of these patients were receiving chronic haemodialysis all of whom required an arterio venous vascular shunt for access. A small proportion (18%) were being managed by peritoneal dialysis and in that year, there were 857 functioning kidney transplants. Of the haemodialysis patients 25% were being dialysed in hospital, 65 % in satellite centres and 9 % at home. Indigenous Australians representing 2.5 % of the population comprised 9% of patients commencing renal replacement therapy highlighting a very significant health burden for first nations people. The main indications for patients receiving dialysis included having severe renal failure with a GFR less than 15ml/min/1.75m2 accompanied by complications such as metabolic acidosis, hyperkalaemia, pericarditis, encephalopathy, intractable volume overload, anorexia with weight loss and lethargy, peripheral neuropathy, intractable gastrointestinal symptoms or having an e GFR of 5-9 ml/min or less despite being asymptomatic.

Vascular access for haemodialysis is accomplished by the creation of an arteriovenous fistula or use of a prosthetic graft with catheters providing temporary access only. As normal veins are not strong enough to cope with the high pump pressures and the rapid blood flow from a dialysis machine a native fistula joining vein to artery, normally in the forearm is created. As the fistula matures over 6 to 8 weeks the vein adapts and thickens leading to a stable fistula ready for use. Both immediate, early and late complications are described including infection, aneurysm, thrombosis and staphylococcal infection. Despite expert surgery up to 30% of fistulas are unusable. The Kidney Disease Outcome Quality Initiative (KDOGI) describes the Rule of 6 for fistulas comprising being: Ready for use 6 weeks or more after being formed, having a blood flow through the fistula of 600 ml/ min, a diameter of 6 mm accessible for 6 cm and at 6 mm depth.

To learn more about arteriovenous fistulas as well as the Do’s and Don’ts of fistula care in primary practice we welcome back Dr Ming Yii. Ming is a well-recognised expert in vascular surgery and is the director of vascular and transplant surgery at Monash Health and adjunct Senior lecturer with Monash University. Ming is also part of the Monash transplant team in kidney and pancreas transplantation and brings a wealth of knowledge and experience as well as an effusive personality to accompany his skills. In this episode he discusses his approach to fistula formation and for their ongoing management and care.

References:

Dr Ming Yii. mingyiivascular.com.au or admin@yiivascular surgery.com.au

www.webmd.com

Webster AC et al. Chronic Kidney Disease. Lancet .2017Mar 25;389 (10075):1238-52.

National Kidney Foundation: kidney.org

Show Notes: Snake Bite Envenomation in Australia with Dr Tim Jackson 

Australia is home to many of the world’s most dangerous snake species so familiarity with snake bite management and understanding the clinical effects of snake bite is vital for Australian doctors, especially those with a rural practice. Each year in Australia there are about 1000 recorded snake bites but fortunately only 2-3 deaths, most of these relate to bites from the brown snake. This contrasts with a vastly higher number of reported deaths from snake bite in India and Africa contributing to a recorded 100 000 deaths from envenomation globally.

Australian snakes, also known as elapids, deliver a venom through their bite which predominantly exerts systemic effects. There are five major venom types for Australian snakes. Minor to moderate local effects may also be experienced depending on the snake genera.

Snake venom is a complex mixture of many components including peptides, enzymes, phospholipases, proteases, and others. The venoms may have a potent pro coagulant effect leading to venom induced consumptive coagulopathy which may ultimately lead to defective coagulation through consumption of clotting factors. D- Dimer levels will be high in such instances. A primary anticoagulant effect may occur without significant D-Dimer production but significant bleeding. Other effects include neurotoxicity where toxins have either pre or post synaptic targets. Early signs of developing paralysis such as ptosis need to be watched for closely in the hope of avoiding a neurotoxic flaccid paralysis that may require ventilation. Myotoxicity predominantly affects skeletal muscle and may lead to profound rhabdomyolysis with renal injury and intravascular haemolysis as associated sequelae.

Clinical diagnosis of envenomation may be based on a definite history of observed snake bite however more cryptic presentations where definite snake bite has not been observed may result in baffling systemic effects with minimal local evidence of a bite. It’s important to be aware of envenomation as a potential diagnosis in such cases.

Detecting coagulopathy is the most urgent investigation to consider after an Australian snake bite. A complete coagulation panel including D-Dimer assessment is essential, electrolyte, renal function and creatinine phosphokinase levels should also be checked. For a well patient these tests should be ordered at presentation, after removal of the first aid pressure bandage and then again at 6 and 12 hours post bite, assuming preceding tests have been normal. Evidence of envenomation requires stabilisation of the patient and administration of antivenom. 

Australia is the only country with commercially available snake venom detection kits that may assist in the identification of venom that has been inoculated and provide a very helpful guide to the appropriate antivenom to administer. A polyvalent vaccine is also available for administration although larger in volume and associated with more side effects than the ‘monovalent ‘antivenoms correctly chosen from the kits mentioned above. Doses are the same for adults, children and the pregnant.  Expert assistance from a toxicologist and intensivist should be sought early if troubling signs and symptoms of envenomation are observed.

In this episode we have a conversation with Dr Tim Jackson who is co-head of the Australian Venom Research Unit at Melbourne University and an evolutionary biologist. Tim brings a huge and enthusiastic wealth of knowledge to this discussion, and it was a real honour to invite him as an expert guest. Please welcome Tim to the podcast.

References:

Dr Tim Jackson - AVRU - Australian Venom Research Unit - Melbourne University 

White, J.A Clinician’s Guide to Australian Venomous Bites and Stings, BioCSL, Melbourne 2013.

Preventing and managing snake bites. (PDF). Qld Govt. May 2018

Episode 162 Show Notes. Medical Outreach Programs with Sister Jodie Manssen

In this episode, we sit down with the inspiring Sister Jodie Manssen, an expert ICU and emergency nurse, adventurer, and philanthropist, whose journey exemplifies compassion and dedication.

In 2023, Jodie self-funded and volunteered with TrekMedic, a Melbourne-based nonprofit comprised of volunteer doctors, nurses, and allied health professionals. This organization provides basic healthcare, education, and emergency aid to underprivileged communities around the world. Jodie spent over two months of her time and expertise participating in TrekMedic’s annual trip to Nepal, sacrificing the financial security of her regular job to make an incredible impact.

Highlights from the Nepal Trip (Sept–Oct 2023):

Jodie’s current work involves supporting First Nations communities in Alice Springs while preparing for her next adventure, attending to ski, snowboard, and mountain trauma in New Zealand’s winter season.

References:

About the Podcast:Join us for this compelling conversation with Jodie, where we dive into her life-changing experiences in Nepal, her dedication to helping underserved communities, and her adventurous spirit. You won’t want to miss this incredible story of resilience, compassion, and purpose.

Michael Kenihan is nothing short of a legend in the Australian allied health community. Over four decades, he has made remarkable contributions as a sports physiotherapist, business manager, sports administrator, entrepreneur, coach, and thought leader in health and sports medicine. A fellow of Sports Medicine Australia, Michael has led Australia’s largest allied health network, Life Care, navigating major acquisitions, divestitures, and even an IPO. His entrepreneurial ventures include founding the Melbourne Stem Cell Centre and the innovative technology application R-U-Ontrak.

Michael's positive energy, vitality, and deep expertise are reflected in his brilliant new book, The Health Practitioners Journey. This essential guide offers a four-stage career plan designed for health practitioners - from recent graduates to seasoned professionals - providing practical strategies for achieving both clinical excellence and financial success. The book lays out a clear roadmap: building and owning a patient list, leveraging that equity, and eventually preparing for a commercial sale.

More than a manual, The Health Practitioners Journey is a companion for all health practitioners, including doctors, physiotherapists, and allied healthcare workers. It emphasises harvesting knowledge, recognising personal potential, and attaining a fulfilling career. Packed with insights, actionable tips, and strategies, it’s a must-read for anyone at any stage of their healthcare career, from starting private practice to navigating the complexities of mature career management.

It was an absolute privilege to be introduced to Michael and to interview him for our podcast. Please join me in welcoming Michael Kenihan to the conversation!

Motor neuron disease (MND) is a rare group of neurodegenerative disorders causing motor nerves in the brain and spine to lose function over time. It affects approximately 2,000 Australians (1 in 11,000), with two new diagnoses daily and a 1:300 lifetime risk. MND is more common in males (60%) than females (40%), particularly those aged 75–84. While 10% of cases have a hereditary cause, the genetic fault is identifiable in only 60% of these cases.

Types of MND

1. Amyotrophic Lateral Sclerosis (ALS): The most common form, affecting both upper and lower motor neurons, leads to muscle weakness in the arms, legs, mouth, and respiratory system. ALS patients typically live 3–5 years post-diagnosis, but supportive care can extend survival. Prominent figures such as Stephen Hawking and Lou Gehrig had ALS. In Australia, Neale Daniher's 2013 diagnosis raised significant awareness. ALS is sometimes associated with frontotemporal dementia (10–15% of cases).

2. Primary Lateral Sclerosis (PLS): A rare, non-fatal form that progresses slowly, affecting brain neurons.

3. Progressive Bulbar Palsy (PBP): Involves the brainstem, causing speech, swallowing, and choking difficulties. Often co-occurs with ALS.

4. Progressive Muscular Atrophy: Affects lower motor neurons, leading to gradual muscle wasting in the arms, legs, and mouth.

5. Spinal Muscular Atrophy (SMA): An inherited condition caused by a genetic change (SMA1), mainly affecting children.

6. Kennedy’s Disease: An inherited disorder affecting males, causing muscle weakness, twitching, and other symptoms such as gynecomastia and azoospermia.

Causes and Risk Factors

While 10% of MND cases are hereditary, the rest arise randomly. The exact causes remain unclear, but factors such as genetics, toxins, viruses, and environmental influences are believed to contribute.

Symptoms and Diagnosis

Early symptoms, such as muscle twitching, weakness, and slurred speech, may mimic other conditions like multiple sclerosis. Diagnosis is challenging due to the lack of specific biomarkers, though imaging like MRI or CT can help rule out other conditions.

Treatment and Management

While MND has no cure, various treatments can slow its progression and help manage symptoms. Medications like Riluzole, which reduces glutamate release, can extend short-term survival in ALS, while Edaravone slows disease progression in milder cases. Baclofen helps alleviate muscle stiffness, and Botox provides temporary relief from muscle spasticity. Supportive therapies, including physical therapy, speech therapy, and NSAIDs, can reduce discomfort from cramps, spasms, and mild pain, improving the patient’s quality of life.

Guest Expert

In this episode, we welcome back Associate Professor Ernie Butler, a consultant neurologist and founding member of Frankston Neurology Group. He specialises in managing multiple sclerosis, myasthenia gravis, and Parkinson’s disease. Prof. Butler holds leadership roles at Peninsula Health, Monash Health, and the Monash MS clinic. He previously joined us on episodes covering multiple sclerosis, myasthenia gravis, and Guillain-Barre syndrome.

Join us as we explore MND in-depth with Associate Professor Butler, gaining insights from his extensive expertise in neurology.

Exploring Parkinson's Disease with Associate Professor Ernie Butler

In this episode, we dive into Parkinson’s Disease (PD), a progressive neurodegenerative disorder that primarily impacts dopamine-producing neurons in the substantia nigra, leading to motor and non-motor symptoms. Our guest, Associate Professor Ernie Butler, consultant neurologist and founder of Frankston Neurology Group, provides expert insights into PD's complexities.

Pathophysiology of Parkinson’s Disease
PD affects dopaminergic neurons in the substantia nigra, leading to a significant drop in dopamine, a neurotransmitter essential for movement. Dopamine loss disrupts communication between the substantia nigra and corpus striatum, impairing motor functions. Additionally, the loss of norepinephrine-producing nerve endings can cause non-motor symptoms like fatigue and blood pressure irregularities. Lewy bodies, protein aggregates containing alpha-synuclein, are also present and may contribute to neuronal death.

Global Impact
As the second most common neurodegenerative disorder, PD affects millions worldwide, with over 200,000 cases in Australia. Around 38 new cases are diagnosed daily, and one in five diagnoses is made before age 50.

Core Symptoms of Parkinson’s Disease
PD's four main motor symptoms are:

Parkinson’s Plus Syndromes
Several conditions mimic PD but include unique symptoms:

Risk Factors
PD risk factors include:

Diagnosis and Treatment
PD is diagnosed through medical history and neurological exams, as CT and MRI scans often show no abnormalities in early stages.

Treatment Options
While PD has no cure, several treatments help manage symptoms:

With extensive experience in managing PD, MS, and myasthenia gravis, Associate Professor Ernie Butler is a senior neurology specialist at Frankston Neurology Group and Monash Health. He has been featured in prior episodes on Multiple Sclerosis and Myasthenia Gravis, providing valuable insights into complex neurological conditions.

References

Frankston Neurologyhttps://www.frankstonneurology.com.au › ...Our Neurologists

Parkinson's Foundationhttps://www.parkinson.org › what-is...What is Parkinson's?

National Institute of Neurological Disorders and Stroke (.gov)https://www.ninds.nih.gov › disordersParkinson's Disease | National Institute of Neurological Disorders ...

It’s difficult to walk through an old-growth natural forest anywhere in the world and not feel awe and a connection to the majesty of our beautifully stunning Earth, however, when these amazing ecosystems burn as forest fires the consequence has devastating outcomes for affected communities. In recent times in Australia the Ash Wednesday fires of 1983 claimed 75 lives, The Black Saturday Fires of 2009 claimed 173 lives, 3500 buildings, and 2000 houses and the Black Summer fires of 2019/2020 claimed 26 lives and 2500 houses.

The health consequences in terms of mental health, acute pulmonary disease and socioeconomic effects from these disasters is difficult to comprehend and the loss of life devastating. 

The normal response to fire prevention has been to recommend controlled burns and to thin forests through commercial logging. Is this scientifically correct? We talk with Professor David Lindenmayer from the Fenner School of Environment at ANU in this episode to explore this idea further. David is a leading world expert on forest ecology and resource management, conservation science and biodiversity conservation. He has published over 900 peer reviewed scientific papers and written 48 books with his latest book The Forest Wars addressing myths concerning forest management and ecology to be released in the next few weeks. He is frequently consulted by government and has lectured widely on this subject.

His scientific work has pointed to the reduced flammability of mature forests, wet or dry, compared to younger forests subject to recent logging or controlled burn offs. Forest disturbance has been found to stimulate flammability; an effect referred to as disturbance-stimulated flammability. Both crown fire -where burn occurs up to 7 times the height of flames, and house loss were more likely in the 2009 tragic Victorian fires if the area within 1 km of houses had been burnt off within the past 5 years. His work highlights the value of reviewing the science on the subject at hand, to be curious and question the evidence and rationale underpinning decision making and to muster the courage and commitment to educate the world despite the resistance and ignorance that exists to hear and understand the truth.

As Bill Mollison said, “If we lose the forests, we lose our only teachers”.

It was a great privilege to have this conversation with David who I believe is at the vanguard of ecological change and thinking both in Australia and on the world stage. I look forward to reading his new book The Forest Wars and hope you will also. Please welcome David to the podcast

References:

Professor David Lindenmayer, Professor of Ecology and Conservation Biology at the Australian National University’s Fenner School of Environment and Society

Identifying and managing disturbance-stimulated flammability in woody ecosystems. David Lindenmayer and Phil Zylstra, Biological Reviews (2023)

The Forest Wars, David Lindenmayer, Allen & Unwin 2024

Globus, a persistent or intermittent sensation of a lump or foreign body in the throat, is a well-defined clinical symptom. Though it is non-painful, it can be long-lasting, difficult to treat, and prone to recurrence. Interestingly, this sensation often improves with eating and typically does not accompany dysphagia (difficulty swallowing) or odynophagia (painful swallowing). Globus is a common condition, accounting for about 4% of new referrals to ear, nose, and throat (ENT) clinics, and is reported by up to 46% of apparently healthy individuals, with peak incidence in middle age. The condition affects men and women equally, though women are more likely to seek medical care for it.

The origins of globus pharyngeus trace back to Hippocrates, who noted it around 2,500 years ago. In 1707, Purcell provided the first accurate description, attributing it to pressure on the thyroid cartilage from the contraction of the neck's strap muscles. Historically, the condition was labeled as "globus hystericus" due to its frequent association with menopause or psychological factors. However, in 1968, Malcomson introduced the more accurate term "globus pharyngeus" after discovering that most patients with globus did not have a hysterical personality. The exact cause of globus remains unknown, but it appears to be multifactorial.

While data are limited, recent studies suggest that factors such as gastroesophageal reflux disease (GERD), abnormalities of the upper esophageal sphincter (UES), psychological and psychiatric disorders, and stress may contribute to the sensation of globus. The variety of potential causes has made it challenging to establish standard investigation and treatment strategies, requiring an open mind when considering possible causes.

Dr. Andrew Martin, a practicing ENT surgeon based in the southeastern suburbs of Melbourne and Northern Tasmania, sheds light on this condition. He completed his MBBS at The University of Queensland in 2008, following a Bachelor of Pharmacy Sciences with Honours from Monash University in 2003. In 2021, he earned his fellowship with the Royal College of Surgeons in Otolaryngology and Head and Neck Surgery in New Zealand and completed an Advanced Fellowship in Head and Neck Surgery at The Royal Melbourne Hospital in 2022. Dr. Martin has special interests in nasal obstruction, obstructive sleep apnea, ear and balance issues, chronic sinus disease, mid-facial pain, pediatric ENT, as well as swallowing, voice, and throat disorders.

Beyond his professional achievements, Andrew is a dedicated family man with two young daughters and enjoys hunting and fishing in his free time. It was a privilege to have this insightful conversation with him about globus symptoms. Please welcome Dr. Andrew Martin to the podcast.

References:

⁠Dr Andrew Martin

"Globus pharyngeus: A review of its etiology, diagnosis and treatment." World Journal of Gastroenterology. 2012 May 28; 18(20): 2462–2471. Published online 2012 May 28. doi: 10.3748/wjg.v18.i20.2462

https://www.uptodate.com/contents/globus-sensation