How Aussie Rheumatologists are using Ultrasound

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Our clinic's ultrasound setup

Our clinic’s ultrasound setup

 

By Dr Irwin Lim, Rheumatologist

Another sunny, glorious Sydney weekend.

I spent it indoors. Being upskilled.

With a bunch of 20+ rheumatologists from around Australia discussing how ultrasound is used to enhance our practices. We also brought in many helpful patients who were happy to allow us to scan their various body parts to educate and teach each other.

This cohort of Aussie rheumatologists are increasingly using an ultrasound machine at point-of-care.

By point-of-care, I mean that we use the technology to enhance our patients experience at our rooms and during our consultations.

The rheumatologist will be there as the ultrasound is performed. In many circumstances, this has a clear advantage over sending a patient away for the scan to be performed at St.Elsewheres.

The rheumatologist already has an in depth knowledge of the complaint, has already physically examined the patient, and has a clear clinical question to hopefully be answered using the ultrasound scan.

I have written about the reasons I think ultrasound is useful in my hands (read it here).

And, it’s a win for patients and a win for us, rheumatologists.

The range of clinical situations my colleagues are finding this technology helpful for them and their patients is large, and include:

  • Assessing the degree of disease involvement. For eg, in rheumatoid arthritis, working out the extent of disease.
  • Assessing the degree of damage that has already occurred in inflammatory arthritis. For eg, we may look for erosions as these predict more aggressive disease.
  • Trying to help make a diagnosis in cases where it’s not otherwise clear. For eg, trying to differentiate between osteoarthritis and a seronegative inflammatory arthritis, trying to help make the diagnosis of psoriatic arthritis, looking for classic changes of gout.
  • Helping to make clinical decisions. For eg, attempting to judge how active the disease still is before modifying medication therapy.
  • Assessing sporting injury or mechanical problems. Commonly, we look at the rotator cuff or the gluteal (buttock) tendons or the wrist or ankle or  elbow tendinopathy.
  • Assessing various lumps, bumps and a variety of swelling. Is it fluid-filled? Is it solid? Should we worry?
  • Guiding cortisone injections to various parts of the body (watch my shoulder injection video)
  • Assessing vasculitis (autoimmune inflammation of blood vessels). I’ve not learned to do this yet but a nice case of temporal arteritis was presented.
  • Assessing nerve problems, commonly carpal tunnel syndrome with the median nerve at the wrist.
  • Helping patients understand their disease better. Some patients do seem to appreciate their problem more if they can watch on a screen what is happening to their joints, tendons or other tissues, rather than just accepting what their doctor may have told them after the usual physical examination.

It’s still early days for ultrasound use in the Australian rheumatology clinic but the tide seems to be turning. It’s a skill that more and more of us are developing.

Could you share your experience of this?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Repeating a 1-year experience 20 times

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Image courtesy of Stuart Miles at FreeDigitalPhotos.net

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

 

By Dr Irwin Lim, Rheumatologist

I was yapping to an esteemed, senior colleague a few weeks ago. We were talking about the practice of rheumatology.

Not so much about how science, medication and knowledge has changed. As that’s a given over time.

But more about how rheumatologists apply the art of medicine.

How do we think about and then execute the actual mechanics of a consultation with this other person in front of us, the person we label a patient.

We have many venerable colleagues with decades of experience but in the field of service delivery, some have not changed much over time. How it has always been done, is not necessarily how it should continue to be done.

He was different.

As we talked, it was obvious to me that he analysed the parts of his consultation, to over the years, improve his own efficiency but also to improve what his patients’ gained from that consultation.

I mean that he was deliberate in how he introduced himself, he was purposeful in how he structured the history taking, the examination of the patient and then the explanation of the problem. This was followed by a considered negotiation, a verbal “contract” as to how the problem would be tackled from then on.

I hope I can be as considered over the next 20 years of my rheumatology practice.

I’d rather improve with 20 years of experience rather than repeat a yearly experience 20-times over.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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What to do for that TNF-inhibitor injection site reaction?

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By Dr Irwin Lim, Rheumatologist

An hour or so after her Enbrel injection, she noticed this rash. It steadily increased in size over the day. A little tender, a little itchy. She was otherwise well.

Enbrel injection site reaction

Injections site reactions do occur with subcutaneous injections, and they certainly do occur with the most commonly used biologic DMARDs, the TNF inhibitors.

What are our options?

  • Do nothing if it’s not particularly irritating for her. Most injection site reactions go away within a few days.
  • Ice the area to reduce the swelling and to soothe the symptoms.
  • Use an anti-histamine to reduce the swelling, itch and discomfort.

She should remember to rotate the sites of injection.

I’ve certainly had patients where the rash occurs with each injection. Sometimes, it’s a very minor reaction. Less often, it’s more pronounced as in this picture.

The 2 strategies I’ve used:

  • Use an anti-histamine on the day of the injection, prior to the injection
  • Swap the medication to another biologic DMARD. Injection site reactions are more common with Enbrel (Etanercept) and Humira (Adalimumab), and are less common with Simponi (Golimumab) and Cimzia (Certolizumab). Or we could swap to another class of biologic DMARD or swap to one with a different route of administration i.e. an Intravenous Infusion.

If you’ve had an injection site reaction, could you share with us how you managed it?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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What’s the Side Effect of Avoiding Medication?

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By Dr Irwin Lim, Rheumatologist

Most patients do ask about side effects.

Their pharmacists helpfully (and sometimes, not so helpfully) provide them lots of information about side effects.

Family and friends helpfully (and sometimes, not so helpfully) share stories about side effects.

The internet is a treasure trove of side effect stories.

“What if you develop this…..”

“I put on 30 pounds on that drug….”

“Made me sick as a dog………”

“Did you hear about that class action running because that drug causes……”

It’s not a bad thing to have an enquiring mind. I don’t expect people to take doctor’s advice or medication prescribed without thinking carefully about it.

I object when I don’t get a chance to discuss and clarify the actual risk.

I like to ask patients to consider the effect of not treating the disease, of not actually using a medication which may be effective in calming down the inflammation, effective in slowing down the progression of disease, effective in preventing deformity or pain or excessive suffering……

Sometimes it’s not clear cut and various options (including not taking any medication) need to be considered.

What I’m suggesting is that when you worry about the (potential) side effects of a medication, that you also worry about the side effects of not taking the medication.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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Using Tree Branches to understand Inflammatory Back Pain

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By Dr Irwin Lim, Rheumatologist

If you present with back pain to your GP, your physiotherapist, your chiropractor, your osteopath, your kinesiologist, your acupuncturist, your massage therapist, etc…….chances are that they’ll try to ask questions and examine you to rule out worrying causes of back pain.

Causes such as compression of the nerve roots. Or even fracture or an occult tumour. Thankfully, these occur infrequently.

Most back pain is then treated as being non-specific.

This means that the health practitioner cannot be absolutely certain of the cause. It’s assumed to be due to a mechanical or degenerative problem, usually due to some strained ligament/tendon/muscle. And in many cases, this is the correct assumption.

The cause which is often missed or overlooked is Inflammatory Back Pain (read here about the distinction between inflammatory vs mechanical pain).

Part of the reason is that this is a difficult type of pain to understand and the terms used to classify inflammatory-type back pain are confusing.

The natural history of this type of back pain is also not clearly worked out.

How many people with inflammatory-type back pain progress to developed Axial Spondyloarthritis?

How many with non-radiographic Axial Spondyloarthritis (what does this term even mean! Read about it here) eventually progress to get damage on their X-rays and get diagnosed with Ankylosing Spondylitis?

I think these graphics help:

from: Unanswered questions in the management of axial spondyloarthritis: by Xenofon Baraliakos & Atul Deodhar.
from: Unanswered questions in the management of axial spondyloarthritis: by Xenofon Baraliakos & Atul Deodhar.
from Unanswered questions in the management of axial spondyloarthritis: by Xenofon Baraliakos & Atul Deodhar

from Unanswered questions in the management of axial spondyloarthritis: by Xenofon Baraliakos & Atul Deodhar

You can access the original article at:  http://link.springer.com/article/10.1007%2Fs10067-014-2740-x

Thanks to my friends, Drs Phil Robinson & Sam Whittle for pointing me towards this tree. I’ll be using it in a talk or two to help others understand Inflammatory Back Pain.

Does this tree make it clearer for you?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
 
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