My favourite rheumatology posts for 2013

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By Dr Irwin Lim, Rheumatologist

This year has flown by, frighteningly quickly. I think that implies that it was busy and overall enjoyable.

Writing this blog has been an important part of my year and I’d like to thank you all for your support. It definitely keeps me going.

I’ll admit that the enthusiasm has waned in recent weeks. I’ve been feeling lazy and less motivated, the blogging has seemed hard work. The end of year holidays are needed.

I sat down yesterday to review what I’d written for the year. Here’s a selection of the posts I thought most useful or enjoyable.

Maybe what my Rheumatoid patient reports is more useful than my tests?

Listening to Professor Ted Pincus led to change at our clinics. While I do measure DAS28, others find it cumbersome. The RAPID3 provided a simple measure, generated by patients. What we like is that it can generate a different line of conversation. “Oh, you’re having difficulty turning the tap?” “I didn’t realise you’re not sleeping well.”

When you google your Rheumatologist, do you want to see Tie & Suit?

I gave up the tie and jacket soon after I started as a consultant in 2004. The paraphernalia did not stop the fact that patients kept thinking I was too young to be a specialist. So, I just told them that I was very bright and got through all my exams very quickly! Think Doogie Howser.

But, others in my clinic (Herman Lau, nudge, nudge) belief that the suit and tie are expected of specialists. It’s the uniform. Perception counts.

By the way, the post points you towards our Dr photos. They’ve been updated since that post, with suit & tie!

How does Arthritis complicate being Intimate?

I have to thank Barry for his suggestion to write about this. Read the comments following the post. I’ll admit I still don’t bring this subject up myself but I’m glad other rheumatologists do (eg Dr Ingrid Hutton).

Do TNF inhibitors make you put on weight?

I’ve only become more aware of this in recent years. Working in a team with exercise physiologists and dieticians, a few of our patients on TNF inhibitors still find it hard to get rid of some of the excess weight. It affects a small proportion of patients using these drugs but which patients, how and why, remains unclear.

Spiderman Says & Rheumatologists should listen

I indulged myself with this. I loved superhero comics growing up and still pick them up from time to time. It’s a call to action to my fellow rheumatologists and to myself.

The BIG 3 Natural therapies for Arthritis

Unfortunately, some people get seduced by the concept that “natural” therapies are much better than medical solutions (i.e. medication). It’s not so natural to pop multiple tablets and capsules filled with oils, herbs, ground cartilage, etc. And yet, these same patients often forget the BIG 3.

Dear Steroid, I love you…
Dear Steroid, I hate you…
Why Rheumatologists will continue to use Steroid

I needed some way to try and explain our love/hate relationship with corticosteroids. These medications are really so useful and it’s highly unlikely we’ll stop needing or using them.

6 reasons why Ultrasound is useful in my Rheumatology hands

More and more rheumatologists are using ultrasound as part of their clinical practice. There are multiple barriers to this, including costs and poor access to training, and when these are overcome, ultrasound becomes a very useful tool for rheumatologists and their patients. I thought it worth explaining why.

Triple Therapy vs Biologic/MTX: the debate rages
Biologic DMARDs have to get cheaper: here’s how

This debate is not going away anytime soon. I wrote “If both were similarly priced, I don’t think we’d be having this debate. I’m guessing most rheumatologists would choose the biologic/Methotrexate combo”. You may disagree. It makes for interesting discussion.

Over 100 blog posts this year. Thanks again for your support!

Please keep those comments coming and I hope I can keep it up in 2014.

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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Your Rheumatologist: partnership vs paternalism?

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Image courtesy of photostock/ FreeDigitalPhotos.net

Image courtesy of photostock/ FreeDigitalPhotos.net

By Dr Irwin Lim, Rheumatologist

As I read patient comments on social media, I get the sense that many yearn for their rheumatologist to be a partner in navigating their disease and helping them make their treatment decisions.

Rheumatology is difficult. Much of what we treat, and especially with autoimmune arthritis, is chronic, and can have profound effects on patients lives. Treatments can be complicated and scary. We are sometimes guided by scientific evidence, sometimes by experience, and often by our sensitivity, the art of medicine.

There is no doubt that for many of my patients, we work together in coming to decisions.

There are however, equally many patients, that to my mind, do not or cannot take a more active part in their management decisions. Some find it very hard to cope with the diagnosis and rather than go out and garner information, they avoid it.

At our clinic, we have created a lot of resources, both paper-based and web-based, to help education. I haven’t formally audited it but I have the sense that it’s appreciated by some and probably unused by many.

“Doc, just tell me what to do.” “You’re the expert.”

Often, I need to be directive and the patient needs to be directed.

It might be heresy, in social media circles, to talk about being paternalistic. I don’t mean to court complaint.

It’s just that different people want and/or need different approaches. Sometimes, doctors get it wrong but most are trying to do the right thing for the people they care for.

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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When is the best time to have your joint replaced?

1

Knee XRBy Dr Roberto Russo, Rheumatologist

The answer to the above question used to be relatively easy to answer. The standard response used to be simply: when all other treatments have failed and the risks of the operation appear less concerning than the prospect of continuing to live with the pain of the arthritis. The focus of non-surgical therapies and interventions has been to retard the progression of the disease and to assist patients with their pain in order to delay the need for surgery for as long as possible.

Whilst this approach is effective in most patients for many years, over time there emerged an increasing proportion of patients in whom these conservative strategies fail and the dilemma of when to have surgery arises.

In that circumstance many a doctor would often refer that decision to the patient, saying ‘let me know when you are ready and I will arrange the operation’.

This is probably the case because clinicians find it very difficult to appreciate on an individual basis the impact of pain and impairment on the quality of life of their patients, despite quantitative methods of measuring quality of life being used in the research arena. As a result, I suspect many a patient chooses to suffer with their pain rather than commit to making such a decision.

Sadly, it is not uncommon for a patient to delay their decision for so long that when they finally choose to have the operation they find that they have developed other health problems which prevents them from proceeding to surgery.

So should clinicians be advocating for joint replacement surgery when symptoms demand rather than leaving it to their patients?

A recent article published in the October issue of the British Journal of Medicine (reference below) adds some interesting results that I feel are worth considering when reflecting on how to address the above question. The researchers evaluated the rate of serious cardiovascular events over 3 years, including cardiac death and myocardial infarction, following joint replacement surgery (of either the hip or knee) in a population of patients with moderate-severe osteoarthritis compared to a similarly affected group who did not undergo surgery. They found that:

  • The group who had joint replacement surgery were significantly less likely to experience a serious cardiovascular event (hazard ratio 0.56, p<0.001)
  • Absolute risk reduction within 7 years was 12.4% and therefore the number needed to treat with arthroplasty to avoid a serious cardiovascular event was 8
  • The significant risk reduction was independent of traditional cardiovascular risk factors.

Therefore, the conclusion of the paper was that primary joint arthroplasty has a cardioprotective benefit in patients with moderate-severe osteoarthritis of the hip or knee. This is reported to be the first time such an effect has been demonstrated.

The reasons that are presented to explain the findings include:

  • Physical activity increases following surgery
  • Reduction in pain leads to a reduced need for NSAID use and less psychological distress, both of which are thought to increase cardiovascular risk

These results, if replicated by larger longer term studies, would suggest that elective joint replacement surgery should be a term of the past.

Instead the decision to proceed to surgery once conservative therapies have failed is a recommendation made on the balance of health benefits (including a reduction in cardiovascular disease risk) to the short and long term risks of the procedure.

Reference:

1. Ravi B, Croxford R, Austin PC, et al. The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis. BMJ 2013; 347: f6187 doi: 10.1136/bmj.f6187

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The window of opportunity to educate about rheumatoid

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By Dr Irwin Lim, Rheumatologist

I met her at the start of 2012. A young lady with a new husband. She presented with a very swollen knee. The diagnosis was rheumatoid arthritis and it was an easy one to make, given she had very raised autoimmune serology (RF and anti-CCP) and her mother also had the disease.

They were trying for a baby so treatment options were limited. And it was just the one joint involved, so treatment was localised to aspiration and cortisone injection.

I think I got to see her three times. Then she disappeared. She cancelled a follow-up appointment, said she’d reschedule, and didn’t.

In a busy rheumatology clinic, it’s hard to have a good follow-up system for patients who don’t want to return. And, I forgot about her.

She’s now back. And the rheumatoid is rampant.

Over 21 months since review and she now has over 20 joints involved, both big and small. Her fingers are all deviated at the MCP joints (knuckles), her wrist movements are restricted and her thumbs are shaped like a Z.

The window of opportunity to switch off her rheumatoid is well and truly over. We missed it.

I had a window period to educate her on how serious her disease could potentially become. I missed that.

I figure all rheumatologists would spent a lot of time up front trying to explain this beast called rheumatoid arthritis. I thought I was relatively effective at this but this sort of occurrence brings me back to earth.

Why didn’t she return?

Well, she was still trying to fall pregnant. And she thought that as long as she was trying, she couldn’t be treated. I suspect she has had difficulty coping with having a chronic disease and just plodded along, accepting her symptoms. Even now in the face of very active, deforming rheumatoid, she tells me she is coping and has little pain.

I feel disappointed and sad at what’s happened. Especially as it was likely to have been preventable.

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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Help us design the Rheumatology Centre you’d like to attend

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Our Parramatta clinic

Our Parramatta clinic

 

By Dr Irwin Lim, Rheumatologist

BJC receptionEffective space. This has been on my mind a lot recently.

Our most established clinic is based in Parramatta, a suburb in Western Sydney.

We’ve been in a 2-storey house since 2005. During this time, we’ve grown and added new staff and new services, squeezing ourselves into all corners, redividing rooms and making do with what space we have.

This has meant compromise. The workflow could and should be much better. We lack a room for staff to congregate. We would love more space to enhance the experience for our patients.

There’s 2 years left on the lease so we’re starting to plan.

A huge, somewhat scary move for us.

Small group exercise area

 

In this planning phase, we’ve decided not to worry about budget and cash flow. I know. Wishful thinking.

BJC IL room

As it stands, we want a site to accommodate:

  • 6 Consulting rooms, to be used by doctors, a nurse, a rheumatology educator, allied health professionals
  • 1 room for musculoskeletal ultrasound
  • 1 room to house a Bone Densitometer
  • A pathology collection area
  • 6 treatment rooms for physiotherapists
  • 2 treatment rooms for remedial massage therapists
  • Office space for the physiotherapists/exercise physiologists
  • A compact central gym area including space for small group exercise classes
  • An area next to the gym for biomechanical testing/assessment
  • Showers & Toilets
  • 2-3 offices, to be used by administrative workers, the practice manager & the managing director
  • A large staffroom which can also function as a small (20 seat) lecture theatre/staff meeting space
  • The staffroom needs to incorporate a functional kitchen which can be utilised for group healthy cooking demonstrations
  • A reception area with space for 5 front-line reception staff
  • A range of seating options for patients & their families
  • An area built for patient self-education utilising smart pads or computers (ala Apple Store)
  • An area to display & demonstrate useful products & devices which are used in managing arthritis
  • An area for kids with TV, DVD, books to entertain

I’m thinking lots of glass, natural light, and parking!

Can you think of anything else that you would like to see in a rheumatology centre?

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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