Grand Rounds is a long-running blog carnival that features some of the best contributors to the medical blogosphere. The latest edition was hosted by Pizaazz, and our post on “The Disease of Kings and the King of Diseases“ gets a mention.
Osteoporosis: a frightening lack of intervention 0
Lunar Prodigy Bone Densitometer (DXA)
A minimal trauma fracture is defined as a fracture that occurs through falling, tripping or slipping from a standing height or a trauma of lesser impact.
Each such fracture is followed by repeat fracture in up to 50% of cases.
Unfortunately, many people who suffered such fractures, even when they presented to hospital, were not told that they could have osteoporosis nor were they investigated or treated for this disease.
The statistics are frightening:
- Someone was admitted to an Australian hospital with an osteoporotic fracture every 5-6 minutes in 2007
- People who suffer one fracture have a 2 to 3 times higher risk of suffering another fracture
- Studies have shown that only 20 to 30% of patients are being identified at the time they present with the first minimal trauma fracture!
Many task forces and medical groups are working hard to change this. Progress has been snail-paced.
A more appropriate response to an osteoporotic fracture would include:
- Assessment of medical history and risk factors
- Detection of the disease, using DXA testing
- Education
- Lifestyle change (such as giving up smoking, regular exercise, dietary measures)
- The risk of falls being assessed & reduced by helping the elderly walk more safely
- Supplementation with calcium and vitamin D when indicated
- Appropriate use of medications
This sort of fracture prevention clinic or fracture liaison service does not currently exist in the majority of Australian hospitals. Why not?
Bureaucracy, lack of health funding, lack of political will, and poor general awareness among the public and health professionals probably contribute.
Effective management of osteoporosis is a wonderful example of the need for the Connected Care model. At BJC Health, we have provided this fracture liaison service for years. Coordinated, conveniently-located, multi-disciplinary care to provide an effective solution.
All evidence-based guidelines highlight the importance in intervening to prevent the next fracture. When will our hospitals get their act together?
Dr Irwin Lim is a rheumatologist and a director of BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients. We call this model of care, Connected Care. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.
This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy.
You won’t know until you break (unless you look for it) 2
If most of us were to stumble and then fall forwards, we probably would stop our fall with our outstretched hands. Would you find it surprising if this led to you breaking your wrist bone?
If you were bumped and fell onto your buttock or the side of your hip, would you be surprised if you fractured your femur (hip bone)?
Should you expect to become much shorter as you enter your 7th or 8th decade of life?
Each year, numerous people, usually over the age of 60, develop such fractures.
The wrist or Colles fracture, and the femoral fracture (typically at the neck of the femur) can cause terrible pain followed by loss of function. In the case of a fracture of the femur, loss of life can result, and probably, worse still, loss of independence with up to 50% of sufferers ending up in a nursing home. Crush fractures of vertebrae can actually be silent, with the only sign being increasing curvature of the thoracic spine (kyphosis or “hunchback”).
These 3 types of fractures are examples of minimal-trauma fractures (also called fragility fractures), given that they occur with at a level of trauma that would not be expected to cause such damage. People who suffer such fractures typically have osteoporosis.
Osteoporosis is present when bone becomes fragile to the point that fractures occur without much trauma.
Osteoporosis is a very common disease. 1 in 2 women and 1 in 3 men over the age of 60 will sustain an osteoporotic fracture.
Effective treatment can prevent the first fracture. Effective treatment can prevent subsequent fractures.
Unfortunately, this disease tends to be silent, with the first symptom and sign of osteoporosis being the fracture. As a result of this, it is commonly undetected prior to fracture. It is estimated that less than 25% of people who suffer an osteoporotic fracture are on appropriate treatment, mainly because the disease is not considered and therefore untreated.
This is a shame, and needs to change. What do you think?
Dr Irwin Lim is a rheumatologist and a director of BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients. We call this model of care, Connected Care. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.
This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy.
Rheumatoid Arthritis: Don’t miss the Window of Opportunity 0
I can’t allow 2010 to end without mentioning the importance of the window of opportunity in the treatment of Rheumatoid Arthritis.
TIME (wasted) = JOINT (damage)
Rheumatoid Arthritis is a chronic inflammatory disease of the immune system, attacking joints primarily.
This disease causes progressive joint pain, stiffness, swelling, difficulty in use and then ultimately, destruction and deformity of the joints.
This path occurs with untreated disease.
It has become clear, through many scientific trials, that early diagnosis, followed by aggressive treatment, can alter this natural history of rheumatoid arthritis.
This window of opportunity is thought to exist in the first few months of the disease.
TIME (wasted) = JOINT (damage)
It is therefore crucial that patients are referred to and assessed by a rheumatologist as early as possible.
If the diagnosis of rheumatoid arthritis is made, treatment will typically be commenced early with the aim of achieving remission as soon as possible.
Rheumatologists now have access to highly effective medications, and we also understand the importance of regular monitoring, measuring disease activity and treating a patient with rheumatoid arthritis holistically.
The aim is to avoid unnecessary pain and suffering. The end result we want to avoid is crippling joint disease.
Don’t accept that “it’s just arthritis”. Please seek attention early.
Dr Irwin Lim is a rheumatologist and a director of BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients. We call this model of care, Connected Care. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.
This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy.
The Disease of Kings, and the King of Diseases: Gout 0
For Christmas Eve dinner, our family congregated at Café Opera, in the Intercontinental Hotel for a scrumptious seafood buffet. Going to a buffet is a little bit evil, as you know that you’re about to commit the sin of gluttony.
I usually tell my patients who suffer with gout to avoid buffets. That 3rd mountain of prawns may precipitate an acute episode of gout. Christmas party season is a dangerous time.
Overindulgence in rich food and wine has long been thought to be the primary cause of gout, a little inaccurately. Gout had been referred to as “the disease of kings, and the king of diseases” on the misperception that it was the joint disease of wealthy men.
Gout is a very common cause for episodic joint pain and swelling. The pain can be severe, with the joint becoming red and hot. Most commonly, the big toe is involved but most other joints can be affected.
In patients who develop recurrent episodes over a long time, chronic joint destruction can occur with a more constant pain pattern.
Gout is classified as crystal arthritis. The crystal, monosodium urate monohydrate, is very irritating to the lining of the joint. The larger a person, the more urate the body produces.
Up to one third of the urate comes from what you eat and drink, and many sufferers try to avoid various foods, often without success unless they really love their seafood and offal.
In many cases, addressing the elephant in the room would also be useful: alcohol, alcohol, and alcohol. Apart from weight loss, this is the most important modifiable factor. It’s often proves very hard to convince your typical middle-aged male drinker to reduce their alcohol intake in a significant way. In the USA, the excessive soft drink intake needs to also be addressed as the high levels of fructose (corn syrup sweetener) increase risk of gout. This isn’t a big issue in Australia as soft drinks typically use sucrose (cane sugar, and this doesn’t have a similar effect) instead.
Dietary modification has a clear place however, in complementing weight loss measures, and in helping the many patients with gout that have coexisting high blood pressure and high levels of cholesterol/triglyceride.
Younger patients, predominantly male, with gout, typically have a different reason. They are typically under-excretors of urate and may to a much lesser extent, be over-producers of urate. This means that they don’t get rid of enough of it through the kidneys and/or make too much of the urate. Such patients typically get severe disease and typically end up with joint deformity and chronic pain. Amongst the hardest patients to treat due to this genetic predisposition are Maori and Polynesians.
I want to draw attention to this disease because it is essentially a “curable” arthritis. If the amount of urate in the body can be lowered sufficiently, the episodes of acute joint pain and swelling will stop, and the risk of chronic joint damage will be substantially reduced.
Combinations of alcohol reduction, some dietary modification, weight loss, and for most, urate-lowering medications can make a huge difference to a gout sufferer’s quality of life.
Yet, most sufferers just treat their pain and swelling (often severe and crippling) at the time of the episode with anti-inflammatory medication or rest. In between episodes, little attention is paid to preventing the next episode.
Treatment compliance is also usually poor in the patient groups who develop this disease.
This is compounded by the fact that the urate-lowering medication, most commonly Allopurinol, is a tricky medication to use. Getting the dose wrong and reducing the level of urate too quickly, can paradoxically trigger a severe episode of gout.
It’s regrettable that gout, a disease that we can effectively stop, is often trivialised by both the sufferer and the doctor. “It’s just gout, it’ll be better in a couple of days”. I would argue that in patients with frequent, recurrent disease, that this isn’t good enough.
Dr Irwin Lim is a rheumatologist and a director of BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients. We call this model of care, Connected Care. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.
