Bjcconnectedcare

October, 2011 — BJC Health Connected Care

Slapped Cheeks & Bad Nights

By Dr Irwin Lim, Rheumatologist

I’ve not slept properly for a week. Some night sweats initially. Stiffness of the shoulders and hips. Sore muscles. Getting out of bed was a bit of a chore and I needed anti-inflammatory medication to get to work.

It’s been better these last few days but I find that I’m left with fatigue. And with that fatigue, comes a lack of concentration. I think I’ve just had a most unproductive week.

The culprit I think is my daughter, E.

E is 5 years-old and 1.5 weeks ago, she developed a bright red rash over both cheeks with a finer rash over the limbs. I’m not a GP but I diagnosed Slapped Cheek syndrome. This occurs commonly in kids and is caused by a virus called Parvovirus B19. She improved without any specific treatment but did have a minor fever.

A few days after E developed her rash, my wife developed fever, sweats, aches and pains, as well as headaches. She needed a few days in bed and has recovered. She didn’t get a rash. Manifestations of Parvovirus B19 infection in adults are different, and typically, adults get more joint pain and stiffness. These symptoms typically resolve within a few weeks but in some cases, the arthritis can become more chronic.

I’m hoping my symptoms go away soon. While it’s good that I’ll be able to empathise, arthritis isn’t fun and I think I’ve had enough.

Dr Irwin Lim is a rheumatologist and a director of BJC Health.

BJC Health provides a connected care multidisciplinary team philosophy to deliver positive lifestyle outcomes through a holistic approach to those with degenerative & inflammatory arthritis, tendon injury and lifestyle diseases. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.

This blog focuses on arthritis-related diseases, healthcare in general, and our Connected Care philosophy.

Thank you, Doc

I was recently ‘thanked’ in a number of different ways and I thought I’d share it as one way did quite upset me.

Rheumatologists typically have long and good relationships with most of their patients, given that many of the diseases we care for are chronic and require regular treatment changes and monitoring.

It’s relatively common to receive a token of gratitude from a patient. It’s usually food in my case, a box of chocolate or some home-made sweets.

I don’t have an issue with accepting these and I’m always very grateful that the person appreciates my effort and bothered to take the trouble. Our clinic staff will share and enjoy this gesture.

A couple of months ago, I received more of a “no- thank you”. A patient presented demanding a treatment I felt was not indicated medically. While we were still discussing reasons, she jumped up from the chair and stormed out of the room complaining bitterly to staff and the other clinic patients. Not a good look. For her and for me.

Around that time, I received a note in the mail, accompanied by an autopsy report. An elderly patient had finally succumbed to her illness. The note was from her daughter, someone I had never met. It was a thank you note in appreciation for the care her mother had received by our BJC Health team. I was sad that this very pleasant lady had passed & I sent back condolences.

I will also share, even though it may seem a little selfish, that getting such a note is gratifying. It’s always nice to get some thanks to balance the occasional unpleasantry.

When is your back pain INFLAMMATORY?

Lumbar Spine Xray showing syndesmophytes

Dr Roberto Russo, Rheumatologist

The characteristic presenting symptom in the majority of patients with Spondyloarthritis (a group of diseases with the prototype being Ankylosing Spondylitis) is inflammatory back pain.

The definition of inflammatory back pain has been debated for many years. No single clinical feature of back pain is sufficiently specific nor sensitive and as such composite criteria have been developed.

The Calin criteria, published in 1977, suggested inflammatory back pain is present when back pain has 4 of the following 5 features:

  1. Age at onset <40 years
  2. Duration of pain > 3 months
  3. Insidious onset
  4. Improvement in pain with exercise
  5. Presence of morning stiffness

The Berlin criteria followed in 2006, which defined inflammatory back pain as present when 2 of the following are present:

  1. Morning stiffness >30 minutes
  2. Improvement in back pain with exercise but not with rest
  3. Alternating buttock pain
  4. Waking during the second half of the night

Most recently, in 2009, the Assessment in SpondyloArthritis international Society (ASAS) gathered a panel of experts who put forward the following criteria:

  1. Age at onset <40 years
  2. Insidious onset
  3. Improvement with exercise
  4. No improvement with rest
  5. Pain at night (with improvement upon getting up)

The ASAS group found that when 4 of the 5 features are present, the back pain was very likely to be inflammatory in nature (sensitivity of 77% and specificity of 91%).

In subsequent studies, the ASAS criteria was found to have the best overall performance, where as the Calin criteria was most sensitive and the Berlin criteria most specific.

In essence if patients present with back pain and have a number of the features presented above, then a spondyloarthritis should be considered and referral to a Rheumatologist is most appropriate.

Dr Roberto Russo is both a rheumatologist and a nuclear medicine physician, as well as 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. Read More.

Snap!

Snap! The Breaking Spine is a project by International Osteoporosis Foundation’s photographer, Gilberto Domingues Lontro. This multimedia project portrays the impact of osteoporosis on the day-to-day lives of 6 patients. Young and old, male and female. People like you.

Osteoporosis is an insidious disease. Until the fracture.

In the case of spinal fracture, the fracture may be silent, meaning that the vertebrae can break without pain. Consider the people you see who look progressively stooped or hunched. One silent vertebral fracture is then followed by the second, then the third….

The 3 major signs of vertebral or spinal fractures are:

  • height loss
  • stoop
  • and/or sudden, severe back pain

This cascade of fractures is preventable, with early diagnosis and treatment.

Please take a look (www.iofsnap.org) and share with us your story.

Rheumatoid Arthritis & DMARDs

When the diagnosis of rheumatoid arthritis is confirmed, it is now standard practice for rheumatologists to commence a disease-modifying anti-rheumatic drug (DMARD) as soon as possible. If there are no contra-indications, the most commonly used medication is Methotrexate.

Unfortunately, patients with rheumatoid arthritis who do not see a rheumatologist are typically not commenced on DMARDs.

One reason may be that general practitioners are not comfortable or experienced in using these medications. Another reason is that there is a lot of misconceptions about these medications. Like all drugs, there are of course, possible side effects and these often scare patients. However, rheumatologists only use these medications when the benefits of the drug clearly outweigh the risks. Education about appropriate use and regular monitoring also reduce any risks dramatically.

In essence, DMARDs are used when the outcome of the disease is bad & the aim of using DMARDs is to prevent this bad outcome.

Rheumatoid Arthritis is a classic example of a disease where effective medication is clearly needed.

Don’t delay. If you have rheumatoid arthritis & haven’t seen a rheumatologist lately, it’s time.