Ultrasound in Rheumatology

Over the years, the role of subspecialties in internal medicine has expanded. Many procedures, which were previously under the purview of other specialties, have since been mandatory skills to be obtained during subspecialty training. In rheumatology, ultrasound is gaining acceptance as a vital tool in aiding diagnosis and monitoring of therapeutic responses to assisting invasive procedures, for example, intraarticular joint injections.

Ultrasound is an imaging modality that is very operator dependant. The skill of the ultrasonographer can determine the quality of images obtained as well as the interpretation of those grainy images. Even existing grading systems are subjective and reproducibility is suspect. Time constraints during patient consultations can also be a deterrent for busy rheumatologists in performing ultrasounds in clinics.

However, if performed well, it could be a potentially important diagnostic tool. In rheumatoid arthritis for example, early damages to the cartilage can be detected even before any changes in Xrays is evident. Even the microarchitecture of tendons and its surrounding structures can be scrutinised for damages.

Ultrasounds can also be used to aid invasive procedures like intraarticular joint injections. Even a fluid collection of 1mm2 can be aspirated under ultrasound guidance. It can also aid in more accurate delivery of drugs to intended targets, like steroid injections which were previously done blindly.

Guidelines for musculoskeletal ultrasound in rheumatology

MSK ultrasound in rheumatology

H1N1: A real life public health drill

With the hype over this global pandemic intensifying, there appears to be an argument as to what this illness should be called. As the world waits intently for a vaccine to be developed, the only method of containment is isolation. With expected rise in the number of cases, it will surely become more costly and labour intensive to maintain a reasonable tab on the cases and their respective contacts. What then can we expect in the coming months?

The origins of this strain of influenza A (H1N1) is still relatively unknown although it closely resembles those found among pigs. It is clearly a mutated strain. Fortunately, the virulence of this virus is low as compared to their cousins, the bird flu or the SARS virus. Most confirmed cases are usually well and might have recovered even without the aid of Tamiflu. Why then are we concentrating our healthcare resources on a ‘mild’ virus?

My belief is that previous deadly encounters with firstly the SARS virus and then the bird flu, has made Asian countries extremely sensitive to such viral outbreaks. The consequences of inaction is no longer acceptable to the general public. Therefore, Governments have taken a cautious approach lest they be accused of being lackadaisical. I prefer to belief that this ‘real life drill’ could be paramount in our future responses to more deadly air borne viruses.

The virus is bound to spread further and the numbers of confirmed cases is expected to rise. Our actions of containment appears only to delay the inevitable. It is hoped that with increasing infections, the global community will develop a herd immunity towards this virus. Until and unless, a vaccine becomes readily available, our strategies only appear to be surmountable barriers for the virus.

Our only prayer is that this virus will not mutate into a more deadly virulent strain that could then inflict high number of casualties.

1st Case of A(H1N1) in Malaysia

First confirmed case detected in Malaysia. Student from US.

Sued for wrong diagnosis and treatment

From malaysiakini

Housewife sues gov't for RM7.5m
Humayun Kabir | 14 May, 09 3:25pm
A 54-year-old housewife is suing the government a whopping RM7.5 million in damages for a wrong diagnosis on cancer, which lead to the unnecessary removal of her left breast.

Silvarany Thangavellu of Batu Gajah would seek RM5 million in general damages, and RM2.5 million in exemplary damages and damages for pain, suffering, embarrassment, trauma and interest and cost.

The case was mentioned in the High Court in Ipoh today.

Silvarany had filed the case on Feb 15, 2008 and is suing Dr L Vasu Pillai and director of the Ipoh General Hospital, the Health Ministry and the Malaysian government for medical negligence.

Her counsel, A Magesan of A Sivanesan & Co, said he would file the notice in court next week to prepare the case for hearing in court.

He said that his client was admitted into the Ipoh General Hospital for a stomach problem and her uterus was removed following the discovery of a fibroid growth.

On her subsequent medical visit on May 16, 2005, she was informed by Vasu that her pathology report showed she has cancer in her left breast.

It was surgically removed in an operation, performed by Vasu on Sept 7, 2005. She was discharged five days later.

A month after, she went for a follow-up medical check-up and was told by Dr Stephen Jacob, a doctor in the Ipoh General Hospital, that she was misdiagnosed for breast cancer and her left breast was wrongly removed.

Demonstrates the importance of ensuring samples are properly labeled and results are cross checked if they belong to the patient. The above report is likely to have omitted important details.

How can breast cancer be diagnosed if no biopsies were taken from the breast?? Why did the patient accept the diagnosis if the breast were not a concern? If indeed there was a mass and the pathology report indicated malignancy, are the attending doctors to be blamed for expeditiously removing the breast? If subsequent pathology of the breast tissue showed no malignancy, were the operating doctors at fault? If there is to be any finger pointing, perhaps it should be directed at the pathologist, should it not?

It will be interesting to know more details.

H1N1 closes in on Malaysia

With the first confirmed case in Thailand, the flu virus is edging closer to our shores. It appears inevitable with the current momentum of spread.

A(H1N1) Flu : Potential Pandemic

A H1N1 variant of the influenza virus which started from Mexico, and now suspected of spreading to the United States, has potential for human to human transmission. Although the mortality is reportedly only 1-3%, dozens have died in Mexico.

Our Health Minster has directed screenings and checks at our entry points especially those from Mexico. How or whether it has truly been enforced is left to be confirmed. Mock preparations by hospitals from previous H5N1 scare might come in useful. Hospitals must strengthen their protocols and all doctors, nurses and paramedics must be well versed in wearing the Personal Protective Equipment.

Useful resource
CDC
WHO