Robin Goodfellow

Robin and his orthopaedic friends (and yes, Robin made it to the ballet last week) have happily slapped patients with spondylolysis and listhesis into corsets or casts before proceeding to fusion, in the belief that the effect of external splinting will predict the success of spinal fusion. Not so, it seems; Bednar reports a trial of pre-operative fixation with a frame (far more rigid than a cast). Sixty per cent reported relief from the fixation, but of 49 who had a spinal fusion only 27 were satisfied symptom wise (J Bone Joint Surg 2001;83A:1656–9).[Abstract/Free Full Text]


Remaining with that journal Robin was mightily impressed by its supplement 2 (Part 2) which recorded a number of scientific exhibits with some fascinating reports (amazingly well-illustrated) of biomechanical work. In particular, he was taken with Greenwald and Garino's contribution on articular bearing surfaces, a study by Giannini et al. on surgical treatment of flat foot and Dennis and colleagues': In vivo three-dimensional determination of kinematics for subjects with a normal knee or a unicompartmental or total knee replacement—20 quite a mouthful, but representative of the work that has made knee surgery so much more effective in recent years.

Oh dear oh dear oh dear. Myalgic encephalomyelitis (ME) exists; it's official. Robin was in his car between hospitals when he heard the lunchtime news of the report from the Department of Health; the impression was given that doctors did not believe in it before because they did not listen to their patients. Tosh. While I accept that chronic fatigue syndrome (CFS) exists I find it difficult to accept that one can make a diagnosis of encephalomyelitis without any shred of evidence that this pathology is present. Which thought takes me back to a previous contention—that we must find a new and sensible name, untarnished by false association but all-embracing. Neurasthenia springs to mind. Two things struck Robin about the report; first, no musculoskeletal doctors were involved in it and second that CFS/ME needed expert help. That might be a Good Thing for the agnostics. Robin is far from expert, and has many other patients to attend to, so can, perhaps, now turn these folk over to proper experts. If there are any.

The science (or art) of assessing risk and cost-effectiveness are bedevilled by the complexity of deciding which, and how many, variables should be entered on each side of the line. In rheumatoid arthritis (RA) we have had this argument in relation to TNF-{alpha} blockade. Is it reasonable to include the potential on-costs of disability that do not accrue to the health budget line (for instance, social service benefits and loss of tax revenue that alter the cost balance when sufferers have to give up work). What about the cost of risk from other disease? Robin was interested to see the paper from del Rincón and colleagues (Arthritis Rheum 2001;44:2737–45) [ISI][Medline] which concludes that RA patients have a higher incidence of cardiovascular disease not explained by traditional risk factors. Perhaps that gives us UK rheumatologists, whose funding has been hit by diversion of funds into fashionable things, the opportunity to tap into the National Service Framework (NSF) for cardiology and get money out of that. Robin suspects, however, that the government will be unconvinced by the paper and insist on commissioning its own research, which will delay matters long enough for them to claim that the NSF has been a great success and is no longer needed.

Recalling the design plaudits awarded to Rheumatology for its typography, Robin was appalled to open his latest copy of the Annals of Rheumatic Diseases and discover an eye-jarring mixture of sans serif (headings, references and captions) and serif (text) typefaces. Why? It is ugly and even unpleasant. Not for nothing were sans serif fonts known as Grotesques. One or the other, but not both. Per-leese.

Meanwhile a few more secretarial diseases have appeared. Defused spondylosis (no longer explosive, or reversed?) appeared in a man with osteoarthritis of the jip joint. I will allow that owing to H and J being adjacent on the keyboard, but how about a CO negative polioarthritis, which presumably is confined to patients in iron lungs. If you read it aloud you can imagine the GP dictating this had trouble with his R's.

Being a garden sort of goblin Robin was intrigued to see that he may now be able to add Berberis clippings from his hedge (Berberis root extracts in rats have proved to be analgesic and anti-inflammatory—Yeilada and Küpeli, J Ethnopharmacology 2002;79:237–48[ISI][Medline]) to the yew clippings he sends to the cancer people.

Robin has written before about the nasty parvovirus which produces an illness that can be mistaken for inflammatory arthritis. Systemic lupus erythematosus has previously been reported as something that is possibly mimicked, but Saeki et al. took the opportunity to do a prospective study during an outbreak of erythema infectiosum and showed a number of clinical and laboratory similarities to lupus (Mod Rheumatol Abstr 2001;11:308–13). On the other hand blaming infectious agents for disease may be overplayed, as Quereshi and colleagues' report with Lyme disease (Paed Inf Dis J 2002;21:12–4). Of 216 patients, 109 showed no evidence of the disease, past or present, but 79% of these were being treated largely, it appears, because Western immunoblot results are being misinterpreted. Which brings Robin neatly back to IL-6; an astronomically high result, which got him really excited as a marker for Williams' variant of polymyalgia rheumatica, was pooh-poohed by the laboratory scientist who measured it and passed a message back that it was probably a contamination from the bung in the blood tube. She suggested I should measure C-reactive protein instead. Bang goes another dream.