Robin Goodfellow

Yo ho ho. Robin is beginning to feel old, for in the last month he has been hugged and kissed by the President-elect of the Royal College of Physicians, the Dean-Director of the London Region and the Executive head of the new National Clinical Assessment Authority. Years ago such figures were unimaginably remote (and male). Now they are all friends, rheumatologists and female. Robin does not fancy an embrace from the Chairman of the General Medical Council, as it would probably be of the ‘Et tu, Brute’ mode. But rheumatology is clearly making its mark on British medicine (or else rheumatologists don't have enough to do, but with all the paperwork involved in TNF-{alpha} patient registering, it is surely not the latter).


However, grizzled though he may be, he is not done yet. The estimable David Scott, who first asked him to commit his scribblings to the journal, has for some reason retired and Robin wishes him well in future endeavours, more time with the family, etc. However he was surprised and delighted to have a telephone call from the new Editor, the just-as-estimable Richard Watts, who has asked Robin to continue on the same terms (i.e. no salary and no editorial control). Robin now finds his head won't fit through the air-raid shelter door, even with his hat off. Some salary would be nice, though.

A trip to the seaside was of interest. Robin would not normally comment on the British Society for Rheumatology's Annual Meeting, because everyone was there and heard it, but there were a few curious and interesting titbits. It seems that there is a problem with prevalence data in the UK not, it appears, because no-one is collecting it but because the National Health Soviet keeps changing the boundaries of Regions, so that whatever data were available before are no longer comparable with those that can be collected in the future. The damage that this must do to epidemiological research is surely incalculable. I add the ‘surely’ because, no doubt, some wise guy will now write to explain why this is not so ...

However, before we cast aspersions on our ministers and civil servants we must make sure that we are singing the same song, all of us. Robin was horrified to find out that we aren't where injections are concerned (Hordon and Miles, Rheumatology 2002;41 Abstracts suppl.: 42). Not only do some folks still put potent steroids into tennis elbows, thereby exposing themselves to litigation for disfigurement, but over a third of those surveyed use local anaesthesia when injecting the carpal tunnel. There is enough risk of damaging the nerve from the steroid on its own. The research is decades old (Linskey and Segal, Neurosurgery 1990;26:512–5).[ISI][Medline] Robin hears a call for national guidelines coming on with regard to this one.

A number of concurrent sessions were disrupted by people suggesting that a number of ‘diseases’ should be de-medicalized. It is the first time that Robin has noted such an undercurrent. Will fibromyalgia be the first to go? Or will it be back pain? But while Robin took copious notes in the pregnancy and arthritis session, the first time he has done so for years, he was most surprised to hear that no-one appears to have done any work on the role of the placenta. As an efficient antibody filter it is without natural parallel. It is disposed of after delivery, presumably with all the rheumatoid factor and other autoantibodies it has sequestered during its existence, and Robin has always supposed that the post-pregnancy flare is due to the sudden disconnection of this antibody ‘sink’. So isn't it time someone started analysing placental tissue? It's not as if any normal mother is going to ask for it back. (Go on, tell me it's been done ...).

UK readers should clock on to Athens through their local NHS Health Information network (it would blow Robin's cover if he indicated which portal he uses, but your librarian will register you). It gives full online access at home or work to a huge collection of databases, including Cochrane, and a large selection of journals. Research will never be the same again. Is there no end to what one can get on the Net?

The New England Journal of Medicine has been soliciting Robin frequently (and solicitously) to take out a subscription and yet another free month's worth has come and gone. As a believer in cock-up rather than conspiracy Robin is quite certain that the inclusion of an excellent review of anti-phospholipid antibody syndrome is coincidence (Levine, Branch and Rauch, N Engl J Med 2002;346:752–63). [Free Full Text] Only one thing puzzles him. They state that the syndrome's diagnosis requires at least one clinical criterion as well as one of the laboratory ones. Now Robin has been in the habit of checking the appropriate antibodies in many of his connective tissue disease patients and, finding them, adding the diagnosis to the list and taking preventative measures, usually aspirin. Surely we don't have to wait for a thrombotic episode? Prevention is better than cure:

T'was a dangerous cliff, as they freely confessed,
Though to walk near its crest was so pleasant,
But over its terrible edge there had slipped
A Duke and full many a peasant.
So the people said something would have to be done,
But their projects did not at all tally.
Some said: ‘Put a fence round the edge of the cliff’.
Some: ‘An ambulance down in the valley’.

... and lest you believe that Jo Malines wrote only this, you can call in to receive a presentation copy of the whole poem, which is a sadly accurate reflection on life in general and perhaps, apropos rheumatoid arthritis and new treatments, points up the difference between rheumatologists and orthopaedic surgeons.





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