Robin Goodfellow

Buenos dias. Robin was appalled to read that the General Medical Council will not only cross-examine those doctors whose revalidation folder is unsatisfactory, but also charge extra for the processing of those that contain too much. Why? Surely they cannot be jealous? Robin had quite forgotten that he himself had been part of the GMC's own pilot. Until, that is, it returned his paperwork. It wasn't that fat, not least because it didn't include a single RG column among the voluminous collection of published papers (nor any complaints), but maybe it was too fat. Perhaps they will waive the excess paper fee if a listed gift bottle of whisky is appended.


The osteoporosis bandwagon has rolled inexorably forwards for years so it is interesting to note the ‘Education and debate’ piece in the BMJ (2001;323:795–99[Free Full Text]), in which the hypothesis (or ‘given’, as our new jargon has it for a certainty) that one can predict hip fracture risk from the bone density is questioned. Wilkin and Devendra argue that the ability to predict is overstated and the data over-interpreted; Dequecker and Lutyen suggest that screening high-risk patients is effective. I fear we will have to wait some decades before we have good data on risk assessment, and prevention with bisphosphonates, particularly if these latter increase bone density but, by over-mineralizing osteoid tissue, predispose to microfracture. Dense bone may not be good bone; we know that from the fluoride experience.

Yet another journal title has been added to Robin's stable (Arch Blind Ob, J Unsurpr Res and Excerpta Déjà Vu)—the Journal of Disappointing Results, into which must go the article by Caporali et al. ( Ann Rheum Dis 2001;60:1021–4) [Abstract/Free Full Text] which sought by a prospective study to determine whether polymyalgia rheumatica could be distinguished in its early stages from rheumatoid arthritis with polymyalgic features. It couldn't.

The Annals of Confusing Data are also actively considering Cosentino and colleagues' paper on extracorporeal shock wave therapy for painful plantar spurs ( Ann Rheum Dis 2001;60:1064–7[Abstract/Free Full Text]). On the one hand they find that this treatment is effective in symptom relief, while on the other they confirm that the presence and size of spurs do not correlate with symptoms. Robin's brain hurts with that one.

There is, of course, a real journal called the Annals of Improbable Research so, in the context of leeches used for osteoarthritis that I mentioned last month, it is pleasing to note that a leech study ( Baerheim and Sandvik, BMJ 1994;309:1689[Free Full Text]) won the 1996 igNobel Prize for Biology. It investigated the effect of beer and garlic on the creatures; garlic was fatally toxic, so anyone using leeches should ensure their patients have not been eating Italian food.

Robin has seen a lot of gout (though most of what he is sent as gout is not) but has never ever heard of it affecting the temporomandibular joint ... until this week, that is ( Barthélémy et al., J Craniomaxillofac Surg 2001;29:307–10[ISI][Medline]). Robin's favourite diagnostic technique of aspiration to look for crystals might be a touch difficult, he thinks. Mind you, one needs to distinguish it from pseudogout ( Berge et al., Mund Kiefer Gesichtschir 2001;5:61–4[Medline]), but they got the histologists involved. Both, incidentally, show as a chronic destructive arthropathy on X-ray or scan.

Gout can appear after total knee replacement, and its mis-diagnosis as sepsis may lead to unnecessary removal of the prosthesis ( Archibeck et al., Clin Orthop 2001;392:377–82[Medline]). One should perhaps remind orthopaedic colleagues not up to speed with physics, that putting specimens in formalin dissolves urate, so samples should go in saline.

Now have we found the cause of fibromyalgia (or is it a consequence—a nice chicken and egg scenario)? Staud and Domingo ( Pain Medicine 2001;2:208–15[ISI]) have reviewed the literature and conclude that it is a neuropathic pain syndrome due to an abnormality of central pain processing. That puts it in the same stable as chronic pain syndrome and even post-traumatic stress disorder, so why don't we rationalize the terms and call the whole caboodle the same thing?

Robin does not see many patients with fibrillar collagen metabolic disorders (Ehlers–Danlos syndrome to you and me). But it's clearly not one disease. Schalkwijk et al. describe a recessive variant due to Tenascin-X deficiency ( N Engl J Med 2001;345:1167–75[Abstract/Free Full Text]), tenascin being an extracellular matrix protein. The defect appears to be due to absence of, or damage to the expressing gene and shows that collagen itself may not be the cause of the problem.

Lastly Robin is keen to share with you a fascinating theory about back pain, the management of which [according to the ‘Sunday Times’ (28th October 2001)] requires a holistic approach, whatever that may be. Syntax Chiropractic ‘starts from the premise that the body becomes overloaded and unable to cope with the emotional, physical and chemical stresses in our lives’ and uses applied kinesiology, a technique that apparently tests muscle balance and so can detect food intolerance. Hmm. According to the piece, a failure of ileocaecal valve function creates a weakness in the main anterior muscle that stabilizes the pelvis, and in turn can create a torsion of the lumbar sacral spine. Cor. Actually the article concludes with an injunction that corsets should only be used for acute back spasm and then discarded; a sentiment with which Robin readily agrees. Back off prescribing corsets, guys.





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