However, Robin does have a warning for potential visitors. He and Mrs Robin were unable to make the cashpoints work at first. It was a while before they realised the problem was one of parallax. Standing head and shoulders above 99% of their hosts (and neither are that tall, really) it became apparent that the buttons and screen only lined up if the point was addressed with the knees bent to about 30°. So now taller EU readers will know that patients who return from their holidays with knee pain may have been trying to get cash out of a Portuguese hole in the wall, and not practising bent ze knees' skiing exercises.
If presented with a new patient with polyarthritis of three months' duration what tests should we do? Saraux et al.
(Ann Rheum Dis 2002;61:6269)
This also applies to tests where there is a long waiting list. Local rheumatologists on Robin's patch no longer do simple electromyography (EMG) and Robin, (not to mention his orthopaedic colleagues) have to rely on a regional neurophysiology service that has a waiting list of about eighteen months. So Robin has been trying to persuade his surgical friends, with mixed success, to abandon EMGs for carpal tunnel syndrome. After all a negative result does not disprove the possibility of median nerve ischaemia from pressure. Some support for this approach comes from Smith a neurophysiologist from Nottingham (J Hand Surg 2002; 27B: 835) whose personal view lists the shortcomings of the test and states If nerve conduction studies do not contribute to that aim [rapid relief of symptoms] it would be better not to do them. He calls for a controlled trial randomizing patients to receive treatment with or without nerve conduction studies to see if outcome is improved. It does seem quite remarkable that such a trial has not been done already.
Modern technology has the capacity to confuse sometimes. Robin was leafing through Casebook (no 19, 2002), the members' journal of the Medical Protection Society when just past the double spread by Hegan entitled "Non-steroidals, needles and negligence" (the pitfalls of intramuscular diclofenac) he lighted on a banner headline over the letters which read "The case for digital rectal examination". Now Robin, being fairly well up with scanners, pixels and jpegs was pondering on the effect of shoving his new electronic camera up said organ when he realised that digital has another, more ancient meaning.
Dr Nick Sheehan reports that he was expecting an anabolic steroid-abusing bodybuilder when he received a letter that began Please see this man who works as a Chef. He has right ankle pain, which appears to be Hercules tendentious. He does occasionally fall over and also knocks himself on things at work.... Read aloud, and you might share Dr Sheehan's disappointment that this was just a man with a sore heel. However Robin wonders about other substance abuse in chefs who fall about at work. Port perhaps.
Walsmith and Roubenoff
(Int J Cardiol 2002;85:8999)[ISI][Medline]
have written an attractive review of possible causes of rheumatoid cachexia. While suggesting that exercise is vital in maintaining muscle strength they theorize that TNF- is a prime mediator, so it will be interesting to see whether muscle wasting in rheumatoid arthritis declines with increasing use of TNF-
blockade.
Confirmation that something is wrong in fibromyalgia and chronic fatigue syndrome, whatever they are, comes from work by Panerai et al. (Clinical Journal of Pain 2002;18:2703) which shows decreased levels of ß-interferon in these conditions, but not in patients with depression. The more we find such things the more likely we are to be able to convince ourselves they are all the same thing, as Robin has boringly belaboured before. On a similar note Robin was interested in another article in the same journal (Vlaeyen et al., Clinical Journal of Pain 2002;18:25161)[ISI][Medline] reporting how back pain patients with fear of movement could be treated successfully by deliberate exposure to fear-eliciting activity. It was a very small study, but every little helps.
Robin is well-aware of the risk of becoming a boring old gas-emitter with his eccentric views on non-diseases, but is prepared to face the music and, for his last item this month, refers readers to a wonderful review by Ferrari (who he?BC Med J 2002;44:25760) endearingly titled Fibromyalgia and motor vehicle collisionsOh the pain! Net-workers will find it on the web in its entirety, and good bedtime reading it is. Night night, sleep tight.