Robin Goodfellow

Robin has just discovered that the NHS open door, open everything policy is about to be extended to letters about patients. From next year all letters between general practitioners and specialists will have to be copied to their subjects. This will increase Robin's hospital's post bill by some £25000 yearly, never mind the paper. His secretary is being enlisted in a pilot study to find out how much extra work will be involved; the hypothesis is that envelope-stuffing alone will take an hour a week but that putting the patient's name and address at the bottom will allow the use of window envelopes and not increase typing time. Maybe rheumatologists, as heavy letter-writers, should do a multicentre trial.


Robin has discussed with colleagues what should be done if the letter contains bad news (‘I think this patient may have spinal secondaries’ etc.). After all, if you don't copy the letter the patient may get suspicious ... We decided we could add postscripts in invisible ink and then send by fax, on the basis the heat of the outgoing machine would develop the invisible ink. This too needs to be tested under laboratory conditions. Any volunteers?

What bugs do cats carry that might be relevant in the aetiology of RA? A review by Torrey and Yolken (Brain Behav Immun 2001;15:401M–10) [Medline] asks this while examining the connection between schizophrenia and RA, noting that childhood cat exposure is greater in both diseases than in controls, as well as other similarities such as tissue type, twin concordance and prevalence. They suggest that the inverse correlation of the two is because development of the one effectively makes one immune to the other.

COX-2 selective agents or no, many arthritis patients must be on proton pump inhibitors and, no doubt, when they develop leucocytoclastic vasculitis this is attributed to their RA. Not so, necessarily; Odeh and colleagues report an association with omeprazole (Postgraduate Medical Journal 2002;78:114M–5).[Medline] Robin thinks he is getting lazy with the side-effect issue; more patients than he warns tell him that their symptoms are iatrogenic. Revalidation will change all that, of course.

OK, so I wasn't first. Remember my note about Pentoxifylline in RA (it's a TNF-{alpha} blocker)? Patrick Kiely kindly, drew my attention to his letter in our very own journal (Kiely, Johnson and Bourke, Br J Rheumatol 1998;37:1033–5) [Medline] and says that I may have been confused because of the different terminology in Europe, where the stuff is called Oxpentifylline (or was). Tony Russell also writes (from the frozen wastes of Alberta) to remind me of his uncontrolled and unsuccessful trial published in J Rheumatol in 1995. Confused? Never. Ignorant? Perhaps. Still, the stuff was poorly tolerated, so cheap though it was, it wasn't any good. Another trial I don't need to do.

Stuart Carter sends a fax from the Department of Veterinary Immunology at Liverpool to draw my attention to his paper that suggests a remarkable parallel with RA in the dog world; susceptibility to canine RA is conferred by alleles containing the human RA shared epitope DRB1 (Ollier et al., Immunogenetics 2001;53:669–73).[ISI][Medline] He adds that dogs are the only non-human species to get RA. What do peccaries get, then? Robin recalls an interesting visit to Whipsnade, following which, one of his colleagues at the time started to collect specimens from these South American piggies that get an erosive, possibly infective, arthritis, but the research died when a cleaner switched off the freezer and the pork joints went off. He shall remain nameless (I imagine the memory is still traumatic—even 20 years on and I can still remember the smell when I opened the freezer), but he went on to develop some pretty good work on early RA in humans. Probably more useful.

Straining the eyes against the ghastly clash of serif and sans serif typefaces, Robin ploughed through the latest ‘Annals’ to find a study of weather change and fibromyalgia pain (no significant effect—Fors and Sexton, Ann Rheum Dis 2002;61:247–50).[Abstract/Free Full Text] Well. As an outdoor goblin, Robin knows that joints are weather-sensitive, not because of theory (proprioceptors are pressure-sensitive), but because of fact (his right shoulder, dislocated in 1974, has told the weather ever since). He suspects that the Trondheim Two have looked at too many weather variables. As time has gone by, Robin's shoulder has become less sensitive, but major swings in pressure still affect it and he is quite happy to explain why to all his RA patients who have noticed the same thing. It's not what the weather is, but how fast it will change to something else that matters. Those in settled climes will not appreciate the phenomenon (which is why everyone comes back from Spain, or Greece, claiming their symptoms disappeared while away).

Robin thought he was a goblin that knew long words. He had to admit defeat with a paper by French (J Advanced Nursing 2001;37:250M–7) entitled ‘What is the evidence on evidence-based nursing? An epistemological concern’, which uses the theory of symbolic interactionism which here ‘has a certain utility in analysing concepts and evaluating their status as constructs’ and the paper contends that ‘the belief that evidence-base practice is a new construct results in the continuing dislocation of the research processes from the quality assurance process in nursing at the practitioner level, and that this is a recipe for further disenchantment if not resolved’. While I have little doubt that evidence-based medicine is what we have all practised for years (except when we test new things) I did feel a referral to J Incomprehens Jarg coming upon me. If these are today's nursing ideas, heaven help the patients that need a wash.

These temporary secretaries are wonderful. I thought I had exhausted all possibilities of new diseases, and then up pops phalangermic rheumatism. A dirty digit? Not for long ... I must lick it and hold it up to see which way the wind is blowing.





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