Robin Goodfellow (41-12)

Namaste. Here's a reverse conundrum. Suppose you are presented with a Hindu girl in her early 20s with a history of back pain, much worse at night, with stiffness every morning. She is a strict vegan, was fairly stiff on examination and had a markedly elevated ESR. Robin's differential diagnosis was osteomalacia or infection. Then suppose you are presented with a Caucasian man, early 20s, with a history of back pain after trauma, early morning stiffness, was fairly stiff on examination and had a high ESR. Robin confidently diagnosed ankylosing spondylitis. You can guess who had the spinal osteomyelitis and who had the sacroiliitis, can't you? It's a funny old world...

The wonderful old NHS creaks on. Robin craves the forgiveness of those who do not understand the next paragraph because they do not work in it. Those who do will know of the government ‘targets' which force all hospitals to grant all new out-patient appointments within 6 months, or 21 weeks from the end of 2002 (actually the figures are 182 and 147 days respectively). The clock starts ticking, folks, from the date of the referral letter, so never mind if it gets lost in the post, the patient fails to pick it up for a month or any other excuse. Before we know where we are the start date will be the first attendance ever for the problem and letters will be pre-dated by a couple of months. This madness (why not start the clock when the letter is received?) is compounded by ubiquitous out-patient surveys that check how long each patient waits from their due time to the time they are actually seen. None of these allows you to credit the number of minutes a patient is seen early. It's a funny and mad old world...

Ever come across settilators? One of Robin's secretaries had, as he discovered reading an old letter that had obviously been sent unamended and would have caused a few furrowed brows at the other end. This particular settilator was of the tortoise variety, i.e. slower. Read it aloud and think drug half lives, and you may just get there.

Robin continues to receive referrals of patients with headache and dizziness, of which less than one per cent are due to vertebrobasilar insufficiency. The dizziness of the majority is in fact vertigo, which Robin thinks ought to be apparent to a chimpanzee from the history, but he has had a couple of ‘muzzy-headed’ patients whose symptoms follow the institution of beta-blockers and angiotensin-converting enzyme (ACE) inhibitors after a coronary thrombosis. One patient, in fact, was sent in with difficulty walking, the cause of which was severe postural hypotension. But then the patient proudly announced (as I was asking about risk factors for his coincident gout) that a well-known lager manufacturer had recently introduced a ‘cardiac allowance’ can of three units (for those who can get it, it's Stella Artois). He was most disappointed when Robin told him the port/porter story and suggested he switched to red wine.

In the good old days lots of surgeons offered fusion as a solution for low back pain and Robin has commented previously on this topic (Rheumatology 2002;41:478) [Free Full Text] and now along comes a review article which may put the interventionists off further (Krismer, J Bone Joint Surg 2002;84B:783–94). After 114 references it concludes with the Cochrane review summary — that instrumented fusion produces better fusion, but without improving clinical outcome; that spondylolysis might be treated just as well by fusion whether decompression is done or not; that fusion with decompression reduces slip and may improve outcome; but that fusion without a slip has no good evidence to recommend it (Gibson, Grant and Waddell, Spine 1999;24:1820–32).[ISI][Medline] So it's all a bit iffy, really and we can still keep patients away from surgery.

Warnings about success, or lack of it, are common in Robin's clinic and no more so than with shoulder replacement. Robin has an automatic verbal macro which spouts that while pain relief will be good to excellent, improvement of range of movement will not. It appears he is wrong for those with osteoarthritis; Fehringer and colleagues tell patients that after surgery about two-thirds of the absent pre-operative function may be regained (J Bone Joint Surg 2002;84A:1349–53). [Abstract/Free Full Text] Another myth is dashed.

In competitive swimmers shoulder pain is more common in those with more flexibility (Ozcaldiran, The Pain Clinic 2002;14:159–63)[ISI] but it also appears that swimmers are more flexible then the normal population. Do you gain some advantage from a degree of hypermobility, or does the intensive training cause it? It would seem at least that exercise regimes that might stretch the shoulder are contraindicated.

Reading the tea-leaves in early rheumatoid arthritis is, it seems, quite easy. Drossaers-Baker et al (Arthritis Care Res 2002;47:383–90) [ISI] report (with a neat algorithm) that disease course can accurately be predicted by a combination of swollen joint score, rheumatoid factor, HAQ score and radiographic changes. What will be interesting to see is whether early aggressive management of the high-risk group will modulate the risk of progression. Mind you, the next paper (Heiberg and Kvien, ibid, 391–7) makes the important point that whatever we measure, it's the pain the patients want to get rid of.

Robin has been scratching his head over the issue of bone densitometry in RA patients on steroids, not least because he has looked at several who have been on steroids for years but don't appear to have any significant bone loss on the scan. Walsh and colleagues have looked at this issue in another group of steroid users –— the chest patients (Am J Respir Crit Care Med 2002;166:691–5). [Abstract/Free Full Text] It seems that steroids do alter bone mineral density (BMD) and that the cumulative dose relates to fracture risk, but this is increased independent of the change in BMD. Robin is not clear from this whether we need to bother measuring BMD any more if we should treat them all anyway. Oh dear. His head all a-spin, he's off to the cinema.





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