Whenever Robin despairs that no misprints have fallen in his lap for the next column, four come along at once. The London College of Physicians is advertising a lecture (in October) entitled Beyond Harvey Crushing: enzymes and the redefinition of corticosteroid hormone action. Methinks someone was thinking of crush injury to inflict such a cushing indictment on medical historybut then again, one of Robins colleagues, invoking the principles of Semmelweiss to persuade his trainees to wash their hands between patients, was asked Whos Semmelweiss?
And the dear Sunday Times has been doing its bit for disease. In an admirable article about designing homes for disability it quoted a sufferer from hip dysphasia, which proves that newspapers talk out of their backsides, or not far off. It also spoke of Susan Hampshire, who has designed in extra wide doorways for her ageing and increasingly disabled husband. I fancied Susan like crazy when she was in the BBC television serial of the Forsyte Saga, so this story made me feel terribly old all of a sudden.
The third puts Robin in mind of George HarrisonWith every mistake we must surely be learninga letter has crossed his desk suggesting that a patient (no doubt with Wegeners granulomatosis) was taking antihistamines for her guitar. Its enough to make anyone weep. And then theres the new knee replacement with new evasive approach. This non-invasive stuff is enough to make anyone run a mile.
Robin knows a few long words (like solecism and oxymoron) and, more to the point, what they mean. Occasionally he trips, as previously reported with epistemological. But goodness, gracious mea case report in the Annals of Rheumatic Disease had him completely foxed. A gemellar pregnancy (
Sibilia et al., Ann Rheum Dis 2004;63:2178
Actually that particular issue of the Annals reinforced Robins self-belief that he is a prophet. Remember my request for your thoughts on the benefit (or otherwise) of arthroscopy of the knee? Requested because I didnt believe in it? Brandts review of the non-surgical management of osteoarthritis says of debridement and lavage Insofar as these procedures are no more efficacious than placebo surgery, the authors (
Moseley et al., N Engl J Med 2002;47:818[CrossRef]) concluded that the approximately $3 billion spent on them annually in America might be used more effectively if directed elsewhere (
Ann Rheum Dis 2004;63:11722
The first leader (and then I shall move away to another journal) is appropriately by Furst (
Ann Rheum Dis 2004;63:1156
Last month Robin alluded to immunosenescence markers in relation to the prognosis of rheumatoid arthritis; the principle of T-cell senescence in the context of autoimmunity is nicely summarised by Cope ( Arthritis Res Ther 2003;5:2234[CrossRef][ISI][Medline]) following which are a couple of interesting papers developing the theme ( Goronzy and Weyand, 2003;5:22534 and Fülöp et al., 2003;5:290302). For brevity I omit the DOI numbers!
This months foray into alternative pathways turned up this gem, from Beffa and Mathews ( J Manipulative Physiol Ther 2004;27:e2[Medline])I quote The purpose of this study was to locate the cavitation sounds during the L5 spinous hook adjustment and a lower sacroiliac adjustment. Cavitation sounds are the cracks produced by chiropractors and osteopaths, just in case you didnt know. Microphones were taped over the relevant parts, but there was no correlation between sound origin and manipulation technique. Robin recalls an orthopaedic friend who got terribly excited over knee crepitus, and tried much the same thing, but was unable to decide what it all meantand that was decades ago.
What do we make of the study by Ørstavik et al. (
Arch Intern Med 2004;164:4205
We should also be wary, perhaps, of treating RA patients with TNF- blockade if they also have obstructive sleep apnoea. Zamarrón and colleagues report a patient whose sleep apnoea got worse after starting on infliximab (
Resp Med 2004;98:1235[CrossRef][ISI][Medline]). They postulate that TNF-
is important in sleep apnoea, although Robins simple brain wonders whether the relief of arthritic symptoms was so profound that the patient did not get woken up by them so often.
Robin would very much like to put all his patients onto a proper database that held sequential records, rather than use the one-point spreadsheet that is all he can currently afford (funny, isnt it, that so many people think that drugs can administer themselves and data entry can be telepathic). So he is pleased to see a report ( Stengel et al., J Bone Joint Surg Am 2004;86-A:55360[Medline]) which indicates that the use of handheld computers improves ward record keeping. Robins managers do like evidence-based stuff, so will shortly receive this article, together with a shopping list of hardware and software, not to mention additional secretarial support and a specialist nurse (or two, perhaps). Else he will close his clinics to new patients (well, our haematologist did that to the anticoagulant clinic when the patient load reached 30,000 with funding for only 10,000, and got the money in a week). It is a risk worth taking? A bluff worth calling? Even a black worth mailing? Your advice would be most welcome, dear friends, so start those emails rolling in again; I am running out of things to discuss with George Ehrlich and its time some others took part. You should however read his back pain masterpiece ( J Rheumatol 2003;30(Suppl. 67):2631) even if he thought, from the references, that the then Editor wrote this column, which he does not. Still the same email address: robingoodfellow_rhu{at}hotmail.com