Robin Goodfellow (43-9)

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Robin has had a funny week; first the managers caved in to all his demands, then his opera-loving orthopaedic colleague took him and Mrs Robin to Glyndebourne (Pelleas and Mélisande; sublime music, pity about the dialogue) and then one of his heartsink patients had transformed into a charming and witty conversationalist. She told Robin of a friend of hers who had rheumatoid arthritis and had developed severe cellulitis of one leg after being scratched by the cat. Anxious to avoid further prolonged ulcer management, she consulted an animal behaviourist for advice. She looked at the cat, sent in a bill for £100 and told the lady to wear trousers. It reminds Robin of a dead parrot joke, but the Editor will no doubt censor it, so Robin will not waste his time by trying to include it. However he was intrigued by an orthopaedic reference to the Atlanta axial joint, presumably named because you get it in the neck from east coast hurricanes.

Robin took Mrs R to Chesil Beach for a week (those who wish for a hotel testimonial should apply by email), where on the last night a party of tourists were accompanied by a guest lecturer, an historian, at dinner. The voice carried somewhat, and Robin's scientific mind was tortured by one quote: ‘Time is a sphere in which notions of causation exist’. The tourists all nodded sagely, but if anyone has the faintest idea what this means please get in touch at once. I don’t want to miss something vital.

Robin floated the concept of transferring services ‘into the community’ with a patient recently. There was a robust response: ‘What? You must be joking! You haven't got enough time to see all your patients as it is without flying round the whole area. They must be barking mad! What lunacy’. Which is Robin's view entirely, as the customer is always right. This sentiment was backed up by the discovery that a nearby rehabilitation unit has no medical cover for emergencies and is now struggling to recruit nursing staff. Being ‘in the community’ can be a synonym for being isolated (and then desolated – or is it decimated?).

A nice review of the history of citrulline and peptidylarginine deiminase (PAD) appears from Utz, Genovese and Robinson ( Ann Rheum Dis 2004;63:330–2[Free Full Text]) pointing out, to amnesics like Robin, that the citrullinated antigens have been around, on and off, since 1964. But it looks as if we are getting somewhere with them now, even if Robin's chemical pathologist is still insisting on a business case. For TNF-{alpha} blockade fair enough, but as the test still appears to cost less than £3 ({euro}6) Robin feels that it's a bit like asking for a business case from Mrs Robin for her shampoo.

One can perhaps understand why osteoarthritis is more prevalent in the right hand than the left ( Neame et al., Arthritis Rheum 2004;50:1487–94[CrossRef][ISI][Medline]) – it gets used more if you are right-handed (though the article's abstract does not indicate whether patients were screened for handedness). Neither is it entirely surprising that the asymmetry in hips and knees is not particularly striking. Robin does not observe people hopping much these days. Given that it is well-known that trauma to knees, such as the performance of a menisectomy, clearly predisposes to OA, Robin refers this paper to Acta Obviosa. However the following paper is a cracker (though it has, eventually, to be consigned to the same journal); Hunter and colleagues report that the regular use of chopsticks is associated with an increased prevalence of OA in the interphalangeal joint of the thumb and in the second and third PIP and MCP joints ( Arthritis Rheum 2004;50:1495–500[CrossRef][ISI][Medline]). Ah so.

Robin has bitten his lip long enough on the disease whose name cannot be uttered (oh, well, fibromyalgia if you must) and recommends the sensible piece by Aceves-Avila et al. ( Best Practice & Research Clin Rheumatol 2004;18:155–71[CrossRef][ISI]) sensibly titled ‘New insights into culture-driven disorders’ – illnesses they describe in the wonderful phrase ‘lacking face value’. The abstract alone was enough for Robin as it confirmed his prejudices (and the Editor still won’t provide any financial assistance to this poor and mean goblin who will not spend $30 on a full download). However if it delineates sensible strategies for management as promised it can only be a good thing. Of course, for those believers whose blood is already boiling I should warn them that Robert Ferrari is a co-author, so where it is coming from should not be a surprise. I like culture-driven disorders even more than my own description (emperor's clothes syndrome).

All rheumatologists and orthopaedic surgeons know that orthopaedic intervention in rheumatoid arthritis patients should be preceded by lateral X-rays of the cervical spine in flexion and extension to obviate the risk of cord damage during anaesthetic manipulation. However they don’t actually. Grauer and colleagues ( J Bone Joint Surg 2004;86A:1420–4[ISI]) have done a proper review to see if they could predict paralysis, finding in the first place that only 47 of 65 patients had appropriate films and, secondly, that the traditional measure (an anterior atlantoaxial difference of more than 3 mm) predicts nothing. It is a posterior difference of less than 14 mm that is significant. Change your teaching, guys.

What about the weather and joints? Patberg and Rasker report that effects in RA have moved from controversy to consensus ( J Rheumatol 2004;31:1327–34[ISI][Medline]) and that humidity is important. Robin still believes that it is changes in weather that matter (because joint proprioceptors are sensitised by arthritis or trauma and detect barometric pressure variations). How else, he asks, can you explain how for years after dislocating his shoulder he could tell when the weather was about to turn? Nowadays it's only hurricanes that work, and the only other time he suffered was when he got campylobacter from a chicken dish and polymyalgia became instantly understandable. Apropos that, if you get patients of any age with PMR symptoms, check first that they are not taking statins (lots of rheumatologists do, as Robin discovered at Edinburgh talking to his similarly ageing friends). Robin has seen several patients with statinomyalgia (his own name, which he feels should be universally adopted) and recognised the cause because he has had it too (forget the sympathy, I’m fine right now and not taking the things but drinking cloudy apple juice instead).

Robin has for years worried about hospital infections (and with the help and support of his excellent staff has largely managed to exclude the hysteria-provoking MRSA from his own rehabilitation unit). It seems the rest of his hospital is waking up at last. In an effort to prevent bugs being carried from one part of a ward to another, different coloured disposable aprons will be supplied for bays, siderooms, sluice and so forth. There are ten colours. Robin suspects that more bugs will be spread by the putting on and taking off of these than it's worth, but we shall see. His own solution is to provide open fireplaces on the wards; these will provide a constant through draught up the chimneys (which will change the foetid air to the benefit of all) and also incinerate the bugs as they are wafted skywards. Perhaps a business case? It seems, however, that this return to the practices of the 1890s will fall foul of Health and Safety regulations ... dream on, Robin!





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