Robin Goodfellow

Bom Dias. How can it be that there is a never-ending string of secretarial misprints? Robin was checking back through a new patient's notes to see whether he was the first to deal with the back pain, only to discover an old referral letter noting the X-ray finding of bilateral parse fractures. He has heard of broken English, but this is the first time he has encountered broken grammar...


Consultants come and go, but Robin was sad at his last interview outing, to a seaside town, to find that the hospital was too far from the beach to go bathing. The compensation was a perfectly grilled hake fillet served by a Terry Waite look-alike in the postgraduate centre dining room. The National Health Service (NHS) cannot be dead yet.

However it may not be long in the dying. The Home Secretary has unveiled a review of the criminal justice system which, along with abolition of the ‘double jeopardy’ rule (you cannot be tried twice for the same offence), proposes that doctors' exemptions from jury service be abolished. The country will suddenly have better trials but cancelled clinics. The number of trainees is so closely matched to consultant vacancies that there is often only one candidate; where, then, will the locums come from for short-term gaps? As a letter from a rheumatologist in ‘The Times' points out (Bamji, July 18th 2002) it is no good drafting doctors in to fill NHS gaps if another government department then drafts them out again to serve on juries.

Trials continue to be a tribulation. It is 20 years since Kirwan launched a critique of clinical trials; so long, in fact, that Robin could barely find the reference — he thinks it is Ann Rheum Dis 1982;41:551–2[ISI][Medline] — but from his recollection only one or two of over 30 trials were reasonably conducted. It appears that not a lot has changed; Scott et al. (J Am Med Assoc 2002;288:358–62) [Abstract/Free Full Text]entitle their blast ‘The continuing unethical conduct of underpowered clinical trials' and comment that there are only two allowable circumstances: in rare diseases where it is explicit that results will be combined with other studies and in some early-phase trials where randomization is not done. Surely, after all this time, no rheumatologists could be criticized? But then who did the Celecoxib CLASS study which I commented upon last month? And there is the paper by Lavalley and Felson (Arthritis Care Res 2002;47:255–9) [ISI]which concludes ‘Ordinal data are common in rheumatology articles, but presentation usually does not conform to recommended guidelines’. Sackcloth and ashes all round, I think (I can supply ashes, as I have just had a nice bonfire).

Following on from my excitement over the prospect of designer amyloid uncouplers as described by Mark Pepys in his Heberden Oration I was disappointed to find the downside has already been reported. Münch and Robinson (J Neural Transm 2002;109:1081–7)[ISI] report that vaccination with antibodies against amyloid-A may provoke encephalitis, with a breakdown of the blood–brain barrier and the invasion of cytotoxic T cells. More research needed, obviously.

The Journal of Disappointing Results would surely have taken the paper by Moseley et al. (New Engl J Med 2002;347:81–8) [Abstract/Free Full Text]which evaluates arthroscopic surgery in osteoarthritis of the knee (full marks to them for devising a dummy procedure). Neither lavage or debridement were any better than placebo. How long, Robin wonders, will it take for orthopaedic surgeons to stop doing it and free up their overcrowded lists for real surgery such as joint replacements in rheumatoid arthritis?

If we are going to be common-sensical about osteoarthritis, this must also apply to re-educating patients that an attitude of ‘defeated resignation’ is inappropriate. Hurley's splendid leader in the still typographically challenged ‘Annals' (Ann Rheum Dis 2002;61:673–5) [Free Full Text]underlines this, but Robin would have been happier with a bit more of the de-medicalization philosophy rather than the exhortation to exercise, worthy and right though that clearly is. Every day and in every way...

In the same issue Buttgereit and others, representing the First European Workshop on glucocorticoid therapy (pp. 718–22) set out definitions and doses. Robin has already reset his ‘Autocorrect’ function so that steroids turn into glucocorticoids — a word which we two-finger typists struggle with. Setting a consensus on these things seems a good idea; Robin is all for precision.

None of you netheads (and I know you all are) seem willing to share good URLs with Robin. Thou art a selfish and stiff-necked lot, and just to remind you I am holier than thou I offer you the Dermatology Online Journal which has lots of nice review articles, with pictures. There is currently an excellent review of erythema nodosum, but if your browser is slow then be aware there are vast numbers of references which, when printed, bring the article length when pasted into Word to over 40 pages. The URL is equally hideous: http://dermatology.cdlib.org/DOJvol8num1/reviews/enodosum/requena.html.

The ATTRACT study rumbles on. Following the suggestion, reported by Robin previously, that infliximab doses can be reduced in controlled patients, comes the further conclusion that some patients should exceed the recommended dose, either by being given the infliximab more often, or by increasing past 3 mg/kg (St Clair et al., Arthritis Rheum 2002;46:1451–9).[ISI][Medline] This is on the basis that trough levels in 26% of patients are so low as to be undetectable. It does not, however, offer any advice as to which patients these might be, so guesswork may still be the order of the day. It will be fun over here explaining to NICE (National Institute of Clinical Excellence) and purchasers why the drug budget has gone up even further (‘Oh, we're just dribbling in a bit more, old chap, evidence base and all that’).

So it is goodbye from me, and I will tell you next time what it is like drinking port in port country, for Robin and Mrs Robin are off up the Douro. Adeus!





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