Robin Goodfellow (43-5)

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 history—but then again, one of Robin’s colleagues, invoking the principles of Semmelweiss to persuade his trainees to wash their hands between patients, was asked ‘Who’s 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 Harrison—‘With every mistake we must surely be learning’—a letter has crossed his desk suggesting that a patient (no doubt with Wegener’s granulomatosis) was taking antihistamines for her guitar. It’s enough to make anyone weep. And then there’s 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 me—a case report in the Annals of Rheumatic Disease had him completely foxed. A gemellar pregnancy ( Sibilia et al., Ann Rheum Dis 2004;63:217–8[Free Full Text])? Robin consulted his dictionary, online dictionary and Google (which latter came up with the case report URL) but could only find gemellar veins (in the calf) and gemella, which is a bug. Until, that is, he started foreign language searches which confirmed his suspicion that the term meant a twin pregnancy. So what’s wrong with twin? (Mrs Robin knew what it was, which suggests that Robin is not as well-educated as he thought). Which all reminds me that I must write out a cheque for the transparent wall maintenance engineer, or window cleaner to you.

Actually that particular issue of the ‘Annals’ reinforced Robin’s 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 didn’t believe in it? Brandt’s 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;47:81–8[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;63:117–22[Free Full Text]). Honest, I never saw the New England Journal paper, but my orthopaedic colleagues did not, apparently, see it either as they are still washing away. I shall send it to the clinical governance office so we can reduce our waiting lists.

The first leader (and then I shall move away to another journal) is appropriately by Furst ( Ann Rheum Dis 2004;63:115–6[Free Full Text]) and discusses mechanisms for acquired resistance to sulfasalazine, suggesting they can point to a rational use for combination therapy. A bit like cancer, really. Now where have I heard that before? This prophecy business can become an obsession.

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;5:223–4[CrossRef][ISI][Medline]) following which are a couple of interesting papers developing the theme ( Goronzy and Weyand, 2003;5:225–34 and Fülöp et al., 2003;5:290–302). For brevity I omit the DOI numbers!

This month’s 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 didn’t 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 meant—and that was decades ago.

What do we make of the study by Ørstavik et al. ( Arch Intern Med 2004;164:420–5[Abstract/Free Full Text])? Vertebral deformity is, they say, more common in rheumatoid arthritis independently of bone density or long-term steroid use. While one can, presumably, mitigate deterioration by anti-osteoporosis treatment, the underlying reason for this finding is obscure to me at least.

We should also be wary, perhaps, of treating RA patients with TNF-{alpha} 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;98:123–5[CrossRef][ISI][Medline]). They postulate that TNF-{alpha} is important in sleep apnoea, although Robin’s 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, isn’t 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:553–60[Medline]) which indicates that the use of handheld computers improves ward record keeping. Robin’s 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 it’s time some others took part. You should however read his back pain masterpiece ( J Rheumatol 2003;30(Suppl. 67):26–31) 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





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