Robin Goodfellow (44-3)

Robin remains grateful to his surgical colleagues for continuing to send interesting referrals. The latest was an ischial bursitis confirmed on MRI (the Robin approach, of course, is inject first and ask questions when it doesn't work). The surgeon wrote ‘Although I do not myself inject bursars ...’ – well, neither has Robin, and he would only consider doing so if they were from an Oxbridge college.

Robin has, with the recent and most welcome arrival of a specialist nurse, started to do some tidying up and the first job was to weed out from the database all those who had not been seen in clinic for two years or more. It is a sad testament to communications that of just over 110 ‘missing persons’ (about 10% of the total), 18 had died without this information filtering through to the department. It really is time for databases and patient systems to talk to each other; Robin's hospital is piloting a new, all-singing, all-dancing PAS but at present he cannot communicate with its builders. Not a good start. He also had fun with one of those little data transfer sticks; it contains the setup program on the stick itself, which is a fat lot of good under anything older than Windows XP. To make it work on anything else you have to download the setup program onto an XP machine, copy it to a CD and then install it from that! Robin hasn't quite got that far, suspecting that once this is done some incompatibility will manifest itself and the IT department will throw a hissy fit over the unauthorized installation of untested software. And, presumably, Robin will have to declare the thing as a freebie from a drug company, complete with photograph.

A bit of magic is needed, and it turns up courtesy of Harlow and colleagues ( Br Med J 2004;329:1450–4[Abstract/Free Full Text]). Magnetic bracelets relieve pain in osteoarthritis of the hip and knee—and they sit on the wrist. So how do they work? Perhaps the same way as those electromagnetic water softeners—the ions line up in the magnetic field, or something. The study excluded those with pacemakers (which I understand) and haemophilia (which I don't. Help).

Robin was also intrigued by a paper from Hengstman and von Engelen ( Br Med J 2004;329:1464–7[Free Full Text]) which questions the histological criteria for polymyositis on the basis that successive studies quote and re-quote criteria, and these new studies, or reviews, then become new references. Of the 205 references they analysed only four contained original data. "Through repetition, conclusions—even though they have become invalid over time—become embedded in the medical literature" they write. Authors also refer to themselves, which presumably helps to jack up the citation index. Robin wonders what other castles are built on foundations of sand, remembering a paper he was once sent to review purporting to be the first description of post-zoster reflex sympathetic dystrophy in the English literature. Robin thought this was odd, and trawled the continental literature—to find cases in Sudek's original description. Boom, boom!

Fix time now, and an impossible new concept for Robin to try and grasp (and fail, as yet)—that of signal transduction pathways, which may be targets for rheumatoid arthritis treatment with things that interfere with protein kinases or transcription factors ( Morel and Berenbaum, Joint Bone Spine 2004;71:503–10[CrossRef][ISI][Medline]). Robin looks forward to next month's BSR meeting at which this will, he hopes, be explained to him, but in reporting something so far over his head that it is stratospheric he notes that the lag time from acceptance to publication in said journal in 8 months (though it did get online in two). Rheumatology is faster, and has a higher impact factor ...

Do we now have a biochemical explanation for the benefit of arthroscopic washouts in knee OA? It seems so; Cameron-Donaldson et al. report that cartilage debris in a knee increases the expression of chondrodestructive tumour necrosis factor-{alpha} ( Arthroscopy 2004;20:1040–3[Medline]). So do we wash out repeatedly, or start biologic agents? Better be sensible about this ... but could we filter blood in rheumatoid?

Robin is not too keen on the types that emerge from his local tanning rooms—often with new tattoos or piercings, but one must not be too pejorative about the lower classes—and expects that a fair proportion of them (and many are fair) will end up with skin cancers. However they may get some bone benefit. Tangpricha and colleagues ( Am J Clin Nutrition 2004;80:1645–9[Abstract/Free Full Text]) report that regular tanning-bed users have higher levels of serum 25-hydroxyvitamin D. Robin dislikes things about vitamins as they prompt family arguments about pronunciation. Being a pedant, he recalls the original derivation is from a contraction of vital amines and therefore should be pronounced with a long and not a short ‘eye’. Even though nearly everyone looks at him oddly he just cannot break the habit, and is just as pedantic with the reversed ‘I’ pronunciation for migraine which, of course, being derived from hemicrania should have the ‘I’ pronounced ‘ee’ ...

Heroic stuff is going on in the osteoporosis world; the latest thing is percutaneous vertebroplasty ( Carlier et al., Radiology 2004;233:891–8[Abstract/Free Full Text]). It reduces one-level kyphosis and seems to work better if there is an intravertebral cleft. In the UK Robin cannot see this catching on just yet, owing to the vanishingly small number of surgeons who seem to be doing spinal surgery and the consequent horrendous waits.

We all know that rheumatoid arthritis can affect the jaw, but what about the ear? In fact it seems that the significant difference in pure tone thresholds in RA is not conductive but sensorineural ( Ozturk et al., Am J Otolaryngol 200;25:411–7). So why? Could it be the drugs? I doubt that a randomised trial of patients who have and have not taken non-steroidal anti-inflammatory drugs is possible—although the COX-2 debacle has perhaps altered our perceptions somewhat.

Now you will recall that Robin told you not to ditch those old conference bags but load then up for barter abroad; you will be pleased to know that this tip has received an official seal of approval from no less a person than Rosie Boycott, who writes the travel column in The Oldie (overseas readers should make their way to the website—it's a great magazine with lots of medical cartoons). So Robin and Mrs Robin have won a weekend bed and breakfast break and are trying to choose a destination.

Meanwhile, changes are afoot. After 60 columns, or five years of penning the Rheumatology tailpiece from the air-raid shelter, Robin is hoping to be kissed by a frog and transmute into something sensible. As a result his present identity, jealously guarded and known only to a few close friends, may be revealed. He has been flattered by correspondents who think he is more than one person, or some eminent professor (he isn't either of these). But he hopes you have enjoyed the experience, and trusts that our esteemed editor may find a successor (who should, I venture to suggest, hold out for some financial inducement). Time will tell!





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