Robin Goodfellow (43-11)

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As the nights fair draw in Robin begins to wonder whether Guy Fawkes had the right idea. A curious ‘Catch-22’ has visited his patch. Others in the UK have, he knows, been scratching their heads over proposed funding rearrangements for TNF-{alpha} funding; one area had decided that it would do this by funding each outpatient appointment for biologics patients to the princely sum of £150. Now it doesn’t take a devalued mathematics ‘A’ level to work out that if a biologic costs £760 a month, then to cover costs each patient will require just over 5 appointments. Monthly. You cannot be serious ... however, Robin's hospital has just been told that its allocation for all drugs approved by NICE (the National Institute for Clinical Excellence, or National Imprimatur for the Crushingly Expensive, as some call it) is to be £241,000. Note the precision. Robin and his colleague are spending three times that on biologics alone (indeed, drug for drug, we are now beating the oncologists) and his locality is staring a £14 million end-of-year deficit in the face. So—the hospital has a statutory obligation to live within its means, and Robin has an equal statutory obligation to prescribe NICE-approved drugs. Now what? Suddenly our specialty has become very powerful indeed, it seems.

Political correctness has also cast its shadow over the proposed National Patient Record, designed to pull together all information on every patient so that any professional needing it can view the lot. Robin has been looking forward to this, as he already has several patients who get seen for other things than their arthritis in other hospitals, and have thus accumulated three, four or more mutually exclusive sets of notes. However a nice lady who appears to be in charge writes in The Times that, to preserve privacy and patients’ rights, patients will have the right to withhold bits of information from professionals if they want to. The lunatics really are in charge of the asylum now. At least if some disaster happens they won’t be able to sue, as for once it will be their fault and not the doctors’ if something dangerous gets done because some professional was unaware of something important. But if the whole system is being fatally compromised by this ridiculous notion that patients can choose who sees what, Robin cannot see that it is worth spending the expected £6 billion. Better to fund the NICE-approved drugs, perhaps.

Enough moaning. Time to hunt a few rheumatological foxes. Robin has been surprised by the number of his patients with cardiolipin antibodies (with and without lupus) and will be looking for them all the more thanks to Jonsdottir et al. ( Ann Rheum Dis 2004;63:1075–8[Abstract/Free Full Text]) who indicate that TNF-{alpha} blockade in rheumatoid arthritis may induce them. Back to treating RA with aspirin, then.

It appears that therapy for HIV may induce osteoporosis ( Groger, Clin Rev Bone Mineral Metabolism 2004;2:167–74[CrossRef]) due to an increase in bone turnover, particularly resorption. Robin confesses that he has not seen a patient with HIV in the last 20 years, and that this should therefore go to the Journal of Not Very Practical Results. Robin has had a lifelong interest in odd parasites but had no idea that little green men could cause arthritis in the immunocompromised (well, have you heard of algemia?). Pascual and colleagues report a patient with arthritis and tenosynovitis caused by the achloric alga Prototheca wickerhamii ( J Rheumatol 2004;31:1861–5[ISI][Medline]). Robin supposes that in immunodeficiency anything goes, or comes. Trust nothing! Anyway it's more fun than the MRSA that currently occupies and obsesses the UK's newspaper hysteria industry. One paper even reported a film star who had acquired MSSA. No really. Robin hasn’t had a boil for years and wonders if she had been picking her nose, or even someone else's—these actresses lead curious lives.

Many years ago Robin's shoulder was dislocated when he fell off his moped, and he has often wondered whether he would be more liable to osteoarthritic changes. So he was interested to note the paper by Buscayret et al. ( Am J Sports Medicine 2004;32:1165–72[CrossRef][ISI]) exploring whether stabilisation surgery influenced the development of OA. It appears not. But he is glad he didn’t need it, all the same. Two weeks in a Bankart bandage is surely preferable to six weeks in an aeroplane splint.

It is easy to forget that others than orthopaedic surgeons operate on our rheumatology patients (and no, I am not entering the debate about ‘consultant’ podiatric surgeons just now). Plastic surgeons have a long and distinguished history of dealing with hands. A systematic review by Martou and colleagues which looks at the thumb base ( Plast Reconstr Surg 2004;114:421–32[CrossRef][ISI][Medline]) concludes that there is not really any good evidence to favour any technique (arthrodesis, trapeziectomy with or without biological/synthetic interposition, osteotomy, and joint replacement) over any other, partly because so many trials had methodological flaws. One would have thought that a large-scale trial, such as they suggest, could not be so difficult in such a common problem.

RA, or UPS? In a cogent, impossible-to-summarize editorial Paget provides a superb overview of the classification dilemma facing rheumatology today ( J Rheumatol 2004;31:1673–6[ISI][Medline]). He wants us to get away from the term ‘early RA’ not least because patients’ recollections are such that it often isn’t that early; and anti-CCP enables us to define ‘true’ RA much more easily. He writes ‘... I believe that persistent inflammation (especially of more than 3 months’ duration) reflects a physiologic process that is potentially "out of control" from an immunologic and inflammatory point of view, which, supported by our less than perfect knowledge base, may very well result in a lifelong disorder that damages joints and other tissues and limits function. Here, a "wait and see attitude" that does not consider employing DMARD is avoiding our responsibility to direct our best therapeutic efforts at the earliest phases of disease, before irreparable damage occurs.’ Strike while the iron is hot seems an excellent maxim. And what has Robin been saying for years? Hit early and hit hard seems to be much the same, he thinks. Knows, even.

What is the cost of a workup in early arthritis, whatever label you stick upon it? Fautrel et al. ( Arthritis Care Res 2004;51:507–12[ISI]) surveyed France and Belgium, and came up with {euro}406.5 ± 194.3 for a case with no diagnostic clues, and {euro}280.7 ± 154.3 for cases suggestive of early RA. Which isn’t a lot, really; but is that what we will get paid per patient in our NHS clinics? Ha! But at least Robin has yet another essential antibody with which to pester his biochemist; it appears that anti-M3R antibodies are pretty specific for systemic sclerosis ( Gao et al., Arthritis Rheum 2004;50:2615–21[CrossRef][ISI][Medline]). And we have almost got him to agree anti-CCP ...

Now (creepy music off). Get out the garlic, and a wooden stake. It's time for the dreaded f-word ... Robin in his charity has suggested that patients with chronic pain have abnormal activation of the cingulate gyrus, and then along come Yunus et al. who compared PET scans in healthy people and those with f**********a ( Arthritis Care Res 2004;51:513–8[ISI]). Guess what? THERE IS NO DIFFERENCE!! What does that tell us? Robin knows, and is now off to dinner with friends (and Mrs Robin, of course) and hopefully some nice Burgundy.





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