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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;41:5512[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;288:35862)
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;109:10817)[ISI] report that vaccination with antibodies against amyloid-A may provoke encephalitis, with a breakdown of the bloodbrain 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;347:818)
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;61:6735)
In the same issue Buttgereit and others, representing the First European Workshop on glucocorticoid therapy (pp. 71822) 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;46:14519).[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!