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NICE (the National Institute for Clinical Excellenceor is it the National Investigation into the Crushingly Expensive?) has at last pronounced on TNF-. To say anything other than the result is a triumph for British rheumatology would be an understatement. Not only are the drugs approved, but the preconditions set by NICE for their use are exactly those devised by the BSRguidelines, Register and all. A little bird has told Robin that the preliminary approval document indicated they were too expensive and they were turned down, but careful reading of the final document reveals that NICE decided its own commissioned cost-effectiveness study was not robust. So, in the wake of the negative decision on beta-interferon in MS effectively overturned by a government caving in to public pressure, and a positive decision for TNF-
parroting the professional guidelines, Robin calls for NICE to examine its own cost-effectiveness and wonders then if it will be like the oojalum bird.
And another triumph for rheumatologythe election for the Presidency of the London Royal College of Physicians has taken place, and Professor Carol Black is the first rheumatologist ever to achieve that noble and prestigious office. The mightiest congratulations that a goblin can bestow are bestowed and, just in case, Robin has retreated to the air-raid shelter and cooked up several spells to help her defeat the evil wizards and spin-trolls that inhabit the strange land of West Minster.
We all know that RA patients have difficulty with child-proof containers, but a letter from Kassimos and colleagues
(Lancet 2002;359:352) [Medline]
reminds us that some of our TNF- patients will have difficulty administering their etanercept, unless they have a dextrous carer. Robin too, nimble-fingered as he is, has found the mixing station to be more trouble than it is worth, and the thought of disabled patients using stuff they have dropped on the floor is not nice. Maybe the infliximab infusion is not such a bad idea, when nice (usual meaning) nurses will do all the work, while they are not being epistemological.
Focal abnormality of the radial styloid correlates significantly with de Quervain's tenosynovitis
(Chien et al., Am J Roentgenol 2001;177:138386).
Sticking with that anatomical area there is a nice summary of osteoarthritis (OA) of the thumb base (scapho-trapezio-trapezoidal joint, the joint below the carpo-metacarpal joint to be exact), a part that Robin needles now and again when CMC injection fails (Davey and Belcher, Curr Orthopaedics 2001;15:2208).[ISI] It can be stressed by the radial grind test. The pros and cons of surgery are well described and there are some nice images.
Robin takes an occasional glance at medical history, so was interested to note the article about Barker the bonesetter (Bishop, J R Soc Med 2002;91:415) which describes the goings-on in 1920 when Barker's services to the military were turned down because he had no formal medical qualification. The row embroiled the Archbishop of Canterbury (who had a right to award honorary doctorates in medicine), George Bernard Shaw, the General Medical Council, the British Medical Association and the media. It was the first real clash between medical establishment and the proponents of alternative medicine and Barker's skill was eventually recognized (he got a knighthood). Shades of today's Prince of Wales and his flirtation with the fringe?
Uh-oh. Robin supposes it is hardly surprising that the COX-2 selective agents are under the microscope, nor that they may be found wanting when weighed in the balance. A case report implicates celecoxib in non-oliguric renal failure
(Alkhuja et al., Ann Pharmacotherapy 2002;36:524.
And then there is Dolly. The first cloned sheep is thought to be old before her time, because she has developed early arthritis in her left hind leg
(Br Med J 2002;324:67).
Learn to look, say Bardes and colleagues who have been developing the observational skills of medical students by taking them to museums to analyse portraits before letting them analyse the faces of patients (Medical Education 2001; 35:115761). [ISI][Medline] What fun. Robin has often thought that facial expression is as useful as the DAS score in assessing disease activity but usually took young ladies to art galleriesand now, of course, takes Mrs Robin.