As regular readers are aware, Robin is a great one for new things, so he was delighted to find that nerve roots are too. A letter he dictated has been transformed to read that the medial side of the calf is innovated by S1. However he is not so keen on political innovation, particularly when it is done for expediency. The UK government's Patient Choice initiative has been developed to cut surgical waiting lists. The gist of the scheme is that patients whose wait may be long can be offered alternative venues for their operation. Apart from reducing surgeons to technicians (given the impracticality of sensible follow-up and the likelihood that someone distant may have to deal with complications without knowing details of what was done) Robin has discovered a new problempatient disenchantment. He saw one recently whose surgery had been switched to a nearby teaching hospital. Her notes had gone with her and had not returned, which hindered our consultation somewhat (never mind that surgery was first postponed because she had an infected ingrowing toenail and then because the surgeon had injured their shoulder). But she was uneasy about the whole process. Pressurised by the phone call offering her jam today she accepted in haste and thennot only realizing that whoever operated on her had never met her before but also never would againdecided that her move had been disloyal. So, meeting targets comes up against the inescapable problem that patients are not production line cans of beans, but people. It is especially curious because the medical bed crisis in Robin's hospital need not be a crisis because there appear to be too many surgical beds for the current workload. Where will it all end? Come back, Kafka; all is forgiven.
From China comes an interesting study, perhaps not so relevant to us Westerners. It seems that lots of squatting predisposes to tibio-femoral OA ( Zhang et al., Arthritis Rheum 2003;50:118792[CrossRef][ISI]). 40% of men and nearly 70% of women squat for more than three quarters of an hour a day. Perhaps someone with a better understanding of ethology will let me know why, and what for. Robin imagines that the lesser association with patellofemoral OA is because these squatters do not bounce up and down while indulging. But how is the best way to manage home physiotherapy for patients with osteoarthritis of the knee? One might, I suppose, argue that such a service is an unaffordable luxury in many areas, and Sen and colleagues hint at this ( Knee 2004;11:1513) in reviewing the Izmir scene. Two groups of patients, monitored six times in 24 weeks, fared no better than those monitored twice. Robin wonders if they need monitoring at all (not least because he spares his own overworked department in most cases by teaching the exercises in clinic himself, and home monitoring is out of the question)thus consigning this paper to the brand new Journal of Unnecessary Interventions.
Robin has been interested for some time in the concept of distance diagnosis, not least since his dermatology colleague dismissed shots from his expensive digital camera as insufficient to make a confident diagnosis (odd, really, as his 19th century predecessors were not so squiffy about the watercolours of lesions sent from the provinces by stagecoach). So he was pleased to learn that histology has taken up the challenge in the most modern-sounding of journals, the Journal of Telemedicine and Telecare. This particular article ( Mireskandari et al., 2004;10:99103) demonstrates the possibilities of developed countries using such a service in the aid of the less developed (or experienced). Robin's only concern was that telepathology sounds a little bit alternative and perhaps suggests that the mode of communicating results does not always require any electronic connections. In similar vein, but perhaps of relevance to those who do clinics in far-flung places where they cannot run round to the laboratory with a fresh, steaming synovial fluid preparation, van Lindhoudt et al. ( J Clin Rheumatol 2004;10:102[ISI]) discuss how to keep a synovial fluid sample in its wet statevery sensible when, as from a finger, there is not a lot.
It appears that B6 T cell receptor (TCR)-/ mice (TCR being, of course, T cell receptor) are a good model from drug-induced cutaneous lupus (
Yoshimasu et al., Clin Exp Immunol 2004;136:24554[CrossRef][ISI][Medline]). Lories et al. report similarly that ankylosing enthesitis, dactylitis, and onychoperiostitis in male DBA/1 mice (
Ann Rheum Dis 2004;63:5958
An interesting article ( Havami et al., Arthritis Rheum 2004;50:1193206[CrossRef][ISI][Medline]) examines the role of subchondral bone remodelling in OA, noting that alendronate prevents cartilage degeneration and prevents osteophyte formation. This sounds like a case for the Journal of Chicken and Egg, if one accepts that the stimulus to osteophyte growth is actually the increased point pressure on subchondral bone from loss of the cartilage cushion. Is osteophyte inhibition a good thing? Robin thinks not, and has said so before. Another of these told you moments appears in the same journal issue ( Ward, Arthritis Rheum 2004;50:112231[CrossRef][ISI][Medline]), with a report of decreased hospitalisation rates for rheumatoid arthritis between 1983 and 2001. While in the UK Robin might be prepared to argue that this is a direct result of falls in bed numbers and thereby a tightening of criteria for admission, this is presumably not the case in Bethesda, Maryland, thereby pointing to the conclusion that the outlook for RA is indeed improving. He also notes a decrease in knee arthroplasty rates; Robin noted this was true of juvenile arthritis a little while ago, and it is pleasing to see similar evidence in adults. We are no longer just managing a chronic and inevitable progressive disease; this is surely a message we must start to shout from the rooftops.
Journal publication can never be immediate, so it will be next month that Robin sifts the wheat from the chaff at the British Society for Rheumatology Edinburgh meeting. He supposes that he could have covered some interesting abstracts, but his abstract book (usually carefully annotated on the train to pick out the must-dos) has failed to materialise. Quite how he finds time to read it through before kick-off will be revealed soon!
Returning to Kafka, Robin is happy to report that the window replacement programme for his hospital is complete; all the rotting frames have been removed and new, in-keeping double glazed no maintenance windows have been installed. Robin has never before seen such an expensive way of cleaning windows; the rolling cradles were unsafe and the only way of doing the outsides was with a huge crane (and not all the windows were accessible anyway). Sothe scaffolding went up, clad the whole building for a few messy months, and then came down. Now the roof is being replaced, and guess what? All the scaffolding has gone up again. So that's where the extra funding went.