Robin does not ski, so is unmoved by news that all the finest European resorts are under threat from global warming. He knows of many orthopaedic surgeons who undertake this pastime (the one who administered on-the-slope treatment to a friend, only to hear in the bar that he was an osteopath, is crossing the pond for his yearly fix, and is wished well).
Robin has previously commented on the Internet abilities of Badal Pal and his team, and is pleased to congratulate them on winning the 2003 Innovation award sponsored by Hospital Doctor. His fact sheet for the judges is attractive and impressive, marred only by the most successful attempt Robin has ever seen to cram all of the NHS's current key jargon into one paragraph, finishing We believe we are moving forward with managing changes and culture in line with NHS modernisation. Robin will definitely follow the model when his team starts bidding to join the stars. However, Pal old chap, four photographs of yourself is perhaps a little over the top. Also, for a wider audience than rheumatologists, all of whom know where he works, it might have been helpful to include a hospital address... and, of course, David James and his team cannot be ignored, having won the rheumatology section. So I wont.
Chronic neck pain is a heartsink diagnosis in most clinics. Robin belongs to the pull yourself together school these days, and sends them off for intensive physiotherapy. Does such dynamism work? Not according to Viljanen et al., who report (
Br Med J 2003;327:4757)
When dealing with knee osteoarthritis one forgets that there is more to the joint than the tibio-femoral joint, patellar articulation and menisci. Öztuna and colleagues remind us that the proximal tibio-fibular joint may be a significant source of lateral knee pain, and it should be properly examined and visualised ( Knee 2003;10:3479)[CrossRef][ISI][Medline].
My indigestible science this month comes from Wang et al. ( Osteoarthitis Cartilage 2003;11:8019)[CrossRef]. I quote (having taken the liberty of removing the abbreviations): Paired analysis of normal and OA chondrocytes from the same knee joint has shown an enhanced capacity of chondrocytes from OA cartilage to produce extracellular matrix macromolecules. However, the same cells have increased catabolic signalling pathways. As a consequence of this increased IL-1 activity and the reduced amounts of IL-1RII decoy receptor, less of the produced ECM macromolecules may persist in the cell-associated matrix of the OA chondrocytes. But after reading it seventeen times, I still do not understand. And anyway, what does it mean? Perhaps that's why I dont work in a teaching hospital (George Ehrlich, that's a clue).
Oh dear; the shockwaves are back an item in JAMA (2003;290:257380)
An aeon ago, before the acceptance of TNF- blockade by the UK's National Institute for Clinical Excellence (NICE), Robin attended a meeting that discussed the ethics of rationing, expensive treatments and the like. Forcefully putting the case for funding of this treatment, he was surprised if not horrified to be confronted with a lay person who suggested that the true choice for patients lay between the drug and the money how many patients, he asked, would take the £10,000 per year instead of the treatment? Robin was stung by this and has, accordingly, asked every patient he has started on TNF-
blockade, after 6 months, what their choice would be. He now has a series of 50. Every one would take the treatment. QED?
Anyone for the Moberg picking-up test? It correlates better with standard disease indices than the button test ( Stamm et al., Arthritis Care Res 2003;49:62632)[ISI]. Our patients will be worn out with all this testing; until we had to do DAS scores it was simplest to ask the patient how they were and allow for simple confounders such as a grotty knee awaiting surgery. We must beware of measuring trillions of things just because we can.
Another article from the same source ( Rao et al., Arthritis Care Res 2003;49:61925)[ISI] indicates that complementary therapies in rheumatology patients, examined over one year, produced no significant change in outcome. How come, then, there is a multi-million pound industry that says just the opposite? Are there no pros, just a con? Robin knows where he stands.
Money makes the world go round, and so it was perhaps not surprising that Robin found himself forking out thirty quid (about 50 euros or dollars) for the privilege of a copy of his criminal file, or Enhanced Disclosure as it is known in the trade. Being of the older generation of rheumatologists, he is still allowed to see children without being a paediatrician, but the private hospital wanted to ensure he was not a paedophile; it would have stopped him seeing kids if he had not paid for the form. How many paediatricians have been through this? Or rheumatologists for that matter? Over 20 years unblemished service counts for nothing. Robin would not have been so unhappy, given that his file will contain only a conviction for speeding, if he had not had to pay, and wondered why the NHS didnt need to know. Mrs Robin, a canny old bird, suggested he should hike his fees to cover the cost, but then she thinks I should be paid for writing this column every month (so what about it, Editor?).
He could of course do with the cash, having just bought a new computer (bigger and better for a reason the old one's hard disk was full and it kept crashing). Sadly his own assessment of his technical abilities was much overrated. The latest version of Microsoft Office wont work until it's registered, which requires an Internet connection and, try as he would, the new machine would not talk to the world. It required Robin Junior to point out that the phone socket must be connected to the modem and not to the network card. Muppet! he said, and he was right. Normal service has now been resumed!