I have also been notified of a rheumatic condition induced by London's latest attraction, the Millennium Wheel, or London Eye. Dr David Oliver reports a patient who fainted (twice) on attempting to gaze skyward beneath this elegant erection on the South Bank. Her vertebral arteries are clearly compromised by cervical spondylosis. How many monuments world wide can induce disease, Robin wonders.
Robin eagerly awaits the new guidelines from NICE, the National Institute for Clinical Excellence, on referrals for back pain and osteoarthritis of the knee and hip. He hears that rheumatology involvement in these was only garnered at the last minute, thanks to the intervention of a London consultant rheumatologist who informed an official of the British Society for Rheumatologya Polish Count, by all accounts. Not a good start for NICE, given that so many rheumatologists see so much of these things, but to quote my friend Will S, all's well that ends well.
Patients still seem to believe that total knee replacement has a high failure rate (Oooh, Dr Goodfellow, I know someone whose sister had one and it was a disaster...). So it was very reassuring to read that in the Bone and Joint Decade, knee replacement is the joint of the Decade. Moran and Horton report in an editorial
(Br Med J 2000;320:820)
A fascinating archaeological study of feet can be found at http://www.archaeology.co.uk/hilites/feet.htm. I discovered it (and the original dates from 1995) through the BioMedNet website at http://www. biomednet.com/home (you need to register to get entry, but it has a splendid online bits and pieces journal). It seems that the modern British foot is a lot less square than the Saxon equivalent. Could the long-standing fashion for pointy shoes have had a Lamarckian influence, Robin wonders. Though a goblin, Robin has a passion for sensible shoes that outweighs comprehension.
Karassa et al. have looked carefully at risk factors for CNS involvement in lupus (Q J Med 2000; 93:16974).[ISI] Perhaps unsurprisingly they conclude that the presence of antiphospholipid antibodies is the most serious risk factor.
Perhaps there is something extra in that perennial restorative of the English housewife, a nice cup of tea. Hegarty et al. looked at over a thousand Cambridge women Am Journal Clin Nutr 2000;71:10037, [ISI] and found that it appears to protect against osteoporosis. Something in tea, perhaps the flavonoids, offsets the osteoporotic effect of caffeine. Drink for thought.
Robin is always keen to keep up to date with new terminology. Old enough to remember when inflammatory arthritis in children was generically known as JRA, he is pleased to see that the transatlantic schism of JRA and JCA has been replaced by the new internationally agreed JIA. Foeldvari and Bidde (J Rheumatol 2000;27:106972) [ISI][Medline] have validated the new criteria and found them largely sound, with 88% of patients clearly classified. The difficulty arose in those with psoriasis.
MRI is not the answer to everything. Robin has had increasing difficulty in convincing his orthopaedic and neurosurgical colleagues that they should operate on the lumbar disc prolapses he sends them. He thinks this is a reflection on the spreading belief that time (and exercise) are greater healers than the knife. Robin's mantra for patients who pitch up with simple backache demanding a scan is coloured by this: I don't think you need an MRI scan because it's only really useful if you have a disc prolapse. That produces sciatica, not back pain. You don't have sciatica. So it won't alter what we do. Anyway, if you do have a disc prolapse do you want a serious operation? Even if the surgeon can be persuaded to do it? Team game this; we all have to agree that an operation is the only way forward. It seems to work here in England. Mind you, Robin reckons it takes twice as long to explain he is going to do nothing than it does to write out the MRI request and dictate the surgical referral letter.
Lastly it's back to money. The British Society for Rheumatology recently issued its clinical guidelines for the use of TNF- blockers, which carefully avoided the debate on cost and postcode prescribing. The Royal College of Physicians (London) almost simultaneously launched its new report (The Prescribing of Costly Medicines, April 2000) which suggests a framework for agreeing availability. It's good in parts. It says Once a new medicine has fulfilled all the criteria necessary to qualify for purchase by the NHS, it should become generally available. Costly new medicines whose use will not produce a net saving should be funded centrally via a separate guaranteed funding stream. However it also says The NHS should not agree to purchase costly medicines of unproven clinical effectiveness or cost-effectiveness, pending evaluation by NICE.... As NICE labours under a huge workload, TNF-
is not even on its advance list and NICE assessments take a minimum of 11 months, Robin wonders whether the British Society for Rheumatology guidelines are a waste of time; unless, of course, NICE bases its decision on them.