Robin Goodfellow (41-11)

Robin has for some time been concerned at the apparent lack of communication across what is known as the primary/secondary care interface but is pleased to find that the jargon is just as bad either side. Robin has for some time been entertaining himself in meetings by playing management bingo. You have a grid of 25 squares filled by management-speak (step change, synergy, joined-up thinking and re-engineering to name but a few) and you cross them off as they are uttered. If a line comes up you can shout a rude word. The latest one is a corker; flow charts of management structure must now be known as organograms, which perhaps is appropriate for X-ray departments. Transparent wall maintenance engineers have nothing on the NHS.

And another secretarial amusement for good measure. One of Robin's rheumatoid arthritis patients with shoulder pain due to severe secondary osteoarthritis (OA) recently had a suprascapular nerve block in the Pain Clinic. The letter says it had a good effect ‘after about five minuets’. As the patient is not up to a sarabande, being largely wheelchair-dependent, Robin thought even one minuet was over-optimistic.

Should we use paracetamol (acetaminophen, for those across the pond) or non-steroidal anti-inflammatory (NSAIDs) agents in osteoarthritis? Courtney and Doherty argue (Ann Rheum Dis 2002; 61:767–73) [Free Full Text] that paracetamol should be the first drug treatment of choice and have surveyed the evidence base in detail. Robin still wonders about whether the effect of NSAIDs on osteoblasts is relevant, given that one might reduce osteophytosis by using them, but the review does not address pathophysiology. Anyway, one could argue that to block osteophyte formation is to interfere with the body's natural attempts to even up the stresses on damaged joints, and so may be a ‘Bad Thing’. Does Indocid Hip exist? Perhaps we need to know.

Robin is often asked (by patients who seem these days to have nothing better to do than trawl the Net before their visit so that they can completely fox their doctor) what the basic pathology of rheumatoid arthritis and lupus are. Sometimes he can get away with a patronizing ‘If you have an hour I'll explain it, but I haven't an hour’. Often though he gets bogged down in a discussion of T- and B-cells, self-associating antibodies and cytokines, hoping that they will get out of their depth first. So is it the B cells or the T cells that matter? In mice, it would appear, the susceptibility gene Sle1 causes abnormal function in both (Sobel et al., J Immunol 2002;169:2694–700).[Abstract/Free Full Text] So that's clear, then.

For a while Robin has been toying with the idea of a journal which reports prophecies that come true. A suitable acronym would be helpful; JOITYSA (Journal of I Told You So Announcements is a bit unwieldy). But after all the fuss in the UK over whether the exhibition of TNF-{alpha} blockade in rheumatoid arthritis may reduce the on-costs of the disease by reducing the need for surgery there is at last evidence that it may indeed be so. Spencer and Bernstein (Curr Opin Rheumatol 2002;14:536–41) [ISI][Medline] write that more aggressive treatment with better drugs in juvenile arthritis may at last mean that fewer children need hip surgery.

Robin is all for good practice, guidelines and so forth so when he was surfing one evening he was interested to find that there was a new code for the administration of hyaluronate injections for OA (ACR News vol. 21, no. 8). Sadly he was disappointed. The code was no practice guideline but a (US) financial one: ‘After a standard 90-day grace period beginning July 1, the old J7316 code will be replaced with Q3030. The memo recommends that during the grace period, providers should choose one code to use rather than using both, with the understanding that the new code will be denied until Oct. 1 due to the system's incapacity to process the new code until that time.’ And who said the NHS was bureaucratic?

After Robin's illustration of a needle, bent by a twitch of the thigh muscles, he was expecting an avalanche of illustrations of the interesting and bizarre. But none has materialized. So he is reduced to another of his own, courtesy of a new digital camera which is revolutionizing his image library. It is an excellent teaching slide. One inevitably focuses on the bullet (fired at close range from a Kalashnikov in Angola — the recipient got in the way of a ‘domestic’) — and fails to notice the fused sacroiliac joints...


FIG. 1.





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