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Could post-traumatic stress disorder be a part of the psychological upset of rheumatoid arthritis? A small study by Smyth et al.
(J Am Med Assoc 1999; 281:13049)
Robin has observed the political scene for some years and suggests that any article about medicine applies equally to education or the law; just change a few words (like teacher to doctor, barrister to consultant, or school to hospital) and the sense is the same. In this vein a dermatological piece by Martin Black (J R Coll Physicians Lond 1999;33:20811) [ISI][Medline] caught my eye. He reviews the experience of UK dermatology and comments on the iceberg of unmet need and the fiasco of outreach clinics. Safeguards over procedures done in primary care appear to have failed. With pressure from the new Primary Care Trusts to develop quasi-secondary services run, unmonitored and without proper training, by primary care physicians, this piece is essential reading; just substitute rheumatology for dermatology and nothing else need change. There is a lot to lose and patients should know it.
Who is not proud that they are at the cutting edge of technology? Certainly the Health and Safety Executive are very proud of their new CD-ROM on vibration white finger: Tomorrow, electronic communication will be the norm. This presents excellent opportunities to HSE... An excellent new tool... ambitious and well-designed. Robin came over all excited until he turned the page and discovered that it cost £95. Perhaps they will read this and send him a review copy. Or put it on the Net, like everyone else does.
Speaking of Nets, have you visited the Johns Hopkins Arthritis Center at http://www.hopkins-arthritis.som. jhmi.edu/index.html? If not, then you should. It's a well constructed and interesting place with some good pictures.
Back pain is increasing, according to Peter Croft
(Br Med J 2000;320:15523).
There can be few rheumatologists who have not encountered patients who are drug-resistantthat is, they won't take them because they are not natural. Such patients are often only too keen to try diets or, most recently in Robin's experience, Chinese herbs. Robin's mantra, when asked an opinion, has been simply we don't know what's in there (although the revolting smell of some concoctions has made him quite ill on occasion). So it's nice to find a handout, in the form of a very well-balanced editorial by Kessler (New Engl J Med 2000:242;17423) commenting on a paper by Nortier et al. in the same issue, reporting on an epidemic of urothelial cancer in Belgium attributed to Aristolochia fangchi. It appears that this herb may be substituted for Stephania tetrandra partly perhaps because the Chinese names are similar. Nortier's series of 105 patients with nephrotoxicity (a well-known side-effect of aristolochic acid) contained 43 who developed end-stage renal failure; prophylactic nephrectomy in 39 revealed evidence of cancer in 46%. Even worse than finding steroids in the mix.
Much debate continues on why women have a post-partum flare of their RA. Barrett and colleagues present evidence that it is related to breast feeding (Arthritis Rheum 2000;43;10105),[ISI][Medline] tying in with Brennan's hypothesis (Lancet 1996:348;1069) [ISI][Medline] regarding prolactin. Robin admits that he thought it all happened because that great immune suppressor, the placenta, was arbitrarily disconnected as part of the process of childbirth, but things are rarely that simple.
The costbenefit analysis of treatment has hit rheumatology in particular in relation to TNF- blockers. While they may be the best thing since sliced bread some doubts are emerging as to whether they have been trialled against appropriate doses of other drugs and, therefore, whether they are really that superior. In scleroderma it would be fair to say that none of the conventional second-line drugs appear to work, so perhaps the use of recombinant human hormones is justified at huge expense, if they work. Seibold et al. report
(Ann Int Med 2000:132;8719)