As winter turns to spring and Robin can examine his garden once more, he turns his attention to examination in general. Michael Docherty in Nottingham has made a special issue out of the paucity of examination of the musculoskeletal system in inpatients; White and two Alcolados in Wales (
Postgrad Med J 2003;79:5889
Robin awaits comment on his previous remarks on the role of arthoscopymuch overdone, in his opinionbut meanwhile notes Oakley and Lassere's article ( Semin Arthritis Rheum 2003;33:83105[CrossRef][ISI][Medline]) which looks at quantitative arthroscopy as an outcome measure. Oh dear. There are 52 distinct systems of measurement and very little data to support any of them except the most simple. They propose a development program to develop valid and responsive assessments; while we wait we should be aware that there's not much science in poking telescopes into knees.
Robin's firm (no pun intended) belief that the only good bed is an expensive one (preferably with a pocket sprung mattress) is given some support from research in the Balearic Isles ( Kovacs et al., Lancet 2003;362:1599604[CrossRef][ISI][Medline]). A multicentre trial concludes that a firm mattress, traditionally recommended by alternative practitioners and others, is less beneficial than a medium one. Robin does wonder whether the trial was randomised for site, as he suspects he might sleep better in Mallorca than in Manchester, especially if the wine flowed and the swimming pool was inviting. But fashionable though it may be to knock everything alternative, we must keep open minds; Wigler and colleagues ( Osteoarthritis Cartilage 2003;11:7839[CrossRef][ISI][Medline]) report the benefit of a ginger extract in symptomatic knee arthritis, though it was a pretty small trial. Robin is still working through his Christmas bottles (all declared and photographed for his revalidation and annual appraisal) but is quite partial to a bit of crystallised ginger, wondering if it might work as a prophylactic.
How does one know whether a patient with inflammatory joint disease who does not have clear cut test results (or clinical signs) has RA or lupus? Robin has been in the habit, somewhat lazily, of dropping them in a bin labelled overlap but may have found an expensive way of making it all clear; treat with a TNF- blocker, and if they have lupus it might become apparent. Swale et al. (
Clin Exp Dermatol 2003;28:604[CrossRef][ISI][Medline]) report a case of etanercept-induced SLE and Robin has just had a patient he thought had RA who has developed a typical lupus rash on infliximab. Apropos lupus and the meaning of antibodies without disease, an interesting survey is reported by Murashima et al. (
Ann Rheum Dis 2004;63:503
Nowadays Robin always checks anti-phospholipid antibodies in his new lupus patients. But should they perhaps be checked routinely, if not in the general population, then as a pregnancy screen? As so many antibodies may appear before their disease does, Robin feels a prospective survey is indicated. He is considering delegating the task to the patient who suggested it. Unless it's already being done... Tell me.
Of course there's no end to the uses for TNF- blockade, and the report by Ulbricht and colleagues of its successful use in sarcoidosis (
Arthritis Rheum 2003;48:35423[CrossRef][ISI][Medline]) raises all sorts of questions about the nature of that disease, its similarities to chronic RA and the meaning of life. Apropos that, it should perhaps be more commonly known that the pass mark for the new MRCP(UK) clinical exam, known as PACES, is set as the magic Hitch-Hiker's Guide number 42. This seems a little creepy, so perhaps it's just as well that it has been dropped to 41 for the last few runs.
Lee and colleagues have examined the association between subclinical neck pain and range of movement, commenting in their background summary Despite the high prevalence of neck problems, few studies are available indicating any physical associations with the development of neck pain, or information regarding early signs of pathology from neck pain for subjects not in treatment. ( Spine 2004;29:3340[CrossRef][ISI][Medline]). They find that loss of range is an early sign, as is a reduction in muscle endurance. Clearly a candidate for the Journal of Obvious Results (or indeed the Archives of Chicken or Egg First Studies). In the same issue ( Kopec et al., Spine 2004;29:707[CrossRef][ISI][Medline]) is an article looking at predictors of back pain. Significant predictors included (and I quote) age (peak effect in 4564 years), height, self-rated health, usual pattern of activity (especially heavy work), yard work or gardening (negative association), and general chronic stress. In women, significant factors were self-reported restrictions in activity, being diagnosed with arthritis, personal stress, and history of psychological trauma in childhood or adolescence. Do those without such factors have pain but not bother us with it, or do they not have pain? I feel a follow-up study coming on.
In the UK a new contract has been agreed both for consultants and general practitioners. There is much speculation about how this will be fully funded. In rheumatology circles there should be concern about what will happen if it isnt (likely, in my view); GPs are already indicating that joint injections and second-line drug monitoring are no-go areas without dosh. But, he wonders, if the Care Trusts cannot pay them to do these things then they wont be able to pay us. Who suffers? The patient, of course. While on the funny money track, Robin was flattered to be asked to join a National Back Pain Collaborative. Having just successfully introduced a back pain triage system with his physiotherapy team he thought he might have some very useful contributions, until he read the small print and discovered that his hospital would have to pay £5000 for the privilege of joining. This appears to be a form of study leave levy, so that all participants can be trained in how Collaboratives work. As the sum is slightly less than the salary shortfall of his secretary, who works full time but is paid part-time, and his hospital cannot afford that, he considered that he did not need to pay to be taught how to suck eggs. No doubt, then, that the others who do have more money than sense, and will probably reinvent the wheel. No wonder the NHS is struggling!