Rheumatology 2001; 40: 479
© 2001 British Society for Rheumatology
Robin Goodfellow
Ho hum, friends. We all get pretty annoyed when patients suddenly descend with newspaper cuttings extolling the latest arthritis cure, wonder why we haven't heard about it first and then spend ages, letting folks down gently. It happened again recently with the B-cell antagonist Rituximab; the BMJ's column ‘The Press’ asks how we can deal with early and silly hype, commenting ‘The facts are always a good place to start ...’ (MacDonald, Br Med J 2000;321:1232).
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The debate continues on whether poor-prognosis rheumatoid arthritis (RA) should be treated aggressively with combination therapy at the outset with a contribution from Proudman et al. (Arthritis Rheum 2000; 43:1809–19).[Web of Science][Medline] It concludes that although disease suppression is more rapid, remission rates did not change. They suggest that ‘step-up’ therapy is more appropriate.
Of course the debate has been moved on in a major way by the full publication of the latest TNF-
data
(Bathon et al., N Engl J Med 2000;343:1586–1602)
Ever heard of autopathography? The entertaining Jeff Aronson, a word-loving pharmacologist, has been collecting examples of authors' illness experiences, and his bibliography can be found on the Web at http://www.clinpharm.ox.ac.uk/JKA/.tales.shtml. There are several examples of connective tissue disease. Robin was moved many years ago by the newsreader Corbet Woodall's account of his own rheumatoid arthritis, entitled ‘A disjointed life’. Perhaps Aronson's examples should be compulsory reading for all trainees.
Robin recently visited a large shopping complex with an amazing restaurant corner; tempted by the on-line sushi, he was dragged by the younger Goodfellows to a pizza establishment. And how glad he was! The eating area curved in a vast semicircle, within which was a curved counter where you could watch your pizza from start to finish. Fascinating. The vegetable sous-chef was chopping so fast he was bound to develop de Quervain's tenosynovitis. The dough maker kneaded so hard his thumb CMC joints were going to become very painful. The base spinner spun his dough so fast he was bound to develop wrist strain. The topping-adder would clearly get tennis elbow from lifting all the ingredient bowls. And the cook, as he deftly twitched the finished pizzas into the oven (which was at head height) had no chance whatever of escaping the development of a rotator cuff injury. After fifteen minutes they all moved round one position. Magic! Rheumatologists with an interest in work-related upper limb disorders, eat your hearts out (but perhaps finish the pizza first).
Mind you, funny non-work related injuries can put paid to the work, as reported by ‘The Independent’ newspaper (Maume, Jan 23rd 2001). Various professional footballers have been stricken after watching television with their feet on a coffee table, kneeling to pick up the TV remote control, doing the ironing, shovelling snow and dropping jars on their foot. You would have thought, given the money they get, that someone would have been employed to do all these things for them.
Many of us check the lupus anticoagulant, but we should make sure our lab has calculated its own reference range (Gardiner et al., Br J Haematol 2001; 111:1230–5). Different laboratories using different kits came up with similar normal distributions but very different means and standard deviations. Like must be compared with like.
Robin has some favourite words and, like the columnist Giles Coren in ‘The Times’, wonders whether he could go a whole year and use one in every column. Schadenfreude is pick of the bunch. How nice, therefore, to see an article called ‘Using evidence to inform health policy: case study’
(Macintyre et al., Br Med J 2001; 322:222–5).
The UK government is trying to create a culture of ‘evidence based policy’ that will apply to public health and social policy as well as to health care. Submissions to a government inquiry about possible interventions to reduce health inequalities lacked evidence of effectiveness and information on costs and possible harms. There is a need to improve the evidence base for making public policy
. In other words while we struggle to conform to the new evidence based culture, the government does not (conform, that is; it does seem to be struggling, but that is another matter). The gospel of St Matthew (7: 1–5) comes to mind.
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  Robin Goodfellow (44-4) Rheumatology, April 1, 2005; 44(4): 568 - 568. [Full Text] [PDF]
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