Rheumatology 2002; 41: 358
© 2002 British Society for Rheumatology
Robin Goodfellow
NICE to see you. Devotees of Bruce Forsyth's ‘Generation Game’ (yes, Robin liked his light relief when he was a young man) may now find a different meaning in this catch-phrase, but is it nice to see NICE (National Institute for Clinical Excellence)? Robin wants to know what rheumatologists think of their injunction not to co-prescribe gastroprotective drugs with COX-2 selective agents. Latest advice is that guidelines will be obligatory, courtesy of a new Bill to pass before parliament. Suppose, he reasons, that you have a patient who has had side-effects on standard non-steroidal anti-inflammatory drugs (NSAIDs), an ulcer even, and gets indigestion on meloxicam, etodolac or a coxib. Stop the drug, or add a gastroprotector? Damned by NICE if you do, and sued if you don't? Suppose they change the guidelines? Answers to me by e-mail please at the Rheumatology office (if any, I will digest and regurgitate them, which is called feedback).
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A few weeks ago Robin saw a delightful and elderly Chinese lady whose problems were due to the curious and barbaric practice of foot-binding as a child. Mercifully her parents had migrated before the process was complete, but her feet were certainly small and high-arched. Robin rails repetitively against the shoemakers (cordwainers for the cognoscenti) who cram nice feet into narrow pointy shoes with ridiculous heels, so he is pleased to record for your benefit a useful patient-orientated site about how to look after your feet—to be found at http://www.footcaredirect.com/index.html#index.
Most of us appreciate that osteoporosis and vascular calcification appear to be related but a recent study in women with systemic lupus erythematosus suggests that the inflammatory mediators play a role in this and explain premature porosis and vascular events in this group
(
Ramsey-Goldman and Manzi, Arthritis Rheum 2001;44:2338–41).[Medline]
No mention, though, of antiphospholipid antibody status; and Robin is also wondering what his new fad, oxypentifylline (that well-known, long-running and cheap TNF-
blocker), might have in lupus.
At the risk of offending readers who have actually read all of Rheumatology and not just the last page Robin wishes to point-out, in response to the Editorial by Chamberlain and Frank (Rheumatology 2001;40:1201–5) that he is very diligent in assessing work-related problems. Many is the keyboard operator that he has fixed—but do not forget, dear readers, that many people drive to work, or drive for a living. I have cured several neck- and shoulder-pain sufferers by sitting with them in their cars; the Governor of the Bank of England is only mobile because I sorted out his driver by sitting in his Jaguar (rather nice actually, but not as comfy as the Aston Martin DB7 Robin got a test drive in the other day; only problem they were rather keen to discuss how I would pay for my undoubted purchase). Car seat checking is a highly effective form of ergonomic assessment, although in the National Health Service the patients have had to park so far away that it is also good exercise for a sedentary consultant rheumatologist.
How nice it is to find that new technology is not as helpful as old. Computed tomography, it appears, is better for determining whether joint deposits are uric acid tophi than magnetic resonance imaging (MRI)
(
Gerster et al., Ann Rheum Dis 2002;61:52–4)
Robin has wittered on about the benefits of exercise in osteoarthritis (OA), but of course the assessment of interventions in any disease is bedevilled by a lack of knowledge of whether the intervention actually happened. This is elegantly explored (for OA) by Alison Carr (Clin Rheumatol 2001;15:645–56). Robin supposes that a ‘well actually, Doctor’ confession is rather better than the aggressive ‘I know them last tablets was different ‘cos when I put them down the loo they floated’. Sad though it is, patients do not always tell their doctors the truth, for whatever reason. It serves to be reminded of this now and again, not least when dealing with absence from work or medico-legal claims. Robin's faith in the common man was severely shaken when a policeman patient, slowly recovering from back pain, was reported to him as having been climbing a ladder with a roll of roofing felt on one shoulder. Likewise he has seen a couple of videotapes that somewhat belied the severe disability apparent in clinic.
More on repetitive strain injury—or not, as the case may be. Non-specific forearm pain is a funny thing, and may be due to retrograde transmission in the median nerve. Greening and colleagues report reduced movement of the median nerve during wrist flexion, which can be demonstrated using ultrasound (J Hand Surg 2001; 26B: 401–406) confirming previous MRI studies. They hypothesize that muscle imbalance may cause multi-level compression, or that endoneurial blood flow is disturbed, or that there is a pathological increase in stretch tension but, whatever the mechanism, all are good explanations. Robin wonders which it will turn out to be. The test may be a useful examination in the medico-legal world ...
... for in the same issue we find an interesting editorial on Miner's nystagmus, a non-disease (industrial) of the 1890s, which serves as a paradigm for work injuries and whether they really exist ( Davis, J Hand Surg 2001;26B:399 ). Miner's nystagmus could, in the end, be diagnosed without the presence of nystagmus if enough of the ancillary features (giddiness, depression, eyelid spasm, etc.) were present. Davis's opinion is worth quoting in full: ‘Firstly the suggestion that symptoms in workers are due to a disease which is caused by their work practices can distort the careful scientific investigation of the proposed new disease, not only because of the interests of parties such as trade unions, company management, the legal profession and the press, but also because of the vested interests of the medical practitioners who wish to support their chosen theory of causation. Secondly, the creation of a set of diagnostic criteria for such a disease which is based exclusively on the presence of symptoms and soft, subjective signs ... should be viewed with caution.’ Whoof! Myalgic encephalomyelitis and fibromyalgia, more over! Robin will now descend from his hobby horse and fork more manure into the compost heap.
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Related articles in Rheumatology:
- Keeping our patients at work: implications for the management of those with rheumatoid arthritis and musculoskeletal conditions
- A. O. Frank and M. A. Chamberlain
Rheumatology 2001 40: 1201-1205.[Extract] [FREE Full Text]
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