Rheumatology 2003; 42: 1028
© 2003 British Society for Rheumatology
Robin Goodfellow |
Robin Goodfellow (42-8)
Summer is icumen in, and as Robin migrates from the air-raid shelter to the tree house, he is pleased, on behalf of one patient, that the spring-cleaning is over. She was having difficulty cleaning windows and hovering. It indicates the importance of using generic terms (here, vacuuming), but Robin has a pair of windows which would be accessible if he could hover. Another patient has pre-empted the development of foundation hospitals (for non-UK readers, a political move designed to mortgage our children to the health service for ever, allowing hospitals to raise money on the open market so we can spend an increasing sum paying back interest). She had her double-standard DNA binding tested. A recent MRI report sent to Robin indicated a slither of fluid in the hip. Now tell me whether a sliver can be anything but solid, or whether the radiologist was reporting some functional anomaly, or whether it was a slip of the pen.Robin recalls that more than one eminent rheumatologist has suffered from in-flight thrombosis, but has never before come across a patient with an airline fracture. One such wrote to Robin asking about the significance of hers. It was a pars fracture, and she, being an estuary girl, obviously required Henry Higgins to do for her writing what he did for Eliza Doolittle's speech (In 'ertford, 'ereford and 'ampshire 'urricanes 'ardly ever 'appen).
And finally in this section I am pleased to report contact from the other side, to go with the meridian nerve of a couple of months ago; a patient with pain in the medium nerve distribution...
We argue often about what pattern of symptoms is due to what part of the shoulder mechanism. Robin has a bit of a thing about this, not least because, in his view, many trials are bedevilled by mis-treatment. For example, how can you treat a frozen shoulder with an injection into the subacromial space? Doubters should consult an anatomy textbook now. However, that petulant outburst brings me to a paper by Beall et al.
(Am J Radiol 2003;180:633–9
Bring in a new test, and you will find things that were not there before. Izumiyama et al. report (Modern Rheumatology 2002;12:311–7) that 40 out of 54 patients demonstrated pathological changes in the lungs using high-resolution CT, when nothing was apparent on the X-rays.
There was a great outcry when the UK rheumatology community discovered that probenecid had been withdrawn without warning, limiting the options for gout patients who were unable to tolerate allopurinol. However it seems that some odd drugs can be uricosuric — fenofibrate and losartan are two
(Bardin, Ann Rheum Dis 2003;62:497–8).
Robin sees a sprinkling of adolescents with back pain — some of whom undoubtedly have spondarthritis, but several of whom appear to have no physical cause. Thus it is reassuring to find Watson et al. reporting
(Arch Dis Child 2003M;88:12–7)
Fentanyl patches seem to be catching on (if not always sticking on) and Robin is interested to learn that there is a new niche market for the product. Victoria Lynn reports that the use of patches may help combat drug abuse in prisons; opiates prescribed for pain get stolen, smuggled and traded, but the patches fail to deliver a ‘hit’ so are not popular currency. The recidivist population has also found that the patches cannot have the active ingredient scraped off or otherwise prepared for inhaling or shooting up. Robin is prepared to bet, as their use escalates, that the incidence of chronic pain in these institutions will diminish smartly.
In rheumatoid arthritis the oil industry proceeds apace. Adam and colleagues from Munich (Rheumatol Int 2003;23:27–36)[Web of Science][Medline] report that a diet low in arachidonic acid supplements the beneficial effect of fish oils. Robin only need to be reminded of what such a diet entails to start recommending it — although he expects it to be as unpalatable as other arthritis diets and would thus himself fail the do as you would be done by test.
Now I know that the UK theme park NHS world really has gone mad. I was pointed towards the website for UK Primary Care Trusts (PCTs for future reference) at http://www.natpact.nhs.uk/. What is the key illustration on the intro page? Face painting at the first annual public meeting of the Bebington and West Wirral PCT. Face painting? Someone please explain to me how this helps, in the words of the page's headlines, to reform emergency care events, or in stregthening [sic] accountability, or designing people-centred services. This last one anyway gets my goat, as I don't treat goats, or any other animals, come to that — only people. When the NHS is bust, is this the way it should be spending its money?
Never say finally, Robin reminds you, and himself. No sooner than he had run out of misprints when his secretary feed him a letter from an oncologist, who was worried to see, on the letter from a colleague, that an X-ray had shown a cannibal secondary in the right lung. He added that he clearly needed to do more peripheral clinics to see more of such interesting things. Maybe he would find that the natives are not entirely friendly, let alone the tumours. Bring me my spear, and the chariot of fire while you are about it.
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