Robin Goodfellow (43-4)

The snow has gone, and Robin has taken delivery of a new flash car of unnecessary size and elegance; is this a mid-life crisis or hedonism? He is rather hoping that the infinitely adjustable seat, which remembers its position even after garage types have fiddled with the settings, will help his back, and that the automatic gearbox will stop the left foot tarsal tunnel syndrome which has plagued him for years in traffic jams. But some things never change. Robin prides himself on his holistic approach to medicine, and will thus talk to patients frankly and with authority about sex (he has done a bit of reading, you understand). Thus, when a recent patient admitted that his neck pain and stiffness had seriously compromised his love life, Robin suggested all manner of things (take away pillows, other way up, over edge of bed, soixante-neuf etc.—why should I be less frank with you professionals?). Patient expressed much gratitude for all this help and then said ‘I don’t suppose you can help with my golf swing...?’. Sadly I could not, being a gardening rather than a golfing goblin, although I have previously given advice on putting and tennis (backhand only). Oh, and car seats. The Governor of the Bank of England was driven more smoothly after Robin had fiddled with the chauffeur's seat (and the car, being the same marque as Robin's, remembered where the seat should be).

Wearing his rehabilitation hat, Robin sees a number of patients with multiple sclerosis and recently received a letter from a urologist indicating that the patient had been taught the technique of self-cauterisation. Ouch. Talk about being in the hot seat.

Pensec and many colleagues report that erosions in the feet were the best predictor of early RA (how the diagnostic performance can be improved by adding hand radiographs, when the feet already give a ‘best’, is however a solecism beyond this goblin's tiny brain). This appeared in J Rheumatol 2004;31:66–70[Medline] – so this year. But Robin remembers being taught this as a registrar, which is a long time ago (in the 1970s, to be precise) and recommends that this paper be reprinted in the Annals of Already Agreed Assessments. While on the subject of erosions, Goronzy et al. ( Arthritis Rheum 2004;50:43–54[CrossRef][ISI][Medline]) have tried to identify markers of progressive erosive disease and suggest that Rheumatoid factor titre, HLA-DRB1 polymorphisms, age and immunosenescence markers are predictors of poor radiographic outcome. The first of these was also known to Robin a quarter of a century ago, but he will be more interested in tissue typing and, noting that a polymorphism in the uteroglobin gene may identify patients who have a low risk of erosive disease, thinks this another great test to try on his long-suffering, cost-cutting chemical pathologist. The paper also reports that clinical disease activity in patients with early RA can frequently be controlled with non-aggressive treatment, but this is not always sufficient to prevent new erosions. So why not be aggressive? After all, the very next paper ( Puolakka et al., Arthritis Rheum 2004;50:55–62[CrossRef][ISI][Medline]) confirms that the use of drug combinations is superior to individual disease-modifying drugs.

Breed a mouse without TNF, and the incidence of B-cell lymphoma goes up ( Batten et al., J Immunol 2004;172:812–22[Abstract/Free Full Text]). Let us hope that the BSR Register does not come up with a similar finding in humans—although the theoretical possibility of oncogenesis is, of course, well recognized.

There is a continuing debate on the whys and wherefores of prescribing COX-2 selective drugs or ‘ordinary’ NSAIDs, which is interestingly informed by a piece from Soloman et al. ( Am J Med 2003;115:715–20[CrossRef][ISI][Medline]). They conclude that physician preference was more important than identified patient risk factors—a conclusion that fits nicely with Robin's belief in the ‘patient cube’. The first face of this is the patient, and there are four quarters—response without side-effects (perfect), response with side-effects, no response but at least no side-effects, and no response with side-effects. The second face is the drug face—with huge numbers of awfully similar compounds. The response of a patient to any of these is so unpredictable that one could stick a pin in—so the third, physician face contains the only variables, such as what mood one is in, which visual clues (such as notepads and pens) trigger some subliminal response, or whether the drug rep is sensible and charming or flip-chart mad and pushy. Copies of the cube in 3-D from the usual email address, which by now you will all possess in your contacts book.

Robin's comments last month about baseline checking of anti-phospholipid antibodies are yet again prophetic; Ruiz-Irastorza and colleagues ( Arch Intern Med 2004;164:77–82[Abstract/Free Full Text]) report that antiphospholipid syndrome with thrombotic complications is a major predictor of severe complications in SLE patients. So we need to know, and know early. But he has met a little resistance to starting a 14-year-old with SLE and a high titre of APL antibodies on low dose aspirin; mum has read about Reye's syndrome. What would you do?

Robin approves of reviews, and found that of Schmitt and van der Woude ( Curr Opin Rheumatol 2004;16:9–17[CrossRef][Medline]) on antineutrophil cytoplasmic antibodies quite useful. They make the point that while sudden increases in ANCA titres may reflect disease activity one should not use changes to direct therapy.

Robin has woken up to a new citation system called DOI (for Digital Object Identifier). It appears to be a sophisticated referencing system for electronic documents, particularly those that have appeared only in e-form. Of course, Rheumatology has been using this for yonks. So I bring you doi:10.1016/j.jbspin.2003.09.006, which takes you to an interesting case report by Michou and colleagues in Joint Bone Spine. It suggests that patients with an acute effusion after injection with Hylan GF-20 may have developed a granulomatous synovitis, and have biopsies to support this. One wonders whether this occurs with all the other viscosupplementation preparations; whatever the evidence, Robin will still use them in last ditch situations (for instance patients who cannot face, or are not fit for surgery), and has had some remarkable results in rheumatoid shoulders and elbows with secondary OA. In fact, in a couple of elbows it has been almost incredible. Try it, guys.

Sometimes it is helpful to re-order one's thinking on diseases, the most prominent in rheumatology circles probably being the classification of juvenile arthritis. Now the nephrologists have had a go at glomerulonephritis in association with SLE ( Weeming et al., J Am Soc Nephrol 2004;15:241–50[Abstract/Free Full Text]). Being amused by little things Robin identified that seven different types of asterisk were used—but then this is an international collaboration.

Rheumatoid arthritis and the ear? That was a new one to Robin, but Salvinelli and colleagues report that RA patients have significant hearing loss ( Clinical Otolaryngol 2004;29:75[CrossRef][ISI]). They are not sure why but suggest the problem may be significant enough to warrant regular audiometric evaluation. More work for the wicked!





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