Robin Goodfellow (43-8)

No sooner has Robin decided that he has quoted enough of George Ehrlich than he receives his copy of the June edition of Ann Rheum Dis with a picture of Nobel Prize-winning Paul on the cover. I wonder if they are related ... Robin was particularly struck by the leader from Ferracioli and Gremese ( Ann Rheum Dis 2004;63:613–5[Free Full Text]) pointing out that the increased risk of cardiovascular disease in RA approaches that from non-insulin dependent diabetes. Ammunition to get funds, that. Breedfeld and Kalden underline Robin's long-held view that early aggressive treatment pays dividends ( Ann Rheum Dis 2004;63:627–33[Abstract/Free Full Text]) but caused this simple goblin a little distress by saying ‘The economic burden of RA can be dichotomised into direct healthcare costs and indirect costs...’. Dichotomised? What's wrong with split? United we stand, dichotomised we fall?

And then, to cap it all, up turns an old patient with a glutinous medius enthesopathy. This soft tissue stuff can get very sticky.

Robin always had the idea (perhaps wishful) that he was a bit of an anorak, but the super-anorak has to be Horst Ibelgauft, who has compiled a Complete and Utter History of cytokines (COPE, it is called, and can be found at http://www.copewithcytokines.de/cope.cgi). There are literally tens of thousands of pages, and Robin got quite dizzy. Prof. Ibelgauft has written an introduction, which is worth looking at first, and is not averse to the odd bit of fun-poking (hence TGIF factor). Thanks to Matthew Grove who pointed me at this one. However, there may be a case for a shell suit rather than an anorak. Running as he does an historical archive on the side, which got itself into the ‘Yellow Pages’ somehow as a storage facility (hence, it appears, previous phone calls from said directory as reported to you), he was intrigued to receive a mailshot asking if he used fork lift trucks. Now some of the patients are, one might say, on the larger side of average but such an item has never proved necessary. Does anyone else get mail like this?

A meta-analysis has at last shown that steroid injections in OA of the knee may be beneficial long-term ( Arroll and Goodyear-Smith, BMJ 2004;328:869[Abstract/Free Full Text]). It appears that there is both short and longer-term benefit, though the latter may require fairly large steroid doses. Robin cannot, however, see any justification in repeating injections every few weeks, and has a low giving-up threshold, sending many on for replacement surgery as he has (as previously stated) an even lower threshold for arthroscopic washouts.

It was only a matter of time, Robin pontificates with the benefit of hindsight, before someone determined that response to TNF-{alpha} blockade might be influenced by genetic factors. So the report of Martinez et al. ( Arthritis Rheum 2004;50:1077–82[CrossRef][ISI][Medline]), demonstrating an HLA association (a bit complex for a gardening goblin, so go and look for yourselves), is perhaps unsurprising. No doubt more such work will follow, whereupon we will be obliged under clinical governance arrangements to run a full gene sequence on every patient to make sure they are in the responding group. Robin might have retired by then!

A thoughtful leader by Peterfy ( Ann Rheum Dis 2004;63:473–7[Free Full Text]) discusses the predictive value of wrist MRI in rheumatoid arthritis. In the same issue ( Ann Rheum Dis 2004;63:555–61[Abstract/Free Full Text]) is an Extended report from Stewart et al., showing that early MRI features can predict outcome at six years. Never being one to shirk expensive tests if they benefit our patients, Robin is instituting the recommendations at once in his early patients where diagnosis is not clear cut—waiting for the flak to fly, and ready to point out that if we base ongoing treatment on the presence of abnormalities, we might reduce the overall numbers of patients being given DMARDs on a wing and a prayer. How long before X-rays are redundant?

Sigmoid diverticular abscess perforation may be provoked by steroids, and to a lesser extent NSAIDs, in rheumatic conditions ( Mpofu et al., Ann Rheum Dis 2004;63:558–90). Indeed, Robin has seen such a case, although the problem was not making the diagnosis but deciding what to do, as the patient had turned their face to the wall. But undoubtedly there are robust patients who would want to be resuscitated, and being aware of the risk might just make it less of a risk (though where Robin works there seems to be a very poor institutional memory for the ‘flesh eating virus’ that provokes necrotising fasciitis, suggesting that experience is important).

And lest you think that Robin is overdoing the Annals, readers should know that an oversight led to his subscription lapsing, and he is catching up. Funny, then, that it took him four months to notice.

Money, of course, is a funny thing, and Robin's work in a relatively underprivileged area does not bring much sight of it (having said which, he is always amazed by how often the most unlikely present-bearers arrive). So it was with interest that he heard how one of his RA patients had decided to find out more about a shabby African woodcarving he had inherited, and taken it to Sotheby's. One thing led to another, and it went for sale in New York—see http://search.sothebys.com/jsps/live/lot/LotDetail.jsp?sale_number=N07996&live_lot_id=60. Strange how something so important (it was the most expensive item in the sale) could have languished so long in a suburban back street. Sadly he had decided that going to New York to see the auction was less important than coming to see Robin—though I doubt my consultation was worth the hammer price of $450,000.

Robin now is not averse to writing sometimes bits of verse (clever that). But he has been upstaged by a patient, Chris Dyos, in an exchange of rhyme—who has written an ode to his rheumatologist thus:

My arm aches and a lousy numbness pains

My joints as if of hooch or plonk I’d drunk;

Which ought to have been emptied down the drains

Along with Jacob's Creek and other junk ...

This is submitted as an incomplete fragment, and Robin will be pleased to share the rest, if it emerges through the haze—not of red wine though (and Robin certainly has no objection to a nice bottle of Shiraz on a cold evening) because the methotrexate precludes such indulgence.





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