Robin Goodfellow (44-1)

Well, here is the New Year and the snow is not exactly deep and crisp and even round Robin's air-raid shelter on the hill; perhaps it should be abolished from Christmas cards now that global warming has made it so scarce. Robin is beginning to wonder how many of the Great Wen's teaching hospitals are going to be inundated by the imminent rise of the Thames, and whether perhaps they might like to relocate to the higher ground round and about. Galveston, of course, will disappear completely. Sorry, guys.

Robin has made a New Year's resolution not to rock too many boats (he made rather a habit of it last year, but did end up getting a specialist nurse for his department after three years of argument). Then along comes a series of new outpatient diktats. The first insisted that his local general practitioner with a special interest (or GPSI, pronounced gypsy) had to have their own separate booking system to encourage local ‘choice’. This sits uneasily with the previous order that consultant referrals should henceforth be addressed to ‘The consultant rheumatologist’ rather than to the individual, but hey. After a row, we agreed to the proposal and to pool all referrals, just as we do now. However, a new arrangement called ‘Book and Choose’ is suddenly being piloted, whereby patients are given their referral letter (written on the spot by their GP, which will be a miracle anyway if the consultation averages 7 minutes including examination) and instructed to ring around and get their appointment date automatically. Robin threw his toys out of the pram. He prefers to prioritize his clinics on the basis of clinical need and not have some clerk do it for him so that he becomes a jobbing plumber getting his call list on a mobile phone. After all, how can 200 GPs know which of all of their referrals are the neediest without Robin telling them? No doubt accusations of arrogance will now fly, but it was unfortunate that the local pilot for gynaecology had the paperwork headed ‘Refferal Form’. And it appears that the GPs don't want to play either.

And then there was MRSA, which caused a little local difficulty. But that is now sub judice. Bang goes another resolution. Suggestions are welcomed for a replacement.

The world has been waiting for TNF-{alpha} blockade to induce (rather than hasten along existing) malignancy. Two cases of aggressive cutaneous T-cell lymphoma are reported by Adams et al. (J Am Acad Dermatol 2004;51:660–2)[CrossRef][ISI][Medline]. However, the authors suspect that both patients had pre-existing disease that might have been held in check by cellular immunity, and that any patient with fever of unknown origin or uncertain immune status should not be started on biologics. Robin has himself seen an unsuspected malignancy go berserk. Care is the watchword.

Robin has commented on several papers about knee osteoarthritis, so he was pleased to see an article that predigested current thinking ( Gidwani and Fairbank, Br Med J 2004;329:1220–4[Free Full Text]). One has to ask whether the varying results of trials of viscosupplementation are due to Robin's big bugbear—poor selection of patients so that like are not compared with like (in this case, for example, control for lateral instability and effusion). Time will perhaps tell.

The clinical impression that renal amyloidosis responds to TNF-{alpha} blockade is given substance by the report from Australia of Smith, Tymms and Falk (Intern Med J 2004;34:570–2)[CrossRef][ISI][Medline]. Robin's experience of the incidence (they report a level of up to 5%) is, however, somewhat different. He hasn't seen a case for many years, and would expect on this statistic to have somewhere around 20–30 patients with it. Could that be because earlier aggressive treatment prevents development? Conversely, Doulton and colleagues report a case of necrotizing crescentic glomerulonephritis, associated with a positive antineutrophil cytoplasmic antibody, in a patient on etanercept ( Clin Nephrol 2004;62:234–8[ISI][Medline]). You win some, you lose some.

What do you make of the study by Vitton et al. (Hum Psychopharmacol 2004;19 Suppl 1:S27–35)[Medline]? Milnacipram, a dual-action noradrenaline and serotonin reuptake inhibitor antidepressant, seems to be effective in fibromyalgia syndrome. I suppose the troops will divide into those who say that psychotropic drugs work in organic diseases and those who reckon that a response to a psychotropic drug makes it a psychological condition. But whichever side you are on, you would say that, wouldn't you?

Robin has previously mentioned studies on knee osteoarthritis that suggest there is benefit from repeated steroid injections, but is interested to see that steroids into osteoarthritic hips may also be good ( Kullenberg and colleagues, J Rheumatol 2004;31:2265–8[ISI][Medline]). The question is, not least because it appears that fluoroscopy is necessary, whether this is something Robin at his advanced age should start doing, or whether he should persuade his orthopaedic colleagues to restart, as they have given it up in favour of obturator nerve blocks (which, of course, they get the pain clinic consultants to do). What do others do? Answers by e-mail, please.

And just as Robin is on the point of rewriting his business case for anti-CCP antibodies (which his NHS lab can't do for want of technicians), along comes another test with which to torment his biochemist—looking for type I collagen N-terminal telopeptides in urine and C-terminal ones in the serum ( Wong et al., Intern Med J 2004;34:539–44[CrossRef][ISI][Medline]); they think they may be useful in longitudinal studies of disease modification. Hmmm. The New Year is yet young, and Robin will be kind, consigning this one to the back burner pending further research.

Now, back to statins. Robin's anecdotal collection of statinomyalgia cases grows, so he is intrigued to read the letter by McInnes and colleagues (Ann Rheum Dis 2004;63:1535–7)[Free Full Text] that they may reduce inflammation and modify vascular risk in inflammatory arthritis. It sounds rather the reverse of rofecoxib, which actually relieved symptoms rather than causing them (while increasing the vascular risks). Much as he would like to put these together to make a nice theory, there seems to be some block in Robin's brain preventing this, like it seems odd to suppose that drugs that work increase peripheral complications while those that are positively horrid do the reverse. And then there are the HRT patients who, when withdrawn, feel awful and beg to go back on, never mind the cancers. What is right? Well, when Robin worked in an ice-cream factory with shop, the door from the one to the other bore a big notice which said ‘The customer is always right’. But then, when you give the customer the customary leaflet with all the side-effects, they freak (even when you try and explain that half the list were reported once and never again). Robin tries to be objective. He suggests that if he were to write an information leaflet in similar style on crossing the road, half his patients would never dare do it again. And adds that we can but suck it and see. Now that's language they understand!





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