Robin Goodfellow (42-1)

Following a quick flit to Paris, Robin had to take a friend in for a check-up. We arrived at the appointed hour to discover that our appointment had been double-booked, so had to sit in the (very pleasant) waiting area — clean, carpeted, supplied with newspapers and with a free coffee machine. It is always a bit unnerving when you are watching a junior examining and can see the doubt on their face, especially when they call a more senior colleague in for a second opinion. But in the end, all was well and the car's MOT certificate was issued, although the rear tyres are only just legal. Robin seems to wear out car tyres very fast, and does not understand why, although Mrs Robin has her own theory, which is to do with driving very fast.

Mind you, most of Robin's clinics are overbooked these days and he seems to be seeing more and more of his follow-up patients for all of their urgent needs. Is it just him, he asks, or are other rheumatologists (whether in the UK or abroad) finding that their generalist and family practice colleagues are increasingly unable to deal with acute rheumatology problems? If so, at least we are becoming indispensable. Robin wonders whether the Editor should commission an editorial on this topic.

Back to business; does glucosamine work? Sometimes it's no, and sometimes it seems to be yes. Pavelká and collegues (Arch Intern Med 2002;162:2113–23)[Abstract/Free Full Text] report a 3 yr study, fully controlled and randomized, which suggests that joint space narrowing is reduced in the active group. Robin has got to the point of awaiting divine guidance on this, preferring, as he has already said, to recommend a decent claret as better value for money, but now he is not so sure. Typical; as they always say, in seven years half of what you believe has been disproved, but you don't know which half.

Harrison et al. (Ann Rheum Dis 2002;61:1007–11)[Abstract/Free Full Text] report a nice little study into the periarticular osteopenia seen in rheumatoid arthritis (RA) and psoriatic arthritis. In RA patients, the extent of bone loss was related to the degree of joint inflammation, while in psoriatic arthritis it was not. They suggest this is further evidence that the primary pathology of psoriatic arthritis is extra-synovial.

One often makes assumption about causality, and Robin is always interested to see research that questions those assumptions, thereby changing thinking, or that makes one question causality. One piece of work in the latter category is from Klaus and colleagues in Ulm (Gut 2002;51:654–8).[Abstract/Free Full Text] They have shown that the frequency of osteoporotic vertebral fractures in Crohn's disease is alarmingly high — 22% — even in patients under the age of 30. Is it steroid therapy that does this, or something else? Robin sees quite a few patients with Crohn's associated arthritis, and is going to start DEXA scanning the lot.

Patch treatment seems to be taking off. Ringe et al. (Rheumatol Int 2002;22:199–203)[CrossRef][ISI][Medline] report benefit from transdermal fentanyl in severe back pain due to osteoporosis. There was quite a high drop-out rate (almost 19%) due to side-effects but, given that many such patients would otherwise need oral opiates this treatment may have a very useful place.

Could alendronate cause the progression of coronary artery calcification? In theory, yes, by inhibiting calcium resorption from plaque. But a small study by Hill and colleagues (Acad Radiol 2002;9:1148–52)[ISI][Medline] suggests it doesn't. So that's all right, then, and it's also quite enough of osteoporosis for this column.

Robin prefers to quote ‘proper’ research but one of his news sites popped up with a piece of work that will be worth watching out for. At the 2002 meeting of the American Neurological Association, Pappagallo presented the results of a small trial of intravenous pamidronate in patients with chronic debilitating low back pain, using three infusions a month apart. However, while the EULAR and ACR congress abstracts and reports seem to go on line almost at once, the most recent ANA meeting for which details are available (at least to the public) is that of 2001, so a press release is all that there is. There appeared to be considerable benefit, with a reduction of pain by just over 40%. Robin awaits further confirmation, and some hypotheses on the mechanism of action.

Robin has previously asked ‘what is scleroderma?’ given the various hypotheses floating around about chimaerism and graft vs host phenomena — and indeed has had one patient with fairly nasty morphoea following a stem cell transplant for leukaemia. One or two case reports thus caught the eye. The first was of a patient who developed rheumatoid arthritis after an autologous stem cell transplant (he had HLA-DRB1 0405 and a positive rheumatoid factor — Imamura et al., Bone Marrow Transplant 2002;30:527-9).[CrossRef][ISI][Medline] The second, in the same journal (Couriel et al., pp. 543–6)[CrossRef][ISI][Medline] reports two patients who developed polymyositis, successfully treated with cyclosporin and tacrolimus. As our treatments for arthritis move ever nearer to the regimes used by haematologists for leukaemia (and Robin has enlisted the help of his oncology service for a few patients needing cyclophosphamide), perhaps we can, by dealing with this sort of thing, return the compliment. Or perhaps the haematologists can manage very well, thank you, on their own. Information please.

There seems to be an awful lot of ignorance about arthritis, still, if a recent telephone call to the charity Arthritis Care is anything to go by. Robina Lloyd, the Press Officer, was asked ‘How do arthritics eat?’. She has, to my mind, responded admirably by informing the enquirer that their handlers take them out on leashes to graze (assuming they can get down on their hands and knees) but that they have to be back before sunset. Robin eagerly awaits the appearance of this gem in some tabloid or other, contrasting the light sensitivity of arthritics with porphyria sufferers (or vampires, for that matter). Byee!





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