Robin Goodfellow

No sooner have we rheumatologists dipped our toe in the waters of COX-2 antagonists when others come along to join the fun. Thus Steinbach and colleagues (and, like the sisters and cousins one can number them in dozens) suggest that celecoxib may stop you getting colon cancer. Their report (N Engl J Med 2000; 342:1946–52) [Abstract/Free Full Text] indicates that the number of polyps found in sufferers from familial adenomatous polyposis decreases significantly with 6 monthsapos treatment. Who will find what next? Perhaps Robin should run a book on this.


Feldman has written an excellent editorial on preventing joint damage from haemophilia (J Rheumatol 2000;27:1579–81).[ISI][Medline] Much of the morbidity from this condition results from intra-articular bleeds, which cause synovial hypertrophy and inflammation but it appears there is growing evidence for direct and immediate damage from blood in joints. Perhaps this could explain why athletes who develop traumatic haemarthrosis of the knee are so prone to later osteoarthritis (OA). Whether rapid aspiration reduces the risk of damage is not clear. However the cost of haemophilia, complications apart, can be horrific; Robin has heard that two patients requiring special Factor VIII, having developed antibodies, is costing their Health Authority £1.5m per year. In days of rationed resources that is an awful lot of hip replacements (or new consultant posts).

Now here is a piece of work that will not change Robin's practice. Iagnocco and Coari (Scand J Rheumatol 2000:>29:170–3) report that ultrasound may be useful in detecting effusion in OA of the carpo-metacarpal joint of the thumb. Robin will go on injecting patients, whether or not there is an effusion; but he does wonder whether the response to injection may differ between those joints with an effusion and those without. So more research, please.

On the other hand the aetiology of disease always excites Robin, so he was very interested to see a report (Wagner et al., Arthritis Rheum 2000;43:1543–51) [ISI][Medline] which suggests that Chlamydia pneumoniae appears in the majority of positive temporal artery biopsy specimens. More study of this is certainly warranted. Polymyalgia so often presents with a flu like onset; does C.pneumoniae produce such symptoms, and will both PMR and GCA turn out to be reactive phenomena?

On this topic Robin will do his internet plug. Having read the above abstract, he forgot to add the reference and so returned to the Net to check by entering the paper's title. It took twenty seconds. What should he also find but another reference (Ljungstrom et al., Scand J Infect Dis Suppl 1997;104:37–40) [Medline] which reported that reinfection with Chlamydia pneumoniae may induce isolated and systemic vasculitis in small and large vessels, so nothing is new. Oh the wonder of it. Mind you, Robin is lazy and does not always read the full article and is thus unaware of whether the second article references the first, but searching done this way is much more comprehensive that ever it was with volumes of Index Medicus. And it can be done at home.

Has anyone tested marijuana in arthritis? Yes they have, and in mice at least cannabidiol (which is not a dream weaver, being psychoinactive) may prevent both disease and joint damage in collagen-induced arthritis (Malfait et al., Proc Natl Acad Sci USA 2000; 97:9561–6).[Abstract/Free Full Text] Cheaper than TNF-{alpha}?

The mice are being tested hard this month. It appears that if you inoculate them with leucocyte migration genes you may produce immunity to autoimmune arthritis (Karin et al., J Clin Invest 2000;106:361–71).[Abstract/Free Full Text] Robin wonders whether there are side-effects; if not, perhaps the Holy Grail of rheumatology is within reach...

A new and interesting immunosuppressant is TRAM-34, which has similarities to scorpion venom and is derived from the antifungal drug clotrimazole. It appears to inhibit T cells by blocking a cell membrane channel (Wulff et al., Proc Natl Acad Sci USA 2000;97:8151–6).[Abstract/Free Full Text] The same group are also investigating sea-anemones that produce a substance which blocks a different channel. Robin could get quite interested in basic science if he wasn’t so busy...

But for all that is new there is something that is not. Perhaps the current fad for herbal medicines (and readers know of Robin's scepticism) is what has led one team to examine willow bark extract in low back pain (Chrubasik et al., Am J Med 2000;109:9–14).[ISI][Medline] It works. Is Robin missing a trick, or does he correctly recall that aspirin is helpful in low back pain? It is probably cheaper than the herbal preparation. But then there are doubtless those health nuts that would rather risk some herb than the pure chemical derived from it.

Lastly, some NHS politics. After an astonishingly thorough review, lasting about 6 days, the government has identified all that is wrong with the UK National Health Service as well as the necessary steps to put it all right. Hmm. We goblins have seen it all before. I suspect that most doctors will spend a lot of time trying to make it all work, and decide that more money is needed (like every other time). However as far as rheumatology is concerned there are steps to prise it out of acute hospital settings and either place it in primary care or somewhere in between. How logical this is, given the drift towards oncological style management of inflammatory joint disease, is questionable. Watch this space.





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