Robin Goodfellow (43-12)

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Oh dear, oh dear, the pressure! Robin unwound beautifully in Marrakech, but seems to have had some difficulty winding back up, and if this column seems hurried it is because of frantic emails from the editorial office that they are waiting to go to print, but are stuck because I am late. Hold the back page, I cry. Sorry, guys; I will try not to let it happen again.

A bit earlier in the year Robin was in his loft having a sort (not least because there was so much stuff that there was no room for anything else—old boxes for dead computers, spare vacuum cleaners, you know the sort of thing). Anyway he discovered a large pile of BSR conference bags, for which he could see no use, and junked the lot. DO NOT DO THIS! Robin took his EULAR 99 bag to Marrakech to hide his guidebook and camera in the souk, and had numerous offers to barter for it. The bags are, it appears, invaluable for kids, and brothers who are medical students. Take a few in a spare suitcase (which you will need for the carpets, lamps, boxes and tagines) and you can start trading. Even without barter items, Mr and Mrs Robin returned with some very nice things and if you have not been to Marrakech then you should do so at once. Robin cannot help doing spot diagnoses when sightseeing, but failed to spot a single case of gout or RA (presumably someone knows why—email me?) although there were some beggars with leprosy and a remarkable number of those old-fashioned bath chairs like an upside-down tricycle that preceded today's electric wheelchair.

Robin has previously passed comment on the unease about COX-2s and their research ( Rheumatology 2000;39:1440[Free Full Text]) and at much the same time there was an article by Mukherjee et al. (JAMA 2001;286:954–9[Abstract/Free Full Text]) which suggested that data from the VIGOR trial indicated an increased cardiovascular risk from rofecoxib when compared with standard NSAIDs. At the time the risk analysis was pooh-poohed, but murder will out and Dieppe and colleagues have revisited the sorry story following the sudden withdrawal—because of increased cardiovascular risk—of rofecoxib ( Br Med J 2004;329:867–8[Free Full Text]). They point out that the apparent lack of evidence so far against the other big COX-2 player, celecoxib, may be because it isn't actually very selective—but the question of a class effect (rather an ironic term, given the name of the main celecoxib trial) remains, and needs to be re-examined ... Meanwhile, and not for the first time (Robin remembers the jolly Frank McKenna waxing lyrical on the subject, but if it wasn't him then apologies), evidence is presented that indicates the superiority of anti-inflammatories over simple analgesics ( Lee et al., Arthritis Care Res 2004;51:746–54[ISI]). Also meanwhile is a timely and sober piece about the cosy relationship between doctors and the pharmaceutical industry ( Blumenthal, New Engl J Med 2004;351:1885–90[Free Full Text]). Should we, or should we not, take the drug companies’ shillings, pens, desk lights, USB storage devices (probably not, because they aren't big enough), grants and so forth? Robin declares a conflict of interest; he has so done, and indeed accepted gratefully the money to employ staff which his hospital had a snowball's chance in hell of funding. Looking gift horses in the mouth is one thing, but cutting off one's nose to spite one's face is quite another. Let a debate follow.

Another BMJ editorial, tail to tail with Paul Dieppe's ( von Elm and Egger, Br Med J 2004;329:868–9[Free Full Text]) bemoans the scandal (their term) of poor epidemiological research, quoting Pocock et al. (Br Med J 2004;329;883–7)[Abstract/Free Full Text]. Confounding is a major issue. One might suggest that this is not new, and in rheumatology one has always had to question the validity of any DMARD trial that compared erosion changes in early and late rheumatoid arthritis. Of course, Robin has questioned this frequently and ad nauseam. Do I need to elaborate on why? Perhaps I do; Fransen and van Riel (Best Pract Res Clin Rheumatol 2004;18:97–109[CrossRef][ISI][Medline]) look at rheumatology trials and make some useful comments about endpoints; they do not, however, spend much time discussing inclusions and exclusions. Anyway, as Robin pointed out last month, it's much too late to wait for X-ray changes, and he wonders when a patient whose DMARD therapy is delayed is going to sue for not having a diagnostic MRI (and where). Given this, it's perhaps a little surprising to read Zangger and colleagues’ article on the Larsen system ( Joint Bone Spine 2004;71:389–96[CrossRef][Medline]) which is a bit like reading a study of how to take rheumatology photographs using a pinhole camera, or shutting the stable door after the horse has bolted. C'est magnifique, mais ce n'est pas la guerre. Rather apt, that, given the recent reconstruction at Balaklava of the riding of the six hundred into the Valley of Death.

Robin is always keen to get explanations for pathology and disease states, so he was interested to see that bone marrow perfusion may correlate with osteoporosis ( Shih et al., Radiology 2004;233:121–8[Abstract/Free Full Text]), suggesting a vascular component. What this means in treatment terms Robin is not sure, but hopes someone might let him know, and, of course, what technique is needed to assess this? You got it—MRI again.

Everyone knows that ankylosing spondylitis has peripheral manifestations, but it was interesting to read that shoulder enthesitis is so common, being almost specific to AS if in the deltoid origin ( Lambert et al., Arthritis Care Res 2004;51:681–90[ISI]). Yet another excuse to do MRI scans! Oh boy. Robin is already purring over the sudden deference shown him by his hospital's finance director because of his inordinate (but not profligate, because guidelines are guidelines) spending on TNF-{alpha} blockade, which has made his department number one in drug spend, even outstripping the oncologists. So a few extra MRIs will pass unnoticed, except that I think she reads my column each month. The power, the power ...

Robin was asked last week, by a relatively young patient with quite severe osteoarthritis of the knees, mainly medial compartment, whether he should go for a unicompartmental operation or the full Monty. Robin pontificated at length on the likely decay of the lateral compartment, which he reckoned would catch up once the varus deformity was corrected. Then he read Rajasekhar's piece in J Bone Joint Surg Br (2004;86:983–5)[CrossRef][Medline], which shows a 10 year survival of 94%, which is little different from a full replacement. So he is sending a copy to the patient, not least because he works in the health Ombudsman's office. Robin has read Clausewitz, you see. And Machiavelli, come to that.

So Christmas comes again, and it's time for Robin to look at his list. Toffee goes down well, so any contributions to this goblin's wellbeing may be submitted to the Editorial Office. Reminds me of when I was a newly qualified doctor and found a jar of something interesting in a ward cupboard. It looked like betel nut, so Robin filled out a form and sent it to pathology for testing. The report read ‘Our expert Oriental taster confirms that this is indeed betel nut. Would you like it back?’ Yes please, replied Robin on another form, which was returned, sans nut, saying ‘Specimen totally consumed during experimental testing’. On the basis that my toffee might meet a similar fate (and Robin is anyway trying to stick to a diet) perhaps a New Year card will suffice. See you all next year.





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