Robin Goodfellow

What ho, pixies and elves. Robin's in-tray overflows with important documents and one is from the Driver and Vehicle Licensing Agency. It has had the sensible idea of issuing its guidelines on medical standards of fitness to drive as a loose-leaf folder so updates can be easily added; however it has had so many updated pages that Robin's copy is getting quite frayed with taking it apart and reassembling it, especially as the hole puncher is differently set for each revision. Robin's fingers have also been frayed by the nasty metal clip. Fortunately it is on the Net (via www.dvla.gov.uk/welcom.htm) although it is not in a very searchable form. However, it does mean a quick printout can be given to patients whose arthritis might make them dangerous behind the wheel.


Another important RA gene is reported; Khani-Hanjani et al. (Lancet 2000;356:820–5) [ISI][Medline] have discovered an association with disease severity and susceptibility with a dinucleotide repeat in the interferon-gamma non-coding region. How this ties in with other gene reports is beyond the understanding of this goblin; Fife et al. report a link with the corticotrophin-releasing hormone region (Arthritis Rheum 2000;43:1673–8);[ISI][Medline] Campbell et al. find roles for the NF-kappaB1 (p50) and c-Rel transcription factors (J Clin Invest 2000;12:1799–806); Justen and colleagues used suppression subtractive hybridization to find a whole series of differentially expressed genes (Mol Cell Biol Res Commun 2000; 3:165–72) [Medline] and Martinez and team found an association with TNF-{alpha} markers (Arthritis Rheum 2000;43:1366–70).[ISI][Medline] Will this alter our treatment? Not awhile, methinks.

Well, it had to happen ... Rofecoxib has a whole page of adverse reactions in ‘Current Problems in Pharmacovigilance’ (vol. 26, Sept 2000) including a number of gastrointestinal bleeds, most of them in the over 65s. Nothing is totally safe, is it? In the same issue there is a warning about methotrexate overdose due to confusion between the 2.5 and 10 mg tablets (which up to now have looked the same). Well done to the rheumatologists who have highlighted this, and the response has certainly been speedy.

A nice review of cervical subluxation in rheumatoid arthritis (E. D. Harris) appears on an excellent website called UpToDate (at http://www.uptodate.com/). Those of you who use Medscape or Doctor's Guide will find links to it and it is certainly worth a visit.

Will methotrexate (MTX) become a treatment for allodynia? Some animal work suggests that it could be; Hashizume and colleagues damaged lumbar roots in rats and administered intrathecal MTX (Pain 2000; 87:159–69).[ISI][Medline] Why it should work is not clear. Does anyone relish the prospect of trialling this in some of their chronic pain patients?

Robin is always terrified by the brilliant case presentations in the New England Journal of Medicine so it came as a pleasant surprise to make a very speedy (and correct) diagnosis in a clinical problem-solving article (Lurie, Gerber and Sox, N Engl J Med 2000;343:723–6).[Free Full Text] An 80-yr-old man presented with back and hip pain, and various traps appeared, including a past history of a colonic polyp and prostate trouble. The soft tissue mass seen on scanning was incorrectly interpreted as a herniated disc. Perhaps it's because I have seen it before (twice) that the possibility of infection was obvious but Robin's mantra for these is ‘if the treatment of the diagnosis fails, it is the diagnosis that is wrong’ (speaking of which Robin has yet to receive a mantra; what's wrong with you all?).

Shoulder surgery makes the shoulder better, but also makes the patient's general health better. That is the conclusion of a prospective trial of 71 patients conducted by McKee and Yoo (J Bone Joint Surg 2000; 82A:970–9). [Abstract/Free Full Text] Interestingly the benefit was nothing like as good in those who had filed for compensation.

Is it the disease or the treatment that causes the damage? A cohort study of lupus suggests that steroids significantly increase the risk of osteoporotic fractures, coronary artery disease and cataract (Zonana-Nacach et al. Arthritis Rheum 2000;43:1801–8).[ISI][Medline] Not surprising, perhaps, to the anecdotalist, but it also indicated an increased risk of avascular necrosis and stroke following high dose pulsed steroids. They conclude that further analysis of the cost–risk analysis of steroids is needed. Nevertheless Robin knows what he would take if he got lupus (mantra: ‘What would I do if it was me?’).

Clinical guidelines for the use of TNF-{alpha} drugs are splendid, but will they turn the stony hearts of those that hold the purse strings? The Birmingham rheumatologists think not, and have put their business case on the Net (at www.rheuma.bham.ac.uk)). This will certainly save a certain amount of wheel re-invention. As a website aficionado, Robin has to confide that he finds the site, like the DVLA site, a little clunky. It would be nice if the whole document could be downloaded in one piece rather than in bite sized chunks. No doubt a.pdf version is planned for the next site update...