Robin Goodfellow (44-4)

Five years, 60 columns and about 70 000 words after the off, Robin has woven a magic spell that will enable him to transmute from goblinity back to the human race. Deadlines have sometimes been tight, but never one was missed. Robin has repeated himself occasionally, but not a lot. A few people recognized him (one, Alison Leak, recognized the Pizza Express he described ( Rheumatology 2001;40:479[Free Full Text]) and some, somehow, saw through the style and accosted him, thinking that somehow if they declaimed ‘You are Robin Goodfellow and I claim my prize’ something nice might happen. Some chance on what I am paid. Quite a few thought he was more than one—not so. George Ehrlich had to be told (numerous clues, in a protracted exchange, failing to give enough away). But enough is enough, and Robin has other fish to fry, books to write, work to do and Mrs Robin to consider. So our esteemed editor will be finding another Robin. I hope.

Robin's name was the invention of polymath Mike Snaith, who thought it would be a suitable nom-de-plume for the sort of column that David Scott, then Editor, envisaged. I trust that he approved. Both David and Richard Watts daringly allowed Robin his head, and he can recall only one editorial intervention on matters of content. Perhaps his only regret is his failure to provoke more than the occasional response, even when being provocative. Maybe he never went far enough; in a previous incarnation as Editor of a Student Union Newsletter (20 pages, monthly, cyclostyled and collated by hand, 200 copies circulated, complete set minus first edition could be made available) he was hauled up before the Dean twice. So what went wrong? Old age, they say, mellows one. I hope not.

A facility with words can be a curse; Robin remembers sounding off once, during a meeting at which the length of a prize essay was to be reduced to 1500 words to encourage entrants. Robin foolishly snorted he could knock off that number in an hour. So he was hoist by his own petard when, a few weeks later, one of those at the meeting asked for a thousand words within a week. But it was done. Within two days, just to prove a point.

And goodness me—how Robin has batted on about the tribulations of trials—poor entry criteria, poor selection, small sample sizes and so on—and wondering who will take up the banner, when along comes Ioannidis ( Ann Rheum Dis 2005;64:345–6[Free Full Text]) saying exactly the same thing, though more scientifically, I am sure.

Anyway, enough of me. I always thought that getting a gong lifted one from being plebeian, so many congratulations to Pat Woo on her CBE. Pity that ‘Hospital Doctor’ belaboured the point unnecessarily by referring to her as Professor Patrician Woo.

T cells or B cells? Robin wonders whether the prime culprit will ever be decided before he retires and doesn't have to bother any more. Lupus nephritis is a nasty thing, and it looks like the B cells are in charge here because if you zap them with rituximab the nephritis subsides ( Sfikakis et al., Arthritis Rheum 2005;52:501–13[CrossRef][ISI][Medline]). But then T helper cell activation is reduced ... still, if it works, who cares?

Likewise there is a temptation not to care about why drugs like methotrexate actually work—except that one's patients often ask, and it's a bit of a cop-out to ask them how many hours they have got to listen. But now we can suggest that it suppresses T-cell activation and adhesion molecules, but not by causing lymphocyte apoptosis ( Johnston and colleagues, Clin Immunol 2005;114:154–63[CrossRef][ISI][Medline]). And Robin won't, he thinks, get many who ask to have that explained. However he has increasing numbers of people asking to come off it. This seems partly related to the actions of the National Patient Safety Agency following a death from overdose. The NPSA recommendations on monitoring seem rather stringent—indeed for many they are unachievable—to the extent that Robin suggests an alternative acronym decode (Nanny's Particularly Suffocating Advice). Especially as Yazici and colleagues report that methotrexate is ‘among the safest treatments’ and that discontinuation is rarely due to lab test abnormalities, but for clinical reasons ( Ann Rheum Dis 2005;64:207–11[Abstract/Free Full Text]). Robin suggests that our cotton-wool politicians, and others, need a half day seminar on the difference between risk and hazard. It might also include a discussion of the relative risk of cardiovascular disease taking COX-2 inhibitors against peptic ulceration on standard non-steroidal anti-inflammatories.

We all know what is related to rheumatoid arthritis severity, but what about psoriatic arthritis? Brockbank et al. suggest that dactylitis may be a marker ( Ann Rheum Dis 2005:64:188–90[Abstract/Free Full Text]). Robin is not so certain, because in his book if you have dactylitis you have more e disease by definition, so it's a circular argument rather like that in the disease whose name may not be spoken. Assessing severity is also an agenda item for Chen et al. (Arthitis Res Ther 2005;7:R310–7)[CrossRef]. They have come up with a near-infrared fluorescence-labelled folate probe and suggest it ‘may facilitate improved arthritis diagnosis and early assessment of the disease progress by providing an in vivo characterization of active macrophage status in inflammatory joint diseases’. Yes. Well. Robin will stick to MRI scans for the minute.

The benefits of herbs are unclear, although the risks may be high as Robin has said before, not least because some contain other substances. From Thailand comes a report on Duhuo Jisheng Wan, which seemed in a trial of 200 patients with OA to be of similar efficacy to diclofenac ( Teekachunhatean and lots of others, BMC Complementary and Alternative Medicine 2004;4:19[CrossRef][Medline]). However they found a similar number of adverse events as well. What is worse is that the herb tested comes from the Min-Kang Drug Manufactory,Yichang, which is listed on an excellent website (http://home.caregroup.org/clinical/altmed/interactions/Herb_Groups/Adulteration_an.htm) as being contaminated with paracetamol (that from Plum Flower is kosher, if that isn't a mixed metaphor). So perhaps this trial of diclofenac against paracetamol should be relocated in the Annals of Already Accepted Axioms which, abbreviation-wise, would head every alphabetical list.

So, there it is. Robin will down his pen, hang up his thinking cap and trust that his musings have amused, confused, and diffused a little knowledge. Living in the shadows and being mischievous has been fun. In signing off, Robin will offer a last website address through which you might learn something of the goblin who has been privileged to serve his friends and others at the start of the 21st century (http://website.lineone.net/~andrewbamji/index.htm) and trust that this final clue to his identity will relieve those who had some nagging feeling that they knew exactly who Robin was. But what's the betting that 50% of you (plus or minus 2 standard deviations) were wrong?