Robin Goodfellow

I'm sorry that you haven't been able to see me as yet. This is because I have not found a nice piece of clipart to include as a footer. Of course, some artistic readers may have a mental image of me already; if so, then do me a favour—draw and scan it, and send it (to the journal; they will forward it by fairy post, otherwise known as e-mail). A little icon would please this little goblin. Don't forget the hat.

One of Robin's pet hates is messy presentation. Indeed, when masquerading as a Clinical Tutor he used to wax lyrical on the evils of crowded slides, sloppy overhead transparencies and funny typefaces such as abound in programs like Powerpoint. How splendid therefore to see that Rheumatology has received the designers' seal of approval. The media magazine Wallpaper waxes lyrical about the OUP: ‘Britain's Oxford University Press is a dab hand at academic journals, imbuing Rheumatology with the kind of typography that less specialised rags would die for’. Wow.

Do you ever feel humbled by a patient? Perhaps Robin has lost his cutting edge, for it happens more than it did, although his sense of inferiority is fuelled by the Internet printouts that form an increasing part of consultations. For years he has taught that the first movement to be lost in ankylosing spondylitis is lateral flexion—an important clinical sign, you will agree. But have you ever thought why? Robin was pontificating on the sign to some captive (and polite) students when the patient somewhat scornfully gave the reason. ‘When do you ever use that movement?’ he said. Thank you, Paul Haskell, for explaining what I should have worked out for myself...

How do you stand on fibromyalgia? A series of reviews (Baillière's Clinical Rheumatology 1999;13) may help you decide. The epidemiologist (Mäkelä) concludes that the clinical entity is not epidemiologically distinct; it is a label ‘applied in some people (in particular, those seeking medical attention) representing the high end of the distribution of several associated variables’. Wessely and Hotopf argue that it is ‘one of many unexplained syndromes which have more similarities than differences...’ and suggest it evolved because of the need for a label. Fitzcharles, the approving rheumatologist, offers little evidence and concedes there are no measurable abnormal findings. Cohen, the disapproving rheumatologist, uses a word new to me (epistemological) and considers that the attempt to create fibromyalgia has foundered on circular argument and violation of its own criteria. I find his argument compelling.

The National Institute for Clinical Excellence (NICE) is reviewing the case of selective COX-2 drugs (and, meanwhile, some drug committees are refusing to sanction their use until a pronouncement rules in their favour, if ever it will). An interesting piece of work by Kristiansen et al. (Arthritis Rheum 1999;42:2293–2302) [ISI][Medline]may give a steer; comparing diclofenac with a diclofenac/misoprostol combination appears cost-effective when restricted to patients already at risk of increased gastro-intestinal events. Admittedly this work was done in RA and in the UK rofecoxib is licensed for OA only at present, but Robin will not be surprised if such evidence is adduced to argue that the selective COX-2 drugs should not be used as a first choice; NICE's rules have been tweaked a little, so that its remit is not confined to clinical matters only and cost is taken into account. At present the differential is not that great.

While on COX-2 drugs the British Medical Journal reports a presentation at the American Society of Gastroenterology by Steinbach which showed that celecoxib reduces the number of adenomatous polyps in patients with familial polyposis (BMJ 1999;319:1155. [Free Full Text]Is there no limit to the application of these wonderful substances?

Now here's a paper to strike fear into the hearts of every cost conscious rheumatologist. Bredella et al. have used MRI to look at tennis elbow (Am J Roentgenol 1999;173:1379–82).[Abstract] They suggest that, in addition to tears of the common extensor expansion, damage to the lateral collateral ligament of the elbow is often found. Such patients often have refractory symptoms, but surgery may destabilize the elbow further and may thus be a Bad Thing. So before surgical referral following failed injection, we should probably be doing MRI scans. I hear screams of fear from my Clinical Director already, as the budget spirals out of control.

Another costly procedure is outlined by Loew et al. (J Bone Joint Surg 1999;81B:863–7).[Medline] Chronic calcific tendonitis of the shoulder can be treated effectively with extracorporeal shock wave therapy. Do patients prefer this to surgery? The report suggests that patients found it ‘unpleasant and sometimes painful’. Perhaps not, then.

Robin wonders whether the mystery of Ekbom's syndrome has at last been cracked by Zoppi (The Pain Clinic 2000;12:1–7). He suggests that the finding of tender myalgic spots in tibialis anterior, and abolition of symptoms by anaesthetizing them, points to a ‘deranged sensory and proprioceptive input’. The theory is nice, and quaintly described.

Robin likes a bit of history and was pleased to find that on the Wellcome Institute site (http://www.wellcome.ac.uk/en/1/awthlt.html) he could access their history journal. There are also some good links for researchers, and grant application information.

Finally to Robin's macro mantra. ‘When the patient indicates the pain is in the hip by pointing to the outer aspect of the thigh (which Robin calls the dressmaker's hip) the pain is not from the hip. Hip joint pain is almost always in the groin, and radiates to the knee. Pain in the dressmaker's hip comes from the gluteus medius enthesis or trochanteric bursa.’