Robin Goodfellow (43-1)

So the new (leap) year comes in, and Robin has a spring in his step, not least because he has read that one's propensity to fall can be reduced by noise. Priplata and colleagues (Lancet 2003;242:1123–4)[CrossRef] report a trial of vibrating insoles which dramatically reduced sway parameters. The diagram indicates that there is some progress needed for functionality, as dragging a large control box (even if on wheels) behind one might be expected to exert an uneven backward pull and elderly people might have some difficulty running the wires inside trousers to a backpack. Wireless technology, maybe. Robin will consult his son who knows a lot about such things. But shouldn't those parameters be variables? Robin can consult no-one in the family on this, for it is he that is the pedant.

Of course, the other reason he will spring is that he is still celebrating England's World Cup rugby win (watching which final he was moved to wonder why we don't see that many rugby players with funny shoulders, knees or whatever; presumably the orthopods have cleaned up the scene as Robin has only ever had one international through a clinic. If anyone wants to send Robin a gift, a DVD of the final will do nicely, thank you.). He was reminded to mention this by a patient who was taking champagne tablets to cure the nausea induced by methotrexate. Mind you, Robin thinks he and Mrs Robin get more of a kick from Dom Perignon than from domperidone. Though Prosecco will do. Certainly any form of alcohol might relieve the traffic jam in the blood vessels of another patient with RA who also had congested cardiac failure.

Sticking with the heart for a moment, Takayanagi and colleagues report a patient with rheumatoid vasculitis who died of a coronary, and was found to have vasculitis in the coronary arteries (Rheumatol Int 2003;23:315–8)[ISI][Medline]. Rare, perhaps, but of interest because an infiltration of T-lymphocytes was noted in the intima (though Robin confesses the presence of multinucleated giant cells is a puzzle). It will be interesting in the longer term to see if knocking off T cells has any influence on the incidence of vasculitis in RA or indeed on excess coronary mortality.

In the same journal, although as yet only as an e-print (but Robin loves to be up to date, cutting edge and the rest) is a paper by Chung and colleagues suggesting that low dose steroids in RA do not significantly alter bone density (Rheumatol Int 2003 Nov 20). This is akin to Robin's anecdotal experience. Admittedly the Peruvian patients appear to have been on steroids for only 3 months, so Robin will open up the new Annals of Essential Follow-up Reports especially for them.

Bone metastases are a not uncommon finding in rheumatology practice. A review of bisphosphonates concludes that they decrease skeletal morbidity significantly and say ‘Treatment should start when bone metastases are diagnosed and continue until it is no longer clinically relevant.’ ( Ross et al., Br Med J 2003;327:469–72[Abstract/Free Full Text]). I expect the cancer fraternity knows this, but if not they should be told.

Robin has another new journal to create—the Journal of Important Genes, Cytokines and Antibodies, or JIGChA for short. Into it must go Zanbelt and colleagues' piece entitled ‘Anti-<-fodrin antibodies do not add much to the diagnosis of Sjögren’s syndrome' from Arthritis Res Ther 2004;6:R33-R38[CrossRef][ISI] (at least, that's what the web reference says and the squiggle before the fodrin is the best Robin can find from the Symbol list, as the font transformation produces a square box). Or perhaps, given the conclusion, it should go to the sister mag called the Journal of Unimportant Antibodies. However a definite must for the former is Okamoto and colleagues' delightful ‘A Role for TARC/CCL17, a CC Chemokine, in Systemic Lupus Erythematosus’ (J Rheumatol 2003;30:2369–73)[ISI] although Robin's biochemist is tiring of his requests to run all these new assays. So he will leave the third paper for JIGChA off his wish list—an investigation of the role of ANKH in ankylosing spondylitis. Sounds like a joke, doesn't it? Timms et al. have however done a study of this human version of a mutated mouse gene to see if it has a role in disease susceptibility (Arthritis Rheum 2003;48:2898–902)[ISI][Medline]. It doesn't.

However, it appears that one can produce spondylitis in mice by exposing them to the proteoglycan versican ( Shi et al., Arthritis Rheum 2003;48:2903–15[ISI][Medline]). Robin awaits further work on this with interest.

Robin has wondered for many years whether it is really worth doing metacarpophalangeal joint arthroplasty in RA, largely because he has seen so many patients whose function has deteriorated rapidly, and whose ulnar deviation has returned. Goldfarb and Stern have wondered too, and have published a long term assessment (JBJS 2003;85a:1869–78)[ISI]. A video supplement is also available; in passing Robin notes that there is now a Video Journal of Orthopaedics (contact at www.vjortho.com) which is obviously the thing of the future, although one hopes it does not have very boring research people reading their results. Goldfarb concludes that MCP arthroplasty is very disappointing in the longer term (average follow-up was fourteen years) and that indications for doing it require careful re-examination ‘in light of the improvements in the medical management of rheumatoid disease’. So Robin was right, and one up to us. While on that topic, Robin would be interested to hear what rheumatologists think about arthroscopy (with or without washout) of the knee, which he thinks is now a redundant technique given its poor clinical results and the advent of MRI. Thoughts to robingoodfellow_rhu{at}hotmail.com as usual.

More orthopaedic research ( Freedman et al., Spine J. 2003;3:502–9[CrossRef][Medline]) suggests that intradiscal electrothermal therapy may be good for chronic low back pain, and a more sensible first treatment option than spinal fusion (though who on earth does that these days?). The evidence does though give credence to the fact that discs are far from inert structures. But I guess we rheumatologists knew that anyway.

Robin has for years postulated that minor anatomical abnormalities in the lumbosacral spine, such as partial sacralisation of lumbar vertebrae, may cause unequal stresses and thus back pain. His theory is extended by an interesting report ( Bottcher et al., Eur Spine J 2003, Nov epub) describing conjoined lumbosacral nerves in 6% of their outpatients and recommending 3D reconstruction to see these. What have we been missing all these years? I wonder.





This Article
Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
PubMed
PubMed Citation