Robin Goodfellow

Welcome to a new column. The Editor has pondered the wisdom of abrogating responsibility for the content of a small part of this excellent organ, and decided that a regular column should be devoted to ‘bits and pieces’ that have caught the eye of this mischievous goblin. There are of course distinguished precedents, not least ‘Minerva’ of the British Medical Journal, so how to name this rheumatological clone? Jupiter? A bit presumptuous. Hippocrates? Boring. Heberden junior? No historical precedent.

So to Robin Goodfellow ... a merry domestic fairy, according to Brewer's Dictionary of Phrase and Fable; synonymous with Puck, and famous for practical jokes; as described in ‘A Midsummer Night's Dream’:

‘Either I mistake your shape and making quite, Or else you are that shrewd and knavish sprite Called Robin Goodfellow ... Those that Hob-Goblin call you, and sweet Puck, You do their work, and they shall have good luck.’

Well, well. I did start my public life as an ill-tempered goblin in a primary school pantomime, and I have been responsible for a few naughty tricks, April Fools and so forth, so time has come full circle. The opinions and choices herein are mine alone; If we shadows have offended, Think but this, and all is mended, That you have but slumber'd here

While these visions did appear.

To work! Knee joint laxity may predispose to OA. Sounds likely, doesn't it! But then one could argue which came first; the laxity, or the cartilage and bone loss that lets the joint settle. If the study from Sharma is confirmed (Arthritis Rheum 1999;42:475–82) [ISI][Medline] the former is true; the varus-valgus laxity in the uninvolved knee of OA patients was greater than in controls. Quite how we might treat this puzzles me, however.

Another article from the same Arthritis Rheum (1999;42:751–6) [ISI][Medline] by Tatsis and colleagues identifies a high incidence of renal cell carcinoma in patients with Wegener's. Clearly something we should watch for, but should we hold our breath (I have seen only two Wegener's in the last fifteen years); and should we tell our renal physician colleagues to reciprocate and look for Wegener's?

Another monitoring question is raised by Dijkstra et al (Scand J Rheumatol 1999;28:33–7) [ISI][Medline] who suggest that ANA positive patients should be followed up, even if well, as 58% will develop some sort of connective tissue disease, three-quarters of these within two yr. I doubt my master Oberon will be pleased with that idea as such a protocol would have me seeing dozens of extra patients each month and the waiting times will soar.

Should we change our technique for carpal tunnel injection? Dammers et al. in Amsterdam think we should (BMJ 1999; 319:884–6).[Abstract/Free Full Text] They conducted a randomized double-blind trial of injection proximal to the tunnel using methylprednisolone and lignocaine; the benefit was so substantial that the ethics committee stopped the randomization after reviewing the first 40 patients. The only thing that worries me is the lignocaine, having been taught by Titania that this near the carpal tunnel can be nasty. I think also I would like to see the video rather than rely on the black and white photograph.

Many rheumatology specialists see depressed patients, so it may be of interest that a recent study from Berlin confirms that the traditional cure, St John's Wort (Hypericum to Linnaeans) is as effective as imipramine (Philipp et al., Br Med J 1999;319:1534–38).[Abstract/Free Full Text] We goblins have, of course, known this for years. Time, perhaps for a trial in chronic pain syndrome?

The New England Journal of Medicine recently tried to inveigle Robin into taking out a subscription by sending him a free month's worth. It was very kind of them, and the issue of November 4th 1999 contained an article (Anderson et al., N Engl J Med 1999; 341:1426–31) [Abstract/Free Full Text] which concluded that osteopathic treatment of low back pain was as good as standard care, but that patients in the standard group needed more medication. Joel Howell has also contributed a nice editorial (N Engl JMed 1999;341:1465–7) [Free Full Text] which looked at how the relationship between osteopathy and ‘conventional’ medicine (or allopathy) might develop. He also asks why osteopathy works, and suggests that it is because the practitioners touch their patients. This reflects the teaching of a neurologist I once worked for, who said that the most important part of the physical examination for headache, as judged by patients, was palpation of the skull. But then I thought all rheumatologists touched their patients. Not enough, maybe.

Robin does a lot of his paper searching on the Internet these days. I shall throw a few Internet tips out each month, but would be delighted if readers with good sites pass them on to me.

My favourite search engine at present is Dogpile (http://www.dogpile.com). It does lovely fuzzy searches on a huge number of sites (although a quick trawl of gardening sites—Robin has green fingers—did turn up Miranda's Sex Garden. Being a Goodfellow he did not of course enter). Those of you that have failed to visit the ILAR site should remedy this, if only to have a chance of winning a tee shirt in the quiz. It is at http://www.ilar.org/ - interface/frsetsearch.asp. I will not insult your intelligence by giving you the URLs of the Big Sites (viz BSR and the ARA).

Robin collects macro mantras. These are little prose pieces that can be inserted into letters at the touch of a key. Here is one:

‘Gout cannot be diagnosed by the finding of a raised serum uric acid level, but only by finding uric acid crystals within an inflamed joint or bursa. Gout attacks can occur when the uric acid is normal, and hyperuricaemia can occur without gout. Thus measurement of the serum uric acid is unhelpful. Do not waste your time, and the laboratory's money, doing it. Please.’

I am sure I am not alone in receiving referrals of patients with nodal OA, or palindromic rheumatism, who have been stuck on allopurinol. More mantras will follow, but if you have a nice one I would love to publish it too, if you are willing.





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