Robin Goodfellow (42-4)

Robin is getting fed up with being told that he must modernize, not least because it appears (to others, if not to him) that far from being able to modernize he is actually ageing. This process seems inevitable, but if anyone has the elixir of eternal life out there, do give me a shout. And I don't want, thank you, to end up like that mythical Greek character whose nymph girlfriend forgot to ask, when she asked for him to be made immortal, that he should not age and he ended up as a chirrupping cicada. Can't think of his name. It will bug me for ages.

While thinking about modernizing, and turning out an antique cupboard at his hospital, Robin came across a short run of Annals of the Rheumatic Diseases from forty years ago. Do you ever look back with the idea of determining what has changed (in ten years, it is said, half of one's knowledge will be proved to be wrong, but which half is not clear). Those dusty journals were quite an education. How about Partridge and Duthie's paper in the March issue: ‘Controlled trial of the effect of complete immobilisation of the joints in rheumatoid arthritis' (Ann Rheum Dis 1963;22:91–9)?[ISI] It begins as follows: ‘It has long been accepted by the majority of physicians that rest in bed forms an important part of the treatment of rheumatoid arthritis during the active phase of the disease...’. Ah. So where have all the beds gone? Methinks the majority of physicians now think something else. More blasts from the past next month.

These patients get very fed up with their arthritis, you know. Recently Robin had one whose methotrexate was stopped when she came into hospital with a deep vein thrombosis (no-one could find the dose, which was slightly better than when she was on the orthopaedic ward and was offered her weekly 10 mg every day). She had, according to the summary, quite an exasperation of her rheumatoid. Given that she was pretty upset by the whole affair of the mistaken doses, it is perhaps hardly surprising. However as Sosin and Handa point out, in a ‘Lesson of the Week’ (Br Med J 2003;326:266–7) [Free Full Text] even low dose methotrexate can cause significant bone marrow suppression, even in the absence of the known predisposing factors of renal dysfunction and concomitant drug administration. Treating urinary tract infections with trimethoprim is not a good idea in this group. Robin had a patient go suddenly pancytopenic recently (she had been on methotrexate for 2 yr, but dropped her haemoglobin by 7 g in a month); he wondered whether she had accidentally been prescribed, and taken, 10 mg instead of 2.5 mg tablets (and thus taken 40 mg weekly for a little) but it turned out not to be the case. Vigilance at all times is the watchword. However this does not make shared care easy, particularly when the specialist is in one hospital and the GP gets the bloods done in another.

There's an interesting piece on osteoarthritis which offers some insights into progression. Bettica et al. (Arthritis Rheum 2002;46:3178–84) [CrossRef][ISI][Medline] have extracted data from the long-running Chingford study and shown that progression is associated with resorption. What of course remains unclear is why resorption occurs in some patients, but not in others. Could it be drug-related, Robin asks, and what is the effect of exercise or lack of it, or is there some primary defect of bone turnover that predisposes patients to progress? A good discussion for the Journal of Further Clarification.

Another paper with the same destination appears in the same journal (Kusunoki et al., Arthritis Rheum 2002;46:3159–67)[CrossRef][ISI][Medline]. It seems that celecoxib induces apoptosis in synovial fibroblasts while other NSAIDs do not. This does, of course, raise the possibility that celecoxib has disease-modifying activity. Now which NSAID has had that said about it in the past? (History time again, folks.) Benoxaprofen, if Robin recalls correctly, so he won't hold his breath just yet.

Dick et al. (Arthritis Care Res 2002;47:639–44) [ISI] investigated attentional functioning in fibromyalgia, rheumatoid arthritis and musculoskeletal pain patients as compared to a pain-free control group. They found no difference between the three groups, though all were worse than the controls. Robin wonders if this is highly significant, as his own attentional functioning seems to be deteriorating. Perhaps the study should be repeated to compare a group of trainee rheumatologists with a group of old lags.

As no-one uses hydralazine these days Robin thought he would never see drug-induced lupus again. However, new drugs cause old problems and the platelet inhibitor ticlodipine is the latest to be implicated (Spiera et al., Arch Intern Med 2002;162:2240–3). [Abstract/Free Full Text] Watch out.

There has been quite a lot of debate on whether it is safe to use methotrexate and leflunomide together, given the theoretical risk of additive side-effects. Kremer et al. have done a randomized, double-blind, placebo-controlled trial across 20 centres (Ann Intern Med 2002;137:726–33) [Abstract/Free Full Text] and say that it is, and adding leflunomide to methotrexate appears to improve benefit. Robin hears this, but will watch those blood tests like a hawk.

It appears that the European Commission has granted a licence for the use of etanercept in psoriatic arthritis. Robin will turn parochial for an instant and wonder how long it will be before he and his UK colleagues will be able to prescribe, under the security blanket of a NICE recommendation. Or will we now have a year of postcode prescribing arguments?

And finally, back to bugs. An interesting news snippet in The Lancet (2003;360:2053) reports the successful production in Japan of human collagen by transgenic silkworms. Robin has a looming vision of sheets of silk/collagen being used to resurface knee joints (yes, that was deliberate if rather contrived) although to be honest he also has nightmares about the maggots used by his Tissue Viability Nurse in pressure sores.

And just in case you were going to write (not many do—what's wrong with you? Or me?) the nymph was Eos, and the bloke was Tithonus. Great invention, Google.





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