Robin Goodfellow (43-7)

Robin's feet have touched the ground again after a whirlwind trip past Hadrian's Wall to the BSR Annual Meeting; back in harness, it appears that someone else's secretary thinks that Tietze's syndrome is an undiscovered Spanish holiday resort. Why otherwise would she have called it costa chondritis? It reminded Robin of that policeman's ball game; ‘Here come Mr and Mrs Coxib, with their French niece Val de Coxib (and their Italian cousin Ettore Coxib)’. Also in the clinic was a delightful man beset, not only with rheumatoid arthritis and a wife recently diagnosed with cancer, but with prostatic cancer himself. He brought a little advice card about his I125 implant; ‘If a seed is passed in urine, pick up using a spoon or forceps and dispose of down the toilet, flushing twice’. Without wishing to be crude, Robin wonders under what circumstances a charming elderly gentleman of restrained habits would actually need to follow this advice; mostly, he thinks, said seed would already be in the toilet. Should one carry a spoon on one's person, just in case one is caught short on a stroll down the Royal Mile? It reminds Robin of the three Fellows in the Royal College of Physicians’ facilities—from Oxford, Cambridge and Sydney ... no, perhaps Robin had better not go on, but you could email me for the rest!

Oh, and Robin forgot the intellectually challenged son, silly Coxib.

Back, then, to Edinburgh, where Robin remains entranced by the two smaller lecture theatres that spin round to join the third and make a mega-auditorium; but his age is beginning to tell. He found it quite depressing that the major topic of discussion among his age-equals was when they could all afford to retire. Is this part of the menopause (either sex) or burnout, or a reflection on growing despair at being unable to achieve what should and could be achieved, targets or no? Robin suspects the last, as his colleagues’ enthusiasm for patients seems undimmed. Thus it is that Robin will wag a finger at the Secretary of State for Health, who swept in and concluded his remarks to the conference (Robin concedes that it was jolly decent of him to come and, in doing so, recognise the importance of our speciality) by suggesting that we must take ourselves ‘into the community’. You what? Robin's hospital is not surrounded by some Berlin Wall with ‘community’ written all over its inner surface; the financial inefficiency of cottage hospitals was recognised by their closure some years ago; our speciality benefits from immediate access to physicians, orthopaedic surgeons and the like; and while Robin has no objection to taking himself to GP surgeries he has tried it, and by and large it does not work. Etc. etc. Neither do patients like the idea, according to the abstract from Dudley (Doulas and colleagues). Maybe Mr Reid is being philosophical rather than material; after all, what is the point of building a diagnostic centre ‘in the community’ when the hospital is there already? Robin could have pointed out that he spent six years reducing from four sites to two for a reason, but before he had a chance to ask for clarification Mr Reid had swept out.

Robin's eclectic and idiosyncratic summary of abstracts included the one that began ‘Mr Chairperson’, and the one in which the musculoskeletal medicine radiologists were blinded. This was as much of an oxymoron, Robin considered, as the sign outside a building on the Royal Mile which read ‘Edinburgh School of English’. It was also rather spooky to note that fibromyalgia patients could possibly be screened for dysautonomia by spectral heart rate analysis...

McBeth and colleagues from Manchester reported an increase in regional and widespread musculoskeletal pain compared to 40 years ago, and wondered why. Perhaps the stresses of life are responsible, or perhaps it reflects an increase (for financial reasons?) in somatisation. On the other hand our estimable Editor reported that systemic rheumatoid vasculitis has declined markedly (and also wondered why, but concluded it might have something to do with the increased early use of methotrexate). Pease et al. (Leeds) suggest that giant-cell arteritis occurring in polymyalgia might be commoner in those who have the genotype HLA-DRB1*04, so Robin's long-suffering chemical pathologist is about to get another ear-bashing. Ryans and Belfast colleagues reported that corticosteroid injection, and physiotherapy after six weeks, were effective treatments, which Robin thought should perhaps be published in the Annals of Accepted Truisms. Tan and the Birmingham lot produced a fascinating study of the high-resolution MRI characteristics of Heberden's nodes, indicating that collateral ligament changes are prominent and possibly important. The Bristol group have extended review of their ‘hands off’ follow-up system to six years and concludes it works. Robin suspects that the patients, and their GPs, are different from his own but is still curious to know how he can make such a system work without specialist nurse support. Dalbeth and the Oxford team have found angiotensin-converting enzyme inhibition to be a successful anti-inflammatory in collagen induced arthritis; we can probably all do a survey of our own patients to compare control in those on ACE inhibitors and those who are not hypertensive. A BHPR abstract (McDonald et al. from Glasgow) points out that many patients are not clear why they are prescribed folic acid with their methotrexate (although they were good, and did)—very timely, given the recent editorial in this journal on the subject. Jois and the Norwich department reported their 31/2 year experience of TNF-{alpha} blockade in over 200 patients, noting that the withdrawal rate was lower than expected (and that reducing the interval between infliximab infusions produced better results). Both points, of course, will have significant influence on cost; so will the observation from the Guy's group (Bennett et al.) that switching to adalimumab in infliximab failure is a successful strategy. Originally, of course, it was assumed that if you failed one then you would fail the next, but Robin's experience of etanercept/infliximab switches (either way) also belies that. The Early Rheumatoid Arthritis Study looked at the rate of progression of erosions, concluding that it accelerates between two and three years. Robin admits to knowing this already (so should it go to the Annals of Already Accepted Axioms?) but thinks that what is seen is actually part of an S-shaped curve. He agrees, however, that this has very important implications for clinical trials that use changes in erosion rates as an endpoint—but at that endpoint déjà vu struck again.

Holden and colleagues from Oxford and Swindon pointed out that many patients who take herbal and over-the-counter remedies are unaware that these could interact with their standard preparations; in 11% (and 44% of patients used them) harm could have occurred. Kumar from Newcastle reported that osteoarthritis is inflammatory, at least judging from the raised CRP and ESR seen in OA patients compared to a control group of RA siblings. That, of course, raises questions about whether one can use OA patients as controls in RA drug trials, particularly when CRP may be used as a marker for cardiovascular risk. Robin's last chosen abstract is from Manchester, where the finding of significant other-disease comorbidity with RA has emerged from the Biologics Register data—proof if any was needed of the potential value of this enormous and growing resource.

Robin could not depart from bonny Scotland without reference to Roger Sturrock's Heberden Round, though he struggled to see the message at first, notwithstanding the technology of a live link to Glasgow. But although the presented patients had no real disease theme, they did have one thing in common; quiet determination in adversity. Their attitude to their often awful disease would make any consultant with such patients proud to be allowed to care for them.





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