Robin Goodfellow (44-2)

It has got a bit colder this last month, but that cannot, surely, last in the white heat of claim and counterclaim over the rofecoxib saga. The New York correspondent of the British Medical Journal (2004;329:1253)[Free Full Text] describes the evidence of one of the FDA's experts, David Graham, in US Senate hearings. Claim now follows counterclaim and the undermining of witnesses has also begun. Oh dear. What fun. Dark mutterings suggest that other drug withdrawals are inevitable, the stockbrokers have caught a cold with pharmaceutical stocks and gossip circulates that a further shakeout and merger round will soon follow. Robin is not certain whether, under these circumstances, rheumatology's exposure under the spotlight is a Good Thing.

What is worse, Robin has to see-saw between contradictory pieces of advice. No sooner has he seized on another trial that ‘proves’ the efficacy of NSAIDs is superior to ordinary analgesics in osteoarthritis (see last month) than along come Bjordal and friends ( Br Med J 2004:329:1317–20[Abstract/Free Full Text]) with a dreaded meta-analysis that proves the reverse. Oh jump down turn around pick a bale of cotton, what is a poor goblin supposed to believe? Mind you, two other offerings from the same journal cheered him up a bit: Peter Maddison's description of the ‘Targeted early access to musculoskeletal services’ (when will these acronymic wonders cease? Br Med J 2004;329:1325–7[Abstract/Free Full Text]), which should be required reading for all those who want to do less, but better, work; and the following clinical review on tibialis posterior dysfunction ( Kohls-Gatzoulis et al., ibid., 1328–33), which lucidly explains most of the valgus ankles that Robin sees, and is scientific in how to deal with them. Mind you, the multiple screw fusion to restore an arch looked a bit heroic, and Robin is a bit wary of triple arthrodesis after three patients of his all failed (miserably) to do well.

Now from Japan comes a curious case report. Hypertrophic pachymeningitis may be an initial and cardinal manifestation of microscopic polyangiitis ( Furukawa et al., Neurology 2004;63:1722–4[Abstract/Free Full Text]). Robin's career is now well into its second half, so having never seen such a case he feels it is unlikely he ever will (thus tipping this paper into the Annals of Hen's Teeth Disorders), but it did remind him of his good friend and neurologist, George Harwood, who opined that physicians were to neurologists as fellows of Oxford colleges were to those of All Souls. Nothing new here, then.

Robin must now report his immunological ‘fix’, which excites briefly and then is followed by a profound depression. This one comes from Ponchel and a galaxy of 26 co-authors. (How interesting it would be if, alongside their institute affiliations, they had to list what they actually did: A held the test tubes, B killed the mice, Z tidied up the spelling. It certainly is a fine example of joint authorship in our field.) Anyway, this paper ( Arthritis Res Ther 2005;7:R80–R92[CrossRef][ISI][Medline]) looks at the importance of interleukin-7 and suggests that the deficiency they see is likely to be an important contributing factor to poor early T-cell reconstitution in RA following therapeutic lymphodepletion. Great. Whatever happened to IL-6? Robin feels like a fly that has landed on an open treacle tin. This sensation is not aided by another article, by Villaneuva et al. (ibid., 2005;7:R30–R37), which talks of macrophage activation syndrome as if it were a common occurrence. Robin has never knowingly encountered it, perhaps because it, and the natural killer-cell dysfunction with which it is associated, seems to be commonest in juvenile RA, of which Robin sees not a lot. Nevertheless, he worries about how many cases he has missed and whether it might matter, and meanwhile injected two children's knees in the anaesthetic room this lunchtime.

He also worries about how his patients suffer for his inability to provide Doppler sonography, particularly when the resolution is supposedly better than MRI and you can diagnose inflammation in the temporal arteries ( Schmidt, Best Pract Res Clin Rheumatol 2004;18:827–46[CrossRef][ISI][Medline]). It all sounds too good to be true, but in the straightened circumstances of Robin's hospital it remains a pipe dream, even if this sad and backward goblin was ready for retraining (which he isn’t).

And if you get a fish sous-chef with tenosynovitis, then beware: it could be due to Mycobacterium marinum, which ultrasonography may help to delineate (well, obviously not with the culture bit, and how many chefs does one see in a normal week?). It's described by Rajadhyaksha and colleagues ( APLAR J Rheumatol 2004;7:242–6[CrossRef]). But now you have thought of it perhaps one will pop up.

Robin is not entirely ready for the explosion in autoantibodies reported in SLE by Sherer, Gorstein, Fritxler and Shoenfeld (Semin Arthritis Rheumatol 2004;34:501–37)[CrossRef][ISI][Medline], which lists 116 antibodies altogether. There is clearly a fruitful field here; deciding which permutations and combinations are significant will occupy at least a hundred researchers for decades. Robin has a little query about this one, however: the footnote to the abstract says ‘Y. Sherer and A. Gorstein contributed equally to this work’. So why are the other two authors there?

A patient turned up in my clinic with an unidentifiable connective tissue problem; several physicians had prevaricated and so, as usual, she was sent to me for sorting. The anchor antibodies were negative. No wonder they were all at sea. But Robin's bid to obtain anti-CCP antibodies is looking a bit more hopeful.

Now it's a while since Robin looked at osteoporosis (though he awaits with interest whether the latest puff for strontium ranelate will disappear in a puff of smoke as longer-term side-effects reveal themselves, not to mention whether the bone density increase, like that from fluoride, is actually of dense but weak bone). But perhaps he needs to call for the Journal of Unsurprising Results again to take note of the paper by Franklyn and Stewart (Clin Endocrinol 2004;61:560–6[CrossRef][ISI][Medline]), which records that testosterone increases bone density in female-to-male transsexuals. Well, well. Fancy that (not really). Curiously, the journal, in its online presence, also lists its impact factor, which seems a slight conceit.

Thrombosis Research produced a special issue for the 11th International Congress on Antiphospholipid Antibodies, within which is a paper by Petri (2004;114:593–5) describing the finding in the Hopkins Lupus Cohort that lupus anticoagulant is a risk factor for myocardial infarction. Robin wonders quietly whether this finding (not entirely new) has anything to do with that rofecoxib thing—in other words, do the studies allow for APL positivity as a confounding factor? It's back to Robin's subgroup obsession and, of course, it's where we came in; but fortunately for you all Mrs Robin has appeared with a household task for him and so he will put down his pen for the month.





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