Robin Goodfellow

Money, money, money, it's a rich man's world ... Robin hears we should not put people onto azathioprine unless they have had their TPMT levels monitored. Apparently you can find an enzyme defect and, if the level is low, the risk of myelosuppression is high; if it's high then you may need a bigger dose to gain a therapeutic effect. Robin found an American Internet lab doing it for $129. Robin's friendly biochemist says he can get it for about £16. The oncologists do it already; should we add it to the BSR second-line drugs guidelines? Oh, by the way, the initials stand for thiopurine methyltransferase.


And yet another temporary secretary is stirring the patients, for she types that ‘patient inflammatory leaflets' will be forwarded. Heaven knows we have enough reform to cope with, without fomenting revolution, although sometimes getting patients' inflammation directed at politicians can be constructive. Suggestions for such inflammatory leaflets are welcome.

Speaking of inflammation, Robin has been stricken by peritendinitis crepitans of tibialis anterior (he did find it rather funny, for someone who rarely runs for a bus, to be told by one of his physiotherapists that he had only seen it in marathon runners). But having to stop and rest after 100 yards is somewhat wearing, and Robin has indulged in an open trial of treatment (no benefit from topical or oral NSAIDs, currently trying pulsed short wave, as orthopaedic colleague won't inject it). Robin is tempted to inject it himself but the maximal area of tenderness lies just over the artery. Having never himself seen this version of tenosynovitis, he went to the Net, finding only one reference (Chazerain et al., Joint Bone Spine 2001;68:430–3)[ISI][Medline] —as a result of which he has also stopped his statin therapy, to the concern of Mrs Robin (not least because Robin has increased his red wine intake to compensate).

How does one define elderly? The state definition is 65, our elderly medical physicians (a.k.a. geriatricians) say 75, and I say it's 30 years older than me (however old that may be, exactly or approximately). Turcu and colleagues define over 80 as being very elderly, and paint a gloomy picture of the prognosis of vasculitis in this group stating: ‘Most patients either died quickly or progressively deteriorated from infections, malnutrition, or functional impairment’ (Gerontology 2002;48:174–8).[ISI][Medline] Rapid diagnosis must be important, but if things are as grim as they say (mortality was 66%) perhaps heroic interventions are unkind.

MRI has now imaged everything, surely, but we are still to some extent feeling our way in determining what abnormalities are predictive. A nice Danish study (Savnik et al., Eur Radiol 2002;12:1203–10) [ISI][Medline]suggests that the presence of wrist bone oedema and increased synovial volume are predictive of erosions in various types of inflammatory arthritis. If the aim of DMARD therapy is to prevent erosions this may be useful indeed, but then who nowadays waits to see erosions before starting such treatment?

Robin has never yet seen one of his joint injections produce an infection (he is hugging a tree as he speaks, with all fingers crossed, but will not rabbit on about steroid gout again). Others have not been so lucky; Laing and colleagues report a case of bacterial knee infection due to inadvertent acupuncture needle penetration (J Infect 2002;44:43–4).[ISI][Medline] They state that viral infection is a well-recognized complication. Is this, Robin wonders, because practitioners re-use needles, or that the needles are just dirty?

More from the murky world of COX-2 selective agents. Robin imagines that most rheumatologists have been exposed to the CLASS study data on celecoxib, no doubt accepting (as Robin did) that publication in a major journal conferred respectability and scientific accuracy. Jüni, Rutjes and Dieppe have published a devastating editorial (Br Med J 2002;324:1287–8) [Free Full Text]which casts doubt on the whole shemozzle. There were ‘post hoc changes in design, outcomes and analysis’ and, it appears, selective reporting of the results to exclude longer term follow-up which indicated that celecoxib was not all it was cracked up to be. The flawed findings, they say, have been widely believed. And Robin thought that, after thalidomide and benoxaprofen, the pharmaceutical industry had got its act together. It seems not. Given media hostility we do ourselves no favours by condoning this sort of thing so it is perhaps as well that we have done the debunking.

Evidence grows for combination therapy. O'Dell and 16 et als. report a comparison of dual and triple therapy using methotrexate, hydroxychloroquine and sulfasalazine which suggests three drugs are best (Arthritis Rheum 2002;46: 1164–70). [ISI][Medline]So when will this combination be compared to the TNF-{alpha} blockers?

After all that Robin has said about whiplash injury it appears that the psychiatrists are quite interested in it. From Oxford comes an analysis of nearly 1500 Accident Department attenders, looking at factors that predict persistence (Mayou and Bryant, Br J Psychiatry 2002;180:441–8). [Abstract/Free Full Text]Individually scored, factors that predicted pain at one year included feeling not to blame for the accident, initial anger or high emotional distress, and claiming compensation, with the latter being the only significant one after adjustment. So those cruel orthopaedic surgeons that used to say ‘The symptoms will not resolve until the case has been dealt with’ may have had a point after all.

Oho. That extracorporeal shock wave thing ain't no good. A proper randomized, double-blind, bells and whistles trial for rotator cuff tendinitis (Speed et al., J Bone Joint Surg 2002;84B:509–12) shows that the effect on pain is no better than placebo. Robin is off to found the new ‘Journal of Results that Come as a Great Relief to Healthcare Purchasers’.





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