Robin Goodfellow (42-6)

It does, of course, take a time to know whether a transplanted shrub will take. Robin likes getting his hands dirty, but it is hard work. Every hole dug produces a pile of rocks; it is understandable that a restrictive covenant on the house forbids quarrying, as Robin has so far dug up enough to build a small church. It is quite relaxing to sit down and write a column...

The osteoporosis industry might take a knock from a paper from the Oxford stable of Richard Doll (Trivedi, Doll and Khaw, Br Med J 2003;326:469–72).[Abstract/Free Full Text] Their 5-yr study of the over-65s shows that Vitamin D3 taken as 100 000 units once every 4 months may prevent fractures, and without adverse effects. It is certainly a lot cheaper than bisphosphonates and presumably if you gave it to everyone you don't have to do DEXA scans (no don't write in – I jest — but on the other hand the capital and revenue investment in scanners is not insubstantial). The debate on bone density measurement also rumbles on (although Robin wonders whether this Vitamin D as a large slug now and then will kill the whole thing). A paper by Williams and Daymond (Br J Radiol 2003;76:123–8)[Abstract/Free Full Text] compares heel density with traditional axial measurement. Specificity at the heel was reasonable, but sensitivity was not so good and there was a high risk of false negatives. Robin found this interesting, as his experience (anecdotal, of course) is that peripheral measurements have rather a high false positive rate — so patients scanned in their local practices end up on unnecessary treatment. Clarity on this would be a godsend.

How do you balance the risk of muscle breakdown with exercise in dermatomyositis against the risks of muscle wasting from inactivity? Without too much difficulty, according to Vargú and colleagues (Clin Rehabil 2003;17:83–7).[ISI][Medline] Physical training started 2–3 weeks after an acute flare seems to be both safe and useful.

Bisphosphonates (which cause awful diarrhoea in rather a large number of Robin's patients) may also cause ocular inflammation, according to a recent report from the Fraunfelders of Portland, Oregon (N Engl J Med 2003;348:1187–8)[Free Full Text]. While most often reported with pamidronate, others can do it too. It makes sense to report any odd potential side-effect; in the UK the ‘yellow card’ system is excellent, but Robin suspects that the scale of adverse events is underestimated because rheumatologists do not bother to report known side-effects (no point, is there, in wasting time on something that is well-recognized). Time, methinks, to be more rigorous.

Robin was pleased to pick up a case of osteitis pubis the other day and found a nice review on the Net at http://www.physsportsmed.com/issues/2001/07_01/vitanzo.htm (for a sports medicine orientated review, try http://www.emedicine.com/sports/topic90.htm). Having previously been a keen advocate of corticosteroid injection he was interested in the very conservative approaches recommended — and also that the standing-on-one-leg pelvic X-ray to detect instability is known as a flamingo view. But I expect you all knew that.

Talking of sports medicine brings Robin back to a piece by Skew (Br Med J careers, 22 March 2003, s89–90) which again advances the argument that musculoskeletal medicine should be a separate speciality. Robin thought this proposal had been laid to rest years ago, but rather like applications for planning permission it seems that some ideas continue to be put forward until everyone gets so weary of protesting that they get carried by apathy. So, UK rheumatologists, gird your loins once again for another struggle. It seems foolish to Robin to divide one's resources between subgroups, particularly when there are no government targets that provide any resources in the first place.

Robin has another journal to found — the Journal of Not Very Helpful Results. To it he might send a paper advertised as examining the cost-effectiveness of biologic agents (Louie, Park and Yoon, Am J Health-Syst Pharm 2003;60:346–55)[ISI][Medline] which concludes ‘The role of BRMs in the treatment of RA will evolve as investigators learn more about the drugs and the disorder’. Or perhaps it should go to the sister journal, the Annals of Obvious Outcomes...

Telephone medicine is developing, and rheumatologists appear to be in the forefront (or at least Badal Pal is — Br Med J 2003;326:607).[Free Full Text] The idea that patients could be reminded by a text message (shd tht b txt msg?) that it is time for their monitoring blood tests or that their next appointment is approaching is an intriguing one. Given the cost of TNF-{alpha} blockade it might well be a drop in the ocean to provide mobile phones to all RA patients. This is especially relevant as Robin has discovered a huge hole in the general practice/hospital interface regarding monitoring; none of the computer systems used by UK GPs can record drugs that they have not themselves prescribed. Thus if any disease-modifying drugs are prescribed from a hospital, they will not appear on the GP database even if a letter with details has been sent. This has the potential for enormous problems, especially if (as in Robin's area) patients may attend as many as four hospitals because of the spread of specialist services.

Most rheumatologists see patients with chronic neuropathic pain, although Robin suspects that they get passed on fairly promptly to the pain services when interventions prove unrewarding. A review of painful sensory neuropathy by Mendell and Sahenk (N Engl J Med 2003;348:1243–55)[Free Full Text] does confirm that most tested treatments are less than satisfactory, but points out that this may in part be due to using insufficient drug doses. Thus they recommend starting with gabapentin at 300 mg three times daily, but using up to 3600 mg if the patient can tolerate it. For refractory cases you should add tramadol and then oxcarbazepine. Bit like RA really — hit early and hit hard.

Robin decided to add to his Continuing Medical Education experience by trying the online teaching provided by the Royal College of Physicians through Doctors.net.uk. Robin failed the rheumatology case first time around, and only passed second time by lying. He passed the one on cardiac failure. How embarrassing — but he did the latter during a medical meeting with a number of colleagues and was shaken by the degree of disagreement. Doctors will always disagree somewhere.





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