Robin Goodfellow

Hi guys. The summer burns on, and Robin has his intellectual boundaries stretched again by the median nerve (as opposed to the medium nerve which magically reappeared in another letter). We are all used to measuring function (and many are unclear about the significance of normal nerve conduction in the presence of clear-cut symptoms) but who looks at structure? Well, Greening has and although it's an old paper (Lancet 1999; 354:217–8),[CrossRef][ISI][Medline] there is some more recent follow-up work which all shows that longitudinal movement of the nerve on flexion and extension of the wrist is impaired in patients with non-specific forearm pain. In fact, on a quick PubMed search, there is quite a lot on this topic. For those of us without ultrasound this could be yet another use for MRI.

And while on the wider horizons revealed by misprints I am grateful to Mark Phillips for telling me of the new joint in the toe—the empty pea joint. Robin also had one of his old RA patients who does have folic acid with their methotrexate (not all do, as he has said before) who wanted a repeat prescription. ‘And don't forget the frolic’, she said. Would that she could...

MRI phlebography is a new way of assessing lumbar spinal canal stenosis (Manaka et al., Journal of Orthopaedic Science 2003; 8:1–7).[Medline] The results suggest that congestive venous ischaemia correlates with the development of symptoms. And Robin, poor heart, thought it was all arterial, so now does he tells his spinal claudication patients to stop smoking and if so with what justification?

Another new test destined to become a routine part of the rheumatologists' armamentarium is surely the anti-chromatin antibody (cost, anyone?). Cervera and colleagues (Ann Rheum Dis 2003; 62:431–4)[Abstract/Free Full Text] report its specificity for lupus and in particular a risk marker for lupus nephritis. Robin likes to tease his biochemist by tweaking his requirements for antibody screens just as the latest update has been finally agreed ...

Raynauld and colleagues have laid to rest another canard—that repeated steroid injections into knees is harmful (Arthritis Rheum 2003; 48:370–7).[CrossRef][ISI][Medline] Three-monthly injections of triamcinolone over 2 years were both effective and apparently lacking in significant deleterious effects on the joint.

I suppose there will be complaints if I don't produce a little proper science now and again, so I will tell you of work from Korea in the popular and well-known Journal of Leukocyte Biology (Han et al., 2003; 73:525–9).[Abstract/Free Full Text] I quote (largely because I don't understand): ‘Hypoxia/reoxygenation strongly activated nuclear factor-{kappa}B (NF-{kappa}B) in synovial fibroblasts to the levels produced by phorbol 12-myristate 13-acetate and caused lymphocyte hyperadhesiveness to synovial fibroblasts as well as up-regulation of ICAM-1, both of which were completely blocked by a NF-{kappa}B antagonist (pyrrolidine dithiocarbamate). These results indicate that hypoxia/reoxygenation has a major role in sequestration of inflammatory cells to synovium mediated by the activation of NF-{kappa}B’. Yet another important molecule in RA; Robin wonders what will happen if we block the lot at once. Maybe a black hole will be generated.

It appears that albumin gets eaten by tumour cells, and Wunder et al. postulate (J Immunol 2003, 170:4793–801)[Abstract/Free Full Text] that the similarity of RA synovium to such cells means that loading methotrexate (MTX) onto the albumin might provide a more effective delivery system for it in RA (it works in cancer). Robin is not so much struck by the therapeutic implications of better MTX delivery as by the bald statement that RA is like cancer—which Robin, of course, has been saying for decades.

It was reported recently that the European Commission of the European Union (EU) has granted centralized marketing authorization to infliximab for the treatment of ankylosing spondylitis. Where does that leave us in the UK? Must we wait for NICE to pronounce, or can we just go ahead, threatening a case in the European Court on human rights grounds when the guardians of the purse strings say no?

Robin recalls an episode some years back when his quiet evening was disturbed by a sudden rhythmic thumping, and the chandelier in the sitting room began to rattle, and then swing. Fearing an earthquake (not that these are common in his locality, but chalk mining was not unknown) he rushed out to discover his mother, who was staying, was conducting her individual anti-osteoporosis exercise class in the bedroom above. How sad, then, to discover (Gerdhem et al., Osteoporos Int 2003; 14:208–12)[ISI][Medline] that physical activity is not of great importance. Robin thinks he will leave the dear old thing in ignorance.

Now then, now then. Is blood flow reduced to skeletal muscle in chronic fatigue syndrome? Nice idea, shame about the result (no—McCully et al., Clinical Science 2003; 104:641–7).[CrossRef][ISI][Medline]

Robin spends ever-increasing hours watering his garden, but as yet the greenhouse effect has not progressed sufficiently to allow him to grow palm trees. One might, therefore argue, in a parochial and xenophobic way, that septic arthritis caused by Pantoea agglomerans after a palm tree thorn injury is something that should appear in the Journal of Overseas Curiosities, but Robin is prepared to concede the growing readership of this journal worldwide make it a necessity that he includes it (Kratz and colleagues, Arch Dis Child 2003; 88:542–4).[Abstract/Free Full Text]

Who knows what Behçet's disease is, but Kaburaki et al. (Graefe's Arch Clin Exp Ophthalmol 2003; 241:353–8)[ISI][Medline] report that disease activity is closely linked to cell-associated IL-8. What Robin wants to know, of course, is whether this is a test that is diagnostic for the disease, but with so many interleukins about these days he is prepared to be disappointed. Indeed he reads that inhibition of IL-17 may prevent Borrelia arthritis in mice (Burchill et al., Infection and Immunity 2003; 71:3437–42).[Abstract/Free Full Text] He had a dream a little while back in which the whole thing became clear (rather like the ‘Lost Chord’) but awoke to find his secretary wheeling in a mountain of BSR TNF-{alpha} register follow-up forms. It has been over 30° in his office lately, so it is not only the computer that has been overheating. Roll on winter!





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