Rheumatology 2001; 40: 240
© 2001 British Society for Rheumatology
Robin Goodfellow
Salutations from the goblin world. As you already know, Robin is a fibromyalgia agnostic, but he is pleased to see an interesting paper which suggests that it is not related to silicone breast implants, although each is separately related to hypermobility—explain that (Lai et al., J Rheumatol 2000;27:2237–41).[Web of Science][Medline]
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Following on from the ‘Archives of the Blindingly Obvious’ suggested last time Robin proposes another journal called ‘Excerpta Déjà Vu’. This is for things that you read and think ‘surely this is a well-known observation—I've been teaching it for years’. A candidate for this might be the study by Gelber and colleagues
(Ann Intern Med 2000;133:321–8)
Robin is not a doer of epidural injections (never taught, not clear about the science, evidence, etc.), but sends folk off to colleagues for same. But do they get epidurals? It seems they may not. A study out of Portsmouth suggests that without screening to be certain of the needle tip position, only 64% of caudal epidurals are where they are supposed to be
(Price et al., Ann Rheum Dis 2000;59:879–82).
Robin is a bit wary of scleroderma after his amnesic episode, but a case report raises some interesting questions. Pulmonary hypertension can be very nasty and is presently treated with prostacyclin infusions at great cost (and considerable inconvenience to the patients). Prasad and colleagues from the Royal Brompton
(N Engl J Med 2000:343;1342)
Robin is tickled that a number of people have written to him (well, one is a number). Brian Sweetman even suggests that fibromyalgia is a joke disease invented by my alter ego, Puck—but more seriously proposes that it is simply premature (and familial) osteoarthritis. The key, he says, is to ask what was the last thing said to the patient as they left for their appointment, and he offers good money that it will either be ‘I wonder if I have got the same thing as you’ or ‘your knees creak like mine’. Robin is not so sure. A large part of his time is spent trying to decide whether the symptoms complained of are worse than his own and he is quite sure he doesn't have fibromyalgia.
Is it time, Robin wonders, for guidelines on the co-prescription of folic acid with methotrexate? There seem to be as many regimes as there are consultants. In the US of A they may not have been able to elect a President without fuss but almost everyone gets folate; in Europe that is not the case. The evidence points to a reduction of efficacy of the methotrexate when folate is thrown in, but when to throw it? Daily? As a single dose the same day, or the day before the methotrexate? Views (and evidence) would be of interest to this small elf.
Many rheumatologists see patients with neuropathic pain, whether peripheral or in the back, and are gloomy about the prospect of cure. Anti-convulsants may help, and a recent trial (McCleane, The Pain Clinic 2000; 12:81–5) reports reasonable results in chronic interspinous ligament pain using gabapentin. Robin has used it a bit, but the side-effects may be a limiting factor.
At last the UK is signed up to the European Human Rights Act. Robin awaits the first case of a patient with arthritis claiming discrimination or rights abuse for not getting TNF-
when indicated on clinical grounds. No doubt they could cite the ready availability of anything needed for the treatment of AIDS (and, if they live in England or Wales, the reduced per capita expenditure on health compared to sunny Scotland). Oh boy. Perhaps it's not too late to retrain as a lawyer.
Robin considers that after his puff of the igNobel Prizes he ought to redress the balance. This was partly because his mother was doing a quiz that asked for the prizewinner for physics in 1920 and, ever happy to help her win, he visited the Foundation's site (www.nobel.se/index.html). And most excellent it is, too.
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