Rheumatology 2003; 42: 1277
© 2003 British Society for Rheumatology
Robin Goodfellow (42-10)
The vegetable patch is beginning to look a little forlorn now, but Robin is grateful that some dread disease (or the foxes) have kept the rabbits away. However, wildlife figures prominently in the anecdotalia for the month. One of Robin's longstanding ankylosing spondylitis patients, who has been eating phenylbutazone for decades and has been apparently cured of lung cancer, suddenly developed severe diarrhoea and weight loss. The gastroenterologists left no stone unturned to find the supposed second cancer, but all to no avail. Robin was thus surprised, noting the gloomy correspondence, to find a bright and cheerful patient tripping into the clinic. It transpired he had been watching an Attenborough classic on the gorillas of Longleat and decided that one of these animals had identical symptoms to his own. ‘If it were good enough for gorillas, it were good enough for me!’, he exclaimed, as he announced that all his symptoms had disappeared on the aloe vera tablets that had been given to the leaky primate. These herbs aren't half a puzzle, but a two stone weight gain (just over 12 kg for the metric among you) cannot be in the mind.
Robin has lowered his MRI threshold for shoulders quite dramatically, allowing only one failed injection for rotator cuff lesions before looking for real evidence of damage with a scan (though, to be honest, he is surprised by the number of entirely normal results in patients with classic symptoms and signs). So he was interested to read that post-traumatic impingement doesn't respond at all (
McInerney et al., Emerg Med J 2003; 20: 218–21
And another for the Journal of Failed Treatments. Haake et al. report (
BMJ 2003; 327: 75–7
Will someone please provide an up to date algorithm, flow chart, patient journey or anything to explain to Robin the interaction of all these cytokines and enzymes? No sooner has he got his head around interleukins 1 to infinity than something new hits the stands. Cytosolic phospholipase A2
is the latest chemical to cause a stir in the corpus callosum; it seems to be essential in prostaglandin E2 mediated bone resorption (
Miyaura et al., J Experimental Med 2003; 197: 1303–10), and so we should inhibit it. Robin will await a visit from a drug rep telling him the necessary compound to do this has now been synthesised, but Lily the Pink has perhaps already succeeded. Robin proposes a competition to name it; Cypholip is feeble but suggestive.
Given the enormous price differential between intra-articular steroid and hyaluronic acid injections one might be watching carefully for the evidence base that supports use of the latter. Robin has certainly had some apparently dramatic effects following failure of steroids (and not just in knees), but a recent paper by Leopold and colleagues pours cold water on the idea ( J Bone and Joint Surg 2003; 85A: 1197–1203). More money saved, or larger studies needed?
Rodney Waterworth writes from the other side of the world. There, it appears, doctors and patients are all on first name terms but his secretary's slip of the finger gave him a very special patient: ‘Last week my typist chose to add the letter "T" to a patient called "Chris" so the sentence went "Christ had normal elbow and shoulder mobility"!’ One wonders whether the second coming has come ...
Robin has often wondered what risk factors cause the development of extra-articular features in rheumatoid arthritis. Turesson and colleagues have come up with a large retrospective study examining patients diagnosed between 1955 and 1994 ( Ann Rheun Dis 2003; 62: 722–27) which implicate early disability and smoking. But why?
More, too, on the psychology of pain. In the same issue Nahit et al. (
Ann Rheum Dis 2003; 62: 755–60
Continuing on the theme of political correctness Robin was irresistibly drawn to a series of five articles on the possible deletion of a rheumatological eponym—Reiter's disease ( start with the editorial, Gottlieb and Altman, Seminars in Arthritis and Rheumatism 2003; 32: 207[CrossRef][Medline]). The affair was aired in 2000 by Wallace and Weisman, but this set of articles includes contributions from a clergyman and an historian. For those who are unaware, Reiter was a Nazi who was recommended for prosecution for war crimes after the Second World War (but wasn't). Some feel he should be penalised for his past. Feedback would be interesting (usual address—robingoodfellow_rhu{at}hotmail.com) and Robin will offer no further comment, except to indicate his unease over rewriting history.
Being fond of eponymous names anyway, Robin has always had a fondness for Lesch–Nyhan syndrome, if only to impress students by saying hypoxanthine-guanine phosphoribosyl transferase without tripping up (and he has often wondered whether he could fool some bureaucrat somewhere with a spoof that blinds with long words). Said syndrome being X-linked, it was most interesting to see a case report of a female patient with phosphoribosyl synthetase overactivity causing hyperuricaemia ( Garcia-Pavia et al., Arthritis Rheum 2003; 48: 2036–41[Medline]). As they say ‘Results of enzymatic and genetic studies supported the view that accelerated purine nucleotide and uric acid production in this woman resulted from defective allosteric regulation of PRS activity, which is, in turn, a consequence of a mutation in one of the patient's PRPS1 genes: an A-to-T substitution at nucleotide 578, encoding leucine for histidine at amino acid residue 192 of the mature PRS1 isoform.’
Wow. Enough of fixes of science. Back to the garden. Rosmarinic acid suppresses collagen induced arthritis in mice (Youn et al,
J Rheumatol 2003;30:1203–7 blockade? Robin will abandon his commitment to oncological drug supplies, cut down his yew hedges and switch to rosemary instead.
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