Revisiting rheumatology 2009
Nonspecific low back pain: A systematic review has shown that spinal fusion surgery is more effective than unstructured nonsurgical care, but equally effective compared to intense multidisciplinary rehabilitation for patients with persistent nonspecific low back pain.[Spine (Phila Pa 1976) 2009;34:1094].
Carpal tunnel syndrome: A randomized controlled trial with 116 patients has demonstrated that surgical decompression for carpal tunnel syndrome is more effective than nonsurgical treatment consisting of multimodal interventions. [Lancet 2009;374:1074]
Fibromyalgia: Compared with control pain free subjects, fibromyalgia patients have both significantly greater neurologic symptoms and abnormal neurologic findings on detailed neurologic examination. [Arthritis Rheum 2009;60:2839]
Osteoporosis: Vertebroplasty: In two short-term, blinded trials comparing vertebroplasty with a sham procedure in patients with osteoporotic vertebral compression fractures, there was no immediate or delayed benefit of vertebroplasty for the reduction of pain. [N Engl J Med 2009;361:557]
Denosumab: In the FREEDOM trial (7868 postmenopausal women with bone mineral density T scores between -2.5 and -4.0 at the lumbar spine or total hip), denosumab, a humanized monoclonal antibody against RANK-ligand that reduces osteoclastogenesis, compared with placebo significantly reduced the incidence of new vertebral (2.3 versus 7.2 percent), hip (0.7 versus 1.2 percent), and non-vertebral fractures (6.0 versus 8.5 percent). [N Engl J Med 2009;361:756]
Rheumatoid Arthritis: Switching to a second TNF inhibitor is effective in patients with rheumatoid arthritis who do not respond adequately to initial TNF inhibitor treatment. In a trial of golimumab as the second agent8 461 patients with active RA despite prior use of at least one TNF inhibitor were randomly assigned to golimumab (50 or 100 mg every four weeks) or placebo, while continuing stable doses of baseline DMRD (MTX, SSZ, and/or HCQ), glucocorticoids, and NSAIDs. Patients receiving golimumab were significantly more likely to achieve an ACR20 response at week 14. [Lancet 2009;374:210]
Letters to the editor
1. Dear Dr. Aggarwal, Here is a synopsis of the Foundation Course in Palliative Care: CanSupport and Institute Rotary Cancer Hospital, AIIMS invite you to attend the 9th Annual Foundation Course in Palliative Care at New Delhi. Basic Foundation Course in Palliative Care 23 & 24 January 2010; Advanced Course in Palliative Care for Nurses 30 January 2010; Workshop on Psychosocial Issues in Palliative Care 31 January 2010. email@example.com
2. The new pandemic H1N1 flu may cause blood clots and other unusual damage in the lungs and physicians need to be on the lookout. Two studies published in the American Journal of Roentgenology show the need to check X-rays and CT scans for unusual features, and also point out swine flu can be tricky to diagnose in some of the sickest patients. H1N1 flu is causing a pandemic, and while it is not particularly deadly, it is sickening many younger adults and older children who usually escape the worst effects of seasonal flu.
It is therefore essential that clinicians be able to recognize possible cases of pandemic H1N1 influenza in high-risk groups so that they order the appropriate diagnostic tests, begin specific antiviral therapy, and prepare to provide intensive supportive measures as needed (Dr. Daniel Mollura of the National Institutes of Health Clinical Center in Maryland)
One middle aged man who died was not diagnosed until after death, but unusual findings on his X rays may be able to help physicians save other, similar patients. A CT scan showed irregularities called ground-glass opacities in the patient's lungs. Although the patient was severely ill and had a fever, he tested negative for flu and doctors did not treat him for it.
The man died five days after he went into the hospital and the autopsy confirmed he had swine flu. The lung lesions seen on his CT scan matched lung damage done by the virus.
In another study in the same journal, CT scans of patients with severe cases of swine flu showed many had pulmonary emboli, a team at the University of Michigan found. Dr. Prachi Agarwal and colleagues examined 66 patients diagnosed with H1N1, 14 of them who were in the intensive care unit. All 66 got standard X-rays. They performed CT scans on 15 of the patients, 10 of them who were in the ICU on ventilators. Five of the ICU patients had blood clots in the lungs.
The study reported that patients who are severely ill with H1N1 are also at risk for developing pulmonary emboli, which should be carefully sought for on contrast-enhanced CT scans. Anticoagulant drugs can break up these clots. The majority of patients undergoing chest X-rays with H1N1 have normal radiographs. Pulmonary emboli are also not normally seen in flu. CT scans proved valuable in identifying those patients at risk of developing more serious complications as a possible result of the H1N1 virus, and for identifying a greater extent of disease than is appreciated on chest radiographs. Dr. Vivek Chhabra.