eLetters

12 e-Letters

published between 2021 and 2024

  • Response to the “Letter to the editor regarding non validated patient and radiofrequency technique for facet pain: re: Truong K. et al.” by Van Boxen, K et al.

    We thank you for your interest in the RCT and the comments to the article.

    Regarding the concerns raised around the methodology of the RCT study, we would like to address the following:

    1) Patient selection and blinded diagnostic block.

    All participants received local anesthetics around the anatomic area of the medial branch block posteriorly to the facet joint. As mentioned in the letter, there is an ongoing debate on the sensitivity and specificity of the diagnostic blocks. We believe the volume of local anesthetics used would anesthetize the medial branch nerve at the innervation site of the facet joint. We challenge the notion that with fluoroscopy, it is possible to locate the medial branch nerve more precisely than using anatomic landmarks. However, we do acknowledge the concern of spread to other pain-generators as acknowledged by the responders, there is a significant prevalence of false-positive response of the lumbar MBBs performed conventionally with fluoroscopy and low volume of local anesthetics, or even placebo with saline (1-5).
    Regarding the Consort flowchart, the majority of the 261 patients invited for screening consultation did not receive the offer of a diagnostic block. Any uncertainty was countered by including several spinal levels for treatment.

    2) The intervention technique

    Regarding the high volume of local anesthetics. All participants received the same procedure and setup. The volume of local anestheti...

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  • Is early use of belimumab in systemic lupus erythematosus really advantageous?

    Dear Editor,

    Tani et al. conducted an interesting retrospective analysis, involving a monocentric cohort of patients with systemic lupus erythematosus (SLE) treated with belimumab (BEL), in an attempt to assess outcomes associated with the “early use” of BEL compared to more routinely used, e.g., after immunosuppressors 1. However, this study displays several types of bias and other limitations, which are not sufficiently discussed by the authors.
    First at all, the term “early use”, such as appears in the title of the original, is a bit confusing, since the duration of the disease was 10.1±8.6 years, without significant differences between the groups under comparison. In fact, the original study by Tani et al. is more focused on naïve immunosuppressors versus non IS-naïve ones. The relatively long duration of the disease in the IS-naïve group strongly suggests that it was composed of non-severe patients. The numerically greater number of nephritis cases in the non IS-naïve group, namely 13/80 (16%) vs 1/22 (8%), though not showing any statistically significant difference, reinforces our hypothesis. In this sense, the variables included in the comparison are not enough to conclude that there were no differences in severity between the two groups, especially in light of the fact that SLEDAI is a poor measure of SLE severity. These features make the groups quite difficult to compare, particularly taking into account the small – in fact, very small – sample size...

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  • Letter to the editor regarding non validated patient and radiofrequency technique for facet pain: re: Truong K. et al.

    We congratulate Truong et al. for performing an RCT with long-term follow-up of patients with chronic low back pain. We do, however, have major concerns regarding significant methodological flaws in this study.
    Patient selection is critical in determining outcomes after interventional pain treatments and image guidance is regarded an essential component of performing procedures for pain management. 1 This is in sharp contrast with the present study: the method used to select the target facet joints wasn’t described and patients were diagnosed with facet joint pain based on a blind injection of local anesthetic around the facet joint. This was performed by a single physician using spinous processes as landmarks. Although there is ongoing debate regarding the sensitivity and specificity of diagnostic blocks, this technique lacks validity. 2 Studies have also shown a higher predictive value when medial branch blocks (vs. facet joint blocks) are used as diagnostic tools.
    As a result, the percentage of patients with a positive response after their diagnostic block was extraordinarily high, much higher than the prevalence rate as determined by high-quality studies using rigorous selection criteria. Only 14 out of 261 patients reported a negative test block.2
    Furthermore, studies have shown that even small volumes (< 0.5 mL) of local anesthetic injected under fluoroscopic guidance can lead to false-positive results via the spread of the injectate into pain-...

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  • “In D2T RA patients, rotator cuff tendinopathy increased disease activity”

    We have read with particular interest the article published in your journal, "Patterns of comorbidities differentially affect long-term functional evolution and disease activity in patients with 'difficult to treat' rheumatoid arthritis," where it was demonstrated that the lack of improvement in disease activity and the presence of comorbidities could be predictive factors of difficult-to-treat rheumatoid arthritis (RA). It is noteworthy the effect size that pathologies classified as osteoarthritis have (OR 1.68), even at the same level as the DAS28 ESR at the beginning of biological treatment, whereas soft tissue pathologies were not categorized. (1)
    Rheumatic regional pain syndromes usually affect the shoulder, causing pain and functional impairment. Rotator cuff tendinopathy (RCT) affects the supraspinatus, infraspinatus, subscapularis, and teres minor muscles less frequently and is the most common cause of shoulder pain, present in up to 85% of cases. (2)
    Underdiagnosed shoulder tendinopathy in patients with RA may be associated with elevated clinimetric scores, leading to incorrect treatment of both conditions.
    We conducted a cross-sectional, observational, comparative study from March to April 2022 in patients from the Rheumatology Service at a reference hospital in northern Mexico. The presence or absence of RCT was evaluated through the following tests: painful arc, "drop arm test" for the supraspinatus, internal rota...

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  • Denervation to treat painful OA of the hand

    I have read with much interest the present article and there are some relevant points that I think should be clarified because they completely disagree with the most recent research regarding hand joint denervation or hand neuroanatomy in general.
    Van Der Meulen C. et al don’t recommend joint denervation to treat painful OA of the hand because of a lack of proper trials and studies to support this treatment. However, in that respect, Hustedt JW et al have recently conducted a prospective study confirming that results of both trapeziectomy (suspension arthroplasty) and denervation are identical (1). This, in my opinion, invalidates the authors’ reccomendations -at least- as far as 1st CMCJ denervation is concerned.
    Furthermore, another of the authors’ reccomendations would be a trial to compare surgical denervation to other interventions targeting articular sensory nerves such as radiofrequency ablation. This technique is already used for spinal facet or knee joint painful arthropathies however it is virtually impossible to be performed at hand level because of anatomical reasons. Identification of articular sensory nerves of the hand can only be achieved through accurate surgical exposure because they are very small branchlets arising from bigger sensory and motor branches. They are only visible under loupe magnification and any local radiofrequency ablation in that area would inevitably cause damage to the main nerves that give off these articular sensory fib...

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  • Clarification and suggestion to Gwinnutt and colleagues

    I would like to congratulate and thank you the authors of this insightful publication on rheumatic and musculoskeletal disease. As an author of an included study, I would like to present a clarification and suggestion to Gwinnutt and colleagues regarding this review article.

    Our study, listed as reference 141 of this review 1, was included as a study on the effect of muscle strengthening exercise in patients with rheumatoid arthritis in this review, perhaps it was not precise. This study was an experiment investigating the effect of nerve mobilization exercise in patients with rheumatoid arthritis indeed. Nerve mobilization exercise is a specific exercise for normalizing the mechanical sensitivity and promoting the metabolism of the neural tissue so that pain sensitivity of the neural tissue could be reduced 2,3. This exercise does not involve resistance training, it is usually considered as stretching, mobilization or physical exercise therapy instead.

    Two studies have been published on the effectiveness of nerve mobilization exercise on pain control in patients with rheumatoid arthritis 1,4. In addition, three randomized controlled trials have been published to show the effects of nerve mobilization on pain sensitivity in patients with hand osteoarthritis 5–7. Therefore, Gwinnutt and colleagues may consider adding a subgroup analysis on the effectiveness of nerve mobilization exercise on pain control in patients with rheumatoid arthritis or osteoarthritis...

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  • Correspondence on “Re-examining remission definitions in rheumatoid arthritis: considering the 28-Joint Disease Activity Score, C-reactive protein level and patient global assessment” by Felson et al.

    Dear Editor:
    We read with great interest the editorial by Felson et al. on definitions of remission in rheumatoid arthritis (RA).[1] It gives a comprehensive and historical overview of the development of remission criteria, and provides a well-founded critique of remission criteria based on the 28-joint Disease Activity Score (DAS28). DAS28 has been primarily developed and validated for evaluations at the group level, i.e. for measuring effects in clinical trials. However, in almost forgotten earlier times, when patient remission was rarely achieved, there was a need for a single index, expressing disease activity of the individual patient, and the only instrument available was the 44-joint Disease Activity Score (DAS).[2] When biologicals become available, in many countries of Europe, use of DAS28 as single index of disease activity was also stimulated by health authorities and insurance companies, requiring DAS28 proof of active RA and documented previous treatment failure (or contra-indication) of conventional synthetic DMARDs, before allowing reimbursement of an (expensive) biological drug. Since then, remission has proved to be an achievable goal, and for clinical trials and for individual patients, DAS28 cut-offs have been used for this purpose, especially in Europe, although their limitations for evaluations at the individual patient level have indeed been recognised.[3]
    Moreover, we agree with Felson et al. that patient global assessment (PGA) is a valu...

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  • Colchicine is useful in outpatients, though not in inpatients

    I agree that the evidence shows no benefit from colchicine in hospitalized patients with covid-19. But I am puzzled by the authors' inclusion of the large, high-quality study by Tardif and colleagues, in high-risk outpatients, as a negative trial. It is true that the benefit of colchicine was not statistically significant when patients who did not have documented covid-19 were included in the analyses. But among patients with positive PCR swabs, those who received colchicine were 30% less likely to develop pneumonia and 25% less likely to wind up hospitalized or dead than those who received placebo - statistically significant in both cases.
    https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(21)00222-8/fulltext

  • Vertebroplasty, the child and the bathwater

    Some of the most compelling clinical questions are hardly amenable to experimentation in randomized controlled trials (RCTs). ‘Does vertebroplasty improve health-related quality of life in elderly patients with an acute osteoporotic fracture?’ is one of those questions that was nevertheless challenged in not less than four RCTs recently. The outcome of this challenge was a disappointment for believers in vertebroplasty (VP): one-to-three against VP, and the invasive intervention was discarded from guidelines, as Christian Roux and colleagues have beautifully explained in a recent opinionated review in RMDOpen. [1] Obviously, an unmet need remained and Roux et al. broke a lance for reconsidering VP as a treatment option in highly selected vertebral fracture (VF)-patients with a bad prognosis. They solicited proposals for clinical studies.
    Such studies should not necessarily have an RCT-design. Indisputably, RCTs provide the most unbiased results, but always at the expense of external validity. This is why clinical epidemiologists keep recalling that the absence of evidence (that VP works) does not imply that there is evidence for the absence of efficacy (of VP).
    Roux et al have a point when they claim that the trials may have focused on the wrong population, that the choice of the trials’ primary outcome was not ideal, and that the duration of follow up was too short to detect clinically meaningful effects beyond pain resolution alone. All these objections invol...

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  • Modifying risk factors to prevent RA

    We would like to thank Prof Wilson Bautista-Molano for his interest in our Editorial and for his insightful comments on it. As Prof Bautista-Molano highlights, a number of risk factors for RA have been identified, including smoking, periodontitis and a high BMI. Data that modifying these will have major positive health benefits, including on cardiometabolic outcomes, are strong. It is also tempting to speculate that modifying these will reduce the likelihood of RA development in individuals at risk.

    In designing studies to assess this, it is important to consider when, during the development of RA, these risk factors may exert their effects. For example, data suggest that cigarette smoking may drive the development of ACPA, whereas the transition from ACPA positivity to RA may be dependent upon a different ‘second hit’ (1). If this is indeed the case, then smoking cessation would be relevant as a primary preventive strategy for RA but may be less useful (at least in the context of RA development) when employed as a secondary preventive strategy in ACPA positive individuals (2).

    Assessing the impact of lifestyle and environmental modification on RA development in seronegative first-degree relatives (FDRs) of RA patients (or seronegative individuals identified as being at high risk on the basis of specific genetic / environmental risk factors) will be challenging. A relatively low rate of RA development, and the fact that those who develop RA may not develop i...

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