19 e-Letters

  • “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.

  • 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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  • Correspondence on “Rheumatoid arthritis prevention: any takers?”

    Correspondence on “Rheumatoid arthritis prevention: any takers?”
    We read with great and special interest the editorial recently published in Rheumatic and Musculoskeletal Diseases by Falahee and Raza. 1 The authors clearly and elegantly state the clinical context in relation to current and potential interventions aimed to delay the onset, reduce the likelihood, or mitigate the severity of rheumatoid arthritis (RA). In addition, the authors present some data based on the perspectives and preferences of individuals who had participated in clinical trials aimed to achieve RA prevention and, on the challenges, related to recruitment for the research community as well. 2
    Preventive strategies targeting RA—especially in the preclinical phases—have recently been developed. Currently, this is an exciting field of research on chronic diseases and more specifically in the field of rheumatology to delineate interventions to modify or at least to delay the onset of RA. There is information provided in the literature related to assessing therapeutic approaches based on pharmacological interventions, such as glucocorticoids, 3 methotrexate, 4 hydroxychloroquine, 5 statins, 6 B cell directed therapy 7 and T-cell co-stimulation modulation. 8
    In contrast, studies on non-pharmacological preventive strategies in high-risk populations for RA are scarce. Thus, some cohort studies are exploring the efficacy of the modification of risk factors previously established as potentia...

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  • Colchicine- A dying hope?

    Dear Editor

    The small randomized clinical trial by Lopes MI et al. has shown a meaningful benefit of colchicine in COVID- 19 patients. However, there are ambiguities in the written study design including the techniques opted for allocation concealment, blinding, and sample size calculations with six primary endpoints. Investigators were not able to analyze four major endpoints including mortality rate, causes of mortality, admission to ICU, and length of stay in ICU [1]. These results became hard to compare with other major studies such as preliminary findings of the RECOVERY trial where investigators have closed the recruitment of colchicine arm. There was no convincing evidence of mortality benefit in the colchicine group. Final results will show more data on secondary outcomes such as length of hospital stay and need for invasive mechanical ventilation [2].
    This may not be the end of the road for colchicine as 26 study groups have been registered with clinicaltrial.gov to prove the beneficial effects of colchicine in COVID patients. At least four of these studies have already been completed. Preprint data from the COLCORONA trial shows a controversial conclusion of reduction in composite rate of death or hospitalization with colchicine in PCR confirmed non hospitalized patients [3]. Another small size COLORIT trial by Mareev V.Yu. et al. showed the median SHOCS score decreased from 8 to 2, i.e., from a moderate to a mild degree in the colchicine group. The...

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  • Viral or Reactive Arthritis?

    Dear Editor,
    We have read with interest the paper written by Dr. Keisuke Ono et al [1] whose title is “Reactive arthritis after COVID-19 infection” and we would like to share some medical thoughts we have concerning its content.
    In this paper, a male patient was admitted with COVID-19 pneumonia. On day 21, he developed an acute bilateral arthritis in his ankles, with mild enthesitis in his right Achilles tendon; given the circumstances and having excluded all the other plausible factors that might be related with this onset, the authors stated that such elements were given by a reactive arthritis whose primer was SARS-CoV-2.
    Regarding the definition of reactive arthritis (ReA), we would like to highlight some doubts and we belive that this element is contradicts the nature of ReA itself; first of all, as of today, ReA is to be given by bacterial infections only, should they be STDs-related or gastrointestinal. No viral agent has ever been either directly or indirectly linked to such element due to its pathogenesis. As Dr. Rebanta K. et al. properly stated in their papers, when ReA- associated invasive bacteria reach the systemic circulation, T lymphocytes are induced by bacterial fragments such as lipopolysaccharide and nucleic acids; These elements activate cytotoxic-T cells then attack the synovium and other self-antigens through molecular mimicry. It is believed that anti-bacterial cytokine response is also impaired in ReA, resulting in the decreased e...

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