eLetters

8 e-Letters

published between 2018 and 2021

  • 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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  • Systemic glucocorticoid use in the C-VIEW study

    Dear Editor,

    I read with interest the results of the C-View study (1). In the study it is reported that 17 patients (19%) were on systemic glucocorticoids in the 48-week pre-baseline period, and 6 patients (7%) used systemic glucocorticoid in the certolizumab (CZP) treatment period. The report does not elaborate on the median dose used by each of these groups of people. Adverse events are increase with increasing doses of systemic glucocorticoid and reporting these doses would be of value to help assess the results of the trial.

    High doses in the pre-baseline period and low doses in the treatment period could have the effect of reducing the estimated treatment effect of CZP on acute anterior uveitis (AAU). Low doses in the pre-baseline period and high doses in the treatment period could have the opposite effect.

    In addition, it was reported that five patients (6%) entered the CZP treatment period with an AAU flare. It was not reported how these patients were assessed for the outcome. Were these flares on entry assumed to be a flare in the CZP treatment period or were only new onset flares in the CZP treatment period counted towards flares in the CZP treatment period?

    Philip C. Robinson
    University of Queensland, Brisbane, Australia

    1. van der Horst-Bruinsma I, van Bentum R, Verbraak FD, Rath T, Rosenbaum JT, Misterska-Skora M, et al. The impact of certolizumab pegol treatment on the incidence of anterior uveitis flares in patients w...

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  • Influence of body mass index on disease activity and therapeutic response in patients with axial spondyloarthritis

    Dear Editor,
    Jean W. Liew and collaborators recently reported a systematic literature review and meta-analysis comprising the association of body mass index (BMI) on disease activity in axial spondyloarthritis (axSpA) [1]. We consider these data very interesting, as BMI is a modifiable factor. The inclusion criteria defined by the authors were based on the following issues: 1) ankylosing spondylitis, non-radiographic axSpA or all spondyloarthropathies; 2) BMI as primary exposure; 3) a validated measure of disease activity or treatment response, measured by BASDAI or ASDAS as the primary outcome. The search date was 15th December 2019. The authors selected 20 articles for full-text review but then excluded 7 articles, three for not having the primary exposure or outcome of interest, three for not reporting disease activity stratified by BMI at baseline and one for incomplete reporting results (no references provided). Finally, the authors included 13 observational studies in the qualitative analysis and 12 studies in the quantitative meta-analysis. In spite of the broad literature search strategy employed by the authors, at least one article is missed in the included studies, which may reduce the strength of the final conclusions.
    Our research group published a manuscript, last February 2019 in the journal Arthritis Research and Therapy, attending this issue [2]. This reported the results of a prospective observational study including a total of 180 patients wit...

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  • The effect of glucocorticoids on bone health in rheumatoid arthritis

    To the Editor,

    I read the article by Hua et al.1 that was published in this journal with great interest. The authors provided an excellent review of the literature regarding the clinical efficacy and toxicity of glucocorticoids (GCs) in rheumatoid arthritis (RA). The review included comprehensive discussion about the efficacy of GCs as a bridging therapy in addition to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) based on the rapid onset of action of these drugs.1 The authors advocate that because even low-doses of GCs might have adverse effects, administration of these drugs should be restricted to the lowest dose for the shortest time.1 The first part about the effectiveness of GCs was well documented and convincing; however, the second part about the safety of these drugs seemed a little less convincing. This might be attributed to the fact that a small number of studies on the safety of GCs have been published. In particular, little evidence regarding bone-related adverse effects has been presented. We have obtained very preliminary data in our hospital about the effects of GCs on bone health, including fractures and osteoporosis, and would like to contribute these as a comment.

    We retrospectively reviewed the medical records of 883 patients with RA who visited our hospital in 2018. Of these, 364 patients (41.2%, Figure 1A) were prescribed GCs. At the last visits in 2018, appro...

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