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Background: Male patients with genital warts are known for higher rates of sexual dysfunction. This study was conducted to investigate whether human papillomaviruses (HPV) infection is associated with an increased risk of erectile dysfunction (ED). Methods: Patients aged over 18 with HPV infection (n = 13,296) and propensity score-matched controls (n = 53,184) were recruited from the Longitudinal Health Insurance Database (LHID). The primary endpoint was the diagnosis of ED. Chi-square tests were used to analyze the distribution of demographic characteristics. The Cox proportional hazards regression was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the development of ED in both groups, after adjusting for sex, age, relevant comorbidities, co-medication, and surgery. Results: ED developed in 181 patients of the study group. The incidence density of ED was 2.53 per 1000 person-years for the HPV group and 1.51 per 1000 person-years for the non-HPV group, with an adjusted HR (95% CI) of 1.63 (1.37–1.94). In stratification analysis, adjusted HR of diabetes-, chronic obstructive pulmonary disease (COPD-), and stroke-subgroup were 2.39, 2.51, and 4.82, with significant p values for interaction, respectively. Sensitivity analysis yields consistent findings. Conclusions: The patients with HPV infection had a higher risk of subsequent ED in comparison to the non-HPV controls. The mechanism behind such association and its possible role in ED prevention deserves further study in the future.

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Jain et al acknowledge the increased efficacy of RTX for patients with PR3-ANCA-positive, relapsing disease. The ACR/VF Voting Panel considered all of these factors when developing the recommendation. As the recommendation is conditional, provider and patient-specific factors may influence the choice of therapy.A second issue raised by Jain et al is that treatment with intravenous (IV) pulse CYC is preferable to daily oral CYC because IV pulse CYC has less toxicity. Whether IV pulse or daily oral CYC is a "better" treatment continues to be an area of debate. While the toxicity of a single course of IV pulse CYC is less than that of daily oral CYC (1), the benefit of this difference is unclear, because patients treated with IV pulse CYC have a significantly higher rate of relapse compared to those treated with daily oral CYC (2), and may need additional treatment. A single course of CYC can also have impactful, long-term consequences, such as affecting ovarian reserve (3). Because the toxicity of CYC can be dependent on the cumulative dose, duration of therapy with daily oral CYC is now usually much shorter than previously employed (e.g., 3 months versus 6 months). The toxicity of daily oral CYC may also be mitigated with proactive monitoring strategies (e.g., obtaining blood cell counts every 1-2 weeks during treatment). Based on these considerations, it is difficult to determine whether IV pulse or daily oral CYC should be preferred. Since both are valid options, physician experience and patient preferences should guide the choice of treatment.The impact of treatment with RTX on COVID-19 infection and vaccine response is important to consider. Jain et al suggest that CYC is a "safer" medication than RTX during the COVID-19 pandemic. Currently, there are not sufficient data published to determine how outcomes of COVID-19 infection differ in patients treated with CYC compared to those treated with RTX. As a B cell-depleting agent, RTX is known to substantially affect antibody responses to COVID-19 vaccination. However, patients with GPA treated with CYC also develop substantial B cell lymphopenia, which can extend past discontinuation of CYC, and can also experience a reduction in B cell function (4,5). Thus, treatment with CYC may also impair vaccine responses. Because therapy with CYC or RTX to induce remission is typically given in conjunction with high-dose glucocorticoids, the relative safety of RTX or CYC use during the COVID-19 pandemic may not be easily determined.Cost is also an appropriate factor to consider in making treatment decisions. These guidelines are based on practice in the United States, and thus the recommendations may need to be adjusted by physicians in other countries based on several factors, including costs and drug availability.The comments of Jain et al highlight many of the unanswered questions that remain when considering treatment options for patients with AAV, as well as the challenges of treating these diseases during the COVID-19 pandemic. The published recommendations were devel...

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Quality of life and productivity loss in patients with ankylosing spondylitis using tumor necrosis factor inhibitorsDear Editor,We have read with great interest the article by Lee et al 1 reporting a comprehensive understanding of the real-world treatment patterns of tumor necrosis factor inhibitor (TNFi) in patients with ankylosing spondylitis (AS) and productivity loss, treatment satisfaction, and associated factors. There are 4 TNFi considered in this study, including infliximab, adalimumab, etanercept, and golimumab. The advantage of this study was that the data collected is extremely detailed and novel, including annual household income, education, and body mass index, which helps us know more about this issue from a different perspective and may arouse much attention to the issue that has usually been neglected previously. However, we found some concerns that we hope to be answered.

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