Aortic-vertebral interaction in inflammationDear editor, We read with great interest the article by Chen et al., in which the aortic-vertebral interaction was proposed in the context of inflammation. 1 The study suggested that inflammation may promote ossification and was linked to a large aorta ipsilateral ratio of the osteophytes. This topic has significant clinical relevance, and future cohort studies covering various aspects are needed to further validate the findings in this study.First, it is important to note that baseline demographics and comorbidities may have influenced the study observations. At Shanghai Renji Hospital between 2013 and 2021, the percentage of male participants in the Takayasu's arteritis (TKA) group, the ankylosing spondylitis (AS) group, the coronary artery disease (CAD), and the diffuse idiopathic skeletal hyperostosis (DISH) group were 38.7%, 65.4%, 70%, and 60%, respectively, compared to 50% in the healthy controls (HC). Male sex may have been a potential confounder, as previous research has suggested that males are at a greater risk of AS, CAD, and DISH 2 than females. Therefore, adjusting or stratifying for sex 3 could provide insights into whether male sex was a mediator or a confounder in the causal relationship between inflammation and radiographic phenotypes. In addition, since inflammation was proposed as a key component in this study, it would be valuable to consider the presence of inflammatory diseases or autoimmune diseases 4-7 such as rheumatoid arthritis, 8-12 psoriasis, 13-15 psoriatic arthritis, [16][17][18] Sjogren's syndrome, 19,20 fibromyalgia, 21,22 periodontitis, 22-28 or other diseases with osteophytes such as osteoarthritis, 23,29,30 as potential effect modifiers.The second issue to be addressed is the potential impact of unmeasured confounders on the observed findings. For example, the article did not report on the common medications used to manage AS and TKA, which are known to reduce C-reactive protein (CRP) levels and heterotopic ossification. These medications include nonsteroidal anti-inflammatory drugs (NSAIDs), which are commonly used to manage AS and recommended as a prophylactic regimen for postoperative heterotopic ossification. 31,32 Similarly, the use of tumor necrosis factor (TNF) alpha inhibitors and interleukin-17 inhibitors may inhibit tenascin-C from affecting aorta-vertebrae remodeling. 1Additionally, low doses of corticosteroids have been found to significantly reduce CRP levels, 33 which can also affect the aorta ipsilateral ratio or observed radiographic progression. Therefore, stratification or adjustment of treatments and medications may clarify whether the observed results were caused by the disease or were modified by the use of medications in these patients. Such analyses could provide evidence regarding the safety and efficacy of NSAIDs, steroids, and biologic disease-modifying antirheumatic drugs (DMARDs) 8,16,32,34 in patients with AS, TKA, DISH, or CAD, which could improve patient care and patient education 6,35,36 on drug safety...
Comment on evaluation of patients with antiphospholipid syndrome subsequently COVID-19 vaccinations: A retrospective cohort studyDear Editor, We read with great interest the article by Karakaş et al 1 regarding the evaluating development of side effects, which conclude thrombotic or obstetric complications, in antiphospholipid syndrome (APS) 2 patients after COVID-19 vaccinations, BNT162b2 and CoronaVac.We appreciate the authors' valuable contribution in analyzing the association between APS and COVID-19 vaccinations. However, there are some points that should be further discussed.First, according to previous study, among those 35 patients, the proportion of patients in this study using antiaggregant or anticoagulant (acetylsalicylic acid n = 16, 59.3% and warfarin 16 48.5%) is significant. The different APS drug might prevent patients from developing thrombotic complications. Therefore, we recommend the authors to conduct extra analyses by acetylsalicylic acid and warfarin. Also, there is doubt whether anticoagulation in COVID-19 vaccination is safe or not. After vaccination, some patients are at the increasing risk of supratherapeutic levels and subtherapeutic levels. 3 Further, in this study, it is unconfirmed how the state of those 35 patients is. The different disease situation greatly influences the occurrence of recurrent thromboses, 4 mainly affecting large vessels, which cause confounding bias.Further, the median (min-max) age was 43 (28-63) years among all the patients. The incidence of thrombosis increases with age because of vascular calcification. 5 In particular, the difference between all age groups after COVID-19 vaccination is significant. 6 Therefore, we cannot confirm the direct association between APS and vaccination. We also notice that there are 33 female patients and 2 male patients among all the patients. However, in this study, the difference between the 2 genders was not considered. We know that APS mostly occurs in females but if we abandon the male group, it will cause selection bias. On account of this potential confounder, we suggest the authors could include more male patients and arrange the patients into 2 groups on the basis of gender.In short, we appreciate the authors' valuable contributions by a retrospective cohort study of evaluation of patients with APS subsequent to COVID-19 vaccinations. On top of that, the authors adjusted for a wide range of covariates to minimize the effects of confounding. We believe that by taking the aforementioned points into account, the study could provide more detailed information.
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