Increased cardiovascular risk in rheumatoid arthritis: mechanisms and implications
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1036 (Published 23 April 2018) Cite this as: BMJ 2018;361:k1036All rapid responses
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Selection bias in BMJ "state of the art" reviews
The title "state of the art" for BMJ published clinical reviews is potentially misleading as these reports are at a high risk of selection bias in relation to the published literature.
The recent review on 'Increased cardiovascular risk in rheumatoid arthritis: mechanisms and implications' (16 June 2018) was restricted to searching only PubMed and identified 2,756 articles.[1] Optimal searching to identify relevant articles for any review needs to include more than one bibliographic database and should also include 'free-text' searching alongside 'controlled vocabulary'. Because only 'medical subject heading' (MeSH) terms were used, only the Medline database has been searched rather than other components of PubMed.
We carried out the same search on Embase [Emtree: “rheumatoid arthritis” and “cardiovascular disease” or “cardiovascular system”] covering the same dates and employed the ‘exclude Medline journals' limit filter. This identified 1,890 results unique to Embase. Without going through all the articles one-by-one it is not possible to identify which 'translational and basic science' studies may have been overlooked by the "state of the art" review. But further searching based on epidemiological study-design identified 40 hits that included two systematic reviews, two randomised clinical trials and one cohort study that were relevant to the review topic.[2-6] The "state of the art" MesH-based search strategy identified none of these five studies, despite two of them being available in PubMed [3, 5].
We are concerned that this reflects a fundamental problem with these clinical reviews. The "state of the art" series was launched in 2014 and the first clinical review included searching Medline, PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL). This high standard has now slipped. Of the 14 BMJ "state of the art" reviews published over the past 12-months, 10 (71%) limited their searching to a single database - almost exclusively PubMed. Only 4 reviews (29%) searched more than one database - all searching three or more databases.
In order to reduce the potential bias identified we suggest that the commissioning and peer reviewing of BMJ “state of the art” clinical reviews should include consideration of the adequacy of the bibliographic database searching.
Emma Whiteley
Medical Student undertaking intercalated MPH
Aberdeen University Medical School
emma.whiteley.13@aberdeen.ac.uk
Paul Manson
Clinical Librarian
NHS Grampian
p.manson@nhs.net
Mike Crilly
Clinical Epidemiologist
Aberdeen University Medical School
mike.crilly@abdn.a.cuk
Competing interests: No competing interests.
References:
[1] England B, Thiele G, Anderson D, Mikuls T. Increased cardiovascular risk in rheumatoid arthritis: mechanisms and implications. BMJ 2018;361:k1036.
[2] Duan H, Heng L, Xiao L, et al. Association of rheumatoid arthritis and the prevalence of metabolic syndrome: An update meta-analysis. Int J Clin Exp Med 2016; 9(9):17334-17344.
[3] Missala I, Kassner U, Steinhagen-Thiessen E. A Systematic Literature Review of the Association of Lipoprotein(a) and Autoimmune Diseases and Atherosclerosis. Int J Rheumatol. 2012;2012:480784.
[4] Komolafe AO, Ally MT, Van Tonder JJ, Greef OB. The anti-inflammatory properties of simvastatin can benefit statin-naive rheumatoid arthritis patients with associated risks for cardiovascular disease. S Afr Fam Pract 2015:57(1):28-30.
[5] Abdollahzad H, Alipour B, Aghdashi M, Jafarabadi M. Coenzyme Q10 supplementation in patients with rheumatoid arthritis: Are there any effects on cardiovascular risk factors? Eur J Integr Med 2015:7(5): 534-539.
[6] Joseph RM, Movahedi M, Dixon WG, Symmons DP. Risks of smoking and benefits of smoking cessation on hospitalisations for cardiovascular events and respiratory infection in patients with rheumatoid arthritis: a retrospective cohort study using the Clinical Practice Research Datalink. RMD Open. 2017;3(2):e000506.
Table: Databases searched in BMJ ‘Sate of the Art’ Clinical Reviews: July 2017 to June 2018
See also for formatting: https://www.researchgate.net/publication/326129377_Selection_bias_in_BMJ...
BMJ "state of the art" review topic area: Databases searched
Autism spectrum disorder: Medline, Embase, CINAHL, PsychINFO, ERIC
Pre-exposure prophylaxis for HIV: PubMed, Embase, CINAHL
Step down chronic asthma drugs: Medline, Embase, Cochrane Central & DSR
Diagnosis and management of neck pain: Medline, Embase, Cochrane DSR, Google Scholar
Perioperative tobacco use treatments: Medline
Cardiovascular risk in rheumatoid arthritis: PubMed
Asthma-COPD overlap syndrome: PubMed
Community acquired pneumonia in adults: PubMed
Pneumonia in children: PubMed
Eosinophilic esophagitis: PubMed
Gut microbiome in systemic inflammatory disease: PubMed
Pulmonary arterial hypertension: PubMed
Robotics in colorectal surgery: PubMed
Secondary peritonitis: PubMed
Cumulative Index to Nursing and Allied Health Literature (CINAHL); Database of Systematic Reviews (DSR); Education Resources Information Centre (ERIC).
Competing interests: No competing interests
In compiling their extensive review England et al.(1) cast a rather narrow net, using only “the MeSH terms ‘rheumatoid arthritis’ and ‘cardiovascular disease’ or ‘cardiovascular system’”. Considering the common denominator that emerged as a major focus, namely, “shared inflammatory mediators”, and the fact that so many other widespread and devastating diseases such as diabetes and cancer are linked to inflammation, it would seem that looking upstream for causes of inflammation rather than downstream toward specific sequelae and treatment regimens for RA and CVD might be more fruitful in identifying common threads and hopefully, better prevention and treatment strategies.
In particular, the simple amino acid glycine is emerging as a key endogenous regulator of inflammation, via direct action on the plasma membranes of macrophages and other effector cells. These glycine receptors are actually glycine-gated chloride channels, by which glycine allows for chloride influx, stabilizing membrane resting potential, and thus raising the threshold for activation to produce an impressive array of poisons necessary to repel a microbial infection. The resulting inflammatory response, when exaggerated and chronic, seems to lie at the root of the chronic diseases under consideration here.
The critical importance of glycine in regulating macrophages—the chief cellular mediators of inflammation—was presaged by of the Thurman group at UNC Chapel Hill back in 1999 (2). They established the presence of classical glycine receptors on different types of macrophages. They reported that Glycine concentrations up to 1 mM in the culture medium blunted—but did not abolish--the exaggerated macrophage response activation to bacterial lipopolysaccharide (2) This was demonstrated to be due to the glycine-mediated influx of chloride ions, which inhibits the depolarization of the membrane that initiates macrophage activation. In 2001 the Thurman group established the role of glycine—acting via the glycine receptor—in preventing disease in a standard rodent model of rheumatoid arthritis (3). Hence, a deficiency in glycine (i.e., levels below the range of approximately 0.5 – 1 mM (2), even though the normal range of plasma glycine is typically 0.1 – 0.4 mM) may predispose macrophages to exaggerated inflammatory responses to stimuli, and thus to the onset of a multiplicity of diseases rooted in chronic inflammation. More recently, the widespread availability of metabolomics has generated many studies showing an inverse relationship between plasma glycine concentration and prediabetes and diabetes (4), cardiovascular disease (5,6) and cancer (7). With regard to cardiovascular disease in particular, note that glycine receptors have also been identified in vascular endothelial cells, platelets (aggregation of which is inhibited by glycine), and cardiomyocites (in which glycine improved survival after reperfusion injury in an experimental rat model(8)).
More recently, I have detailed (9) how glycine levels tend to be historically low due to the typical omnivorous diet that is high in(methionine-rich) muscle meats, to the exclusion of the glycine-rich collagen of bone and connective tissue. Thus, while the intake of all amino acids—including glycine—is historically high, the relative depletion of plasma glycine (which is needed for the clearance of excess methionine) among meat-eaters, was recently demonstrated in an Oxford arm of the EPIC study (10).
Since glycine is a simple bulk nutrient, it would seem that investigation of its potential in the prevention and reversal of arthritis and cardiovascular disease, as well as other inflammatory conditions, may provide safer and more cost effective solutions than traditional pharmacological approaches.
Correspondence to: joelbrind@yahoo.com
References cited
1.England BR, Thiele GM, Anderson DR, Mikuls TR. Increased cardiovascular risk in rheumatoid arthritis: mechanisms and implications. BMJ 2018;361:k1036.
2.Wheeler MD, Ikejema K, Enomoto N, et al. Glycine: a new anti-inflammatory immunonutrient (Review). Cell Mol Life Sci 1999;56:843–856
3.Li X, Bradford BU, Wheeler MD, et al. Dietary glycine prevents peptidoglycan polysaccharide-induced
reactive arthritis in the rat: role for glycine-gated chloride channel. Infect Immun 2001;69:5883–5891. DOI: 10.1128/IAI.69.9.5883–5891.2001
4.Guasch-Ferré M, Hruby A,Toledo E, et al. Metabolomics in Prediabetes and Diabetes: A Systematic Review
and Meta-analysis. Diabetes Care 2016;39:833–846. DOI: 10.2337/dc15-2251
5.Ding Y, Svingen GFT, Pedersen ER, et al. Plasma glycine and risk of acute myocardial infarction in patients with suspected stable angina pectoris. J Am Heart Assoc. 2016;5:
e002621 doi: 10.1161/JAHA.115.002621
6.Hartiala JA, Tang WHW, Wang Z, et al. Genome-wide association study and targeted metabolomics identifies sex-specific association of CPS1 with coronary artery disease. Nature Comm 2016; DOI: 10.1038/ncomms10558
7.Osman D,, Ali O, Obada M., et al. Chromatographic determination of some biomarkers of liver cirrhosis and hepatocellular carcinoma in Egyptian patients Biomed Chromatogr.2017;31. doi: 10.1002/bmc.3893. Epub 2016 Dec 28.
8.McCarty MJ, DiNicolantonio JJ. The cardiometabolic benefits of glycine: Is glycine an ‘antidote’ to dietary fructose? Open Heart 2014;1:e000103. doi:10.1136/openhrt-2014-000103
9.Brind J. Re: Cancer risk associated with chronic diseases and disease markers: prospective cohort study. BMJ 2018;360:k134
10.Schmidt JA, Rinaldi S, Scalbert A, et al. Plasma concentrations and intakes of amino acids in male meat-eaters, fish-eaters, vegetarians and vegans: a cross-sectional analysis in the EPIC-Oxford cohort. Eur J Clin Nutrition 2016;70:306–12. doi:10.1038/ejcn.2015.144
Competing interests: No competing interests
Re: Increased cardiovascular risk in rheumatoid arthritis: mechanisms and implications
We thank Crilly and colleagues for their interest in our State of the Art review and the literature search strategies in the other State of the Art reviews. The State of the Art reviews provide a summary of the literature condensed into an up-to-date review of the topic for clinicians and researchers. The commission is not for a systematic literature review of the topic, and the search strategy is not described as such. There are strengths and tradeoffs for different literature search approaches including reproducibility, exhaustiveness, resources required, and breadth of topic that can be covered, among others. Conducting a systematic literature review of our topic would have necessitated narrowing the scope of the review, which we believe would not have provided readers with an adequate understanding of the breadth of mechanisms and implications of cardiovascular disease in rheumatoid arthritis.
Bryant R. England, MD
Assistant Professor
Division of Rheumatology & Immunology
VA Nebraska-Western Iowa Health Care System
University of Nebraska Medical Center
Omaha, NE, U.S.A
Ted R. Mikuls, MD, MSPH
Umbach Professor of Rheumatology
Division of Rheumatology & Immunology
VA Nebraska-Western Iowa Health Care System
University of Nebraska Medical Center
Omaha, NE, U.S.A
Competing interests: No competing interests