Letter To Editor

Rituximab is a monoclonal antibody that targets CD20 on peripheral B cells, depleting them from the circulation and consequently decreasing disease activity. Regarding the safe use of rituximab during pregnancy, it has been shown that significant placental passage of rituximab occurs starting week 16 potentially affecting the development of fetal and neonatal B-cells, and leading to increased predisposition to infections. We describe the first case in Henoch-Schonlein purpura of maternal exposure to rituximab shortly before conception. Follow up neonatal immune studies demonstrated normal B-cell counts and immunoglobulin levels without any serious infectious complications. Given the facts that data from animal studies are inadequate, human studies are lacking, and rituximab is detectable in serum of neonates for up to 6 months, rituximab carries an FDA Pregnancy Category C and is not recommended during pregnancy or lactation. However, based on our case report, together with published cases, it is suggested that rituximab exposure soon before conception or during pregnancy, does not carry serious immunologic effects on the neonate.

A recent study suggested that withdrawal of nonsteroidal antiinflammatory drugs could be possible with only minor intervention. We raise certain issues about the dose of oral glucocorticoids and acetaminophen during the study.

Many rheumatological conditions have a clearly understood aetiology and unequivocal clinical and laboratory features, such septic arthritis. However, a significant number of complex conditions do not. There is uncertainty about what actually distinguishes one disease from health or from another similar disease or within a group of diseases, separating one type of condition from another. Adding to the potential confusion are terms such as disease definition. We have been concerned about the way these three terms (classification, diagnosis and definition) have been used interchangeably in medical publications as well as in medical practice and discuss ways to address this issue.

The "treat to target" (T2T) approach, aiming to manage rheumatoid arthritis (RA) more tightly, is becoming rather popular. This idea was derived from the therapeutic approach used in conditions such as diabetes mellitus (DM), hypertension (HTN) and dyslipidemia. The idea is well taken but there are important caveats which mainly stem from the fact that there are fundamental differences between RA, DM, HTN and dyslipidemia. The same holds true for the medications that we use to manage RA versus the medications used in the other listed conditions.

As practicing rheumatologists, we still have unmet needs in the management of patients with SLE. A major one of these is the lack of a new drug with acceptable profile, which enables the reduction of the steroid dosage in those patients who do not show a good response to immune-suppressive drugs or cannot use these agents because of the serious adverse effects.

Effective Consumer Scale (EC-17) is a new scale to be used in trials of self-management or empowering patients with chronic diseases such as arthritis. Investigators are invited to include this scale in such trials.

Worldwide, gout is the most common inflammatory arthropathy, and its treatment is often complicated by the co-presence of renal insufficiency. Renally impaired gout patients are generally undertreated with urate-lowering agents due to fears of serious side effects, but a recent study suggests that more aggressive treatment may be safer than previously thought.

Rhabdomyolysis may rarely be observed as a complication of dermatomyositis. Here we report a case of paraneoplastic dermatomyositis with rhabdomyolysis as a presentation of lung cancer.

In a recently published article in Current Rheumatology Reports, the ultrasonography features of gout are described in detail. Because most of the ultrasound findings of musculoskeletal diseases are nonspecific and this information is relevant for an objective assessment of arthritis, some points need further discussion.

New criteria to classify rheumatoid arthritis (RA) have been formulated in order to increase the specificity and sensitivity in early RA compared with the 1987 ACR criteria with the ultimate aim of starting effective treatment as early as possible. The aim of this letter is to list our concerns about the methodological problems in the formulation of these criteria and their possible consequences in a real world application.

A recent study suggests that rheumatoid arthritis patients treated with anti TNF-α agents and steroids are at a higher risk for hospitalization for infections compared to those treated with other disease modifying antirheumatic drugs (DMARDs). This conclusion is misleading since the results were clearly due to a selection bias, the comparator group using non-cytotoxic DMARDs having mild disease.

A recent report suggests that FDG-PET/CT is a good alternative to conventional malignancy screening in patients with inflammatory myopathies. However interesting, this may be a premature conclusion, as the equivalence of both strategies for the detection of certain types of cancer still has to be proven. Keywords: Cancer, myositis, PET/CT, screening.

Recently, Boehme and colleagues described a new automated polymerase-chain-reaction- based test for diagnosing Mycobacterium tuberculosis and detecting resistence to rifampin. There are certain issues regarding the sensitivity and specificity calculations in this study, as outlined in the present article.

The New England Journal of Medicine states that it complies with the CONSORT guidelines in reporting clinical trials. However, it does not follow these guidelines in reports of 7 of 13 clinical trials at the Journal website in September 2010. These reports include formal statistical tests to compare baseline characteristics of patients between different study groups. Reasons are cited why this practice is undesirable.

In a report of a multinational trial of a new Sky inhibitor (R788) among patients with rheumatoid arthritis with unsatisfactory response to methotrexate, the authors did not include the baseline methotrexate dose among patients from different geographies. This information is important for a fair assessment of this trial.