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Systemic vasculitides.

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LETTERS
847
out issues of selection, study design, and analysis that may
be insightful.
First, there are certainly differences in patient selection between the study by Lockshin et a1 (1) and ours (3).
Our study included 3 women whose diagnosis of SLE was
first made while they were pregnant, but omitting them does
not change our results (P = 0.006 for the comparison with
after-pregnancy flare rate; P = O.OOO1 for the comparison
with nonpregnant flare rate). Our study included a higher
percentage of blacks, although we did not find a difference in
flare rates between our black and white patients. We wonder, as does Dr. Lockshin, if the higher percentage of
patients with antiphospholipid antibodies in his study (who
may have been taking a preestablished dosage of prednisone)
and the higher percentage of miscarriages (and therefore
foreshortened pregnancies) may be among the reasons for
the differing results.
Second, our study used a quantified definition of flare
that includes the entire spectrum of disease activity, from
none to mild to moderate to severe (4). Although, as Dr.
Lockshin states, 8 of the flares (30%) that occurred during
pregnancy reflected a change from no activity to mild
activity (and 6 of these 8 did not necessitate an increase in
prednisone dosage), our 2 comparison groups also included
patients whose flares were from no activity to mild activity.
Omitting these no-activity to mild-activity flares does not
change our results (flare rate 1.05/person-year for pregnant
patients, 0.53/person-year for nonpregnant patients; P =
0.005). Similarly, although a patient in the pregnancy group
could have more than one flare (and 4 did), the patients in the
comparison groups also could have more than one flare.
Omitting the second flare that occurred in 4 patients does not
change our results (P = 0.008 for the comparison with
after-pregnancy flare rate; P = 0.003 for the comparison with
nonpregnant flare rate).
Third, we included renal (detailed in our Table 3) and
hematologic system flares, but only after first carefully
reviewing these flares to justify their attribution to lupus and
not to pregnancy-induced hypertension.
We believe that our results, and those of others (5),
justify again raising the question of the biologic basis of
increased SLE activity during pregnancy. Recent work on a
possible exacerbating role of prolactin in animal models of
lupus (6,7) and in human pregnancy (8) is particularly
relevant to this issue.
BOOK REVIEWS
divide the vasculitides into primary and secondary disease
categories. The editors address the heterogenous clinical
manifestations of these diseases by broadening the spectrum
of disease expression within the recognized vasculitic syndromes, rather than by defining “overlap” groups as some
have done. They successfully blend the contributions of
authors with a variety of experiences and perspectives, into
a well-organized book. The individual chapters fit well into
the overall format of the book and appropriately reflect the
editors’ approach to classification.
The sections 00 pathology of the vasculitic syndromes are unquestionably the strength of this book. Detailed discussions of light, electron, and immunofluorescence microscopy findings, as well as the results of autopsy
studies, are included where appropriate. The written text is
liberally illustrated with more than 270 pictures, over 150 of
which are color reproductions. Generally, the full histo-
Systemic Vasculitides. Edited by Andrew Churg and Jacob
Churg. New York, Igaku-Shoin, 1991. 389 p p . Illustrated.
Indexed. $1 75.
Systemic Vasculitides is a detailed review of current
information on inflammatory diseases of blood vessels. As
recognized authorities on the pathology of the lung and
kidney, Drs. Andrew Churg and Jacob Churg are uniquely
qualified to provide editorial oversight for such a work.
Like all who endeavor to provide an overview of this
heterogenous group of diseases, the editors recognize that
the classification of the vasculitides is problematic and is
significantly limited by the current level of knowledge of
disease-associated pathologic mechanisms. They elect to
Michelle Petri, MD, MPH
Johns Hopkins University School of Medicine
Baltimore, MD
John Repke, MD
Brigham and Women’s Hospital
Boston, MA
1. Lockshin MD, Reinitz E, Druzin ML, Murrman M, Estes D:
2.
3.
4.
5.
6.
7.
8.
Lupus pregnancy: case-control prospective study demonstrating
absence of lupus exacerbation during or after pregnancy. Am J
Med 77:893-898, 1984
Lockshin MD: Pregnancy does not cause systemic lupus erythematosus to worsen. Arthritis Rheum 32:665-670, 1989
Petri M, Howard D, Repke J: Frequency of lupus flare in
pregnancy: the Hopkins Lupus Pregnancy Center experience.
Arthritis Rheum 34:153&1545, 1991
Petri M, Genovese M, Engle E, Hochberg M: Definition, incidence, and clinical description of flare in systemic lupus erythematosus: a prospective cohort study. Arthritis Rheum 34:937944,1991
Zulman J1, Tala1 N , Hoffman GS, Epstein WV: Problems associated with the management of pregnancies in patients with
systemic lupus erythematosus. J Rheumatol7:37, 1980
McMurray RW, Keisler D, lzui S, Hoffman RW, Walker SE:
Postpartum disease activity in the female B/W mouse model of
SLE (abstract). Arthritis Rheum 34 (suppl9):S163, 1991
McMurray RW, Keisler D, Walker SE: Hyperprolactinemia
accelerates disease activity in the male NZBW mouse model of
SLE (abstract). Arthritis Rheum (suppl 9):S163, 1991
Jara-Quezada L, Lavalle C, Fraga A, Gbmez-Sanchez C, Silveira
LH, Martinez-Osuna P, Germain BF. Espinoza LR: Prolactin,
immunoregulation and autoimmune diseases. Semin Arthritis
Rheum 20:273-284, 1991
BOOK REVIEWS
pathologic spectrum of vasculitis is demonstrated in the
photomicrographs, which include examples of early, fully
established, and healing lesions. In addition to the “classic”
histopathologic findings, examples of atypical or less common lesions are frequently included. The extensive use of
figures effectively amplifies the written text on pathologic
findings. Although the legends provide adequate detail for an
understanding of the findings shown in most of the figures,
nonpathologist readers might have benefited from a greater
use of arrows or pointers in some of the pictures. The
sections on clinical expression of disease are detailed with a
systematic review of appropriate literature. The sections on
treatment tend to provide more of a synopsis, rather than a
detailed approach to therapeutic management.
The book also successfully addresses a very important area of concern: the need for effective communication
between pathologists and clinicians in assessing a patient
with systemic vasculitis. The recent publication of the American College of Rheumatology criteria for the classification
of vasculitis (Hunder GG, Arend WP, Bloch DA, Calabrese
LH, Fauci AS, Fries JF, Leavitt RY, Lie JT, Lightfoot RW
Jr, Masi AT, McShane DJ, Michel BA, Mills JA, Stevens
MB, Wallace SJ, Zvaifler NJ: The American College of
Rheumatology 1990 criteria for the classification of vasculitis. Arthritis Rheum 33:1065-1144, 1990) has served to
emphasize the importance of combining clinical and pathologic information in establishing the correct diagnostic category. Pathologists reading this book should acquire a renewed appreciation for the importance of interpreting
histopathologic data within a clinical perspective. Because
of the detailed descriptions and the effective use of figures in
the sections on the pathology of the vasculitides, clinicians
should be able to discuss histopathologic findings knowledgeably with the pathologists. Due to the multisystemic
nature of the vasculitides, a variety of clinicians, including
primary care physicians, pediatricians, internists, and subspecialists including dermatologists, pulmonologists, nephrologists, immunologists, as well as rheumatologists, will
find this book to be a useful reference resource. Of note, Dr.
Andrew Churg has previously emphasized the importance of
communication between pathologists and clinicians (Churg
A: Pathologist and pulmonologist: ever the two shall meet?:
Hum Pathol 17:763-764, 1986).
In Systemic Vasculitides, the editors and contributors have crafted an effective tool for improving the communications between pathologists and clinicians in the area of
inflammatory vessel diseases. This book is destined to
become the classic work on the pathology of the vasculitic
diseases.
Thomas R. Cupps, MD
Georgetown University Medical Center
Washington, DC
A Concise International History of Rheumatology and Rehabilitation: Friends and Foes. George D. Kersley, John Howard Glyn. London, Royal Society of Medicine Services, Ltd.,
1991. 150 pp. (paperback). Illustrated. Indexed. €12.95
(hardback), f 7.95 (paperback).
Certain portions of this friendly book are ascribed to
Dr. Kersley and others to Dr. Glyn, both writing in a
personal and chatty vein. Dr. Kersley discusses the early
years when, in the army in the Middle East, he was an
adviser in physical medicine. Dr. Glyn, who had part of his
rheumatology training at New York University-Bellevue
Hospital, emphasizes the later days and the happy fusion of
rehabilitation and rheumatology in the 1983-minted British
Society of Rheumatology.
The book is neither an “international history” nor a
“history of rheumatology and rehabilitation.” Strictly British in orientation, there is, for example, much more about
the National Health Service and the Arthritis and Rheumatism Council (ARC) than about the growth of either science,
if science they be.
There are excellent photographs of various luminaries, most of the photo legends ending “(Eric Bywaters)”from his collection, no doubt. At least a quarter of the
illustrations are autographed copies of programs, menus, or
wine lists from bygone convivial events. The finale of the
book includes about 150 one-paragraph biographies (with a
number of name misspellings), historical descriptions of
British academic units with professorial chairs, and chronological lists of presidents of international and regional
Leagues Against Rheumatism, as well as society presidents,
orators, and roundsmen.
The introduction notes that histories of the Heberden
Society, the ARC, and the British Association of Physical
Medicine are available or in the works. That is good news.
John L. Decker, MD
NZH
Bethesda, MD
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