in the literature.’’ A sentence in the introductionreads: ‘‘This case report describes a colonic perfora-tion that resulted from a VC, a finding that, to ourknowledge, has not been reported previously in theliterature.’’ The conclusion begins with the procla-mation: ‘‘This report discusses the first describedcomplication of cecal perforation from a VC.’’Ironically, a case report also describing colonicperforation caused by VC appeared a few pagesearlier in the very same issue.6 Both cases areimportant in the developing literature for VC be-cause these perforations occurred in one patient5

with a history of inflammatory bowel disease anddaily steroid use, and the second patient6 possesseda rectosigmoid tumor—all known risk factors forbowel injury with subsequent perforation that canbe encountered with traditional colonoscopy.

The likely explanation for this inaccurate priorityclaim is that both reports were at a similar point in thepublication process, and the authors5 would nothave had knowledge of the other case6 that precededtheir paper by only a few pages. The authors did notspecify their literature search strategy, but evena last-minute literature search in the proofing stagewould not have revealed this additional case becauseit would not yet have been published or indexed.Also, this situation might have been overlooked ifthese cases were evaluated by different reviewers oreditorial staff members. And, unfortunately, theauthors encountered a bit of bad luck by the orderin which these two articles were compiled into thatparticular journal issue.

This case is a good illustration of the dilemma thatpriority claims cause authors and editors. Even withan adequate literature search, including a reviewduring the proofing stage, priority claims can some-times be difficult to substantiate because authorsusually lack knowledge of similar in press cases,those published in foreign languages, or ones notindexed. Examples such as this not only illustrate thedilemma of firstedness claims, but they also demon-strate the importance of post-publication peer re-view to improve the accuracy of the literature. Whilenot intending to embarrass authors of erroneouspriority claims, we feel it important to clarify suchsituations to maintain the chronology of the medicalrecord, as best as possible, and to acknowledge theearlier work of others. We are not the first to cautionagainst making priority claims in papers, and weexpect not to be the last.

James Bradley Summers, MS, MDa

Joseph M. Kaminski, MDb

Departments of RadiologyUniversity of South Alabama Medical Centera

Mobile, AlabamaMedical College of Georgiab

Augusta, Georgia

Correspondence and reprint requests:James Bradley Summers, MS, MD

PO Box 16343Mobile, AL 36616

REFERENCES

1. International Committee of Medical Editors. Uniform require-

ments for manuscripts submitted to biomedical journals. Ann

Intern Med 1997;126:36-47.

2. Summers JB. Journalology and citation etiquette: firstedness

might matter, but only if you’re really first! J Am Acad Dermatol

2003;48:309-10.

3. Summers JB, Kaminski JM. Citation etiquette in biomedical

publications. Comp Med 2002;52:396.

4. Jellinek NJ, Desousa RA, Bernhard JD. The clinical influence of

the JAAD. J Am Acad Dermatol 2004;50:470-4.

5. Coady-Fariborzian L, Angel LP, Procaccino JA. Perforated colon

secondary to virtual colonscopy: report of a case. Dis Colon

Rectum 2004;47:1247-9.

6. Kamar M, Portnoy O, Bar-Dayan A, Amitai M, Munz Y, Ayalon A,

et al. Actual colonic perforation in virtual colonoscopy: report of

a case. Dis Colon Rectum 2004;47:1242-4.

doi:10.1016/j.jaad.2004.12.051

J AM ACAD DERMATOL

APRIL 2005

736 Letters

Remission and time of resolution of nailpsoriasis during infliximab therapy

To the Editor: Nail psoriasis is common in adultpsoriatic patients and its frequency reaches 80%in psoriatic arthritis. It may vary from slight to in-valid forms, with functional and psychosocial im-pairments as well as severe impact on the patient’squality of life.1 There is a strong need of treatment,which may induce a complete and long-lasting clin-ical remission, especially in those cases refractoryto most therapies. Many options exist for the treat-ment of nail psoriasis, although complete remis-sion is not always obtainable and it often requiresa long period of time.2 Recent studies state thatinfliximab, which is a chimeric monoclonal IgG1antibody antietumor necrosis factor-a (TNF-a), ishighly effective and tolerable for the treatment ofmoderate-severe plaque psoriasis and psoriatic ar-thritis.3,4 There is no data, however, on its effect onnail psoriasis. Clinical remission and time of resolu-tion of nail involvement in 25 plaque-type andarthropathic patients during infliximab therapy wasevaluated. These patients, consisting of 17men and 8women between the ages of 23 and 69 years (meanage = 47.8; median age = 48), presented a severeonychodystrophy with Nail Psoriasis Severity Index5

(NAPSI)[ 14 and were not responsive, or had con-traindications to conventional therapies.

J AM ACAD DERMATOL

VOLUME 52, NUMBER 4

Letters 737

Group I, which is comprised of 9/25 (36%)plaque-type patients, measured a NAPSI of 16 to 54and a mean NAPSI (NAPSIm) of 28.3 (SD = 15.1492).Group II, made up of 16/25 (64%) arthropathicpatients, measured a NAPSI of 22 to 68 anda NAPSIm of 33.3 (SD = 13.40009). All patients en-rolled in this open-label, not placebo-controlled, pro-spective study, provided written informed consent.A local ethical committee allowed the compassion-ate use of this agent. Patients received intrave-nous doses of infliximab measuring 5 mg/kg at 0,2, 6, 14, and 22 weeks. Infliximab induced a slowbut progressive nail improvement synchronousto a novel physiological growth. At week 2, no sig-nificant changes were found. At week 6, group Ipresented NAPSIm = 25 (SD = 13.4814), whilegroup II NAPSIm = 31.0 (SD = 12.1874). At week14, group I presented NAPSIm = 13.8 (SD = 7.3446),while group II NAPSIm = 16.4 (SD = 8.2694).Therefore, all patients showed a 50% reduction ofthe initial NAPSIm (NAPSI50). At week 16, betweenthe 4th and 5th infusions, a further visit took place inorder to assess and confirm the results emergedat week 14. Group I presented NAPSIm = 10.1

Fig 1. Mean NAPSI variations of group I and II againsttime. Infliximab induced a progressive clinical improve-ment of nail psoriasis at the dosage of 5 mg/kg as shownby the statistically significant (P \ .0001) reduction ofNAPSIm from baseline to week 22.

Fig 2. Clinical picture of nail psoriasis of fingernails before(a) and after (b) treatment with infliximab at 22 weeks.

(SD = 5.2847), while group II NAPSIm = 13.1(SD = 5.6269). At week 22, NAPSIm was 0 for bothstudy groups (P\ .0001), which indicated a clinicalremission (NAPSI75) of the onychodystrophy in100% of all patients (Figs 1 and 2). No significantdifferences in terms of nail growth and maintenanceof the clinical results were noticed comparing groupI and II. Furthermore, during a follow-up period of12 weeks from the last infusion, patients maintainedtheir clinical remission of nail psoriasis.

Recognizing that basic nail care is important, top-ical therapies represent the main modality of treat-ment in the majority of cases. In patients with severeonychodystrophy, there is no consistently effectivetreatment nor definite protocols which may clinicallyresolve the nail alterations. This study shows how thenovel biologic agent induces a complete and longlasting clinical remission in those cases refractory tomost therapies. Conversely, it is noted that infliximabhas potential limitations in its use such as expectedhigh costs of treatment, clinical indications and strictinclusion criteria for the patient selection.

Luca Bianchi, MDAntonio Bergamin, MD

Catia de Felice, MDElisabetta Capriotti, MD

Sergio Chimenti, MDDepartment of Dermatology

Tor Vergata University of Rome, Italy

Correspondence to: Luca Bianchi, MDDepartment of Dermatology

Tor Vergata University of Rome, ItalyViale Oxford 81, 00133 Rome, Italy

E-mail: lucabianchiroma@yahoo.it

REFERENCES

1. De Jong EM, Seegers BA, Gulinck MK, Boezeman JB, van de

Kerkhof PC. Psoriasis of the nail associated with disability in

a large number of patients: results of a recent interview with

1,728 patients. Dermatology 1996;193:300-3.

2. De Berker D. Management of nail psoriasis. Clin Exp Dermatol

2000;25:357-62.

3. Chaudhari U, Romano P, Mulcahy LD, Dooley LT, Baker DG,

Gottlieb AB. Efficacy and safety of infliximab monotherapy for

plaque-type psoriasis: a randomized trial. Lancet 2001;357:

1842-7.

4. Gottlieb AB, Masud S, Ramamurthi R, Abdulghani A, Romano P,

Chaudari U, et al. Pharmacodynamic and pharmacokinetic

response to anti-tumor necrosis factor-a monoclonal antibody

(infliximab) treatment of moderate to severe psoriasis vulgaris.

J Am Acad Dermatol 2003;48:68-75.

5. Rich P, Scher RK. Nail psoriasis severity index: a useful tool for

evaluation of nail psoriasis. J Am Acad Dermatol 2003;49:

206-12.

doi:10.1016/j.jaad.2004.09.012