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Internists gain some guidance on identifying systemic lupus erythematosus (SLE) and why they should work with rheumatologists. Meanwhile, two UK studies outline paths to successful gout treatment and lower mortality rates after hip replacement surgery. Finally, the use of imaging, including ultrasound, are refined for diagnosing sarcoidosis.
Last week's articles on rheumatology topics in the major non-rheumatology journals.
Systemic Lupus ErythematosusAnnals of Internal Medicine, October 1, 2013
This clinically-oriented continuing medical education review is directed at internists identifying and treating systemic lupus erythematosus (SLE), and assumes a consultation with a rheumatologist after diagnosis.
Seminar: SarcoidosisLancet, October 1, 2013
The indications for endobronchial ultrasound (US) for diagnosis and positron emission tomography (PET) in the assessment of inflammatory activity are now better specified for sarcoidosis. Recognition of unexplained persistent disabling symptoms, fatigue, small-fiber neurological impairment, cognitive failure, and changes to health state and quality of life, has improved.
The molecular mechanisms for inflammation, granuloma formation, and genetics are reviewed up to 2012. The pulmonologist and radiologist authors review current diagnostic techniques, including endobronchial US-guided transbronchial needle aspiration for mediastinal and hilar lymphadenopathy, and 18F-fluorodeoxyglucose PET. The diagnosis of cardiac sarcoidosis, without consensus, is the most challenging. Treatment, including infliximab, etanercept, adalimumab, rituximab, apremilast, and dexmethylphenidate is reviewed.
Clinical Review: GoutBMJ, October 1, 2013
This review, and a patient perspective, follows UK practices for Gout diagnosis and management, which are similar but not identical to U.S. practices. Two of the authors are advisors to the National Institute for Health and Care Excellence (NICE).
90-day mortality after 409 096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysisLancet, September 28, 2013
In a retrospective national registry analysis of more than 400,000 primary hip replacements for osteoarthritis (mean patient age 64), surgical mortality dropped by almost half from 0.56% in 2003 to 0.29% in 2011.
Four modifiable causes were associated with lower mortality:
1. A posterior surgical approach, which has more muscle preservation and less bleeding than a lateral approach;
2. Mechanical thromboprophylaxis;
3. Chemical thromboprophylaxis with heparin with or without aspirin; and
4. Spinal rather than general anesthesia.
The type of implant had no effect. Being overweight was associated with lower mortality.
Molecular medicine:PLS3 Mutations in X-Linked Osteoporosis with FracturesNew England Journal of Medicine, October 2, 2013
Plastin 3 (PLS3) is a protein involved in the formation of filamentous actin bundles. Variants in PLS3 were identified as a cause of X-linked osteoporosis in five families, and a different variant was identified as a cause of osteogenesis imperfecta type I in an additional five families.
Severe skeletal defects were confirmed via an in vivo analysis of zebrafish with knockout pls3 genes. This is distinct from another pair of mutations, COL1A1 and COL1A2, which code for collagen type Iα1 and collagen type Iα2, and are associated with Ehlers-Danlos syndrome and osteogenesis imperfecta.
IL-29 Is Produced by TH17 Cells and Mediates the Cutaneous Antiviral Competence in PsoriasisScience Translational Medicine, September 25, 2013
Patients with psoriasis vulgaris are less likely to have cutaneous viral infections than patients with atopic dermatitis or even normal controls. It was determined the T helper 17 cells produce IL-29 in these patients, which is an upstream promoter of antiviral proteins such as MX1, BST2, ISG15, and OAS2.