Internist最新文献

Background: Systemic lupus erythematosus (SLE) is a heterogeneous disease with a complex pathogenesis. Until now, the choice of therapeutic agents has been limited.

Objective: This review revisits known forms of treatment for SLE and introduces new recently approved agents and agents currently under investigation in clinical trials. The aim of this article is to map the current data from phase 2 and phase 3 studies and European recommendations for the management of SLE and to provide an outlook on the future of lupus treatment.

Data situation: As the focus of SLE treatment is on the achievement of remission with low steroid dosages, early and effective immunosuppressive therapy is essential. With the interferon type I receptor antagonist anifroluma, a treatment for extrarenal lupus has been approved for the first time since 2011. For lupus nephritis, the well-known belimumab (approval by the U.S. Food and Drug Administration, FDA and the European Medicines Agency, EMA) and the calcineurin inhibitor voclosporin (FDA) are newly available. In addition, a large number of substances are currently undergoing clinical trials, e.g. the CD-20 inhibitor obinutuzumab, Janus kinase inhibitors and low-dose interleukin‑2.

Conclusion: New and innovative treatment concepts are finding their way into lupus treatment and other promising substances are in the pipeline; however, only long-term data will show to what extent these improve the long-term outcome of patients. Nevertheless, these are important and much needed advances in the treatment of SLE.

A 61-year-old male patient underwent a colonoscopy for cramp-like upper abdominal pain of 3 weeks duration. An endoscopically irresectable ulcerated mass was seen in the transverse colon. The patient spontaneously excreted in the feces a tumor node measuring 4.1 × 3.5 × 2.8 cm with the histological features of a submucosal lipoma 4 days after the colonoscopy. A benign lipoma confined to the submucosa was operatively confirmed. It is extremely rare for a tumor node to be shed in feces. If the benign nature of the entire lesion is doubtful, standard oncological procedures are advocated.

Here, we report on a patient with deep vein thrombosis of the right leg, in whom diagnostic work-up revealed a previously unknown chondrosarcoma of the tibia. Physical examination revealed a firm, nondisplaceable mass on the dorsal side of the right knee that appeared as a cystic formation on ultrasound. X‑ray, computed tomography, and magnetic resonance imaging were consistent with chondrosarcoma, which had likely provoked the thrombosis by local compression or paraneoplastic mechanisms. After resection of the tumor, anticoagulation was continued. In a review of all findings, a final diagnosis of highly differentiated chondrosarcoma with thrombosis of the popliteal vein was made.

Despite the availability of the instruments of advance directives, power of attorney and healthcare proxy, the patient's preferences for life-sustaining medical treatment in a specific situation often remain unknown. The aim of the systemically designed German Advance Care Planning (ACP) program is the reflection, documentation and implementation of patients' preferences regarding future medical treatment in case they are incapable of legally binding decision-making. A specially trained ACP facilitator initially supports the verbalization of the attitudes towards life, severe illness and death on an individual level. Based on these principal views, concrete preferences on how to be treated under defined medical circumstances can be discussed and documented in an advance directive. This includes the three scenarios medical emergency, inpatient hospital treatment in situations with decisional incapability of unknown duration and the situation of permanent cognitive impairment. Through cautious, nondirective conversational techniques in the sense of shared decision-making, the person is enabled to reflect and decide well-informed according to the informed consent standard. All persons participating in decisions regarding future medical treatment, especially future surrogate decision makers, are involved in the process as early as possible. A systematic institutional and regional implementation of the concept is necessary to ensure that the carefully assessed and documented preferences of the patients will be known and honored. The new German § 132g of the Social Code Book V (SGB V) enables institutions for long-term care and for the care of disabled persons, to offer facilitated ACP to all residents at the expense of the statutory health insurance funds. An increased dissemination of this concept is to be expected.