The edition · Top Clinical Updates
Cellulitis without the bloods, rheumatoid arthritis to target, and a pregnancy history that belongs in the risk score
Two reviews that settle common decisions, a phase 3 trial that displaces tacrolimus in membranous nephropathy, and the argument for treating an obstetric history as cardiovascular data.
The edition in brief
A BMJ review of skin and soft tissue infections makes the operational splits explicit: non-purulent infection is usually streptococcal and purulent usually staphylococcal, laboratory testing adds little in most patients, and point-of-care ultrasound is what distinguishes cellulitis from abscess when the examination is equivocal. Abscess is treated by incision and drainage with antibiotics only in selected patients. A JAMA review of rheumatoid arthritis sets out a treat-to-target approach: diagnose within six weeks of symptom onset where possible, start methotrexate at 7.5-10 mg weekly and escalate to 20-25 mg within four to eight weeks, consider short-course glucocorticoid tapered within three months, aim for at least 50% improvement by three months and remission or low disease activity by six. About 40% reach remission on first-line treatment; adding a biological DMARD or JAK inhibitor takes remission or low disease activity to around 80%. In the MAJESTY phase 3 trial, 142 adults with primary membranous nephropathy were randomised to intravenous obinutuzumab or oral tacrolimus: complete remission at two years was 37% versus 6%, an adjusted difference of 31 percentage points, with similar rates of serious adverse events and infection — though the kidney function endpoint did not separate. The practice-changer is a Lancet Series review arguing that hypertensive disorders of pregnancy, gestational diabetes and preterm birth are sex-specific cardiovascular risk indicators that belong in routine risk assessment decades later.
Skin and soft tissue infection, decided at the bedside
Decide purulent versus non-purulent on examination, drain what needs draining, and stop sending bloods that will not change the prescription.
Rheumatoid arthritis: the targets, the doses, and the six-week window
Get suspected rheumatoid arthritis to treatment within six weeks, escalate methotrexate on schedule, and measure against a target rather than an impression.
Obinutuzumab beats tacrolimus in membranous nephropathy — on proteinuria
In primary membranous nephropathy, obinutuzumab achieves complete remission far more often than tacrolimus — but say clearly that kidney function preservation is not yet shown.
Bilateral cellulitis is almost never cellulitis
If both legs are red, the diagnosis is probably not cellulitis — take the time course and look for the signs of chronic venous disease.
An obstetric history is cardiovascular data, decades later
Add three questions about past pregnancies to cardiovascular risk assessment in women, and record the answers where they will be found again.
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