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The clinical management of systemic lupus erythematosus. Peter H. Schur editor. New York Grune & Stratton 1983. 290 pages. Illustrated. Indexed. 39.50

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BOOK REVIEW
The Clinical Management of Systemic Lupus Erythematosus.
Peter H . Schur, editor. New York, Grirne & Strattoti, 1983.
290 p a g e s . Illustrated. Indexed. $39.50.
M y first response, on being asked to review this
book, was "Why another book on lupus?" In this era of
information overload, and of a new rheumatology text every
year, what difference could there be in a new monograph? In
fact there is a difference, and this book, while it has flaws,
has a tone that is unique and interesting.
First, the basic facts: this is a short, multipleauthored book. I t has overview chapters at the beginning
and the end, and chapters on serologic immunology and
immunopathology. The rest of the chapters are organized by
organ system. The final overview chapters are on management. References in most chapters are as recent as 1982 and
in many chaptcrs are organized into a standard footnote-type
reference and a second, general. bibliography. The index is
scanty. It doss not do justice to what is actually in the.text.
The authors constitute a Who's Who of Americans
working in the field of lupus. There is the expected amount
of repetition, particularly concerning general or common
symptoms, serologic abnormalities. and therapeutic approaches: in the latter there are even contradictions (Zvaifler
and Kogers handle psychosis differently; Rothfield says
aspirin doesn't cause renal dysfunction, while Decker says it
does [Decker is right]). As advertised, the book is very
clinically oriented, with a clear "how to" and "why"
approach; i t is thus helpful for the clinician.
Some chapters present, extremely lucidly, concepts
at the front lines of contemporary knowledge. I would cite.
for their excellence, Winchcster's review of immunogenetics. Reichlin's of serology, and Provost and Dorc's of
dermatologic aspccts. In the latter chapter, however, the
reproductions of what once must have been excellent photographs arc poor. Othcr chaptcrs review, fairly and completely, Contemporary knowlcdgc. ZiLic's chapter on gastrointcstinal manifestations does this particularly well. The basic
bias of the book is immunologic; there is little attention given
to mechanisms of inflammation, hormonal aspects of the
disease, prostaglandin system mediation of blood flow (for
instance. in discussion of renal function), and other phcnomena.
What is missing in this book? The epidcmiology of
lupus is almost ignored, though Winchester briefly mentions
race. Contemporary interest in sex hormones is not mentioned. yery serious, though uncommon, management problems are mentioncd superficially or not at all: severe systemic hypertension, pulmonary hypertension, chronic dementia,
infection in the immunocompromiscd host, evaluation of
fever, vasculitis of the polyarteritis or malignant hypertension type. Does race, age, or sex alter prognosis?
One
. cannot learn the answer from this book.
One also gets little hint of common concerns in the
management of the 10-20-year disease-duration chronic lupus patient:
cataracts, atherosclerosis with ischemic cardio.
myopathy and stroke, spontaneous tendon ruptures, and
diverticulitis in the under-40 age group. Osteoporosis and
dialysis are discussed; in discussing osteonecrosis, Stevens
makes the rather surprising implication that core decompression of bone is a trivial procedure of proven value. The
possibility that different patient populations, rather than
different treatments, may account for differences among
results from one clinic to the next is not considered.
There are some editorial annoyances. There is not a
uniform manner of presentation from chapter to chapter.
Some chapters present tabular data as percentage occurrences with no descriptions of the patient populations from
which the data arc drawn and no references; with detective
work, the reader can locate the original references. but this
is an unnecessary burden. Other chapters clearly indicate
the sources of the tables.
There are also some editorial delights: Reichlin presents a nice Boolean logic diagram (without the diamonds,
squares, and circles that frighten so many people) of serologic evaluation in the collagen diseases; Koffler and Biesecker's graph of "Mechanisms of Tissue Injury in SLE"
may be the funniest chart I have ever seen in a medical text.
I have already made a slide of it. and I intend to use it
shamelessly.
Why is this book unique? Almost every chapter has
been written in the following format: What is the problem?
What data exist to solve the problem? What data do not exist
and, therefore, what must we guess at? What is the author's
personal opinion (clearly labeled as personal opinion)? The
opinions also support my prcjudiccs: that mixed connective
tissue disease is not a distinct entity (Provost and Dore), that
central nervous system-lupus consists of many diseases
(Zvaifler).
The format provides a forum for the authors to
explain why, in 1983, not every question is answerable, and
it provides the thoughtful clinician, to whom the book is
prcsumably addressed, an opportunity to understand the
thinking behind the reasoning and to feel more comfortable
in his or her own uncertainty. Thc subtlcty of the argumcnts
may be missed by medical students or clinicians who want
superficial answers to simply posed questions. Although
these answers can be found, those who seek only those
answers will miss the value of this book.
Michael D. Lockshin. MD
The Hospitul f o r Special Siirgeq
N e ~ sYork. N Y
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schur, illustrated, systemic, editor, erythematosus, stratton, new, page, management, 290, lupus, york, 1983, clinical, indexes, grund, peter
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