Reviews & Analysis

Despite exciting progress in the understanding and treatment of gout, management of this condition remains suboptimal. In the face of this inadequacy, new guidelines provide recommendations both for therapeutic approaches to hyperuricaemia and for the management and anti-inflammatory prophylaxis of acute gouty arthritis.

Advances in imaging have improved our understanding of the relationship between pathology and the structural changes to joints affected by osteoarthritis. New research indicates that subchondral bone marrow lesions might represent a potential imaging biomarker to quantify such structural changes.

New data demonstrate that cobalt ions promote immune system activation through Toll-like receptor 4 signalling. This finding adds to our understanding of the adverse innate and adaptive immune reactions evoked by debris released from metal-on-metal total or resurfacing joint replacement implants, which have provoked recommendations against their use.

The emphasis placed on HLA-B27 positivity in classification criteria for axial spondyloarthritis has generated some concern over potential misclassification of patients with chronic back pain. The results of a recent study suggest that these worries could have some foundation, at least in regions with high HLA-B27 prevalence.

In the wake of publication of clinical data for new drugs in the management of lupus nephritis, European rheumatology and renal societies have issued new recommendations for management of this condition. Coming hot on the heels of American guidelines, how does this latest advice compare?

Physical activity is paramount in the treatment of juvenile fibromyalgia, although some interventions use indirect methods to increase activity levels rather than address physical dysfunction head-on. New research explores the effects of a psychotherapeutic approach on levels of physical activity in adolescents with fibromyalgia.

Arthropathy is a common manifestation of systemic lupus erythematosus (SLE), but remains poorly understood. Recent ultrasonographic evidence demonstrating high levels of joint and tendon pathology in SLE challenges our previous concepts of arthritis subtypes in this multisystem disease.

Following a decade of substantial improvements in sensitivity and usability, MRI is increasingly used to assess primary outcomes of therapeutic trials in rheumatoid arthritis (RA). In the wake of an MRI-based evaluation of treatment efficacy, what lessons are emerging about the clinical value of this technique for patients with RA?

Early diagnosis of psoriatic arthritis will prevent joint damage and improve long-term patient outcome. For dermatologists and general practitioners, early recognition of the diverse musculoskeletal manifestations can prove problematic. Screening tools and biomarkers offer great promise—the recent description and initial validation of the EARP tool is an encouraging development.

Vaccination for the prevention of herpes zoster with the attenuated live vaccine is currently not recommended for patients with rheumatic diseases while they are receiving biologic agents, but new evidence calls the validity of this guidance into question. Is it time to rethink the use of the herpes zoster vaccine in these patients?

Achievement of a state of inactive disease has become a realistic goal in juvenile dermatomyositis. The development of a standardized definition of inactive disease in this disorder is a critical step in measuring outcomes, and might now be a step closer.

Insulin resistance is closely associated with an increased risk of subclinical atherosclerosis in patients with rheumatoid arthritis (RA). Anti-TNF therapy reduces insulin resistance and improves insulin sensitivity in patients with severe RA. New findings have shown, however, that the efficacy of these agents in this regard is impaired by obesity.

In the absence of definitive diagnostic tests, several schemes for the classification of paediatric vasculitis have been devised and periodically updated, but are these revisions necessary and useful?

Study of the efficacy of fracture prevention approaches has been neglected in men, in comparison with women. Guidelines from the Endocrine Society for the management of osteoporosis and fracture risk in men are thus welcome, but further research into fracture prevention in men is required.

Determining the potential success of investigational therapies for rheumatoid arthritis early in the development process would enable better allocation of increasingly limited resources. Such 'go or no-go' decision-making could be improved by a method of analysing longitudinal clinical trial data to establish a threshold for success of a new drug.

The latest in a series of meta-analyses of trials assessing viscosupplementation for knee osteoarthritis is the first to raise concerns about its safety. Questions remain, however, regarding the methodological rigour with which the serious adverse events were analyzed, and the biological plausibility of the events reported.

Establishing a standard definition of systemic lupus erythematosus is a continuously evolving challenge for researchers. How does the latest set of classification criteria compare with previous endeavours?

The past decade has seen exciting progress in the management of lupus nephritis, a manifestation of systemic lupus erythematosus that accounts for its major morbidity and mortality. The American College of Rheumatology has issued new guidelines for screening and treatment of lupus nephritis, based on expert recommendations.

Gout is often poorly managed, with low rates of successful long-term urate lowering. A new 'package of care' intervention for treatment of patients with gout now offers ways to improve outcomes. The intervention, involving both a rheumatologist and gout nurse specialist, provides a framework for best practice in gout management.

The performance of the CASPAR criteria, which are known to have high specificity and sensitivity in classifying patients with long-standing psoriatic arthritis, has now been evaluated in early disease. Whereas the findings are likely to boost clinical research, implications for daily practice—and diagnosis—are less certain.