Reviews & Analysis

Juvenile rheumatoid arthritis is one of the most common chronic diseases of childhood. In this Viewpoint, Dr Connelly and Dr Schanberg discuss the limited knowledge regarding the widespread occurrence of pain in children with arthritis. Research into treatment with opioids in these patients has fostered clinical myths inhibiting optimum patient care.

Systemic lupus erythematosus is a disease triggered by environmental factors in individuals with a genetically predetermined alteration of the threshold for induction or maintenance of immune tolerance. In this Viewpoint, Professor Davidson discusses the immune activation pathways involved in systemic lupus erythematosus, and highlights the importance of understanding these pathways and their role in disease activity.

Tumor necrosis factor (TNF) inhibitors have changed the therapeutic standard of treatment for patients with rheumatoid arthritis. Despite the efficacy of these agents, a significant proportion of patients demonstrate an inadequate response to one or more TNF inhibitor. In this Viewpoint, Dr Keystone discusses the outstanding issues related to the scientific and clinical rationale for switching TNF inhibitors.

Although sciatica is usually caused by a mechanical abnormality, pathophysiologic considerations provide a sound rationale for local corticosteroid therapy. There is evidence that this treatment should be started early to prevent persistent nerve-root pain due to peripheral and central sensitization. In this Viewpoint, Dr Valat discusses the use of epidural corticosteroid injections in early sciatica.

Antimalarial drugs have been used for many years to treat rheumatic diseases such as rheumatoid arthritis and systemic lupus erythematosus. This Viewpoint will discuss the recent advances in understanding the mechanisms of action of hydroxychloroquine and the possibility of establishing toll-like receptor signalling molecules as targets for new therapies.

New insights into the etiology of rheumatoid arthritis have suggested that humoral autoimmunity might have a substantive, possibly even causal role in the pathogenesis of disease. In this Viewpoint, Dr Holers will discuss the basis of this hypothesis, focusing on the role of anti-cyclic citrullinated peptide antibodies.

Gene therapy suffers the negative perception of being unsafe, expensive and ultimately inapplicable in clinical practice. In this Viewpoint, the authors discuss the benefits of gene therapy being used to treat rheumatic disease, and the requirements that have to be satisfied in order for this to become a clinical reality.

Tumor necrosis factor (TNF) inhibitors have proven highly effective in improving the signs and symptoms of rheumatoid arthritis, in inhibiting the progression of joint damage, and improving patients' quality of life. This Viewpoint will discuss the major concern relating to the actual use of TNF inhibitors in the clinic: their relatively high acquisition costs.

The introduction of tumor necrosis factor antagonist therapies has transformed expectations for the management of rheumatoid arthritis. Although all available agents have demonstrated comparable clinical efficacy, heterogeneity of response and treatment failure has been observed in up to 40% of patients. This Viewpoint will discuss the use of alternative TNF-blocking therapy in patients who have failed treatment.

Randomized, blinded, controlled experiments have often been considered the highest level of evidence in the methodological hierarchy. This Viewpoint discusses the strengths and limitations of both observational studies and randomized controlled trials, and the benefits that can be gained by researchers and clinicians through the appreciation of both methods.

Chronic back pain has a huge impact on health-care systems and governments globally, being responsible for millions of days of lost work and disability. In this Viewpoint, Dr Hadler discusses how improved patient management and workplace policies can help reduce the escalating costs that are associated with this condition.

MRI shows great promise as a scoring system for spinal inflammation in ankylosing spondylitis. This Viewpoint discusses the progress in the development of MRI scoring methods and the prospective use of MRI as a tool to evaluate disease activity in patients with ankylosing spondylitis.

There have been many exciting advances in tissue engineering. This Viewpoint discusses the future application of this technology in the chronic rheumatic diseases, focusing on the advantages of methods of cartilage regeneration, such as scaffolds, gels, cell-seeding, fibers or cell cultures.

The widespread use of screening for circulating anti-neutrophil cytoplasmic autoantibodies (ANCA) in the diagnosis of ANCA-associated vasculitis has resulted in an increased occurrence of false-positive results and greater difficulty in the interpretation of such test results. Therefore, a rational strategy for ANCA testing is needed. The main problems with ANCA testing are discussed in this Viewpoint and some practical guidelines are given.

Evidence-based medicine and, primarily, data from randomized controlled clinical trials are continually regarded as the only valid sources for all clinical knowledge. This Viewpoint discusses the merits of 'practice-based evidence' and how this important information is currently undervalued in the clinical community.

There has been significant progress in the development of biological markers to assess joint and tissue damage in osteoarthritis. In this Viewpoint, Patrick Garnero discusses the developments in this field and how they will affect the future management of patients with osteoarthritis.

Trials investigating T-cell targeted therapies for rheumatoid arthritis have been of limited success. This Viewpoint considers whether or not the hypothesis that T cells are involved in the pathogenesis of rheumatoid arthritis is true and, if so, why trials so far have not led to an applicable therapy.

Pharmacogenetics is the study of the genetic characteristics that dictate drug response and toxicity. This Viewpoint discusses this rapidly advancing field that might improve the clinician's ability to match a patient with the right drug or drugs for their disease.