News & Views in 2011

Biomarkers and surrogate outcome measures can be used to monitor disease development, but what can biomarkers tell us about disease processes in axial spondyloarthritis? New research suggests that some biomarkers might be useful in monitoring patients with ankylosing spondylitis, but greater understanding of the pathological mechanisms is needed.

Lessons from the study of other rheumatic diseases are improving our understanding of diffuse idiopathic skeletal hyperostosis (DISH). New data implicate Dickkopf-1 in the evolution of the most severe manifestations of the condition. Nevertheless, real insights into the pathogenesis—and treatments that might result from them—are still lacking.

Peripheral neuropathy can be a manifestation of small-vessel vasculitides such as antineutrophil cytoplasmic antibody-associated vasculitis. Diagnosing vasculitic neuropathy is, however, difficult in many cases. Early treatment focused on achieving remission of the underlying vasculitic process is important as chronic neuropathy has a major influence on a patient's quality of life.

The reproducibility and reliability of ELISA assays used to detect autoantibodies that recognize cardiolipin or β₂-glycoprotein I remain unacceptable, which can complicate the diagnosis of antiphospholipid syndrome. Now, much needed international consensus guidelines have been proposed for the development and use of these diagnostic tests, which should improve their performance.

New data—this time from genetic association studies—again implicate the Wnt signaling pathway in the etiology of Dupruyten Disease. Nevertheless, functional studies, and cohorts of different ethnic backgrounds, are needed to distinguish cause and effect in this enigmatic fibrosing disorder.

Measuring bone structure could improve prediction of bone strength, but the clinical feasibility of available imaging technologies is limited. The trabecular bone score—a dual-energy X-ray absorptiometry texture algorithm—has shown promise in fracture prediction in a large cohort study, and might provide a practical means of assessing bone quality.

The precise role that basic calcium phosphate microcrystals have in the pathogenesis of osteoarthritis (OA) is controversial. The recent paper by Jin et al. provides new insights into the potential mechanisms that link these microcrystals to joint damage, and highlights the role of the NLRP3 inflammasome in the pathogenesis of OA.

The use of biologic therapies for off-label conditions in daily clinical practice is increasing, yet few studies have detailed the safety of these agents with regards to infection in patients with systemic autoimmune disease. New research offers a glimpse at the infection rates in these vulnerable patients.

Assigning osteoporosis treatment on the basis of bone mineral density alone is difficult, and incorporating even simple clinical risk factors into the decision-making process is challenging. When launched, the FRAX^® risk assessment tool was met, unsurprisingly, with both enthusiasm and skepticism; despite improvements, some obstacles still prevent its universal implementation.

Systemic sclerosis is associated with a high level of patient mortality. A promising prognostic model that could enable more effective management and improve survival was recently validated; however, the results demonstrate that choosing the best cohorts for development and validation of predictors of mortality is essential.

Repair of bone erosions in rheumatoid arthritis has been considered a difficult goal to achieve. However—with better therapies at hand to control synovial inflammation—sensitive μCT imaging techniques now available confirm that repair of bone erosion is possible, and begins at the base of erosive lesions.

The diverse clinical symptoms associated with systemic lupus erythematosus (SLE) probably reflect its complex genetic underpinnings. Evidence from a new study indicates that analysis of common risk alleles can predict susceptibility to several end-organ manifestations of SLE, which could influence patient screening and support personalized approaches to treatment.

'Re-setting' autoimmunity through autologous hematopoietic stem cell transplantation is undergoing extensive clinical testing. A small randomized clinical trial in patients with systemic sclerosis now reports positive outcomes in all those treated with the therapy, compared with those receiving cyclophosphamide. Nevertheless, major questions about toxicity and long-term efficacy remain unanswered.

Rituximab has emerged as an alternative to cyclophosphamide for remission induction in anti-neutrophil cytoplasmic antibody-associated vasculitides, with recommendations now developed to direct its use in these diseases. However, data from extended clinical trials are required to determine whether rituximab is safer or more efficacious than cyclophosphamide in the long term.

Irksome to debilitating, fatigue is a frequent symptom of rheumatoid arthritis (RA). Patients regard it as an important, neglected facet of the disease. An analysis of the effect of biologic therapies on fatigue has yielded disappointing results—do current treatments lack efficacy, or are we failing to measure adequate parameters?

Systemic lupus erythematosus is frequently associated with neuropsychiatric syndromes, which can have a serious impact on the quality of a patient's life. Several methods are used to characterize cognitive impairment in these patients; however, studies have identified flaws in these assessments, highlighting the careful consideration needed when undertaking neuropsychological testing.

Cyclo-oxygenase (COX) inhibitors are associated with increased cardiovascular risk, and are, therefore, contraindicated in patients with a previous myocardial infarction (MI). Although NSAIDs might induce a similar cardiovascular risk, some guidelines suggest that they can be administered safely for a short period of time. But is this really true?

Early symptoms of arthritis either resolve spontaneously or progress into erosive disease; being able to predict the disease course would inform decisions about intensive early therapy. One predictive factor, according to a new multicenter study, is the season of first symptoms—so how does the Earth's movement influence disease progression?

A new single cell detection technology allows simultaneous measurement of up to 100 surface markers and signaling proteins of immune cells. This method provides the opportunity to make great advances into the scientific understanding of rheumatic disease and the provision of individualized patient care.

New guidelines for the management of ankylosis spondylitis provide evidence-based disease management recommendations, which aim to be the ideal standard practice. How robust are these suggestions and are they applicable to the worldwide community of rheumatologists practicing in very different clinics around the globe?