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A biomarker is a biological parameter that can be measured in blood or other body fluids or tissues and used as a sign of a normal or abnormal process, or of a condition or disease. In medicine, a biomarker can be used to diagnose a disease, to establish its prognosis or as a surrogate marker of outcome in research. In recent years, there has been strong interest in discovering new biomarkers, as well as in the development of new uses for well-known biomarkers in distinct diseases. In this article, the utility of several biomarkers not routinely used in rheumatology (procalcitonin, natriuretic peptides and cardiac troponins) in the diagnosis and follow-up of patients with systemic autoimmune diseases is reviewed.

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease. Autoantibody production plays a critical role in its pathogenic pathways. Thus, B-cell directed biologic therapy is a logical option. The present article reviews the latest advances in the development of B-cell directed biological agents in the treatment of SLE. Rituximab has been studied in a number of open series of patients that suggest efficacy but two recent controlled clinical trials have failed to show efficacy versus placebo. In contrast, a recent placebo-controlled, double-blind, randomized trial has reported that belimumab has statistically significant efficacy versus placebo. Atacicept, a fusion protein that blocks cytokines that play a critical role in the differentiation and survival of B-cells and plasma cells, markedly reduces autoantibody levels but could increase the risk of infection. Further studies are needed to establish the role of B-cell directed biologic therapy in SLE.

Shoulder pain is one of the most common presenting complaints in daily clinical practice. The assessment of patients with shoulder pain is usually complicated due to the wide variety of possible etiologies. Physical examination of the shoulder is especially important in the assessment of soft tissue disorders, since there are a number of physical examination manoeuvres specifically designed to examine particular structures. In this article, the various clinical tests and their diagnostic utility for examining subacromial impingement, supraspinatus, infraspinatus, subscapularis and biceps tendons, gleno-humeral instability and the acromioclavicular joint are reviewed and compared with procedures considered as the gold standard.

Interstitial lung disease (ILD) occurs frequently in patients with systemic sclerosis (SSc), with a burden of significant morbidity and mortality. SSc-ILD resembles idiopathic pulmonary fibrosis (IPF) in many respects, including a restrictive ventilatory defect that results from an active fibrosing process in the lung interstitium, a ground glass opacification on high resolution computed tomography, and inflammatory cells in bronchoalveolar lavage fluid. Differences in the classification of lung histo-pathology are noted frequently and may account for some of the differences in outcome for patients with SSc-ILD and IPF. Optimal treatment of SSc-ILD remains to be determined, but cyclophosphamide has been reported to be effective in several open observational studies. Results from the Scleroderma Lung Study are expected to add new insights into the optimal therapy for SSc-ILD.

Rheumatoid arthritis (RA) is a severe disease that leads to joint destruction, loss of function and premature death. To achieve the induction of remission is a major therapeutic goal. The use of conventional disease-modifying anti-rheumatic drugs (DMARDs) as monotherapy rarely allows to achieve and maintain an adecuate clinical response over the course of the disease. This article reviews the role of the combination therapy with conventional DMARDs in the early-onset and refractory rheumatoid disease. In addition, the role that should play these combination therapies in the current therapeutic armamentarium of RA after the advent of the new biologic agents is critically discussed.

Current treatment options for systemic lupus erythematosus (SLE) fail to control all the manifestations of the disease or fully prevent flares. The most extensively studied biological therapies are directed against B cells, although other biological targets have also been explored. Biological agents against tumor necrosis factor-alfa differ in their efficacy and have been associated with the generation of antinuclear and anti-dsDNA antibodies. Anti-interleukin-10 and anti-interleukin-6 agents have also been studied, with encouraging results. Abatacept, which has been approved in rheumatoid arthritis, has not shown efficacy in placebo-controlled clinical trials.