The following represent additions to UpToDate since the last version that were considered by the authors and editors to be of particular interest. The new material described below represents a small subset of the updating that has been performed, since approximately 40 percent of the topic reviews are updated during each four-month cycle.

BACK PAIN

Treatment of nonspecific low back pain — For patients with persistent nonspecific low back pain, a systematic review found that spinal fusion surgery may be more effective than unstructured nonsurgical care, but equally effective compared to intense multidisciplinary rehabilitation [1]. Practice guidelines from the American Pain Society, based on this review, recommend that surgery be presented as an option to patients with persistent disabling nonradicular low back pain [2]. Shared decision making should take into account that most patients who undergo surgery will have some residual symptoms, and that interdisciplinary rehabilitation may be equally effective. (See "Subacute and chronic low back pain: Surgical treatment", section on 'Spinal fusion'.)

CARPAL TUNNEL SYNDROME

Surgery for carpal tunnel syndrome — A randomized controlled trial with 116 patients demonstrated that surgical decompression for carpal tunnel syndrome is more effective than nonsurgical treatment consisting of multimodal interventions [3]. However, the benefit of surgery was small and of modest clinical significance. (See "Treatment of carpal tunnel syndrome", section on 'Surgery'.)

DUPUYTREN'S CONTRACTURE

Collagenase injection — The injection of clostridial collagenase into the Dupuytren's lesion was beneficial in a randomized trial of 308 patients with fixed flexion contractures of ≥20 degrees at the MP or PIP joints and may be an effective alternative to surgery [4]. Cords injected with collagenase rather than placebo were significantly more likely to show a reduction in the contracture to 0 to 5 degrees of full extension 30 days after the last injection (64 versus 7 percent). (See "Dupuytren's contracture", section on 'Collagenase injection'.)

FIBROMYALGIA

Neurologic signs and symptoms — A study found that fibromyalgia patients, compared with control pain-free subjects, had both significantly greater neurologic symptoms and abnormal neurologic findings on detailed neurologic examination [5]. Sensory and motor neurologic findings were generally consistent with the patient complaints. (See "Clinical manifestations and diagnosis of fibromyalgia in adults", section on 'Clinical manifestations'.)

MEDICATION RISKS

TNF inhibitors — Based upon a safety review of tumor necrosis factor (TNF) inhibitors, the US Food and Drug Administration (FDA) concluded that that there is an increased risk of lymphoma and other cancers associated with their use in children and adolescents [6]. This information has been included in a boxed warning for TNF inhibitors. This FDA alert also reviewed 69 cases of new onset psoriasis in patients using TNF inhibitors for autoimmune and rheumatic diseases other than psoriasis and psoriatic arthritis. Drug discontinuation resulted in improvement of the psoriasis in the majority of patients. (See "Tumor necrosis factor-alpha inhibitors: Risk of malignancy", section on TNF inhibitor FDA warning.) (See "Tumor necrosis factor-alpha inhibitors: An overview of adverse effects", section on 'Psoriatic skin lesions'.)

OSTEOPOROSIS

Vertebroplasty — In two short-term, blinded trials comparing vertebroplasty with a sham procedure in patients with osteoporotic vertebral compression fractures, there was no immediate or delayed benefit of vertebroplasty for the reduction of pain [7,8]. (See "Clinical manifestations and treatment of osteoporotic thoracolumbar vertebral compression fractures", section on 'Vertebroplasty and kyphoplasty'.)

Denosumab — In the FREEDOM trial (7868 postmenopausal women with bone mineral density T-scores between -2.5 and -4.0 at the lumbar spine or total hip), denosumab, a humanized monoclonal antibody against RANK-ligand that reduces osteoclastogenesis, compared with placebo significantly reduced the incidence of new vertebral (2.3 versus 7.2 percent), hip (0.7 versus 1.2 percent), and nonvertebral fractures (6.0 versus 8.5 percent) [9]. (See "Overview of the management of osteoporosis in postmenopausal women", section on Densomab.)

Vitamin K — In nonosteoporotic postmenopausal women receiving calcium and vitamin D supplements, vitamin K (1000 micrograms phylloquinone or 45 mg menatetrenone daily) did not have any effect on bone mineral density [10]. (See "Overview of the management of osteoporosis in postmenopausal women", section on 'Vitamin K'.)

PSORIATIC ARTHRITIS

Methotrexate-induced hepatotoxicity in psoriasis — Revised recommendations from the American Academy of Dermatology for monitoring for methotrexate (MTX)-induced hepatotoxicity in patients with psoriasis suggest an individualized decision to perform liver biopsy based on a patient's risk factors, liver chemistry results, and cumulative dose [11]. Previous guidelines advocated performing liver biopsies after every 1 to 1.5 g of cumulative MTX. The new recommendations are dependent upon the presence or absence of patient risk factors for methotrexate-induced hepatotoxicity. (See "Treatment of psoriasis", section on 'Hepatotoxicity and liver biopsy'.)

RHEUMATOID ARTHRITIS

Randomized trial after failure of methotrexate monotherapy — In a randomized trial of 258 patients with rheumatoid arthritis (RA) of less than one year in duration who had not achieved low disease activity with methotrexate (MTX) alone (20 mg once weekly), MTX plus infliximab was compared with triple therapy using MTX, sulfasalazine (SSZ), and hydroxychloroquine (HCQ) [12]. By nine months after randomization there was a significantly higher proportion of good responders among the group receiving infliximab (39 versus 25 percent). Further studies will be important in developing optimal treatment algorithms for patients with RA, as few regimens have been compared with each other in randomized trials. (See "Treatment of persistently active rheumatoid arthritis in adults", section on 'Partial response to MTX alone'.)

TNF inhibitor switching — The best data to date illustrating that switching to a second tumor necrosis factor (TNF) inhibitor is effective in patients with rheumatoid arthritis (RA) who do not respond adequately to initial TNF inhibitor treatment are from a well-designed trial of golimumab as the second agent [13]. In this trial, 461 patients with active RA despite prior use of at least one TNF inhibitor were randomly assigned to golimumab (50 or 100 mg every four weeks) or placebo, while continuing stable doses of baseline nonbiologic disease-modifying antirheumatic drugs (MTX, SSZ, and/or HCQ), glucocorticoids, and nonsteroidal antiinflammatory drugs. Patients receiving golimumab were significantly more likely to achieve an ACR20 response at week 14. The results of this trial are consistent with findings from observational studies of other TNF inhibitors. (See "Treatment of persistently active rheumatoid arthritis in adults", section on 'TNF inhibitor switching'.)

SCLERODERMA

Anti-beta2-glycoprotein I antibodies — Anti-beta2-glycoprotein I (beta2GPI) antibodies, which are associated with recurrent thromboembolic events in patients with the antiphospholipid antibody syndrome, are also associated with macrovascular disease in systemic sclerosis (SSc) [14]. Both anticardiolipin and anti-beta2GPI antibodies can be seen in SSc. Anti-beta2GPI antibodies, particularly the IgA isotype, were associated with increased risk of ischemic digital loss, active digital ischemia, and echocardiographic evidence for pulmonary hypertension. (See "Diagnosis and differential diagnosis of systemic sclerosis (scleroderma) in adults", section on 'Laboratory tests'.)

Interstitial lung disease — Among patients with systemic sclerosis (SSc) and interstitial lung disease (ILD), centrilobular fibrosis is a rare pattern on high resolution computed tomography (HRCT) that shows patchy ground glass or consolidative opacities with a central distribution. In a series of 28 patients with SSc-ILD, six had centrilobular fibrosis on biopsy that was associated with pathologic evidence of recurrent aspiration [15]. (See "Clinical manifestations of systemic sclerosis (scleroderma) lung disease", section on 'Imaging'.)

SYSTEMIC LUPUS ERYTHEMATOSUS

Cardiovascular disease risk — Systemic lupus erythematosus (SLE) is one of several connective tissue diseases associated with a higher incidence of coronary heart disease (CHD) events. The relative risk of CHD (angina, myocardial infarction, revascularization) among 148 women in the large Nurses' Health study who developed SLE after study enrollment was 2.25 (95% CI 1.77-4.27) [16]. The risk is lower than previously reported in other observational studies, and may be explained by the age at diagnosis (52.6 years), favorable socioeconomic status, and predominantly Caucasian mix in the study population. (See "Coronary heart disease in systemic lupus erythematosus", section on 'Epidemiology'.)

VASCULITIS

Pathogenesis of ANCA-positive vasculitis — A mechanism used by neutrophils to defend against invading pathogens may contribute to the pathogenesis of ANCA-associated vasculitis. Webs of decondensed chromatin, called neutrophil extracellular traps (NETs), are typically released into the extracellular space in the setting of a bacterial or fungal infection. NETs are also released by ANCA-stimulated neutrophils, contain PR3 and MPO autoantigens, and co-localize with PR3 and MPO in the kidneys of patients with ANCA-associated vasculitis [17]. (See "Pathogenesis of Wegener's granulomatosis and related vasculitides", section on 'NET formation'.)