Pathological fractures under anti-osteoporotic and antirheumatic treatment are very rare events. Nevertheless, atypical femoral fractures occur during antiresorptive treatment with bisphosphonates or denosumab, the latter especially in patients previously treated with bisphosphonates. Treatment with teriparatide can be helpful. While glucocorticoids have a well-known influence on the development of osteoporosis and thus also fractures, the probably unproblematic use in the low-dose range has so far found little acceptance. Methotrexate-induced osteopathy is also a rare phenomenon but is now well accepted and known. There are several approved medications for the treatment of glucocorticoid-induced osteoporosis and for methotrexate-induced osteopathy, discontinuation of methotrexate is particularly essential.

Inflammatory rheumatic diseases, such as rheumatoid arthritis (RA), are characterized by local and systemic bone demineralization. Local demineralization is manifested in the periarticular region of the inflamed joints, particularly at the metacarpophalangeal and metatarsophalangeal joints. Local demineralization shows a significant correlation with inflammatory activity, whereas systemic osteoporosis, predominantly affecting the spine and hip, is typically associated with a prolonged disease duration, glucocorticoid treatment and immobilization. The receptor activator of the nuclear factor-kB ligand (RANKL)/osteoprotegerin (OPG) system and the Wnt signaling pathway play a pivotal role in regulating bone metabolism and are themselves negatively influenced by inflammatory cytokines such as tumor necrosis factor alpha (TNF-alpha) and interleukin (IL)-6. The diagnostics include both imaging procedures and procedures for bone mineral density measurement, employing techniques such as high-resolution peripheral quantitative computed tomography (HR-pQCT) and dual energy X‑ray absorptiometry (DXA). These are used for quantification of the bone mineral density. The objective of therapeutic approaches is to reduce disease activity and modulate signaling pathways in order to slow down demineralization and reduce the risk of fractures.

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children and adolescents. Currently, JIA is classified into seven categories according to the International League of Associations for Rheumatology (ILAR) criteria. Diagnosis is primarily clinical and involves excluding age-specific differential diagnoses, which can be particularly challenging in very young children. Early and effective treatment is crucial to minimize disease burden, chronic morbidity and reduced quality of life. Treatment strategies depend on the JIA category and comorbidities. The treatment should follow consensus treatment plans/strategies published by the German initiative Protocols for Classification, Monitoring and Therapy in Pediatric Rheumatology (ProKind) considering the treat-to-target strategy. Since a significant number of patients continue to have symptoms into adulthood, a well-structured transition from pediatric to adult rheumatology care is essential.

Pregnancy and lactation-associated osteoporosis (PLO) is a rare but serious condition. Multiple fractures often occur, mostly in the form of vertebral fractures, the mother is severely restricted and caring for the infant is barely possible without assistance. The fractures causing the complaints usually occur in the last trimester of the first pregnancy or in the first weeks of lactation. Magnetic resonance imaging (MRI) can be used to detect vertebral fractures and also edematous vertebrae. Bone densitometry is helpful for the diagnostics and assessment of progression. It is extremely important to distinguish PLO from other secondary forms of osteoporosis that can also be manifested during pregnancy and lactation. The mother is advised to stop breastfeeding immediately in order to interrupt calcium mobilization from bone and to achieve a normalization of hormone levels. Calcium and vitamin D should be supplemented and adequate pain treatment and physiotherapy should be initiated. The quality of data is poor due to the rarity of the disease, all available anti-osteoporotic drugs have been used in case reports but overall, in the last decade off-label treatment with teriparatide has been proven to be helpful and safe.

Metabolic bone diseases cause bone and joint pain and are manifested as rheumatism. Typical for the rare genetic disease hypophosphatasia is a reduced activity of alkaline phosphatase (AP), where the variable residual activity causes the heterogeneous symptoms (e.g., arthralgia, myalgia and fractures). It is indicated by repeatedly low AP measurements. The diagnosis requires a meticulous medical history and laboratory-based clarification in order to rule out other differential diagnoses. Although supportive measures form the basis of treatment, costly enzyme replacement therapy is a possible treatment option for severe forms. Multidisciplinary care under the direction of a rheumatologist experienced in osteology or an osteologist is crucial in order to provide adequate care to affected patients. Phosphate loss syndromes due to overactivity of fibroblast growth factor 23 (FGF-23) lead to deformities of the lower extremities and short stature (in congenital disorders), bone and muscle pain, muscular weakness and pathological fractures, depending on the time of occurrence during life. In genetic forms of the disease (especially X‑linked hypophosphatemia), supplementation with calcitriol and phosphates and, if necessary, complex corrective surgery in adolescence are traditional treatment methods, which are increasingly being replaced by treatment with antibodies against FGF-23. The acquired variant is a paraneoplastic phenomenon from small mostly benign mesenchymal tumors, which clinically shows a relatively acute course with severe bone pain, pathological fractures and muscle weakness in previously healthy patients and can ideally be cured by resection of the tumor. The disease can be suspected by significantly reduced serum phosphate levels and narrowed down with further laboratory diagnostics. In our opinion, the measurement of calcium, phosphate and alkaline phosphatase should be part of the primary laboratory diagnostics performed by rheumatologists and the follow-up of pathological findings is indicated.

Herbal preparations and phytotherapeutic substances are offered for symptoms and diseases of the rheumatic spectrum and are often intensively advertised in the lay press. The German Society for Rheumatology and Clinical Immunology (DGRh) Committee on Complementary Medicine and Nutrition reviewed the scientific literature on selected over the counter preparations and prescription phytotherapeutic substances and examined the possibilities for their use in rheumatology.

The Irish author James Joyce (1882-1941) suffered from chronic recurrent iritis with a variety of complications that led to almost complete blindness. Syphilis and a rheumatic disease, such as Reiter's syndrome were discussed as the main causes. The coincidence of a venereal infection, arthritis and the characteristic medically documented features of iritis, including typical complications, together with the chronic recurrent course of the eye disease, are convincing arguments for postvenereal reactive arthritis. A familial predisposition and smoking could have been responsible for the unfavorable course of the iritis. There is no reliable evidence of syphilis and, above all, the multiple recurrences of the iritis are not compatible with a syphilitic infection. Even after the medical publications in which the rheumatic genesis was convincingly discussed and in the knowledge of these, art historians have held on to the diagnosis of syphilis. It is therefore to be hoped that in the future the art historical literature will accurately reflect Joyce's illness in accordance with the medical knowledge.

The model advanced training regulations define the content of advanced training to achieve the qualification of medical specialist in all specialties and sub-specialties of medicine. As rheumatology is one of the ten specialties for internal medicine in Germany, regulations cover basic competencies of general and all other specialties in internal medicine as well as special skills in rheumatology. There are currently no criteria for issuing the authorization in advanced training. This position paper describes the criteria proposed by the German Society for Rheumatology and Clinical Immunology (DGRh), which should be the foundation for the issuance of authorization for advanced training in the field of internal medicine and rheumatology and for the assessment of the duration. The model advanced training regulations 2018 and the advanced training plan recommended by experts function as the basis for this. Based on the criteria, the authorization for advanced training to advanced specialist training in internal medicine and rheumatology can be allocated in a standardized, graded and transparent manner throughout Germany. This enables an optimal quality of advanced training in rheumatology, which can be adapted to the future developments in the discipline.

Connective tissue diseases as systemic autoimmune diseases are frequently associated with lung involvement. The diagnostics are often delayed by initially mild and unspecific symptoms. As lung involvement in these diseases can be chronically progressive and sometimes rapidly progressive, early and regular screening and monitoring are essential. This article focuses on typical findings and the diagnostic value of useful examination methods. Ideally, the diagnostics and treatment of lung involvement in connective tissue disease should be performed on an interdisciplinary basis in collaboration between pulmonology and rheumatology.

Rheumatoid arthritis (RA) is a pervasive chronic inflammatory condition exerting a substantial impact on global morbidity and mortality. This study provides an in-depth analysis of the epidemiological trends of RA across China, America, India, and Europe as well as at a global level from 1990 to 2021, with forward-looking projections extending to 2030.

Anti-MDA5 positive dermatomyositis is a rare subtype of idiopathic inflammatory myopathies often accompanied by rapidly progressive interstitial lung disease and severe cutaneous ulcerations. It is associated with a high mortality. The simultaneous occurrence of sarcoidosis with multisystemic involvement of myositis has only been described very rarely in the literature to date.

Chronic pain is a common problem in rheumatology. Nociceptive pain is distinguished from neuropathic and nociplastic pain. Mechanistically, the former is explained by persistent inflammation, for example. Included in the second category is nerve damage of various causes. In contrast, nociplastic pain is not caused by tissue damage or a lesion in the somatosensory nerve system. It is caused by an altered sensation of pain through the modulation of stimulus processing. The concept of central sensitization, together with further neurobiological and psychosocial mechanisms, best explains such pain conditions. Fibromyalgia (FM) plays a big part in rheumatology - on the one hand, as a differential diagnosis, and on the other, because the management of inflammatory rheumatic conditions is made more difficult by the simultaneous occurrence of FM. In the context of the coronavirus pandemic, persistent pain syndromes with similarities to FM have been described after COVID-19 infection. There is an increasing scientific controversy whether the so-called long Covid syndrome is an actual entity or "only" a variant of FM. This discussion and the current state of knowledge on the problem are the subject of this review.

Acute and chronic pain play an important part in the care of patients with musculoskeletal diseases. For rheumatologists this represents a frequent challenge. For the management of chronic pain conditions in rheumatology those that cannot be explained by objective tissue damage are particularly important-which makes patients' subjective assessment of pain a central building block of the diagnosis. For the diagnosis of fibromyalgia (FM) standardized questionnaires such as the Widespread Pain Index (WPI) and the Symptom Severity Score (SSS) are used. In connection with the recent global SARS-CoV‑2 pandemic protracted courses and health problems have been described, which have been termed long COVID syndrome and have some similarities but, as is shown in the following, also demonstrate some differences from FM. There has recently been an interesting scientific controversy that culminated in a pros and cons session at the EULAR congress 2024, following several publications. The arguments and citations exchanged have served as the basis for the overview produced here, which is intended to offer rheumatologists confronted with such clinical pictures assistance with the assessment of these diseases, even if the results of the studies presented are definitely controversial.