The revised criteria for the classification of rheumatoid arthritis (RA) were formulated from a computerized analysis of 262 contemporary, consecutively studied patients with RA and 262 control subjects with rheumatic diseases other than RA (non-RA). The new criteria are as follows: 1) morning stiffness in and around joints lasting at least 1 hour before maximal improvement; 2) soft tissue swelling (arthritis) of 3 or more joint areas observed by a physician; 3) swelling (arthritis) of the proximal interphalangeal, metacarpophalangeal, or wrist joints; 4) symmetric swelling (arthritis); 5) rheumatoid nodules; 6) the presence of rheumatoid factor; and 7) radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints. Criteria 1 through 4 must have been present for at least 6 weeks. Rheumatoid arthritis is defined by the presence of 4 or more criteria, and no further qualifications (classic, definite, or probable) or list of exclusions are required. In addition, a "classification tree" schema is presented which performs equally as well as the traditional (4 of 7) format. The new criteria demonstrated 91-94% sensitivity and 89% specificity for RA when compared with non-RA rheumatic disease control subjects.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.1780310302

The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis.

The 1971 preliminary criteria for the classification of systemic lupus erythematosus (SLE) were revised and updated to incorporate new immunologic knowledge and improve disease classification. The 1982 revised criteria include fluorescence antinuclear antibody and antibody to native DNA and Sm antigen. Some criteria involving the same organ systems were aggregated into single criteria. Raynaud's phenomenon and alopecia were not included in the 1982 revised criteria because of low sensitivity and specificity. The new criteria were 96% sensitive and 96% specific when tested with SLE and control patient data gathered from 18 participating clinics. When compared with the 1971 criteria, the 1982 revised criteria showed gains in sensitivity and specificity.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.1780251101

The 1982 revised criteria for the classification of systemic lupus erythematosus

K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification

In 1982, the Diagnostic and Therapeutic Criteria Committee of the American College of Rheumatology (ACR)published revised criteria for the classification of systemiclupus erythematosus (SLE) (1). During the ensuing decade several investigators, including Drs. Graham Hughes and Donato Alarcon-Segovia, among others, have described the presence and clinical associations or antiphospholipid antibodies in patients with SLE, as well as the occurrence of theprimary antiphospholipid syndrome (2-5). In 1992, Piette and colleagues suggested that the ACR revised criteria be reevaluated in light of the above discoveries (6).

https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.1780400928

Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus.

To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in greater than or equal to 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1002/art.1780330203

The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee.

The management of asymptomatic hyperuricemia is controversial. Reported benefits from treatment prevention of acute gouty arthritis, chronic tophaceous gout, urolithiasis, or gouty nephropathy. A review of experimental and clinical data suggests that the risks of asymptomatic hyperuricemia are small or unknown and the efficacy of long-term treatment in preventing gout or renal disease is unproved. The costs and risks of prolonged drug administration and practical considerations such as patient compliance mitigate against long-term therapy in asymptomatic persons. We offer some recommendations for an expectant approach to the management of asymptomatic hyperuricemia.

Asymptomatic Hyperuricemia: The Case for Conservative Management

OBJECTIVE: To describe changes in antirheumatic medication use by patients with rheumatoid arthritis (RA) over the 15 years 1981 to 1996. METHODS: Medication use was ascertained every 6 months by mailed Health Assessment Questionnaire in a cohort of patients recruited from the local community (n = 305; mean duration of RA at study entry 14.2 yrs). Patients were treated by 53 rheumatologists and over 200 other physicians during the study. The proportions of patients treated with nonsteroidal antiinflammatory drugs (NSAID), disease modifying antirheumatic drugs (DMARD), prednisone, intraarticular corticosteroids, and analgesics were determined in serial cross sectional analyses, and trends in medication use over time were analyzed using linear regression. RESULTS: From 1981 to 1996, the proportion of patients treated with DMARD increased from 32 to 47% (average increase 1.06% each year; p < 0.0001), while the proportion treated with NSAID decreased from 86 to 76% (average decrease 0.57% each year; p < 0.0001). The proportion of patients treated with prednisone remained between 30 and 40%, with a trend toward increasing use over time (average increase 0.2% each year; p = 0.05). In contrast, the proportion treated with intraarticular corticosteroids decreased from 14.4 to 6.7% (average decrease 0.46% each year; p < 0.0001). In 1996, the most prevalent patterns of medication use were the use of NSAID alone (24.4%), use of an NSAID and DMARD (16.3%), and use of an NSAID, DMARD, and prednisone (12.2%). Use of an NSAID as the only antirheumatic medication decreased over time, and the use of DMARD in combination with other medications increased. CONCLUSION: The proportion of patients with RA treated with DMARD increased substantially from 1981 to 1996. This change in practice occurred during the time in which the concept of inverting the traditional therapeutic pyramid became popular, and may reflect a translation among clinicians of the philosophy of "early DMARD use" to "consistent DMARD use," even among patients with RA of moderate or longstanding duration.

Trends in antirheumatic medication use among patients with rheumatoid arthritis, 1981-1996.

OBJECTIVE The hypothesis of a seasonal pattern in the onset of symptoms for some vasculitides has been raised in previous small studies. METHODS Using the data collected by the American College of Rheumatology (ACR) Subcommittee on Classification of Vasculitis, we specifically tested for a higher proportion of onset of symptoms in winter, lower in summer, and intermediate for the other seasons for polyarteritis nodosa (PAN) and Wegener's granulomatosis. We also tested for a higher proportion of onset of symptoms in the spring-summer months for giant cell arteritis (GCA). RESULTS AND CONCLUSIONS The results of our study support the hypothesis of a seasonal trend for the onset of symptoms of Wegener's granulomatosis (p = 0.04) as described previously. No seasonal pattern was found for the other vasculitides studied (PAN and GCA).

Seasonal variation in the onset of Wegener's granulomatosis, polyarteritis nodosa and giant cell arteritis.

OBJECTIVE Quality-of-life assessment is receiving increased attention as an outcome measure in rheumatoid arthritis (RA). The most widely used instruments use variations on a vertical visual analog scale (VAS). Since the Health Assessment Questionnaire (HAQ), Arthritis Impact Measurement Scales (AIMS), and other instruments have long included a "global" arthritis horizontal VAS (GLOB), we studied whether these 2 approaches assess the same concept. METHODS We studied 663 patients with RA from 4 ARAMIS (Arthritis, Rheumatism, and Aging Medical Information System) centers and had them complete, in different parts of the same HAQ, the GLOB and the Torrance "feeling thermometer" (FT). RESULTS The 2 scales were highly correlated (r = -0.676; p < 0.001). Reliability (estimated by 6 month test-retest) was 0.62 for the FT and 0.83 for the GLOB. The GLOB correlated more strongly than the FT with disability (r = 0.561 vs -0.507) and pain (0.630 vs -0.553). In stepwise regressions, pain and then disability were the dominant predictors of both GLOB and FT, followed weakly by joint count and then other variables. Patients with greater disability placed more emphasis on pain and patients with greater pain appeared to value more the contribution of disability. Change scores over 6 months between GLOB and FT correlated very well (-0.59). CONCLUSION "Health" and "health related quality-of-life" are nearly equivalent terms. Since large longitudinal rheumatology databases contain thousands of global health VAS values, data for longitudinal quality-of-life studies in arthritis are already available, and this dimension may readily be added to longterm outcome assessment. In patients with RA, "generic" and "disease specific" assessments yield very similar results.

James F. Fries

Papers

Asymptomatic Hyperuricemia: The Case for Conservative Management

Trends in antirheumatic medication use among patients with rheumatoid arthritis, 1981-1996.

Seasonal variation in the onset of Wegener's granulomatosis, polyarteritis nodosa and giant cell arteritis.

"Arthritis specific" global health analog scales assess "generic" health related quality-of-life in patients with rheumatoid arthritis

Late-stage lupus nephropathy.