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.

Health-related quality of life is best thought of simply as 'health'. Life quality in patients with rheumatoid arthritis (RA) is affected, for good or ill, by treatment effects. Health status now is readily and validly measurable, using the Health Assessment Questionnaire or other instruments. Disability and pain are reduced by disease-modifying anti-rheumatic drugs (DMARDs) much more than by non-steroidal anti-inflammatory drugs (NSAIDs). Toxicity considerations vary among individual drugs but are roughly comparable between NSAIDs and DMARDs, mandating DMARD-based treatment strategies. Future therapies must accentuate the positives (reduction in pain and disability) while reducing the negatives (unwanted effects) if the health of RA patients is to be improved.

How may quality of life for rheumatoid arthritis patients be enhanced by current and future treatments

Chronic rheumatic diseases can severely compromise a patient's functional ability. These limitations are often better appreciated through a patient's self-report and a physician examination than through laboratory and radiographic assessments. Researchers are adapting the established health status questionnaires for non-English-speaking patients and for other rheumatic conditions besides rheumatoid arthritis. Rather than tailoring existing instruments for other diseases, some clinician investigators are developing entirely new disease-specific self-assessment questionnaires. Physicians are also addressing the subjectivity of their physical examination techniques. They are devising consistent and sensitive parameters that can be combined with health status questionnaires to monitor disease activity, gauge therapeutics, predict health services utilization, and predict work disability.

Health status instruments and physical examination techniques in clinical measurement methodologies.

The hierarchy of outcome assessment.

Background: The magnitude and duration of the benefit of running and other aerobic exercise on disability and mortality in elderly persons are not well understood. We sought to quantify the benefits of aerobic exercise, including running, on disability and mortality in elderly persons and to examine whether morbidity can be compressed into later years of life by regular exercise. Methods: A 13-year prospective cohort study of 370 members of a runners’ club for persons aged 50 and older and 249 control subjects initially aged 50 to 72 years (mean, 59 years), with annual ascertainment of the Health Assessment Questionnaire disability score, noting any deaths and their causes. Linear mixed models were used to compute postponement in disability, and survival analysis was conducted to determine the time to and causes of death. Results: Significantly (P.001) lower disability levels in runners’ club members vs controls and in ever runners vs never runners were sustained for at least 13 years. Reaching a Health Assessment Questionnaire disability level of 0.075 was postponed by 8.7 (95% confidence interval [CI], 5.5-13.7) years in runners’ club members vs controls. Running club membership and participation in other aerobic exercise protected against mortality (rate ratio, 0.36 [95% CI, 0.20-0.65] and 0.88 [95% CI, 0.770.99], respectively), while male sex and smoking were detrimental (rate ratio, 2.4 [95% CI, 1.4-4.2] and 2.2 [95% CI, 1.1-4.6], respectively). Controls had a 3.3 times higher rate of death than runners’ club members, with higher death rates in every disease category. Accelerated rates of disability and mortality were still not seen in the runners’ club members; true compression of morbidity was not yet observable through an average age of 72 years. Conclusion: Running and other aerobic exercise in elderly persons protect against disability and early mortality, and are associated with prolongation of a disabilityfree life. Arch Intern Med. 2002;162:2285-2294

Postponed Development of Disability in Elderly Runners

Time-related aspects have attracted an increasing interest in medical decisions. Health promotion often works toward remote goals, and many clinical judgments and decisions include an exchange of costs today for benefits in the future. The concept of diminishing value over time is positive discounting when the benefits occur so far in the future that they seem of little value relative to the immediate cost. If there is a preference to live for the present rather than save for the future, such a preference might not contribute to good health according to a lower discount rate. As discounting is related to risk an analysis of uncertainty is required being an unavoidable condition in health work. Shared decision-making between doctor and patient has increasingly been emphasized, where risk characteristics and time-related aspects should be taken into account to reach a decision based upon mutual agreement. The framework of time and risk for analysis can perform a useful role in clinical judgments and decisions, where framing of different features of risk might diminish discounting and increase compliance to treatment. A summary of valuation factors in medical decision making is presented: (a) long-term decisions are sensitive to discount rates; (b) discount rates vary by domain, by outcome, by individuals and by level of certainty; (c) probability discounting is used if the risk is perceived as controllable; (d) the doctor uses expected value, the patient is risk aversive; (e) asymmetric discounting for patients and doctors gives poor compliance; (f) discount rates are influenced by framing.

James F. Fries

Papers

How may quality of life for rheumatoid arthritis patients be enhanced by current and future treatments

Health status instruments and physical examination techniques in clinical measurement methodologies.

The hierarchy of outcome assessment.

Postponed Development of Disability in Elderly Runners

Discounting and risk characteristics in clinical decision-making.