Rheumatoid arthritis criteria 1987

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  • Introduction
  • CRD summary
  • Publication types
  • Summary of 1987 ACR criteria for the classification of RA
  • Introduction

    References of retrieved studies and abstracts from relevant international congresses between and were screened. The review was restricted to studies published in English, French and Spanish. Study selection Studies that evaluated accuracy of the ACR criteria in adults compared to the reference standard of expert opinion and that reported sufficient data to allow calculation of sensitivity and specificity were eligible for inclusion.

    Cases in the studies had rheumatoid arthritis that ranged in duration of from less than three months to 16 years. Controls had osteoarthritis, systemic autoimmune disease, undifferentiated arthritis, spondyloarthritis, other diagnoses such as fibromyalgia, septic or viral arthritis and crystal-induced arthropathies.

    The authors stated neither how the papers were selected for the review nor how many reviewers performed the selection. Assessment of study quality The authors did not state that they assessed study quality. Data extraction One reviewer extracted data as 2x2 tables of test performance. Methods of synthesis Data were pooled using a summary receiver operating characteristic SROC approach. Sensitivity and specificity were pooled using the arcsin of transformed proportions.

    Heterogeneity was assessed using the Q statistic. A random-effects model was used where heterogeneity was present. A regression model was used to assess the effect of disease duration on accuracy. Publication bias was assessed with a funnel plot. The funnel plot suggested some evidence of publication bias. Authors' conclusions Specificity of ACR criteria in early rheumatoid arthritis was low and these criteria should not be used as diagnostic tools.

    Sensitivity and specificity in established rheumatoid arthritis were higher, which reflected their use as classification criteria gold standard. CRD commentary The review addressed a focused question supported by clearly defined inclusion criteria. The literature search involved two relevant databases, but use of a diagnostic filter and restriction of the review to studies published in certain languages meant that relevant studies may have been missed.

    This has resulted in an explosion of targeted biologic therapies for RA that have proved significantly more effective than previously available treatments in improving disease activity, preventing joint destruction and preserving physical function. Using these new therapeutic agents, remission of disease activity is now a realistic possibility [ 1 ]. Patients with established RA typically require continued drug administration to control disease activity. The observation that delays in treatment with conventional DMARDs resulted in worse outcomes led to the finding that effective therapeutic intervention to reduce synovitis during a window of opportunity earlier in the course of disease effectively reduced structural damage [ 2 ].

    The appropriate intensive use of conventional DMARDs has resulted in patients achieving better structural and functional outcomes than with routine treatment strategies [ 3 ]. Over the past decade, new biomarkers such as ACPAs have been shown to predict an aggressive disease course that often is accompanied by joint destruction.

    The ARA revised criteria for the classification of RA, which have been used to define this disease in clinical trials of novel therapies, fail to diagnose some patients with early RA who might benefit most from the initiation of early, aggressive treatment.

    The main purpose of these criteria was to distinguish RA from other forms of arthritis, rather than to identify and diagnose patients with RA in the earlier stages of disease when they might benefit most from intervention [ 4 ]. These classification criteria were developed before the diagnostic and prognostic importance of ACPAs were recognized; thus, only serum RF was included as a serological marker.

    The inclusion of radiographic changes bony erosions or periarticular decalcification as a diagnostic criterion was clearly consistent with the goal of avoiding the overdiagnosis of RA, as opposed to identifying patients with disease who would respond to treatment.

    Thus, the window of opportunity to receive treatment that could control disease activity and prevent structural damage might already have passed for many of the patients classified as having RA using the ARA criteria [ 5 ]. The RA classification criteria In , a group of American and European rheumatologists who were experts in the diagnosis and treatment of RA met in Zürich to discuss the limitations of the existing ARA criteria and to plan the development of a new set of criteria to diagnose and classify patients with RA early in the course of disease.

    Such criteria would facilitate early therapeutic intervention to prevent structural damage and permanent functional limitation [ 5 ].

    Rheumatoid arthritis criteria 1987

    In turn, emphasis has shifted to intervention early enough in the disease course to prevent the joint destruction that follows inflammation. References of retrieved studies and abstracts from relevant international congresses between and were screened. The authors stated neither how the papers were selected for the review nor how many reviewers performed the selection. These rules, or criteria, would be used not only to identify individuals at high risk for chronic disease activity and erosive damage but also as a basis for choosing patients in whom to initiate targeted DMARD treatment early in the disease course [ 5 ]. Funding Not stated. The review was restricted to studies published in English, French and Spanish.

    CRD summary

    The review was restricted to studies published in English, French and Spanish. Study selection Studies that evaluated accuracy of the ACR criteria in adults compared to the reference standard of expert opinion and that reported sufficient data to allow calculation of sensitivity and specificity were eligible for inclusion. Cases in the studies had rheumatoid arthritis that ranged in duration of from less than three months to 16 years.

    Controls had osteoarthritis, systemic autoimmune disease, undifferentiated arthritis, spondyloarthritis, other diagnoses such as fibromyalgia, septic or viral arthritis and crystal-induced arthropathies. The authors stated neither how the papers were selected for the review nor how many reviewers performed the selection. Assessment of study quality The authors did not state that they assessed study quality. Data extraction One reviewer extracted data as 2x2 tables of test performance.

    Methods of synthesis Data were pooled using a summary receiver operating characteristic SROC approach. Sensitivity and specificity were pooled using the arcsin of transformed proportions. Heterogeneity was assessed using the Q statistic.

    A random-effects model was used where heterogeneity was present. A regression model was used to assess the effect of disease duration on accuracy. Publication bias was assessed with a funnel plot. The funnel plot suggested some evidence of publication bias. Authors' conclusions Specificity of ACR criteria in early rheumatoid arthritis was low and these criteria should not be used as diagnostic tools.

    Sensitivity and specificity in established rheumatoid arthritis were higher, which reflected their use as classification criteria gold standard. CRD commentary The review addressed a focused question supported by clearly defined inclusion criteria. The literature search involved two relevant databases, but use of a diagnostic filter and restriction of the review to studies published in certain languages meant that relevant studies may have been missed.

    It was unclear whether appropriate steps were taken to minimise bias and errors in the selection of studies; no such steps were taken for data extraction. These classification criteria were developed before the diagnostic and prognostic importance of ACPAs were recognized; thus, only serum RF was included as a serological marker. The inclusion of radiographic changes bony erosions or periarticular decalcification as a diagnostic criterion was clearly consistent with the goal of avoiding the overdiagnosis of RA, as opposed to identifying patients with disease who would respond to treatment.

    Thus, the window of opportunity to receive treatment that could control disease activity and prevent structural damage might already have passed for many of the patients classified as having RA using the ARA criteria [ 5 ]. The RA classification criteria In , a group of American and European rheumatologists who were experts in the diagnosis and treatment of RA met in Zürich to discuss the limitations of the existing ARA criteria and to plan the development of a new set of criteria to diagnose and classify patients with RA early in the course of disease.

    Such criteria would facilitate early therapeutic intervention to prevent structural damage and permanent functional limitation [ 5 ].

    Such patients would be classified as having RA. These rules, or criteria, would be used not only to identify individuals at high risk for chronic disease activity and erosive damage but also as a basis for choosing patients in whom to initiate targeted DMARD treatment early in the disease course [ 5 ].

    The criteria were developed in three phases. Phase I: cohort analysis The initial phase of this process consisted of an analysis of data from seven European cohorts and one North American cohort of patients who presented with early undifferentiated synovitis. Initiation of MTX therapy to prevent structural joint damage was considered to be a surrogate for the diagnosis of RA.

    Those common clinical and laboratory variables that had prompted experienced clinicians to initiate MTX therapy in these patients within 1 year of enrolment were identified.

    Anatomic location of swollen and tender joints, levels of acute-phase reactants and titres of serological biomarkers were identified as being those variables that contributed most to the decision to initiate MTX therapy among these patients.

    The relative contribution of each variable to this decision was estimated Table 1 [ 5 , 6 ].

    Publication types

    Rheumatoid arthritis criteria 1987

    Study selection Studies that evaluated accuracy of the ACR criteria in adults compared to the reference standard of expert opinion and that reported sufficient data to allow calculation of sensitivity and specificity were eligible for inclusion. Cases in the studies had rheumatoid arthritis that ranged in duration of from less than three months to 16 years. Controls had osteoarthritis, systemic autoimmune disease, undifferentiated arthritis, spondyloarthritis, other diagnoses such as fibromyalgia, septic or viral arthritis and crystal-induced arthropathies.

    The authors stated neither how the papers were selected for the review nor how many reviewers performed the selection. Assessment of study quality The authors did not state that they assessed study quality.

    Data extraction One reviewer extracted data as 2x2 tables of test performance. Methods of synthesis Data were pooled using a summary receiver operating characteristic SROC approach.

    Sensitivity and specificity were pooled using the arcsin of transformed proportions. Heterogeneity was assessed using the Q statistic. A random-effects model was used where heterogeneity was present. A regression model was used to assess the effect of disease duration on accuracy. Publication bias was assessed with a funnel plot. The funnel plot suggested some evidence of publication bias.

    Authors' conclusions Specificity of ACR criteria in early rheumatoid arthritis was low and these criteria should not be used as diagnostic tools. Sensitivity and specificity in established rheumatoid arthritis were higher, which reflected their use as classification criteria gold standard. CRD commentary The review addressed a focused question supported by clearly defined inclusion criteria.

    The literature search involved two relevant databases, but use of a diagnostic filter and restriction of the review to studies published in certain languages meant that relevant studies may have been missed.

    It was unclear whether appropriate steps were taken to minimise bias and errors in the selection of studies; no such steps were taken for data extraction. Study quality was not assessed and details on individual studies were lacking, especially in relation to study design; therefore, validity and generalisability of the findings were unclear.

    The ARA revised criteria for the classification of RA, which have been used to define this disease in clinical trials of novel therapies, fail to diagnose some patients with early RA who might benefit most from the initiation of early, aggressive treatment.

    The main purpose of these criteria was to distinguish RA from other forms of arthritis, rather than to identify and diagnose patients with RA in the earlier stages of disease when they might benefit most from intervention [ 4 ]. These classification criteria were developed before the diagnostic and prognostic importance of ACPAs were recognized; thus, only serum RF was included as a serological marker. The inclusion of radiographic changes bony erosions or periarticular decalcification as a diagnostic criterion was clearly consistent with the goal of avoiding the overdiagnosis of RA, as opposed to identifying patients with disease who would respond to treatment.

    Thus, the window of opportunity to receive treatment that could control disease activity and prevent structural damage might already have passed for many of the patients classified as having RA using the ARA criteria [ 5 ]. The RA classification criteria In , a group of American and European rheumatologists who were experts in the diagnosis and treatment of RA met in Zürich to discuss the limitations of the existing ARA criteria and to plan the development of a new set of criteria to diagnose and classify patients with RA early in the course of disease.

    Such criteria would facilitate early therapeutic intervention to prevent structural damage and permanent functional limitation [ 5 ]. Such patients would be classified as having RA. These rules, or criteria, would be used not only to identify individuals at high risk for chronic disease activity and erosive damage but also as a basis for choosing patients in whom to initiate targeted DMARD treatment early in the disease course [ 5 ].

    The criteria were developed in three phases. Phase I: cohort analysis The initial phase of this process consisted of an analysis of data from seven European cohorts and one North American cohort of patients who presented with early undifferentiated synovitis.

    Initiation of MTX therapy to prevent structural joint damage was considered to be a surrogate for the diagnosis of RA. Those common clinical and laboratory variables that had prompted experienced clinicians to initiate MTX therapy in these patients within 1 year of enrolment were identified.

    Summary of 1987 ACR criteria for the classification of RA

    The methods used to investigate publication bias were not appropriate for diagnostic accuracy data and were unlikely to produce reliable results. Publication bias was assessed with a funnel plot. Sensitivity and specificity in established rheumatoid arthritis were higher, which reflected their use as classification criteria gold standard. The funnel plot suggested some evidence of publication bias. Search terms were reported and included a diagnostic filter.

    Methods of synthesis Data were pooled using a summary receiver operating characteristic SROC approach. Sensitivity and specificity were pooled using the arcsin of transformed proportions. Heterogeneity was assessed using the Q statistic. A random-effects model was used where heterogeneity was present. A regression model was used to assess the effect of disease duration on accuracy.

    Publication bias was assessed with a funnel plot. The funnel plot suggested some evidence of publication bias. Authors' conclusions Specificity of ACR criteria in early rheumatoid arthritis was low and these criteria should not be used as diagnostic tools. Sensitivity and specificity in established rheumatoid arthritis were higher, which reflected their use as classification criteria gold standard. CRD commentary The review addressed a focused question supported by clearly defined inclusion criteria.

    The literature search involved two relevant databases, but use of a diagnostic filter and restriction of the review to studies published in certain languages meant that relevant studies may have been missed. It was unclear whether appropriate steps were taken to minimise bias and errors in the selection of studies; no such steps were taken for data extraction. Study quality was not assessed and details on individual studies were lacking, especially in relation to study design; therefore, validity and generalisability of the findings were unclear.

    Methods used to pool studies were appropriate and results were clearly presented with the aid of graphical displays. However, there was considerably heterogeneity in pooled estimates and so these should be interpreted with extreme caution; further investigation of differences between studies may have helped determine the true accuracy of these criteria. The methods used to investigate publication bias were not appropriate for diagnostic accuracy data and were unlikely to produce reliable results.

    The review councluded that ACR criteria had greater overall accuracy in established than with early rheumatoid arthritis; however, the summary estimates of sensitivity were similar for early and established rheumatoid arthritis.

    The authors' conclusions were based on very heterogeneous pooled data from studies of unknown validity, which combined with a lack of details on the included studies meant that the authors' conclusions are unlikely to be reliable.

    Implications of the review for practice and research Practice: The authors stated ACR criteria should not be used as diagnosis tools in early rheumatoid arthritis. The inclusion of radiographic changes bony erosions or periarticular decalcification as a diagnostic criterion was clearly consistent with the goal of avoiding the overdiagnosis of RA, as opposed to identifying patients with disease who would respond to treatment.

    Thus, the window of opportunity to receive treatment that could control disease activity and prevent structural damage might already have passed for many of the patients classified as having RA using the ARA criteria [ 5 ].

    The RA classification criteria In , a group of American and European rheumatologists who were experts in the diagnosis and treatment of RA met in Zürich to discuss the limitations of the existing ARA criteria and to plan the development of a new set of criteria to diagnose and classify patients with RA early in the course of disease.

    Such criteria would facilitate early therapeutic intervention to prevent structural damage and permanent functional limitation [ 5 ]. Such patients would be classified as having RA. These rules, or criteria, would be used not only to identify individuals at high risk for chronic disease activity and erosive damage but also as a basis for choosing patients in whom to initiate targeted DMARD treatment early in the disease course [ 5 ]. The criteria were developed in three phases.

    Phase I: cohort analysis The initial phase of this process consisted of an analysis of data from seven European cohorts and one North American cohort of patients who presented with early undifferentiated synovitis.

    Initiation of MTX therapy to prevent structural joint damage was considered to be a surrogate for the diagnosis of RA. Those common clinical and laboratory variables that had prompted experienced clinicians to initiate MTX therapy in these patients within 1 year of enrolment were identified. Anatomic location of swollen and tender joints, levels of acute-phase reactants and titres of serological biomarkers were identified as being those variables that contributed most to the decision to initiate MTX therapy among these patients.

    The relative contribution of each variable to this decision was estimated Table 1 [ 5 , 6 ]. Table 1 Criteria identified during phase 1 and the relative weight assigned to each [ 5 , 6 ] Variable.

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