Numerous methods for reading abnormalities of rheumatoid arthritis in hand and wrist radiographs have been proposed over the past several decades. There are many differences among these methods, one of the more striking of which is the variation in the number of joints that are scored. In this study, we tested the number of joints that need to be read in order to represent abnormalities accurately and reproducibly, using the scores of multiple observers. Thirteen rheumatologists and radiologists each read a set of 41Presented at a workshop sponsored by the Joe and Betty Alpert Arthritis Center, Rose Medical Center, Denver, CO, November [28][29] 1983.Supported by a grant from the Eli LiHy Company, Indianapolis, IN.John T. Sharp hand and wrist films from patients with rheumatoid arthritis. Ten of 13 readers scored 27 joints in each hand and wrist; the other 3 readers scored fewer areas. Fourteen combinations of joints were selected based on the frequency of involvement and the technical adequacy of routine films in assessing a given area. After testing these 14 different combinations, 1 scheme, which included 17 areas read for erosions and 18 areas read for joint space narrowing, was tested further. The correlation coefficients for 10 intraobserver scores derived from this modified scheme compared with the original scores were between 0.981 and 0.997. Seventy-one of 78 interobserver comparisons were better using the new scheme than using the original scheme. These data indicate that the simplified scheme, using a combination of 17 joints to score erosions and 18 to score joint space narrowing, more accurately reflects the extent of abnormalities perceived by a panel of experts than does the original scheme. This abbreviated number of joints shortens the amount of time required to read a set of films and simplifies the scoring of films, since a number of areas that are difficult to read are eliminated from radiographic assessment.Destruction of bone and cartilage is a regular consequence of persistent, active synovitis in patients with rheumatoid arthritis (RA). Because finger and wrist joints are frequently involved in this disease, a number of investigators over the past several decades have proposed that an assessment of the severity of erosions and cartilage loss in hand and wrist joints, logically, would represent an index of the outcome of this disease process (1-6). More recently, it has been proposed that individual joints should be scored separately and the scores summed in order to accurately

summARY We have studied the radiological features in 94 patients with early rheumatoid disease followed prospectively for 5 years. The changes appeared very early and occurred in up to 71-3 % of patients. Erosive changes occurred in the feet much more commonly than in the hands and considerably earlier. Erosive changes were present before there was joint-space loss. Frequent x-ray examination of feet and hands in the first 2 years after presentation is required if we are to identify patients at risk for serious joint damage.A recent prospective study of early rheumatoid disease has enabled us to follow the radiological features almost from onset. Although the radiographic appearances were described by Nichols and Richardson in 1909, correlation with modem clinical classification was not made until 1932 (Scott). The frequency of the various x-ray manifestations was reported by Fletcher and Rowley in 1952. Subsequently, large surveys (Soila, 1958;Berens and Lin, 1969) have shown that x-ray abnormalities may be an early feature. Soila studied the films of 1032 patients but compared only the first x-rays with the last, the interval between the two sets of films being anything up to 6 years. Furthermore, x-rays of the feet were not taken as often as x-rays of the hands. We have therefore reviewed our material in order to establish a more complete study of radiological manifestations with respect to time. Patients and methodsThe design of the Middlesex Hospital Prospective Study of early rheumatoid disease has been described (Fleming et al., 1976a, b) and the present material is taken from the 102 patients seen within one year of onset and followed up for at least 21 months or until death. The mean radiological follow-up of all patients was 63-1 months.Each patient was x-rayed on presentation and then annually. Radiographic follow-up was inade- (posteroanterior) and feet (anteroposterior) were done as part of the routine outpatient service. The films were read by the same observer (A.B.) consecutively and without knowledge of the clinical state. Osteoporosis, erosions, joint-space narrowing, and periosteal reaction were looked for. We accept that interobserver and intraobserver errors in such readings are considerable (Kellgren, 1956) and this paper is concerned only with changes confirmed in subsequent x-rays by the same observer.Erosive changes were regarded as 'diagnostic' if there were two large erosions (1-5 mm or more of cortical defect). Smaller erosions and subchondral cysts were included in assessment of the extent and progression of involvement. The 'pre-erosive' changes described by Fletcher and Rowley (1952)

Sixty-four survivors from a prospective study of early rheumatoid disease were assessed again at a mean of 15.2 years from presentation and their status compared with 29 patients who had died. Eleven of the dead and only two of the survivors had been treated with steroids. There was a small increase in mortality due to the disease itself but only one death was directly caused by it. As might be expected, those who died were older. In the first year of disease, they had lower haemoglobin levels, a lower body mass, higher sedimentation rates and higher levels of blood urea. One-fifth at entry to the study and two-fifths by the time of death, had poor functional capacity. Of 64 survivors, six had poor functional capacity at entry and nine after 15 years. Discriminant analysis was performed to identify the most powerful combination of early features predicting a poor functional outcome. A combination including early erosive change, seropositivity, poor grip strength and cervical subluxation predicted the outcome correctly in 73% of survivors. Almost 60% of survivors remained with or improved to normal function at 15 years suggesting that morbidity is not as bad as has been suggested in the past.

Fleming, A., Crown, J. M., and Corbett, M. (1976). Annals of the Rheumatic Diseases, 35, 357-360. Early rheumatoid disease. L. Onset. We describe features with onset in 102 patients seen within the first year of rheumatoid disease. The male:female ratio was approximately 3:4, suggesting a near equal sex incidence at onset. The disease started more often in the colder months and was usually insidious, symmetrical, and involved the upper limbs.The patients were followed prospectively and outcome was assessed after a mean of 4 5 years. Older patients fared worse and there was a trend for a poorer prognosis to be indicated by an insidious onset and early progression to symmetrical involvement.The importance of observing all phenomena associated with onset in a condition such as rheumatoid disease, where cause and cure are unknown, has been stressed by Jacoby, Jayson, and Cosh (1973). Studies attempting this rely on patient memory, and a defect of many such works has been the length of time after which patients have been asked to recall early episodes. It is difficult to find and follow rheumatoid sufferers early in the course of their disease, and as a result only a few reports are based on data obtained near the onset of joint symptoms (Otten and Boerma, 1959; Rotes-Querol and RoigEscofet, 1968; Jacoby and others, 1973).A recent prospective study of early rheumatoid disease, undertaken at the Middlesex Hospital, has provided information on various aspects of onset, including age, sex, time, type, site, symmetry, and time-lag to presentation, enabling the significance of these data to be assessed in relation to other disease features and to subsequent course. The information was taken at a mean 4-6 months from onset, when patient memory was relatively fresh.Patients and methods Patients were invited to enter the study if the rheumatologist suspected rheumatoid disease of less than one year's duration. Those with evidence of psoriatic arthritis, gout, ankylosing spondylitis, Reiter's disease, or colitic arthropathy were excluded. At this first specialist rheumatological consultation the historical data on onset was gathered. The patient subsequently attended a special research clinic three times a year.At the special clinic the site of involvement (swelling, tenderness, or pain on movement) was noted, the rheumatoid status was recorded (American Rheumatism Association, 1959), and the patient was placed in one of four functional grades (Duthie and others, 1955). Annual radiographs were taken of hands, feet, and cervical spine, and the presence of erosions was recorded. The sheep cell agglutination test (SCAT) was used to estimate rheumatoid factor (Roitt and Doniach, 1969). The clinics were quite distinct from the regular outpatient visits and treatment was not influenced.One hundred and two patients were studied, and were followed in the clinic for 18 months or longer, or until death. The mean delay from onset to the first specialist consultation and to the first research clinic visit was respectively 4 6 months ...

Forty-one coded radiographic films from 16 patients with rheumatoid arthritis were read by 13 observers, using 4 different methods for scoring abnormalities. Although absolute scores differed widely among individual observers, correlation coefficients were greater than 0.850 for approximately 2 of 3 comparisons. When films were ranked, using the median rank of all readers, 72% of individual ranks were within 10% of the median ranks. Among serial films on individual patients, 92% of comparisons between early and late films were interpreted as demonstrating progression of abnormalities when mean standardized scores showed an increase in scores of 15 units or greater. Films with lesser changes were interpreted inconsistently. This study shows good general agreement among readers in scoring radiologic abnormalities of hands and wrists, when applied to a film set showing a broad spectrum of severity, and defines the sensitivity of radiologic detection of disease progression.