In patients with rheumatoid arthritis (RA), joint erosions occur at a very early stage of the disease before clinical symptoms can be detected. Early treatment with currently available antirheumatic drugs may stop or delay the development of such erosions. A simple and specific diagnostic test is needed for treatment to be initiated at an early stage. The specificity of the routinely used rheumatoid factor (RF) test is too low for that purpose. A novel autoantibody, directed to citrullinated antigens in the synovium, seems to provide a new starting point. These citrullinated autoantigens (e.g. fibrin) are specifically present in inflamed synovia and the antibodies for these are locally produced. The autoantibodies can be detected in the blood of the patients with RA years before the first clinical signs are manifest, and high titres appear to correlate strongly with erosive disease. The test for cyclic citrullinated peptide, which has recently become available, has a specificity of 98-99% and a sensitivity of 75-80%.

Ann Rheum Dis. 2002 Jul;61(7):630-4.
Practical progress in realisation of early diagnosis and treatment of patients with suspected rheumatoid arthritis: results from two matched questionnaires within three years.
Aletaha D, Eberl G, Nell VP, Machold KP, Smolen JS.
Division of Rheumatology, Department of Internal Medicine III, University of Vienna, Austria.

BACKGROUND: Early diagnosis and treatment with disease modifying antirheumatic drugs (DMARDs) have been advocated for patients with rheumatoid arthritis (RA). This survey focuses on the individual definitions and treatment modalities of rheumatologists, and aims at determining the practical realisation of these concepts. METHODS: A questionnaire to be self completed was handed out at the EULAR Symposium 1997. The main issues dealt with were definition, referral time, diagnosis, follow up, and treatment of early RA. Of the 111 participants, who were from all continents and all age groups, 85 (77%) gave their name and address. In 2000, the same questionnaire was sent to these 85 primary respondents. Forty four questionnaires (52%) were returned, and their results were matched and further evaluated. RESULTS: The definition of early RA was heterogeneous, but two of three rheumatologists use the term "early" for symptoms shorter than three months. There was a drift towards acceptance of involvement of fewer affected joints. Serological tests obtained for early diagnosis were mostly rheumatoid factor and antinuclear antibodies, usually in combination (approximately 70%), while other tests (antikeratin antibodies, antiperinuclear factor, anti-RA33) were used rarely, but increasingly (21-25% all together). No significant change in the lag time of referral to the specialist of patients with suspected early RA was seen within these three years (<3 months for 50%, >6 months for 20%), while the proportion followed up during the first three months increased. At both times, every second rheumatologist started DMARD treatment only when the 1987 American College of Rheumatology (ACR) criteria were fulfilled. However, in 1997 about 10% were willing to wait for erosions before starting DMARDs, while none did so in 2000. Methotrexate, sulfasalazine, and antimalarial drugs were the most commonly prescribed DMARDs in early RA, with the first two of these still being in increasing use. CONCLUSION: The understanding of "early" rheumatoid arthritis is heterogeneous, but the vast majority of the rheumatologists surveyed regard symptom duration of <3 months as early. Rheumatoid factor was the most useful laboratory support in early diagnosis. Because there has been no shortening of referral time of patients with new RA within the past three years, and many rheumatologists start DMARDs only when the ACR criteria are fulfilled, it is concluded that guidelines for early referral, as well as for early (rheumatoid) arthritis, are needed.

Z Rheumatol. 2002 Apr;61(2):120-9.
Value of arthrosonography in early arthritis diagnosis
Backhaus M.
Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie Universitatsklinikum Charite Humboldt-Universitat zu Berlin Schumannstr. 20/21, 10098 Berlin, Germany.

Sonography of joints and peri-articular soft tissue has become an established imaging technique for the diagnosis and follow-up of patients with rheumatic diseases. Sonography allows a good differentiation of exsudative and proliferative changes of synovialis as well as tenosynovitis. Superficial cartilage and bony lesions may be seen before they are apparent on x-rays. Sonography is helpful in the diagnosis of early arthritis. Dynamical examination of joints allows the detection of structural abnormalities. Sonography can also be used for interventional procedures such as joint aspirations, guidance of therapy and needle biopsy.

Z Rheumatol. 2002 Apr;61(2):110-9.
Early diagnosis of chronic polyarthritis with conventional roentgen imaging
Wassenberg S.
Rheumaklinik Evangelisches Fachkrankenhaus Ratingen Rosenstr. 2, 40882 Ratingen, Germany.

Radiographs used to be the gold standard of imaging techniques in rheumatoid arthritis. New imaging techniques allow more detailed examinations of soft tissue changes, the predominant features of early RA. This could change the place of radiography especially in this phase of the disease. The best available radiographic technique is necessary to capture the changes of early RA. Radiographs of both hands and feet are needed for early diagnosis and standardized follow-up. Extent and distribution of indirect signs of arthritis (soft tissue swelling and juxtaarticular osteoporosis) vary with disease activity but can provide important information also for the differential diagnoses. Inter-reader reliability of these changes is low, thus, questioning the validity of these findings. Direct signs of arthritis (erosions and joint space narrowing) are more easy to detect and are used for the quantification of the long-term disease course, in clinical studies, as proof for the disease modifying property of an intervention. Direct signs of arthritis are also found in other diseases, so they are not exclusive signs of RA. Nevertheless a typical radiographic finding in early RA is highly specific and is the most important risk factor for a poor prognosis. Therefore, it serves as the basis for therapeutic decisions, e.g., for an early aggressive treatment. As long as there are no data that the findings with the new imaging techniques are as relevant for prognosis, radiographs cannot be replaced in early RA.

Zhonghua Yi Xue Za Zhi. 2000 Jan;80(1):20-4.
Specific antibodies for the early diagnosis of rheumatoid arthritis
Li H, Li X, Gan X.
Department of Rheumatology and Immunology, Peking Union Medical College Beijing 100730, China.

OBJECTIVE: To assess the specificity and sensitivity of antiperinuclear factor (APF), anti-keratin antibody (AKA), anti-Sa antibody and anti-RA33 antibody in the diagnosis of RA. METHODS: 128 patients with RA, whose durations were within 1 year, were included. APF and AKA were detected by indirect immunofluorescence on the human buccal mucosa cells and the straum corneum of Wistar rat esophagus. Anti-Sa antibody and anti-RA33 antibody were examined by Western blotting. Sa antigen was extracted from human placenta while RA33 antigen from Ehrlich cells. RESULTS: (1) The specificities and sensitivities of APF, AKA, anti-Sa antibody and anti-RA33 antibody were 91.4% (224/245) & 35.2% (45/128), 90.2% (221/245) & 32.0% (43/128), 90.6% (222/245) & 33.6% (43/128), 89.8% (220/245) & 28.9% (37/128), respectively, versus 72.3% (177/245) & 44.5% (57/128) for rheumatoid factor (RF). There were no statistical differences in the specificity between the four antibody groups and RF until 1:128 were taken as positive titer. Among 71 patients with RF-negative RA, 15 (21.1%) were positive for APF, 18 (25.4%) positive for AKA, 21 (29.6%) positive for anti-Sa antibody and 17 (23.9%) positive for anti-RA33 antibody. (2) Specificity and sensitivity were 95.1% (233/245) and 46.1% (59/128) respectively when two of the four antibodies turned out to be both positive. If three or more kinds were detected simultaneously, specificity was as much as 99.6% (108/128). (3) Statistical difference was found among the four groups defined by the number of positive antibodies in radiographic stage and patients assessment of illness. CONCLUSION: (1) Dictation of APF, AKA, anti-Sa antibody and anti-RA33 antibody can greatly improve the specificity of diagnosis of early RA and serve as a complement when RF is negative. (2) Combined detection of the above four antibodies has a better discrimination ability as a laboratory criterion than that of RF. (3) Three or more positive antibodies may be an indicator of severe bone erosion and emergent demand for early treatment with better outcome.

Ter Arkh. 2000;72(5):19-21.
Immunological aspects of early stage rheumatoid arthritis diagnosis
Timofeev VT, Shostak NA, Loginova TK, Muradiants AA, Shvyreva NM, Dunaeva IuV.

AIM: To study immune status of patients with rheumatoid arthritis (RA) to improve immunodiagnosis at early stage of the disease. MATERIALS AND METHODS: Immunological examination covered 28 patients with rheumatoid arthritis (RA) aged 16 to 72 years. The duration of RA varied from 1.5 months to 1.5 years. Lymphocyte population and T-lymphocyte subpopulation were measured using monoclonal antibodies. Serum Ig were measured in Reafarm plates. RESULTS: Patients with stage II articular function insufficiency (AFI) demonstrated a significant lowering of the absolute number of lymphocytes, natural killers, elevated concentration of IgA compared to patients with less severe AFI. Patients with systemic symptoms had significantly decreased percentage of T-lymphocytes vs patients with isolated articular syndrome. Natural killers' levels were elevated in all the patients in early RA. A significant rise in the percentage of B-lymphocytes and serum IgG concentrations were also seen. In T-lymphopenia, relative amount of T-helpers and T-suppressors was significantly elevated while the ratio T-helpers/T-suppressors was reduced. CONCLUSION: Changes found in the immune status allows diagnosis of early RA, characterize immune disorders, help to select adequate immunomodulating therapy supporting function of the suppressor cells.

Orthopade. 1999 Sep;28(9):812-8.
Arthroscopy for diagnosis and therapy of early osteoarthritis of the hip
Dienst M, Seil R, Godde S, Georg T, Kohn D.
Orthopadische Universitatsklinik, Universitat des Saarlandes, Homburg/Saar.

Failure to conservative treatment in patients with less advanced radiographic signs of osteoarthritis of the hip (Danielsson grade 2-5) confronts with the decision of further treatment. Since radiographic imaging has not been proved very useful in demonstrating intraarticular structures and results of hip arthroscopies have been promising, arthroscopies have been performed in 17 hips from November 1997 to September 1998. Arthroscopic findings were exceeding preoperative imaging. In addition to cartilage degeneration, concomitant loose bodies, impinging osteophytes, degeneration of the labrum and synovial disease were found. Removal of loose bodies and osteophytes, partial resection of labral tears and partial synovectomy were performed. 1 month after arthroscopy (n = 15), mean Harris-Hip-Score was increased by 13 points und pain reduced by 39 % on average. 6 months after arthroscopy (n = 9), mean Harris-Hip-Score was increased by 14 points and pain reduced by 32 % on average. In addition to its therapeutic benefit, arthroscopy offers direct visualisation of the hip providing important information for the decision of further treatmen.