A review of radiographic evaluation of rheumatoid arthritis is given. Standard reference films are introduced for evaluation of rheumatoid arthritis and related conditions in the extremity joints. In this system, numerical evaluation of arthritis is given for individual joints in a patient.

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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

Objective-Recent studies have demonstrated the short term eYcacy of leflunomide. This study evaluates the eYcacy and safety of leflunomide and sulfasalazine in rheumatoid arthritis over a two year follow up period. Methods-358 patients with rheumatoid arthritis in a double blind trial were randomly allocated to receive either leflunomide 20 mg/day, placebo, or sulfasalazine 2 g/day. Those completing six months of treatment (n=230) were given the option to continue in 12 (n=168) and 24 (n=146) month double blinded extensions; the placebo group switched to sulfasalazine. This report compares eYcacy and safety of leflunomide with sulfasalazine in the 6, 12, and 24 month patient cohorts. Results-The eYcacy seen at six months was maintained at 12 and 24 months. Twenty four month cohorts on leflunomide showed significant improvement compared with sulfasalazine in doctor (−1.46 v −1.11, p=0.03) and patient (−1.61 v −1.04, p<0.001) global assessments, ACR20% response (82% v 60%, p<0.01), and functional ability ( mean HAQ −0.65 v −0.36, p=0.0149; HAQ disability index −0.89 v −0.60, p=0.059). Improvement in other variables was comparable for the two drugs, including slowing of disease progression. Improved HAQ scores in 6, 12, and 24 month leflunomide cohorts were seen in both non-responders (24%, 29%, 35%, respectively v sulfasalazine 8%, 10%, 27%) and ACR20% responders (leflunomide 63%, 62%, 66% v sulfasalazine 50%, 64%, 44%). Leflunomide is well tolerated at doses of 20 mg. No unexpected adverse events or late toxicity were noted during the two year period. Diarrhoea, nausea, and alopecia were less frequent with continued treatment. Conclusion-These long term data confirm that leflunomide is an eYcacious and safe disease modifying antirheumatic drug.

Earlier reports, including a comprehensive 1983 review, had indicated that slowing of radiographic progression was relatively unusual in treatment of rheumatoid arthritis (RA) using traditional disease modifying anti-rheumatic drugs. However, in recent years, slowing of radiographic progression has been documented in a number of clinical trials, as well as long-term observational studies, with use of (in alphabetical order) adalimumab, anakinra, corticosteroids, cyclophosphamide, cyclosporin, etanercept, gold salts, infliximab, leflunomide, methotrexate and sulphasalazine. At this time, disease modification is a realistic goal in the clinical care of patients with RA. Documentation of improved long-term outcomes requires long-term observational data over 5-20 yr to supplement data from randomized controlled clinical trials over 6-24 months.