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From the change of classification standards, we can see the development journey of RA early diagnosis and early treatment

 Last Update: 2022-11-15
 Source: Internet
 Author: User

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Appropriate application of the classification and diagnosis criteria of RA to achieve early diagnosis and early treatment
.

"After I graduated, I was assigned to the 'Hematology and Rheumatology Department',
and at that time the Hematology and Rheumatology departments were together.
" Professor Li Meiling, director of the Department of Rheumatology and Immunology of the Second Affiliated Hospital of Guangxi Medical University, recalled the past and said, "But in clinical work, I have seen too many incurable hematological cancer patients, and finally separated
from their families.
Rheumatism is mostly chronic, and through standardized treatment, we can control the disease, delay the progression, and even help patients return to normal life, and doctors have a greater sense of accomplishment, so I chose rheumatology
.
"
However, due to the late start of rheumatology in China, the shortage of doctors, the relative lag in the development of disciplines, and the uneven level of practitioners, the current status of rheumatology treatment is still not optimistic
.
The data show that 34.
82% of RA patients in China have moderate disease activity, and 47.
18% of patients have severe disease activity ^[1].

Professor Li Meiling said: "In the past nearly 30 years of career, I have seen many RA patients
who have developed joint deformities, disabilities, and cannot take care of themselves.
Whenever this happens, I feel deeply guilty and ashamed, and I am determined to work harder to contribute more to the rheumatology profession and reduce the teratogenicity and disability rate
of RA.
”

Journey through the change of RA classification standards

Early treatment is one of the most important treatment strategies for RA in recent years [^2], and early and active treatment can stop joint destruction and reduce the rate of disability ^[3].
Over the past three decades, the diagnostic criteria for RA have evolved with the times, with several versions updated to make an accurate diagnosis
at an early stage of the disease.
Professor Li Meiling introduced
us one by one.

ACR 1987 CriteriaThe American College of Rheumatology (ACR) 1987 classification standard is currently commonly used in the clinical practice of RA, and its content is ^[4]:

1.
Morning stiffness lasts at least 1 hour (course of disease≥ 6 weeks) 2, 3 or 3 joint swelling≥ 6 weeks 3, wrist, metacarpophalangeal or proximal interphalangeal arthritis, at least one joint swelling (course ≥ 6 weeks) 4, symmetric arthritis course ≥ 6 weeks 5, rheumatoid nodules 6, rheumatoid factor positive 7.
Radiological changes: radiological changes in rheumatoid arthritis must include bone erosion or clear bone decalcification
of the affected joints and their adjacent parts, and more than 7 meet 4 or more and exclude other arthritis and symptoms can be diagnosed
after more than 6 weeks.

The 2010 ACR/EULAR standard ACR The 1987 standard was proposed for the purpose of studying a homogeneous patient population of RA, so it was based on patients with an average course of disease of 7 years, so it was not sensitive enough for patients with early RA [3]

。 In 2010, ACR/EULAR published the article "New RA Classification Standards and Their Methodology", officially proposing the new RA classification standards
.
This standard is mainly applicable to the following ^{groups of people [5]}:

At least 1 joint is clearly manifested as synovitis (swelling);
Synovitis cannot be explained
by other diseases.

The scoring system includes varying numbers of joint involvement, serologic results (rheumatoid factor versus anti-cyclic citrullinated peptide antibodies), acute reactants (C-reactive protein versus erythrocyte sedimentation rate), and duration of symptoms, and the diagnosis of RA is confirmed when the patient achieves an overall score of at least six ^{points [5].}

Table 1 ACR/EULAR 2010 RA Classification Standard and Scoring System^[5]ERA StandardIn
2012, Professor Li Zhanguo of Peking University People's Hospital proposed ERA standards for early RA
。 The criteria are ^[6]:
1, morning stiffness ≥ 30min2, arthritis involvement in at least 3 or more of the 14 joint areas3, at least 1 joint swelling of the wrist, metacarpophalangeal or proximal interphalangeal joints 4.
RF positive 5, anti-CCP antibody positive
meet 3 of the following 5 conditions can be classified as RA.

This standard has been validated by international multicenter clinical studies, and its positive predictive value and negative predictive value are better than the 1987 ACR and 2010 ACR/EULAR classification standards
.
In early RA with a course of ≤ 1 year, its sensitivity was 84% and its specificity was 87%; In very early RA (duration < three months), sensitivity remains 83.
1 percent, specificity is 84.
5 percent, and is simpler to apply ^[7].

Four "many" and two "high"/two "low"

However, the early diagnosis rate of RA in China is still relatively low ^[1].
Professor Li Meiling introduced that now RA patients in China have four "many" characteristics: "Four 'many' are a large number of patients, a large number of delayed diagnosis and treatment, a large number of moderate and severe patients, and a large number of comorbidities ^[1].
"
The number of patients is large: It is estimated that there are about 5 million RA patients in China, and the incidence is increasing and showing a younger trend ^[1].

Delayed diagnosis and treatment: The survey shows that the average time interval between the onset of symptoms and the definitive diagnosis of RA patients in China is more than 2 years, suggesting that most patients have not received timely and early diagnosis ^[1].

There are many serious patients: 34.
82% of RA patients in China are moderately active and 47.
18% are severely active, indicating that RA patients in China are seriously ill ^[1].

There are many comorbidities: 10.
32%, 1.
97%, 3.
04% and 0.
83% of RA patients in China have pulmonary interstitial lesions, fragile fractures, cardiovascular and cerebrovascular complications and tumors, respectively ^[1].
。
Professor Li Meiling pointed out: "Although there is now a 2010 ACR/EULAR classification standard and ERA standard, there are still many doctors who use the 1987 ACR standard in the clinic, which brings a certain delay to the diagnosis of
RA.
The treatment of RA in China is also not standardized, manifested as two 'high' and two 'low', that is, the high utilization rate of non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids; the low use rate of methotrexate and biological agents and small molecule targeted drugs
.
In addition, RA is a chronic disease, but we still lack an effective chronic disease management system, patient compliance is poor, and many patients do not have the habit
of long-term follow-up.
Due to the small number of medical staff engaged in rheumatology and immunology specialties, the education of disease science is not enough ^[1].

Professor Li Meiling believes that the urgent task to improve the level of RA diagnosis and treatment is to cultivate talents, develop disciplines, and strengthen publicity: "For example, Professor Zeng Xiaofeng of Peking Union Medical College Hospital proposed the strategy of 'one city and one center' ^[1], that is, each county-level city has at least one independent rheumatology and immunology department.
Solve the problem of lack of
medical treatment.

As the head of the department, Professor Li Meiling also shouldered a heavy burden, "The rheumatology department was established late, which also gives us more challenges and opportunities
.
Whether in medical treatment, teaching or scientific research, we must be worthy of the signboard of Guangxi Medical University, help more young doctors realize their personal value and career pursuits, and let more rheumatism patients get medical help
as soon as possible.
"The photo of the expert profile
has been informed by the expert Professor Li Meiling

Director of the Department of Rheumatology and Immunology, The Second Affiliated Hospital of Guangxi Medical University
Leader of the Department of Rheumatology and Immunology, a key clinical specialty in Guangxi Zhuang Autonomous Region
Deputy Director of the Department of Internal Medicine, The Second Affiliated Hospital of Guangxi Medical University
Doctor of Medicine, third-level professor, chief physician, master supervisor
Member of the International Association of Women Physicians
Member of the Standing Committee of the Hemophilia Professional Committee of the China Alliance for Rare Diseases
Member of the Rheumatology and Immunology Rehabilitation Professional Committee of the Chinese Society of Rehabilitation
He is a member of the Rheumatology Professional Committee of the Chinese Society of Traditional Chinese Medicine Information
Member of the Hematology Professional Committee of the Chinese Association of Women Doctors
Member of the Immunosorbent Academic Professional Committee of the Chinese Medical Doctor Association
Member of the Rheumatology and Immunology Professional Committee of the Cross-Strait Medical and Health Exchange Association
Member of the Chronic Disease Group of the Rheumatology and Immunology Professional Committee of the Cross-Strait Medical and Health Exchange Association
Member of the Rheumatology and Immunology Professional Committee of the Asia-Pacific Society of Medical Bioimmunology
A first-class expert specially appointed by the Rheumatology Branch of the Information Society of Chinese Medicine
Expert of the evaluation expert database of Guangxi Medical Security Bureau
He presided over 12 provincial and municipal scientific research projects, participated in a number of National Natural Science Foundation projects, 973 projects and provincial (state) level scientific research projects, 1 invention patent, and 2 new utility patents
He has published more than 30 academic papers as the first author or corresponding author
He has published 3 academic monographs as the first chief editor and deputy editor, participated in the editing of 4 monographs, and translated 1 book
Associate Editor of The International Journal of Rheumatic Diseases
Editorial board member of Inflammation and Cell Signaling, reviewer of Journal of Computational Medicine, Open Journal of Chemistry, Global Journal of Cancer Therapy, and Chinese New Clinical Medicine

References: [1] Tian Xinping, et al.
Chinese Journal of Internal Medicine, 2021, 60(7): 593-598 Geng Yan, et al.
Chinese Journal of Internal Medicine, 2022, 61(1): 51-59 [3] HOU Yong, et al.
Clinical Journal of Practical Hospitals, 2011, 8(2):3 [4]Amett FC,et al.
Arthritis Rheum.
1988,31(3):315-324.
[5] Zhang Zhuoli.
Chinese Journal of Rheumatology,2010,14(03): 212-213 [6] Zhao Jinxia, et al.
Chinese Journal of Rheumatology,2012,16(10): 651-656 [7] Li Xue, et al.
Chinese Journal of Internal Medicine, 2020, 59 (09): 724-727

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