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      Rheumatoid Arthritis Onset from Shoulder Monoarthritis

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          Abstract

          Purpose

          To investigate the incidence and clinical characteristics of rheumatoid arthritis (RA) presenting with shoulder monoarthritis.

          Patients and Methods

          Our study included 113 patients (77 females; mean age, 63.0 ± 13.1 years) whom we newly diagnosed with RA in 2012–2016. We investigated cases with onset from shoulder monoarthritis. Specifically, we examined physical findings, blood test results, radiographic findings, magnetic resonance imaging (MRI) findings, and duration from initial visit to diagnosis. RA was diagnosed based on the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria.

          Results

          Overall, mean 2010 ACR/EULAR criteria score was 6.8 ± 1.8, and median duration to diagnosis was 3 days (interquartile range: 0–14). Two patients (1.8%) were identified as having RA with onset from shoulder monoarthritis. Both were late middle-aged women with MRI findings of rotator cuff tear and remarkable synovial proliferation. However, neither patient fulfilled the 2010 ACR/EULAR criteria. It took 85 and 98 days to make a definitive diagnosis, respectively.

          Conclusion

          Early diagnosis is difficult when RA synovitis develops from shoulder monoarthritis, especially, in elderly patients who have a rotator cuff tear. In addition to MRI, culture-based and pathological examinations may be helpful for early diagnosis of RA.

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          Most cited references21

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          2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative.

          The 1987 American College of Rheumatology (ACR; formerly, the American Rheumatism Association) classification criteria for rheumatoid arthritis (RA) have been criticized for their lack of sensitivity in early disease. This work was undertaken to develop new classification criteria for RA. A joint working group from the ACR and the European League Against Rheumatism developed, in 3 phases, a new approach to classifying RA. The work focused on identifying, among patients newly presenting with undifferentiated inflammatory synovitis, factors that best discriminated between those who were and those who were not at high risk for persistent and/or erosive disease--this being the appropriate current paradigm underlying the disease construct "rheumatoid arthritis." In the new criteria set, classification as "definite RA" is based on the confirmed presence of synovitis in at least 1 joint, absence of an alternative diagnosis that better explains the synovitis, and achievement of a total score of 6 or greater (of a possible 10) from the individual scores in 4 domains: number and site of involved joints (score range 0-5), serologic abnormality (score range 0-3), elevated acute-phase response (score range 0-1), and symptom duration (2 levels; range 0-1). This new classification system redefines the current paradigm of RA by focusing on features at earlier stages of disease that are associated with persistent and/or erosive disease, rather than defining the disease by its late-stage features. This will refocus attention on the important need for earlier diagnosis and institution of effective disease-suppressing therapy to prevent or minimize the occurrence of the undesirable sequelae that currently comprise the paradigm underlying the disease construct "rheumatoid arthritis."
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            Early rheumatoid arthritis: the performance of the 2010 ACR/EULAR criteria for diagnosing RA.

            New classification criteria for rheumatoid arthritis (RA) were presented by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) in 2010, aiming for early identification of patients at risk of developing persistent and erosive arthritis. Since their publication, the criteria have been extensively validated against several reference standards, but there is still debate regarding how the criteria should be implemented in studies and clinical care. We present an overview of the published validation studies and discuss the strengths and limitations of the classification criteria, as well as whether the criteria are ready for diagnostic purposes in clinical practice.
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              Rheumatoid arthritis of the shoulder joint: comparison of conventional radiography, ultrasound, and dynamic contrast-enhanced magnetic resonance imaging.

              To determine the role of ultrasound and magnetic resonance imaging (MRI) compared with conventional radiography in the detection of chronic and acute inflammatory manifestations of rheumatoid arthritis (RA) of the shoulder joint. Forty-three consecutive patients with known RA prospectively underwent clinical examination, radiography, ultrasound, and MRI of the shoulder joints. Each patient was assigned a clinical/laboratory score consisting of 7 parameters, including measurements of shoulder mobility, the erythrocyte sedimentation rate, and C-reactive protein level. Conventional radiography was standardized and performed in 2 planes. Ultrasound was performed in 10 predefined planes using a 7.5-MHz linear transducer. MRI at 1.5T comprised transverse and oblique coronal T1- and T2*-weighted fast spin-echo, gradient-echo (GRE), and inversion-recovery sequences with a matrix size of up to 512 pixels. A dynamic T1-weighted GRE sequence was acquired with intravenous administration of contrast medium. Erosions were assessed using all 3 imaging techniques on a 4-point scale. Soft-tissue involvement was evaluated according to the presence of synovitis, tenosynovitis, and bursitis on ultrasound and MRI. The results in the study group were compared with those obtained in a control group of 10 patients with shoulder pain. In the study group, erosions of the humeroscapular joint were detected by conventional radiography in 26 patients, by ultrasound in 30 patients, and by MRI in 39 patients; the differences were statistically significant for the comparisons of conventional radiography with MRI and for ultrasound versus MRI (P < 0.0001). Conventional radiography detected 12 erosions of the scapula and MRI detected 15. Synovitis was demonstrated in 12 patients by ultrasound and in 27 patients by MRI (P = 0.0003). Tenosynovitis was observed in 15 patients by ultrasound and in 28 patients by MRI (P = 0.0064). Bursitis was detected in 13 patients by ultrasound and in 18 patients by MRI. The findings on dynamic contrast-enhanced MRI correlated significantly with the detection of synovitis by ultrasound and erosions by static MRI (P < 0.05). Ultrasound and MRI supplement conventional radiography in assessing the shoulder joint. Although conventional radiography can be used as the sole method of following up known joint destruction in RA, ultrasound and, preferably, MRI are recommended as additional techniques in the initial diagnostic evaluation when radiography yields negative results.
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                Author and article information

                Journal
                Open Access Rheumatol
                Open Access Rheumatol
                oarrr
                rheu
                Open Access Rheumatology : Research and Reviews
                Dove
                1179-156X
                07 May 2021
                2021
                : 13
                : 103-109
                Affiliations
                [1 ]Department of Orhopedic Surgery, Faculty of Medicine, Tottori University , Yonago, Tottori, Japan
                [2 ]School of Health Science, Faculty of Medicine, Tottori University , Yonago, Tottori, Japan
                Author notes
                Correspondence: Keita Nagira Department of Orhopedic Surgery, Faculty of Medicine, Tottori University , 36-1 Nishi-cho, Yonago, Tottori, JapanTel +81-859-38-6587Fax +81-859-38-6589 Email nagira@tottori-u.ac.jp
                Article
                297106
                10.2147/OARRR.S297106
                8113011
                6f22542a-425b-46c2-9517-ffb6087cab03
                © 2021 Ishida et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                : 26 December 2020
                : 19 March 2021
                Page count
                Figures: 4, Tables: 3, References: 21, Pages: 7
                Categories
                Original Research

                rheumatoid arthritis,monoarthritis,shoulder,rotator cuff tear

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