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Selection of study population in the development of rheumatic disease criteriacomment on the article by the american college of rheumatology diagnostic and therapeutic criteria committee.

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722
LETTERS
rapacious lawyers, misguided or greedy physicians, and the
feminist agenda, whose gravamen gave impetus to the spurious epidemiology. The media and some well-placed politicians aggravated the problem.
Taking the data from all published findings, one
could conclude that fewer cases of rheumatic disease than
actuarially predicted develop in silicone implant recipients.
To infer that such implants protect against rheumatic diseases would be as preposterous as the obverse. Rather, the
women who seek such implants for cosmetic reasons, even
after surgery, probably are healthier than the average because they obviously care about their appearance, probably
also their health (more wholesome diets, more exercise,
better medical care), and likely come from a more affluent
segment of the population. These speculations need to be
affirmed, but they at least explain the paradox better than
other less likely possibilities. As the majority of alleged
associated diseases fall under the rubric of fibromyalgia and
similar rheumatic syndromes without objective changes, and
most emerged after extensive media hyperbole and panicked
regulatory reaction, with the real possibility of compensation
from manufacturers to avoid even more expensive litigation,
a causal relationship with implants remains to be established. One cannot deduce parallels with the tobacco companies’ denial of harm from smoking; for implants, not even
circumstantial evidence has emerged. The post-removal
improvement (save for local problems from leakage and
rupture) may well be furthered by the dollar poultice.
George E. Ehrlich, MD
Philadelphia, PA
Selection of study population in the development of
rheumatic disease criteria: comment on the article by
the American College of Rheumatology Diagnostic and
Therapeutic Criteria Committee
To the Editor:
We read with interest the clear and concise overview
of criteria for rheumatic diseases by the American College of
Rheumatology (ACR) Diagnostic and Therapeutic Criteria
Committee (1). We would, however, take issue with one
point which reflects a wider problem we see with many of the
published ACR criteria schemes. The authors argue that
when criteria are applied in a population setting, “the
sensitivity will remain the same.” This is, however, only
true for the classification of cases similar to those in whom
the original criteria were derived. If, for example, the
severity profile varied between the specialist centers providing the cases for criteria derivation and the proposed target
study population, then sensitivity may indeed be lost.
Two examples illustrate the point. The first concerns
the 1987 revised criteria for rheumatoid arthritis (RA) (2).
These were derived using patients who were current attenders of academic medical centers or private physician practices and had a median disease duration of 8 years. It is likely
that such patients had more severe and widespread disease
than would be seen either in an early-RA clinic or in the
population setting. Indeed, one study has demonstrated that
the sensitivity of the criteria in patients with early RA is
lower than that reported in the original publication (3).
Second, in relation to systemic sclerosis, the Diagnostic and
Therapeutic Criteria Committee accepts that the criteria (4)
were developed from a population with a “disproportionately high representation of diffuse cutaneous disease.” The
results from population studies suggest that the proportion
with limited cutaneous disease may be substantially higher
than the 10% suggested in this overview (5).
These differences, in part, reflect the earlier access to
specialist care in countries outside the U.S. As an example,
in our population-based prospective incidence study of RA,
74% of cases were seen in a specialist center within 12
months of the appearance of symptoms (6).
The authors complete their overview with the valuable suggestion that methods sections of articles should give
more details of the results achieved when applying the
relevant classification scheme. We would urge the Diagnostic and Therapeutic Criteria Committee, in subsequent studies, to test its criteria in populations of patients seen outside
specialist centers and early in their disease. It is the study of
these individuals that will yield vital information on prognosis and outcome, and with current criteria, there is an
important risk of misclassification.
Alan J. Silman, MD
Deborah P. M. Symmons, MD
ARC Epidemiology Research Unit
Universio of Manchester
Munchester, UK
1. Fries JF, Hochberg MC, Medsger TA Jr, Hunder G G , Bombardier C, and the American College of Rheumatology Diagnostic
and Therapeutic Criteria Committee: Criteria for rheumatic disease: different types and different functions. Arthritis Rheum
37:45#62, 1994
2. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF,
Cooper NS, Healey LA, Kaplan SR, Liang MH, Luthra HS,
Medsger TA Jr, Mitchell Dm, Neustadt DH, Pinals RS, Schaller
JG, Sharp JT, Wilder RL, Hunder GG. The American Rheumatism Association 1987 revised criteria for the classification of
rheumatoid arthritis. Arthritis Rheum 31:315-324, 1988
3. Bernelot Moens HJ, van de Laar MAFJ, van der Korst JK:
Comparison of the sensitivity and specificity of the 1958and 1987
criteria for rheumatoid arthritis. J Rheumatol 19: 198-203, 1992
4. Subcommittee for Scleroderma Criteria of the American Rheumatism Association Diagnostic and Therapeutic Criteria Committee: Preliminary criteria for the classification of systemic
sclerosis (scleroderma). Arthritis Rheum 23581-590, 1980
5. Silman A, Jannini S, Symmons D, Bacon P: An epidemiological
study of scleroderma in the West Midlands. Br J Rheumatol
27:28&290, 1988
6. Symmons DPM, Barrett EM, Bankhead CR, Scott DGI, Silman
AJ: The incidence of rheumatoid arthritis in the United Kingdom:
results from the Norfolk Arthritis Register. Br J Rheumatol
33:735-739, 1994
Reply
To the Editor:
We thank Drs. Silman and Symmons for their comments. Their point that the sensitivity of criteria sets may
vary in populations with differing severity of disease is
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development, population, articles, selection, disease, diagnostika, criteriacomment, stud, rheumatic, therapeutic, rheumatology, american, criterias, college, committee
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