Reflecting on Early Arthritis

> “To become a man is to be responsible; to be ashamed of miseries that you did not cause.” > > — Antoine de Saint-Exupery1 I recently returned from a much-anticipated Hawaiian vacation. During the lengthy plane ride, I had time to relax and reflect. I thought about the provocative work by Tavares, et al , showing that only 41% of patients with rheumatoid arthritis (RA) were started on therapy within 6 months of presumed onset of disease, and that 78% of the delay was attributable to processes/events that occurred before the patients ever saw a rheumatologist2. I thought about the excellent literature review categorizing delays of diagnosis and treatment by time from symptoms to assessment by a primary care physician (PCP), from PCP to rheumatology referral and then assessment, and finally to commencement of disease-modifying antirheumatic drug therapy3. I thought about a patient from a few months ago — an otherwise healthy young woman with palindromic arthritis following a sore throat, whose symptoms quickly and fully resolved; I suspected her illness likely viral and transient in nature4, even though she had mentioned some prior complaints that were suspicious, but not definitive, for RA. Antibodies to anticitrullinated protein and rheumatoid factor had been measured and were positive. How do I classify and treat this patient? I thought about this patient’s relative good fortune in having ready access to expert care in contrast to those, for example, at … Address correspondence to Dr. R. Panush, 2011 Zonal Ave., HMR 711, Keck School of Medicine, USC, Los Angeles, CA 90032, USA. E-mail: panush{at}usc.edu