Pendidikan Perubatan Berterusan (CME) tidak terlepas dari cabaran era Teknologi Maklumat (IT).  Seperti cabaran-cabaran yang lain, ianya wajar ditangani dengan kebijaksanaan dan bukan diketepikan.

Buletin CME kali ini memberi tumpuan kepada beberapa isu kontemporari. Perkongsian bistari (smart partnership) mutakhir ini menjadi 'catch-phrase' bukan sahaja dalam dunia perubatan tetapi juga bidang-bidang lain dalam kehidupan.  Buletin CME mengkhususkan perbincangan disekitar isu tersebut.  Satu lagi sudut perkongsian (partnership) yang disentuh ialah perkongsian maklumat dalam penjagaan pesakit.  Di sini hubungan dan perkongsian berkesan di kalangan jabatan-jabatan klinikal dan bukan klinikal amatlah penting.  Contoh pengendalian spesimen dalam Buletin kali ini menonjolkan cara betul perkongsian ini harus diwujudkan.  Perkongsian bistari diantara jabatan-jabatan klinikal dan jabatan-jabatan berasaskan makmal akan mengurangkan pembaziran, meningkatkan mutu penjagaan pesakit dan mewujudkan suasana akademia yang baik untuk pengajaran dan pembelajaran.

Buletin kali ini juga mengemukakan pendekatan rasional dalam penggunaan drug yang sangat kerap digunakan iaitu paracetamol.  Diharapkan ianya dapat mengoptimakan  penggunaan suatu drug yang senang diperolehi oleh masyarakat umum tetapi juga berpotensi menjadi racun dengan mudah.

Akhir sekali saya berharap pembaca akan datang beramai-ramai menghadiri persidangan Kebangsaan Ke 4 Sains Perubatan demi untuk menghidupkan CME ke arah mencapai kecemerlangan yang berterusan.

Sekian, terima kasih.

Prof. Madya Dr. Abdul Rashid Abdul Rahman
Editor

 

Diari / Pengumuman

 

Tarikh	Event	Tempat	Jabatan Kakitangan terlibat
7 Mei 98 (8.30 am)	Pembentangan Kes	DK5	0 + G & Patologi Kimia   Pengerusi: Dr. Nor Aliza A. Ghaffar
14 Mei 98  (8.30 am)	C.P.C	DK5	Perubatan
28 Mei 98 (8.30 am)	Pembentangan  Penyelidikan	DK5	Prof. Madya Wan Abdul Manan Wan Muda Dr. Ahmad Munir Prof. Madya MazidahAhmad Mansur
4 Jun 98 (8.30 am)	C.P.C	DK5	Otorinolaringologi
8 - 9 Jun 98 (8.30 am)		DK 3 & 4	Persidangan Kebangsaan ke-4 Sains Perubatan
25 Jun 98 (8.30 am)	Pembentangan  Penyelidikan	DK5	Dr. Aida Hanum Ghulam Rasool En. Hasenan Nordin Prof. Madya Kyaw Tun Sein
2 Julai 98 (8.30 am)	C.P.C	DK5	Pediatrik
9 Julai 98 (8.30 am)	Pembentangan Kes	DK5	Psikiatri dan Perubatan   Pengerusi: Dr Hasanah Che Ismail
16 Julal 98 (8.30 am)	Pembentangan Kes	DK5	Surgeri dan Hematologi   Pengerusi: Prof. Madya Normah Jamaluddin
23 Julai 98 (8.30 am)	C.P.C	DK5	Ortopedik
30 Julai 98 (8.30 am)	Pembentangan  PenyeIidkan	DK5	Prof. Madya Mafauzy Mohamad Dr. Dhruba Chakraborty Dr. Rowani Mohd. Rowi

 

Developing Smart Partnerships for Continuing Medical Education

Assoc. Prof. Dr. Rogayah Jaafar MBBCh MHP Ed
Department of Medical Education
School of Medical Sciences
University Science Malaysia
Kubang Kerian, Kelantan
 

As Malaysia strives to reach a developed nation status by the year 2020, the government as well as the private sectors have been asked to develop smart partnerships with each other to face the challenges of upgrading and improving vital public services in the country. Among the more talked about partnership endeavors is the setting up of a cybercity in Putra Jaya as well as the Multimedia Super Corridor in Sepang where all systems are handled via computer networks.

As we approach the next millennium, the public's expectation and demand for specialized health care will continue to  grow. The Ministry of Health and medical schools in the country have rightly doubled their efforts and drive to train more specialist doctors and to ensure that current medical practitioners both in the public and private sectors are kept up to date via more formalized continuing medical education programs. This strategy consists of actively identifying what medical practitioners need to learn  in order to cope with new demands and challenges in the health care system and searching for suitable and appropriate educational methods that would be both effective and acceptable to meet these demands.What is really at stake is the acquisition by medical practitioners not only of new scientific knowledge and an acquaintance with new bio-medical technologies, but also the skills and attitudes necessary to function appropriately in practice patterns that are in line with defined social and health policies and standards of quality assurance.

It is thus vital that the objectives for continuing medical education be set  after a careful review of current medical practice and how it affects the health of the population. Involvement of medical practitioners, health care managers, medical educators and representatives of consumers in the objective setting stage would be a useful means towards this end.

The "distance-education" arrangement between the Ministry of Health and medical schools in the country, to enable young doctors to take up post-graduate training while maintaining their work schedule in the government hospitals constitutes one smart partnership model that should be  fostered and propagated.

In order to meet the needs of post graduate distance education, the Ministry of Health is compelled to upgrade educational facilities such as medical libraries, tutorial rooms, audiovisual aids and electronic mail facilities at their training sites in state hospitals as well as health clinics. Improved educational facilities at training sites under the Ministry of Health will create a more academic environment and will promote and facilitate continuing education not only for the doctors but also for the other health service staff of the hospital. The utilization of audio and tele-conferencing as well as data sharing and other electronic networks between practice sites of the trainees and their teachers in the Universities, will  open greater opportunities for tele-consultations, audit sessions as well as research collaborations between the two parties.

Academic staff of the universities on the other hand would need to work closely with their service counterparts in the Ministry of Health in designing training programs, as well as  ensuring adequate supervision and preceptorship of their trainees in the regional hospitals. In the process of planning, implementing and evaluating programs of continuing medical and post graduate education in close collaboration with the Ministry of Health, medical schools could learn a great deal about relevance in medical education and about effective teaching learning strategies. In their contact and contract with health care administrators, medical schools would also have an opportunity to question the impact of continuing education, as well as undergraduate and postgraduate education, on the quality of health care. By extending the partnership beyond the Universities and Ministry of Health, to the various private medical complexes, professional medical bodies in particular the Malaysia Medical Association as well as related consumer organizations, a more comprehensive and formalized system of accreditation for CME can be instituted.

The potentials for utilizing smart partnerships for CME are already on the drawing board. The challenge for all of us is to foster the spirit of true partnerships where all partners speak the same language and in the same tone with regards to manpower development and training in our health care system. Only then can we move from the individual to the collective CME initiative - so that hopefully, the individual sweet sound of CME can be blended together as beautiful music of an orchestra!!

Further readings:

1. H.G.Schmidt et al (eds.), 1989. New Directions for Medical Education, Springer  -Verlag, New York Inc.
2.  WHO Technical Report: 1993, Changing Medical Education: An Agenda for Action
3. Quality Health Care Through CME, Recommendations of the Kuala LumpurSeminar on Continuing Medical Education, 5-11 November, 1990

Paracetamol in Paediatric Practice
 

Dr. Mohd Suhaimi bin Ab Wahab  MD (UKM), MMed. Sci, MRCP (UK)
Departments of Pharmacology and Paediatric
School of Medical Sciences
University Science Malaysia
Kubang Kerian, Kelantan

Paracetamol (acetaminophen) is a very common drug given to children. In a survey in Bristol, England, 84% of infant aged 6 months or below received paracetamol, either prescribed or as over the counter medication. With such a frequency one should be familiar with the possible problems with paracetamol.

The most common reason for giving paracetamol is fever. Fever is a body response toward certain disease, particularly infection. Giving paracetamol may not be helpful to such patient. One case control study showed that children with pneumonia received higher daily dosage of antipyretic compared to a control group with similar degree of fever. The study also suggested that frequent administration of antipyretic to children with infectious disease may lead to worsening of their illness. However if the patient has cardiac or respiratory failure, treating  fever may improve oxygen consumption and carbon dioxide production.

Discomfort of a febrile child may be relieved by antipyretic. One controlled study showed that paracetamol improves activity and alertness in children with acute infection. However there was no significant improvement in mood, appetite or fluid intake. Paracetamol has been shown to reduce fever and abnormal behaviour in children who have had triple antigen vaccination. This may help to improve immunisation rate. Paracetamol is generally recommended as prophylactic against recurrence of febrile fit. However there is no evidence that such approach is effective.

The other important use of paracetamol is pain relief. It is of help for children with mild degree of pain such as headache or minor trauma. It also provides good post operative analgesia in minor operation, such as herniotomy and tonsillectomy. To have good effect, it should probably be given before surgery, rather than waiting for the pain to develop after surgery.

DOSE OF PARACETAMOL
The suggested dose for fever is 10 - 20mg/kg every four to six hourly, not exceeding 100mg/kg/day. It is advised that paracetamol be given only if the temperature is higher than 39OC. In neonates, paracetamol is usually used for pain relief. The recommended dose for such indication is 24mg/kg every 8 hours.

One should be careful in writing prescription for paracetamol. It is advisable to write in mg rather than ml as the elixir comes in two concentrations, 120mg/5ml and 240mg/5ml. Writing in volume (ml) may pose the risk of giving higher dose.

TOXICITY
Paracetamol is metabolised in the liver. One of it’s metabolites is highly active and can cause cellular damage. Fortunately only small amount of that metabolite is produced at therapeutic doses, which is quickly neutralised by hepatic glutathione. In high dosage, glutathione will be depleted and this will expose the cells to be damaged by the metabolite. Ingestion of more than 150mg/kg/day causes hepatotoxicity, and if the dose is more than 300mg/kg/day, it is usually fatal. For obvious reasons, one should be careful in prescribing paracetamol in the presence of liver disease.

The risk of toxicity can be predicted if the blood level of paracetamol and the time of ingestion are known. In acute poisoning, treatment with acetylcysteine should be started within 10 hours. If the quantity ingested is believed to be high, one may start treatment before the plasma level is known.

CONCLUSION
Although paracetamol is generally safe in children, one must always exercise caution in using it. Try to avoid using paracetamol in low grade fever. It should be explained to parents that fever is a natural response to infection, and the use of paracetamol is  more for the relief of discomfort rather than to treat fever.

Further reading:
1.  F. Shann, Paracetamol: use in children; Australian Prescriber, Volume 18 1995.
2.  Neonatal  Formulary 1996, The Northern Neonatal Network, BMJ
 

 

What every doctor needs to know

 

The facts and fallacies of specimen sampling.  What you should and should not do.
 
Dr Nor Hayati Othman MBBS, M Path
Associate Professor and Head
Department of Pathology
University Science Malaysia
Kubang Kerian, Kelantan

Introduction

This article is appropriate in the light of the current economic setback.  Wasting should be minimised and resources optimized.

With the increasing numbers of specimens received by pathology laboratories in the country these days, and the inadvertent 'carelessness' and 'inadequacy' with which samplings are done, the need to have 'reminders on how to collect specimens' is overdue.  Medical students are taught to understand diseases and they learn the theories behind each investigative procedure.  However, when they graduate and become doctors many of the chores of supervising patients to produce specimens for investigation are left to the paramedical staff.  Even if the specimens are taken with care, despatch to the laboratories is not supervised as it is left to the hospital porters who have their own schedules of collection and delivery, this often results in the arrival of specimens to the laboratory in an unsatisfactory state for processing.

Specimens

Sputum
Sputum is one of the commonest specimens received by any pathology laboratory. However, the positive cellular yield is low.  Many a times,  it is saliva and not sputum that is submitted.  Periodic sputum cytology can be used to screen lung cancers in high risk group. A good sputum need not be mucoid as sputum from small cell carcinoma of the lung is associated with a thin clear secretion Sputum cytology can be highly effective for detection of early squamous cell carcinoma, less effective for small cell carcinoma and usually not effective for adenocarcinoma or large cell carcinoma.

Sampling Techniques

1. It must be an early morning 'deep cough' specimen.
2. It should be collected before food/drink and before the teeth are cleaned.
3. It has to be sent fresh to the laboratory (It is useless to ask the patients to bring  the sputum he coughed out the night before).  If for some reasons, the sputum  cannot be sent immediately, it can be refrigerated for up to 24 hours as cell preservation is still reasonable.
4. At least 3 specimens taken on 3 consecutive days should be evaluated in suspicious cases.
5. Post-bronchoscopic specimens can give positive yield in a previously negative  samples.
6. Alveolar macrophages ( seen under the microscope ) must be present in order to interpret sputum cytology . The presence of alveolar macrophages indicate the specimen is from the lungs and not from the throat!  "Sputum" without alveolar macrophages is labelled  'inadequate specimen'.

Sampling Techniques

1. Voided Urine
2. Catheter Specimens

Early morning specimen, formerly recommended is unsuitable as the cells in such highly concentrated urine are too degenerate to be assessable.  Mid-morning urine is satisfactory, preferably 30 minutes to an hour after a drink such as tea/coffee.

Cerebrospinal Fluid (CSF)

Most of CSF samples submitted  to pathology laboratories is to identify leukaemic/lymphoma  and neoplastic cells in primary or  metastatic tumours.  Other reasons include confirming the presence of certain microorganisms, eg. cryptococcus

Sampling Techniques
1. Avoid bloody tap/aspirations
2. Avoid aspirating solid materials such as nucleus pulposes which can lead to false-positive diagnosis.
3. Like urine, CSF contains low protein or mucous, therefore, speed in delivery  to the laboratory and immediate processing are imperative.  Indeed diagnostic materials may disintegrate in less than an hour    yielding   a   false-negative  assessment.

In the laboratory, the CSF is cytocentrifuged, then air-dried and stained with Wrights stain (optimal to illustrate blasts in leukaemia) or alcohol-fixed for Papanicolaou staining. Tumours that are most likely to shed cells into CSF are meningiomas, metastatic carcinomas, medulloblastomas, ependymomas and sarcomas. The ability of the tumours to shed cells depends on the cohesiveness of the tumour.  Squamous carcinoma  and  adenocarcinoma metastasize more or less equally to the CNS but the detection of squamous carcinoma is uncommon.
 

Effusions
Serous effusion may clot on standing and the speed of clot formation depends on the protein content i.e. whether the effusion is an exudate or transudate.

Sampling Technique
1. Immediately place the fluid into sterile bottles ( specimens placed in unsterile bottles may contain bacteria or fungus which may distort cellular pathology and interfere with cytologic interpretation.  For a 20 ml fluid, the proportions of one of the anti-coagulant listed below is adequate:
 i) EDTA 20 mg
 ii) heparin 2 mg (or 200 units)
 iii) sodium citrate 2 ml oxalate is unsuitable as it can distort the cell morphology

2. Since the fluid is protein containing, the cells remain preserved for 1-2 days,  therefore, there is no hurry in sending it to the laboratory.  However, a fresh   specimen processed immediately gives the best results.

Pap Smear
A few local studies done recently (1,2,3,4) showed that there is a significant number of inadequate pap smear  sampling . Pap smear is an established screening procedure to detect cervical cancers.  Lower genital tract smears tend to be less than optimal during the first 4 days of menstruation and among females taking oral contraceptives.  Advise patients not to do any douching during the 24 hours preceeding vaginal specimen collection.

Sampling Techniques

1.  Vaginal pool smears
They represent cells which are dropped off from the cervix, vagina, uterine cavity and even fallopian tube.  The cells are usually poorly preserved.  It is not a representative specimen to exclude cervical dysplasia , however it is useful in detecting hormonal changes in the patients.

2.  Pan-Cervical Specimen
The specimen is obtained by either scraping the ecto-endocervix with a specially-designed spatula in which the thinner (narrower) tip can be inserted into the endocervical canal or by inserting an endocervical brush (cytobrush) into the canal and twisting it once or twice to scrape the cells at the transformation zone.  Note, it is the cells at the transformation zone (i.e. endocervical cells) which is important and should be studied microscopically when  excluding  CIN (cervical intra epithelial neoplasia) changes. The transformation varies with age, thus there is slight alteration in the technique of sampling of different age groups.

The smear should be well spread over the glass slide and should be rapidly fixed in 95% ethyl alcohol.  The fixative must be by the patients' bed if not between her legs and not located at some distance from her.  If no ethanol is immediately available, the slide can be fixed by gentle spraying using 'ladies' hair spray'.

Fine Needle Aspiration Cytology (FNAC)

This is currently the most popular and fashionable investigative procedure for almost all lumps/masses in the body either externally accessible or for deep-seated lesions.  More and more hospitals in the country are having this facility.  It is highly acceptable by patients and the positive yield is high (depending on the experience and expertise of the cytopathologist ).  FNA diagnosis is most accurate when the same qualified person performs the aspiration, prepares the smears and interpret the cytology.  The technique of FNAC is described in many recent cytology textbooks and it will not be discussed here.  Unless some is dealing with a cyst, all of the diagnostic material should be contained in the needle, not in the syringe itself.  The critical step is at the preparation of the smear.  A good smear results in an evenly distributed monolayer of cells.  It must be fixed immediately in 95% ethanol for Papanicolaou or Haematoxyline-eosin staining or air-dried for Romanowsky-type staining.  Generally Romanowsky-type stains yield more information about the morphology of the cytoplasm while the Papanicolaou stain provides excellent nuclear detail. Any general practitioner who wishes to offer this services should ideally undergo at least a weeks' attachment in any pathology laboratory which does such services as inexperience in needling a mass would result more damage to the lession thus distorting the morphology of the lession when it is excised later.

A note of caution is addressed to doctors doing FNAC that cytodiagnosis of a lymphoma is often feasible but may be more tentative than in other cases for the following reasons.  Distinction between a mixed centrocytic-centroblastic lymphoma and benign reactive hyperplasia may not be clear-cut.  An abundance of large mononuclear lymphoid cells may reflect a focus of transformed reactive lymphocytes rather than a high grade Non-Hodgkins lymphoma.  In cases in which the neoplastic characters of the cells is obvious on cell morphology, the all important distinction between a Hodgkins and a Non-Hodgkins lymphoma may not be possible in the absence of Reed-Sternberg cells.  Furthermore, the pattern of growth whether diffuse or nodular cannot be determined by this technique.

In short, when lymphoma is the clinical diagnosis, and the enlarged lymph node is peripheral, an excision biopsy at the outset is better than subjecting it to FNAC  first and confirmative excision biopsy later.  Once the diagnosis is established, cytology (FNAC only) is very helpful in monitoring the course of the disease.  The major contribution of FNAC of lymph nodes is in the diagnosis of metastatic cancers.

Endoscopic Biopsy
With the advent of fiberoptic scopes, many internal organs which were unvisualised in the past become accessible these days. Endoscopic biopsies are usually small, often crushed, thus making histologic interpretation difficult. The clinicians who are performing endoscopy should take several bites and the tissues must be handled very gently to avoid crushed artefact. Brushing as well as washing the sampled area and reaspirating the fluid will certainly increase the pick up rate.

Surgical Specimens
Surgical specimens form the bulk of specimens received in most if not all pathology laboratories. Ideally they should be sent in a fresh state so that the pathologists can view the specimens and take photographs if necessary.  Big specimens are sliced or cut open, pinned on cork board to avoid distortion after fixation. However, the common practice is sending specimens which are already immersed in formalin.  If specimens are going to be fixed before sending to the laboratory, please take note of the following:
1. The containers you are putting the specimens into must be a lot bigger than the specimens so that a ratio of at least 1:10, tissue: formalin content can be obtained.  Specimens which are inadequately fixed will show partial autolysis thus histological interpretation can be affected.
2. Please open or slice up big specimens such as gastrointestinal organs, enlarged  uterus or large tumour masses so that fixatives can penetrate the deeper/inner tissue.
3. 10% buffered formalin is the most commonly used fixative, however the best is Zenker's, but it is expensive.
4. If the specimens float on a fixative they should be covered by a thick layer of gauze.

Conclusion

All specimens submitted to pathology laboratory must be accompanied by a good clinical summary of the case. The pathologists are interpreting the histology/cytology based on the clinical information provided. If all practising clinicians and other medical personnel observe these basic rules in specimen collection, a lot more meaningful results can be attached to each specimen and less blame will fall on the laboratory staff when the investigation results are not in accordance to what the clinicians expect.
References
1. Pap smears : A Kelantan experience; is it and effective screening method for cervical cancers?
    Nor Hayati Othman, Mukarramah Che Ayob,Mazlan Muda, S. Selvarajan, Rahim Wahid.
    Malaysian Journal of Pathology , Vol 17, No.1 June 1995 , pg 53 ( abstract)
2. Pap Smears - A Kelantan experience ; a follow - up study.
    Nor Hayati Othman  et al . Malaysian Journal of Medical Sciences Vol 3 No 2, 1996 (supplement ) pg 14
3. Pap Smear study - is there a need to change the sampling tool?
    Nor Hayati Othman, Mukarramah Che Ayob. Malaysian Journal of Pathology
    Vol 19 No 1 June 1997  pg 77 (abstract)
4. Is Pap Smears effective, A Kelantan experince with 5000 cases
    Nor Hayati Othman, Mukarramah Che Ayob. Malaysian Journal of Medical Sciences
    Vol 4 No 1 Jan 1997 , 45-50

Further Readings
1. Chandra Grubb.  Diagnostic Cytopathology.  A text and colour Atlas.
    Churchil Livingstone 1988.
2. Robert W. Astarita.  Practical Cytopathology.  Churchil Livingstone 1990.
3. Juan Rosai.  Ackerman's Surgical Pathology.  7th Edition The C.V. Mosby Company 1989.
 

 

CPC / Case Presentation

 

Radiologic  Evaluation  of Progression  of  Rheumatoid Arthritis

Dr. Azian Abdul Aziz MD(USM)
M.Med.(Radiology)Year III
University Science Malaysia
Kubang Kerian, Kelantan

Case 1

A 40 years old Malay schoolteacher presented initially with multiple joint pain and morning stiffness for 6 months duration. The affected joints are the wrists and knees bilaterally. This problem have resulted in limited functional status e.g. difficulty combing hair; wearing clothes and needed a walking stick. It also disrupted her work as a teacher.

Physical examination revealed satisfactory general condition with normal vital signs. Hands showed no swelling or deformity but range of movement is limited with reduction in the power of grip. Examination also disclosed swollen and tender knee joints with limited range of movement. Other systems were unremarkable.

History and physical examination are suggestive of Rheumatoid Arthritis and the subsequent blood investigations revealed a positive rheumatoid factor as well as an elevated ESR. Radiograph of the hand (reviewed by doctors in Rheumatology Clinic) showed periarticular osteoporosis but no obvious erosive changes. Knee x-ray showed evidence of soft tissue swelling with joint effusion.

Case 2

59 years old Malay housewife was referred to Rheumatology Clinic for pain, swelling and stiffness of the wrist and ankle joints for the past 7 months. She mentioned that the problems involved the joints symmetrically and bilaterally, worst in the morning.

Generally she looks well with normal vital signs. Wrist and PIP joints are bilaterally swollen and tender with thickened synovium. Ranges of movements are limited. Both ankle joints are also swollen and felt warm.

Her blood investigations disclosed a raised ESR and positive rheumatoid factor. The history, examination and blood investigations point towards Rheumatoid Arthritis.

Radiographs of the affected joints (reviewed by doctor in Rheumatology Clinic) noted to be non-specific for Rheumatoid Arthritis.
 

Rheumatoid Arthritis
A common arthritis of unknown etiology that causes synovial inflammation and articular destruction that is invariably polyarticular. Autoimmune cause has been implicated with visceral involvement.

What is the role of radiology and radiologist in the management of patients with Rheumatoid Arthritis?

1.Confirms & categorise the type of arthritis.
2.Monitor progression of the disease.
3.Assess effects of treatment.
4.Detect complications.

Radiologist must know:
1. How to look (imaging modalities).
2. Where to look (disease distribution).
3. What to look for (imaging findings).
 

1. How to look (imaging modalities).
Several modalities have been tried to improve early detection of arthritic changes.

Plain x-ray
Modalities of choice (1st. line). May not show early/subtle changes.

Ultrasound
Can show effusion and synovial thickening, but limited to few accessible areas.

Dynamic ultrasound
It is ultrasound of superficial moving structures. Useful to diagnose rupture of tendon or ligaments. However, does not indicate the cause of it. Therefore, it is non-specific.

Arthrography
Good to demonstrate synovial changes. Due to its invasive nature, it is considered as not suitable for screening purposes.

Radioisotopes scan
Will show increase uptake of tracer in the affected joint, but it is non-specific. Several studies have documented that for RA, the sensitivity and specificity are too low to be use as early screening method.

CT scan
Thin sections will have better sensitivity and equal specificity compared with plain films. However, because CT does not alter diagnosis in cases where conventional x-rays are unequivocally positive, therefor, plain x-rays remain a good screening test.
It is reserved for patients with negative / equivocal findings on plain radiograph and high clinical suspicious of disease.

MRI
The advantage is that it is multiplanar. However, careful and controlled studies comparing CT and MRI have not been reported, but MRI shows a potential for early detection of arthritis. It clearly shows joint effusion, tenosynovial fluid, synovial thickening, and cartilage erosions; which are not seen on plain x-rays but, clinically detected.

Conclusion
Plain x-ray is still the modality of choice for screening in early arthritis. If it is positive, no further imaging workout is needed. Views of x-rays requested is also important especially if the routine views are normal e.g. hand - "Ballcatcher's" view, shows early rheumatoid erosion not seen on PA film; intercondylar osteophytes best seen on tunnel view; knee joint - loading the joint (patient standing) can bring out joint space narrowing; and SI joint - proper SI view.

2. Where to look (disease distribution)
Most RA patients develop erosions of hands within 2 years of disease onset.  However, erosions are more common and earlier in the feet i.e. MTP joint (especially 5th.).  49% of patient have only MTP erosions at presentations.  Hands; radiovolar aspects of 2nd. & 3rd. MCP, PIP & ventral-ulnar surfaces of IP of thumbs are targets for early erosions.  Wrist; earliest erosions is in ulnar styloid.

3. What to look for (imaging findings).
Hallmarks of radiological changes in Rheumatoid Arthritis are soft tissue swelling; osteoporosis; joint space narrowing; and marginal erosions.  However, early changes are subtle.

Understanding the disease process is essential to correlate with the radiological features expected at a particular stage of the disease process.
 

References

Britton, C.A. & Wasko, M.C. (1996). Rheumatoid Arthritis. Seminars in Roentgenology. 31(3), 198 - 207.

Rakel, R.E. (1995). Textbook of Family Practice, 5th. edn. Philadelphia : WB Saunders.

Resnick, D. & Niwayama, G. (1988). Diagnosis of Bone and Joint Disorders, 2nd. edn. Philadelphia : WB Saunders.

Rubin, D.A. (1996). The radiology of early arthritis. Seminars in Roentgenology. 31(3), 185 - 197.

Yochum, T.R. & Rowe, L.J. (1996). Essentials of Skeletal Radiology, 2nd. edn. Baltimore : Williams & Wilkins.
 

Presented during
Master of Medicine (Radiology) CME session on the 11th. of January, 1998.
 

Supervisor:
Dr. Ibrahim Lutfi Shuaib
Head of Radiology