ARTHRITIS & RHEUMATISM

Vol. 64, No. 10, October 2012, pp 31503155

DOI 10.1002/art.34536
2012, American College of Rheumatology
Sensitivity and Specificity of the Classification of
Psoriatic Arthritis Criteria in Early Psoriatic Arthritis
Laura C. Coates,
1
Philip G. Conaghan,
1
Paul Emery,
1
Michael J. Green,
2
Gamal Ibrahim,
3
Helen MacIver,
3
and Philip S. Helliwell
1
Objective. To assess the sensitivity and specificity
of the Classification of Psoriatic Arthritis (CASPAR)
Study Group criteria in early psoriatic arthritis (PsA)
and to compare them with the sensitivity and specificity
of the Moll and Wright criteria.
Methods. The CASPAR Study Group criteria were
applied to patients with early PsA (<24 months symp-
tom duration) and to control patients with other new-
onset inflammatory arthritides. Both groups were naive
to all disease-modifying antirheumatic drugs. The gold
standard diagnosis was confirmed by the consulting
rheumatologist using radiography and magnetic reso-
nance imaging where required. Proportions of patients
and control patients meeting the criteria were compared
using McNemars tests.
Results. We recruited a total of 111 patients with
early PsA and 111 control patients with other forms of
inflammatory arthritis (82 with rheumatoid arthritis, 13
with undifferentiated arthritis, 9 with spondylarthritis,
4 with inflammatory osteoarthritis, and 3 with crystal
arthritis) to the study. The sensitivity of the CASPAR
Study Group criteria in classifying early PsA was 87.4%
compared to 80.2% for the Moll and Wright criteria.
The specificity for both criteria was 99.1%. When con-
sidering different cut points for the CASPAR Study
Group criteria, the best cut point for classification
remained a score of >3 as in the original CASPAR
Study Group analysis. Considering a score of >2 gave a
higher sensitivity of 99.1% but resulted in a drop in
specificity to 94.6%. Regression analysis determined
that psoriasis and rheumatoid factor negativity were
the most important features that differentiated PsA,
followed by nail psoriasis and current or previous
dactylitis.
Conclusion. The CASPAR Study Group criteria
are more sensitive than the Moll and Wright criteria in
classifying early PsA. Although their sensitivity for early
PsA is lower than that for established disease, the
CASPAR Study Group criteria are valid for use as
inclusion criteria for trials in early PsA.
The Classification of Psoriatic Arthritis (CASPAR)
Study Group criteria were developed as new classifica-
tion criteria for psoriatic arthritis (PsA) using a large
cohort of patients with PsA and controls with other
inflammatory arthritides. They include characteristic
features of PsA and have been shown to have high
sensitivity and specificity in a population with estab-
lished disease (1). However, one of the limitations of the
CASPAR Study Group criteria is that they have not
been validated in early disease. A retrospective survey of
the Toronto database found that the CASPAR Study
Group criteria had high sensitivity for identifying early
disease within their PsA clinic population (2). However,
that study included only patients referred to a specialist
tertiary referral clinic; therefore, there is a significant
risk of overestimating the sensitivity of the criteria.
Studies in Italy and Sweden have also investigated the
Dr. Coates was recipient of a Clinical Research Fellowship
from Arthritis Research UK (grant number 18364).
1
Laura C. Coates, MBChB, PhD, MRCP, Philip G.
Conaghan, MBBS, PhD, FRCP, FRACP, Paul Emery, MA, MD,
FRCP, Philip S. Helliwell, MA, DM, PhD: University of Leeds and
NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK;
2
Michael J. Green, MBChB, MRCP: York Teaching Hospital NHS
Foundation Trust, York, and Harrogate and District NHS Foundation
Trust, Harrowgate, UK;
3
Gamal Ibrahim, ABMS, MSc, FRCP, Helen
MacIver, MBChB, MRCP: St. Lukes Hospital and Bradford Teaching
Hospital NHS Foundation Trust, Bradford, UK.
Dr. Emery has received consulting fees, speaking fees, and/or
honoraria from Pfizer, MSD, Abbott, Roche, UCB, Celgene, and
Bristol-Myers Squibb (less than $10,000 each).
Address correspondence to Philip S. Helliwell, DM, PhD,
Division of Musculoskeletal and Rheumatic Diseases, Chapel Allerton
Hospital, Chapeltown Road, Leeds LS7 4SA, UK. E-mail:
p.helliwell@leeds.ac.uk.
Submitted for publication July 15, 2011; accepted in revised
form May 3, 2012.
3150
sensitivity of the criteria in early PsA (3,4), but as yet no
studies have been completed with a control population
to address the sensitivity and specificity of the CASPAR
Study Group criteria in early disease. The criteria cannot
currently be recommended for use in studies of early
PsA.
The other key issue raised with the CASPAR
Study Group criteria is the entry criterion that states
that the patients must have inflammatory articular
disease (joint, spine, or entheseal). Particularly in early
PsA, the pattern of disease may be evolving and may be
different from that of established disease.
This study aimed to emulate the methodology of
the original CASPAR study and to recruit both patients
with early PsA and control patients with other inflam-
matory arthritides to allow calculation of the sensitivity
and specificity of the criteria in this population of
patients with early PsA. The Moll and Wright criteria,
which state that patients have PsA if they have inflam-
matory arthritis, psoriasis, and (usually) are negative for
rheumatoid factor (RF) (5), were used for compar-
ison. In addition, an assessment of arthritis, enthesitis,
and axial involvement was included to investigate the
pattern of disease in treatment-naive patients with early
arthritis.
PATIENTS AND METHODS
Patient and control selection. Patients and controls
were recruited from Early Arthritis Clinics and from new
referrals to rheumatology clinics in 4 hospitals based in the
Yorkshire region. Consecutive clinic attendees newly diag-
nosed as having PsA were enrolled in the study. All PsA
patients were required to have active inflammatory musculo-
skeletal disease comprising arthritis and/or enthesitis and/or
dactylitis. For each patient enrolled, a consecutive control
patient with new-onset inflammatory musculoskeletal disease
was also enrolled. The gold standard diagnosis was confirmed
by the consulting rheumatologist using radiography and mag-
netic resonance imaging (MRI) where required. All patients
and controls were required to have disease duration of 2
years (from onset of symptoms) and to be disease-modifying
antirheumatic drug naive.
Data collection. Data were recorded on standardized
forms that included demographics, date of onset of arthritis,
duration of early morning stiffness, activity of arthritis/
enthesitis and axial disease, and application of the CASPAR
Study Group criteria. Activity of arthritis and enthesitis was
assessed using clinical examination. All patients underwent a
swollen joint count (66 joints), a tender joint count (68 joints),
and clinical assessment of entheses, including the entheseal
sites required for the Leeds Enthesitis Index (6), the Maas-
tricht Ankylosing Spondylitis Enthesitis Score (MASES) (7),
and sites used in the Infliximab Multinational Psoriatic Arthri-
tis Controlled Trial (IMPACT) and IMPACT 2 clinical trials
(bilateral Achilles tendon and plantar fascia) (8,9). Entheses
were considered to have active enthesitis if they were tender
and/or swollen. The presence of axial involvement was assessed
clinically by questioning the patient about inflammatory back
pain using the Calin criteria (10).
All patients underwent plain radiography of the hands
and feet and additional imaging as deemed clinically necessary
by the treating physician. Patients with symptoms suggestive of
inflammatory back pain underwent radiography and MRI as
clinically indicated. Results of all relevant investigations were
recorded, including levels of inflammatory markers, IgM-RF
and anticyclic citrullinated peptide antibodies, presence or
absence of typical PsA-like periosteal new bone formation on
radiographs, and evidence of axial involvement identified with
radiographs or MRI by consensus of radiologists and the
referring rheumatologist in each center (11).
When considering patterns of arthritis, oligoarthritis
was defined as 5 joints with active disease and polyarthritis as
5 joints with active disease. Small joints were defined as
temporomandibular joints, sternoclavicular joints, acromiocla-
vicular joints, carpometacarpal joints, metacarpal joints, prox-
imal and distal interphalangeal (DIP) joints, metatarsophalan-
geal joints, and interphalangeal joints of the toes (total of 58
joints). Large joints were defined as the glenohumeral joints,
elbows, hips, knees, and ankle joints (total of 10 joints). The
symmetry number was calculated as the number of joints as
symmetric pairs/total number of joints involved. Symmetry
was defined as a symmetry number of 0.5 as previously
described (12).
Statistical analysis. Values for sensitivity and specific-
ity for the CASPAR Study Group criteria in established
disease are 0.91 and 0.99, respectively. Prior to the develop-
ment of the CASPAR Study Group criteria, the Moll and
Wright criteria were traditionally used, and the values for
sensitivity and specificity for the Moll and Wright criteria in
the CASPAR study were 0.99 and 0.92, respectively. Assuming
that in early case definition the emphasis is on specificity, the
null hypothesis is that the specificity for the CASPAR Study
Group criteria will be equivalent to that for the Moll and
Wright criteria (H
A
H
O
, respectively). The alternative
hypothesis is that the specificity for the CASPAR Study Group
criteria differs from that for the Moll and Wright criteria
(H
A
H
O
). According to Obuchowski (13), the number of
patients required to test the alternative (2-tailed) hypothesis
with an alpha value of 0.05 and a beta value of 0.20 is 111.
Therefore, 111 patients and 111 consecutive control patients
were required.
Sensitivity and specificity of the CASPAR Study
Group criteria and Moll and Wright criteria were compared
using McNemars tests for paired variables. Receiver operating
characteristic (ROC) curves were used to estimate the area
under the curve (AUC) for both criteria and the optimal cut
point for the CASPAR Study Group criteria for the diagnosis
of early PsA. Univariate and multivariate forward stepwise
binary logistic regression was used to identify which features
included in the CASPAR Study Group criteria were indepen-
dently associated with PsA. Significance testing was performed
USE OF CASPAR CRITERIA IN EARLY PsA 3151
using McNemars tests for categorical variables and Mann-
Whitney U tests for continuous variables.
RESULTS
We recruited a total of 111 patients with early
PsA and 111 control patients with other forms of
inflammatory arthritis (82 with rheumatoid arthritis
[RA], 13 with undifferentiated arthritis, 9 with spondy-
larthritis, 4 with inflammatory osteoarthritis, and 3 with
crystal arthritis) to the study. The baseline features of
these patients are shown in Table 1. The sensitivity of
the CASPAR Study Group criteria (score 3) in classi-
fying early PsA was 87.4% compared to 80.2% for the
Moll and Wright criteria (P 0.008). The specificity for
both criteria was 99.1%, with only 1 control patient
fulfilling both criteria for PsA.
Using ROC analysis, the AUC for the CASPAR
Study Group criteria was 0.991 compared to 0.896 for
the Moll and Wright criteria (Figure 1). When consid-
ering different cut points for the CASPAR Study Group
criteria, the best cut point for classification remained a
score of 3 as in the original CASPAR Study Group
analysis (Table 2). Considering a score of 2 gave a
higher sensitivity but resulted in a drop in specificity that
would not be ideal for classification criteria.
When considering the individual components of
the CASPAR Study Group criteria, 96.4% of PsA
patients had current or previous psoriasis or a family
history of psoriasis with 84% having current psoriasis.
Dactylitis and nail psoriasis were highly discriminatory,
as only 1 control patient each had these features.
Univariate binary logistic regression analysis determined
that all of the features of the CASPAR Study Group
criteria, with the exception of radiographic evidence of
new bone formation, were significant in distinguishing
Table 1. Baseline features of the PsA patients and control patients
recruited to the CASPAR study*
PsA
patients
(n 111)
Control
patients
(n 111)
Age, median (IQR) years 44 (3455) 52 (3866)
Disease duration, median (IQR) months 8 (514) 5 (39.25)
Consultant diagnosis, no. of patients
PsA 111 0
RA 0 82
UA 0 13
SpA 0 9
ReA 0 6
IBD related 0 2
Axial SpA 0 1
Inflammatory OA 0 4
Crystal arthritis 0 3
Arthritis, % 100 99
Enthesitis, % 67 52
Axial symptoms, % 5 1
Early morning stiffness, median (IQR)
minutes
60 (20120) 60 (30120)
Fulfilling Moll and Wright criteria for
PsA, %
80 1
Fulfilling CASPAR Study Group criteria
for PsA, %
87 1
* PsA psoriatic arthritis; CASPAR Classification of Psoriatic Ar-
thritis; IQR interquartile range; RA rheumatoid arthritis;
UA undifferentiated arthritis; SpA spondylarthritis; ReA reac-
tive arthritis; IBD inflammatory bowel disease; OA osteoarthri-
tis.
P 0.05 versus control patients.
Figure 1. Receiver operating characteristic curve for the Classifica-
tion of Psoriatic Arthritis (CASPAR) Study Group criteria and the
Moll and Wright criteria predicting psoriatic arthritis diagnosis.
Table 2. Receiver operating characteristic curve analysis of the Moll
and Wright criteria and the CASPAR Study Group criteria*
Criteria Score Sensitivity Specificity
Moll and Wright Positive 80.2 99.1
CASPAR Study Group
criteria score
1 100 42.3
2 99.1 94.6
3 87.4 99.1
4 42.3 100
5 15.3 100
* CASPAR Classification of Psoriatic Arthritis.
3152 COATES ET AL
PsA patients from control patients. Multivariate forward
stepwise logistic regression determined that current or
previous psoriasis, RF negativity, nail psoriasis, family
history of psoriasis, and current or previous dactylitis
were all associated with PsA. Table 3 shows in more
detail the proportion of patients fulfilling each individ-
ual aspect of the CASPAR Study Group criteria.
When considering the diagnosis of inflammatory
articular disease (joint, spine, or entheseal) required for
the first aspect of the CASPAR Study Group criteria,
there were some minor differences between the PsA
patients and control patients. Nearly all patients had
arthritis. Enthesitis was significantly more frequent in
PsA patients than in control patients (67% versus 52%;
P 0.029). There was a trend toward higher enthesitis
counts in PsA patients compared to control patients, but
this was not significant. When considering the 3 clinical
indices for enthesitis (MASES, Leeds Enthesitis Index,
and IMPACT) individually, there was again a trend
toward higher enthesitis scores in PsA patients com-
pared to control patients, but this was only significant
when using the IMPACT tool (P 0.022). There were
no individual entheseal sites or other combinations of
entheseal sites that could distinguish PsA patients from
control patients. Spondylitis appeared more frequently
in PsA patients, but the difference was not significant
due to small numbers (5% versus 1%; P 0.055).
Further analysis examined the pattern of arthritis
seen in PsA patients and patients with other inflamma-
tory arthritides (Table 4). The average tender and
swollen joint counts and the proportions of people with
oligoarticular and polyarticular disease did not differ
significantly between PsA patients and control patients.
Involvement of large and small joints was also similar
when comparing PsA patients to all control patients.
The 82 control patients with RA were found to have
significantly higher joint counts (P 0.008), principally
due to an increased number of small joints involved.
More than 60% of RA patients had predominantly small
joint disease. However, DIP joint involvement was sig-
nificantly more common in PsA patients than in all
control patients (32% versus 16%; P 0.007) and more
Table 3. Proportion of PsA patients and control patients fulfilling
each aspect of the CASPAR Study Group criteria*
PsA
patients
(n 111)
Control
patients
(n 111)
Any psoriasis 96 12
Current psoriasis 84 4
Previous psoriasis 6 1
Family history of psoriasis 18 8
Nail psoriasis 38 1
Rheumatoid factor negative 96 47
Current or previous dactylitis 28 1
Radiographic evidence of new bone formation 2 0
* Values are the percent of patients. See Table 1 for definitions.
P 0.05 versus control patients.
Table 4. Disease patterns in PsA patients, all patient controls, and RA patient controls*
PsA patients
(n 111)
All patient controls
(n 111)
RA patient controls
(n 82)
Proportion with arthritis, % 100 99 100
Oligoarthritis, % 30 24 15
Polyarthritis, % 70 76 85
DIP joint involvement, no. (%) 35 (32) 18 (16) 15 (18)
Tender joint count, median (IQR) 7 (316) 8 (419) 12 (622)
Swollen joint count, median (IQR) 5 (29) 5 (312) 7 (314)
Joints with active disease, median (IQR) 9 (417) 10 (520) 12.5 (723)
Predominantly small joint arthritis, no. (%) 59 (54) 59 (54) 50 (62)
Predominantly large joint arthritis, no. (%) 51 (46) 50 (45) 31 (38)
Small joints involved, median (% of total) 7 (12) 9 (16) 11.5 (20)
Large joints involved, median (% of total) 1 (10) 1 (10) 1.5 (15)
Symmetry number, median (IQR) 0.5 (00.78) 0.67 (0.290.86) 0.73 (0.490.89)
Symmetric disease, no. (%) 58 (52) 72 (65) 62 (76)
Proportion with enthesitis, % 67 52 52
Enthesitis count, median (IQR) 2 (04) 1 (03) 1 (04)
Proportion with spondylitis, % 5 1 0
* DIP distal interphalangeal (see Table 1 for other definitions).
P 0.05 versus all control patients.
P 0.05 versus RA control patients.
USE OF CASPAR CRITERIA IN EARLY PsA 3153
common in PsA patients than in RA patients alone
(18%).
It has been suggested that a symmetry number of
0.5 defines symmetric disease (12). The symmetry
number was significantly higher in all control patients
than in PsA patients (P 0.003), and this difference was
even more pronounced when comparing RA control
patients with PsA patients (P 0.0001). The remaining
control patients (without RA) had a lower median
symmetry number, but this was not significant when
compared to PsA patients (0.27 versus 0.5; P 0.58). A
higher proportion of control patients, particularly those
with RA, had symmetric disease compared to PsA
patients. When we compared PsA patients to all control
patients, there was no significant difference in the
proportion with symmetric disease (P 0.11); however,
there was a significant difference when we compared
PsA patients to RA control patients (P 0.001).
DISCUSSION
These data confirm that the CASPAR Study
Group criteria have greater sensitivity than the Moll and
Wright criteria in the identification of early PsA. The
most important difference between the 2 criteria is that
the CASPAR Study Group criteria allow a diagnosis of
PsA to be made in patients without skin psoriasis. The
CASPAR Study Group criteria use additional features
such as dactylitis, nail psoriasis, and positive family
history to increase their sensitivity. This is particularly
relevant in early disease, when not all features of PsA
may have become manifest. In particular, 20% of people
presenting with PsA do not have skin psoriasis, thereby
excluding them from a diagnosis using the Moll and
Wright criteria. All RF-negative patients who fulfill the
Moll and Wright criteria will also fulfill the CASPAR
Study Group criteria, so there is significant overlap
between the 2 sets of criteria.
In comparison with their sensitivity for detecting
established disease, the sensitivity of the CASPAR
criteria remains slightly lower for detecting early PsA. A
short duration of disease means that many patients will
not yet have experienced all of the typical features of
PsA that they may develop during the course of their
disease. In particular, there is a much lower incidence of
typical radiographic changes that can be identified in
patients with early PsA. The vast majority of patients
with new onset of inflammatory arthritis have normal-
appearing radiographs at presentation. This problem
has been identified in previous cohorts of patients with
early PsA, in whom little new bone formation could be
identified (3).
When considering the pattern of inflammatory
articular disease, a higher proportion of PsA patients
had enthesitis compared to control patients. Most of the
clinical indices and clinical examinations of individual
enthesis sites were not able to discriminate between PsA
patients and control patients. It is known that clinical
assessment for tenderness near an enthesis correlates
poorly with ultrasound or MRI in identifying enthesitis.
Therefore, this may reflect a failure of the clinical
entheseal indices rather than a similar picture of enthesi-
tis in the PsA patients and control patients. More PsA
patients had axial disease, although this difference was
not significant due to small numbers affected in both
groups. Patterns of arthritis showed that PsA patients
had a lower total number of involved joints compared to
RA control patients, and this difference was principally
explained by a higher number of involved small joints in
RA patients, confirming the identification of RA as a
predominantly small joint polyarthropathy. Symmetric
joint disease was less common in PsA patients than in
RA control patients, and there was a significant differ-
ence in symmetry number between PsA patients and all
control patients.
The most significant limitation of this study re-
lates to the selection of the PsA patients. PsA patients
were recruited only if they were diagnosed by an expe-
rienced rheumatologist as having PsA, and few patients
presenting with undifferentiated arthritis were included
in this study. This may be less important when consid-
ering the use of the CASPAR Study Group criteria as
classification criteria for enrollment in clinical trials, as
originally intended. The results of this study support
their use as inclusion criteria for future research studies
of recent-onset PsA. However, these data will result in
an overestimate of the sensitivity of the criteria if their
use is considered as a diagnostic or screening tool in a
general Early Arthritis Clinic population. Nearly all of
the patients and controls recruited into this study had
active arthritis, although this was not a mandatory
inclusion criterion. Patients presenting with isolated
enthesitis or dactylitis are less common and may have a
delay in diagnosis that would have excluded them from
participation in this study. The other limitation is the
identification of ideal controls. Again, controls are more
likely to have a certain diagnosis, such as RA, and
patients with undifferentiated arthritis were not seen in
significant numbers. It is also difficult to identify a sig-
3154 COATES ET AL
nificant number of controls presenting with axial spon-
dylarthritis who have 2 years of symptom duration.
This work supports the use of the CASPAR
Study Group criteria as classification criteria for future
research in early PsA. Although the sensitivity of these
criteria is slightly lower than that in established disease,
the specificity is reassuring. Their use as diagnostic
criteria in cases where diagnosis is unclear cannot be
recommended based on this study, but future work
evaluating their use in an unselected Early Arthritis
Clinic population would address this issue. A different
clinical phenotype cannot be relied upon in isolation to
identify early PsA, but different patterns are seen in PsA
patients compared to patients with other inflammatory
arthritides. Enthesitis and DIP joint involvement are
more frequent in early PsA compared to other forms of
inflammatory arthritis; however, a significant proportion
of controls (including a significant proportion of patients
with RA) also have clinical enthesitis. Spondylitis is
likely to be more frequent in PsA than in RA; however,
it cannot be relied upon to differentiate PsA from other
forms of inflammatory arthritis. Patterns of arthritis
confirm the typical view that RA is a symmetric predom-
inantly small joint polyarthropathy, whereas patients
with PsA generally present with fewer involved joints,
particularly fewer involved small joints, and with less
symmetric disease.
AUTHOR CONTRIBUTIONS
All authors were involved in drafting the article or revising it
critically for important intellectual content, and all authors approved
the final version to be published. Dr. Helliwell had full access to all of
the data in the study and takes responsibility for the integrity of the
data and the accuracy of the data analysis.
Study conception and design. Coates, Helliwell.
Acquisition of data. Coates, Conaghan, Green, Ibrahim, MacIver,
Helliwell.
Analysis and interpretation of data. Coates, Conaghan, Emery,
Helliwell.
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