Edit concept Create issue ticket

Rheumatoid Arthritis

RA

Rheumatoid arthritis is a chronic systemic inflammatory disease. It may affect many tissues and organs and any joint lined by a synovial membrane may be involved.


Presentation

The active disease presents itself as fatigue, loss of appetite, muscle and joint pain and stiffness. The muscle pain is more prominent in the mornings after a period of inactivity. Following the active disease, it goes into a period of remission. The active disease is usually called the flare up marked by red, warm, painful, tender and swollen joints as a result of inflammation of the synovium.

Complications

Rheumatoid arthritis may not limit itself only to the joints but can also affect various other parts of the body such as eyes, lungs, skin, blood vessels, heart and other major organs. Moreover most of the patients affect by rheumatoid arthritis suffer from emotional distress.

Effect of rheumatoid arthritis on the skin

Rheumatoid arthritis can produce small lumps on the skin called the rheumatoid nodules in 1/5 th of the people. They develop on the skin over the elbows, heels, fingers or forearm. Ulcers due to vasculitis can cause changes on the skin and may indicate a serious disease activity [4].

Effect of rheumatoid arthritis on the eye

Rheumatoid arthritis can cause inflammation of the episclera, a condition called scleritis. It is usually mild but in some extreme cases can become red, painful and inflamed and may even lead to vision loss.

Effect of rheumatoid arthritis on the heart and blood vessels

Rheumatoid arthritis can result in the accumulation of fluid around the heart resulting in pericarditis. Inflammation of the heart muscle itself, myocarditis can develop in some rare conditions. Vasculitis, the inflammation of the blood vessels can also occur, which can affect many organs [5].

Effects of rheumatoid arthritis on the lungs

Rheumatoid nodules can develop in the lungs resulting in collapsed lung, coughing up blood or pleural effusion [6]. Interstitial lung diseases and pulmonary hypertension may also develop as a result of rheumatoid arthritis.

Effect of Rheumatoid arthritis on blood cells

Rheumatoid arthritis can cause anemia and can result in Felty's syndrome. In this condition, the spleen is enlarged, the white blood cell count decreases and may even lead to lymphoma in rare conditions.

Easy Bruising
  • They can also cause side effects, such as easy bruising, bone thinning, cataracts and diabetes. Antirheumatic (say: “anti-roo-mat-ick”) medicines can help fight RA.[familydoctor.org]
  • Corticosteroids are normally only used in this way because long-term use of corticosteroids can have serious side effects, such as weight gain, osteoporosis (thinning of the bones), easy bruising, muscle weakness and thinning of the skin.[nhsinform.scot]
  • These side effects include weight gain , facial puffiness, thinning of the skin and bone, easy bruising, cataracts , risk of infection, muscle wasting, and destruction of large joints, such as the hips.[medicinenet.com]
  • These side effects are serious and can include easy bruising, thinning of the bones (osteoporosis), cataracts, weight gain, a round face, susceptibility to infections, diabetes and high blood pressure.[orthop.washington.edu]
Splenomegaly
  • […] associated with several autoimmune and chronic infectious diseases anti-cyclic citrullinated peptide (anti-CCP): it is more than 80% sensitive and more than 95% specific elevated ESR or C-reactive protein Associations Felty syndrome : rheumatoid arthritis, splenomegaly[radiopaedia.org]
  • This is characterized by splenomegaly, and leukopenia – predominantly granulocytopenia. Recurrent bacterial infections and chronic refractory leg ulcers are the major complications.[hopkinsarthritis.org]
  • Felty's syndrome is characterized by neutropenia, often with associated anemia and thrombocytosis, with splenomegaly and occasionally with leg ulcers. This closely resembles the large granular lymphocyte (LGL) syndrome in RA.[clevelandclinicmeded.com]
  • Neutropenia occurs in 1 to 2% of cases, often with splenomegaly (Felty syndrome). Acute-phase reactants (eg, thrombocytosis, elevated ESR, elevated CRP) reflect disease activity. A mild polyclonal hypergammaglobulinemia often occurs.[merckmanuals.com]
Pleural Effusion
  • Pathogenesis A variety of mechanisms have been postulated for pleural effusions occurring in rheumatoid arthritis patients.[err.ersjournals.com]
  • Effects of rheumatoid arthritis on the lungs Rheumatoid nodules can develop in the lungs resulting in collapsed lung, coughing up blood or pleural effusion .[symptoma.com]
  • "Rheumatoid pleural effusion". Seminars in Arthritis and Rheumatism . 35 (6): 368–378. doi : 10.1016/j.semarthrit.2006.03.002 . ISSN 0049-0172 . PMID 16765714 .[en.wikipedia.org]
  • Systemic disease marked by pleural effusions, pericarditis, pulmonary fibrosis, neuropathies, and ocular disorders may occu. Symptoms usually develop gradually over the course of several months but may begin abruptly in some patients.[medical-dictionary.thefreedictionary.com]
  • Fluid may collect around one or both lungs and is referred to as a pleural effusion . Inflammation of the lining tissues of the lungs is known as pleuritis.[emedicinehealth.com]
Pain
  • The primary outcome will be foot pain measured via the Foot Function Index pain subscale at 12 months.[ncbi.nlm.nih.gov]
  • […] tendon pain Flatfoot Ankle pain Diagnosis RA is diagnosed on the basis of a clinical examination as well as blood tests.[acfas.org]
  • […] tendon pain Flatfoot ankle pain Diagnosis RA is diagnosed on the basis of a clinical examination as well as blood tests.[foothealthfacts.org]
  • Ask your doctor about the tools that are available to make your daily life easier.To ease pain, you can also apply heat or cold to your painful joints. Heat relaxes tense muscle and cold can numb pain.[familydoctor.org]
Fatigue
  • Almost all (  94%) could distinguish general fatigue from RA fatigue.[ncbi.nlm.nih.gov]
  • In these patients, there was no significant change to any value except for fatigue. A variety of both biological and social factors influences depressive symptoms in RA.[ncbi.nlm.nih.gov]
  • Fatigue You may feel unusually fatigued well before any other symptoms become obvious. Fatigue can precede the onset of other symptoms by weeks or months. It may come and go from week to week or day to day.[healthline.com]
  • In addition to triggering painful joint swelling and stiffness, rheumatoid arthritis can cause fever and fatigue and potentially lead to long-term joint deformities.[arthritis-health.com]
Fever
  • Fever When accompanied by other symptoms like joint pain and inflammation, a low-grade fever may be an early warning sign that you have RA.[healthline.com]
  • Symptoms include high fevers that often increase in the evenings and then may suddenly drop to normal. During the onset of fever, the child may feel very ill, appear pale, or develop a rash.[kidshealth.org]
  • In addition to triggering painful joint swelling and stiffness, rheumatoid arthritis can cause fever and fatigue and potentially lead to long-term joint deformities.[arthritis-health.com]
  • One week after admission, she developed fever, dyspnea, hypoxemia, tachycardia, and increased serum C-reactive protein level.[ncbi.nlm.nih.gov]
Weakness
  • Common symptoms including fever, fatigue, weakness and generalized pain. In the first weeks and months of the disease, gradual pain and swelling may occur in the joints of the body.[techtimes.com]
  • If rheumatoid arthritis has caused muscles around the joints to become weak, exercise will help strengthen them. Exercises that do not strain the joints are best, such as swimming.[medicalnewstoday.com]
  • Joint stiffness in the morning (that lasts more than 60 minutes) Joint pain Joint swelling (often seen in the hands) Weakness Tiredness Your doctor will look for these signs and symptoms to help diagnose you.[enbrel.com]
  • These can help protect your joints and strengthen weak joints. Surgery. In some cases, the doctor may recommend surgery to correct any deformities caused by rheumatoid arthritis. In severe cases, joint replacement surgery may be performed.[intermountainhealthcare.org]
  • This pathology causes pain, stiffness in the morning and after periods of inactivity, joint swelling, weakness, fatigue and restricted joint mobility leading to reduced function.[physio-pedia.com]
Anemia
  • Even treatment of the patient's anemia by transfusion of red blood cells was ineffective. Laboratory tests showed high levels of IL-6 (214.24 pg/mL).[ncbi.nlm.nih.gov]
  • Other common tests include the erythrocyte sedimentation rate, which indicates inflammation in the body, as well as a white blood cell count and a blood test for anemia. X-rays: X-rays may be used to determine the amount of joint damage.[ucsfhealth.org]
  • […] in the joint, even when it is not being used A feeling of warmth around the joint Deformities and contractures of the joint Symptoms throughout the body, such as fever, loss of appetite and decreased energy Weakness due to a low red blood cell count (anemia[orthoinfo.aaos.org]
  • A low blood level (anemia), positive rheumatoid factor, and a high erythrocyte sedimentation rate can be signs that a patient has RA. With RA, a patient typically undergoes painful flare-ups rather than having continuous pain.[footeducation.com]
Loss of Appetite
  • Read More Rheumatoid Arthritis Symptoms Along with joint inflammation and pain, many people experience fatigue, loss of appetite and a low-grade fever. Because RA is a systemic disease, it may also affect organs and body systems.[arthritis.org]
  • These include feeling sick, loss of appetite, a sore mouth, diarrhoea, headaches and hair loss.[express.co.uk]
Tachycardia
  • One week after admission, she developed fever, dyspnea, hypoxemia, tachycardia, and increased serum C-reactive protein level.[ncbi.nlm.nih.gov]
Xerostomia
  • Sjogren’s syndrome is an autoimmune condition that affects exocrine gland function, leading to a reduction in tear production (keratoconjunctivitis sicca), oral dryness (xerostomia) with decreased saliva of poor quality, and reduced vaginal secretions[hopkinsarthritis.org]
Subcutaneous Nodule
  • The most characteristic lesions of rheumatoid arthritis are subcutaneous nodules, which may be present for weeks or months and are most commonly found over bony prominences, especially near the elbow.[medical-dictionary.thefreedictionary.com]
  • Joint involvement and subcutaneous nodules can result from gout, cholesterol, and amyloidosis as well as RA; aspiration or biopsy of the nodules may occasionally be needed.[merckmanuals.com]
  • The subcutaneous nodule is the most characteristic extra-articular lesion of the disease. Nodules occur in 20 to 30% of cases, almost exclusively in seropositive patients.[hopkinsarthritis.org]
Urticaria
  • Patients with urticaria, rhinitis, or asthma caused by aspirin can have the same problems with these other NSAIDs, but celecoxib may not cause these problems.[merckmanuals.com]
Palmar Erythema
  • erythema , and skin fragility (often worsened by corticosteroid use). [ citation needed ] Diffuse alopecia areata (Diffuse AA) occurs more commonly in people with rheumatoid arthritis. [21] RA is also seen more often in those with relatives who have[en.wikipedia.org]
Arthritis
  • Interstitial lung diseases and pulmonary hypertension may also develop as a result of rheumatoid arthritis. Effect of Rheumatoid arthritis on blood cells Rheumatoid arthritis can cause anemia and can result in Felty's syndrome.[symptoma.com]
  • Foot pain is common in rheumatoid arthritis and appears to persist despite modern day medical management.[ncbi.nlm.nih.gov]
  • Rheumatoid Arthritis. Available online at . Accessed March 2014. Arthritis Foundation. Rheumatoid Arthritis (RA). Available online at . Accessed March 2014. HealthCentral. What Your Rheumatoid Arthritis Lab Results Mean. Available online at .[labtestsonline.org]
  • Rheumatoid arthritis is a chronic disease of the joints, which causes joint pain and disability.[ncbi.nlm.nih.gov]
Joint Deformity
  • In addition to triggering painful joint swelling and stiffness, rheumatoid arthritis can cause fever and fatigue and potentially lead to long-term joint deformities.[arthritis-health.com]
  • Some of the conditions the doctor looks for include swelling and warmth around the joint, painful motion, lumps under the skin, joint deformities, and joint contractures (inability to fully stretch or bend the joint).[orthoinfo.aaos.org]
  • RA can cause joint deformity and may lead to physical disabilities. Approximately 1.5 million people in the United States have rheumatoid arthritis. RA is more prevalent in woman than men—in fact, it affects 3 times as many adult females than males.[spineuniverse.com]
Morning Stiffness
  • Pain, morning stiffness, swelling, and systemic symptoms are common.[orthoinfo.aaos.org]
  • Morning stiffness Morning stiffness is often an early sign of arthritis. Stiffness that lasts for a few minutes is usually a symptom of a degenerative form of arthritis.[healthline.com]
  • Serum sST2 level was correlated with the morning stiffness time and ESR, as well as scores of HAQ and DAS28 (P 0.05).[ncbi.nlm.nih.gov]
  • This is called morning stiffness. Slowly the symptoms may worsen as the joint is affected to a greater extent leading to severe pain on movements and difficulty in performing daily tasks. Symptoms may suddenly worsen. This is called a flare up.[news-medical.net]
Joint Stiffness
  • Rheumatoid arthritis (RA) is a debilitating and excruciating chronic inflammatory disease of connective tissues causing joint stiffness, swelling and pain.[techtimes.com]
  • Joint stiffness Stiffness in one or more of the smaller joints is a common early sign of RA. This can occur at any time of day, whether you are active or not. Typically, stiffness begins in the joints of the hands.[healthline.com]
  • It can also be difficult to diagnose because many conditions cause joint stiffness and inflammation. Your doctor may do a physical examination to check your joints to see if they are swollen and to find out how easily they move.[healthdirect.gov.au]
  • The most common signs and symptoms of RA-related foot problems, in addition to the abnormal appearance of deformities, are pain, swelling, joint stiffness, and difficulty walking.[acfas.org]
Joint Swelling
  • By Joseph Bennington-Castro Rheumatoid Arthritis Complications and Comorbidities By Joseph Bennington-Castro Rheumatoid Arthritis Symptoms The main signs of rheumatoid arthritis are joint swelling, pain, and stiffness.[everydayhealth.com]
  • RA symptoms, which can occur throughout the body, include: joint pain joint swelling joint stiffness loss of joint function Symptoms can vary from mild to severe. It’s important not to ignore your symptoms, even if they come and go.[healthline.com]
  • In addition to triggering painful joint swelling and stiffness, rheumatoid arthritis can cause fever and fatigue and potentially lead to long-term joint deformities.[arthritis-health.com]
Peripheral Neuropathy
  • The most common neurologic manifestation of rheumatoid arthritis is a mild, primarily sensory peripheral neuropathy, usually more marked in the lower extremities.[hopkinsarthritis.org]
  • Common complications of rheumatoid arthritis include the following: Peripheral neuropathy and carpal tunnel syndrome : This condition results from damage to nerves, most often those in the hands and feet.[emedicinehealth.com]
  • neuropathy and mononeuritis multiplex may occur.[en.wikipedia.org]

Workup

Diagnosis is usually made by several tests such as blood tests involving the Erythrocyte Sedimentation Rate and C-reactive protein (CRP). X-rays are made to evaluate joints. Various imaging techniques such as MRI and CT scans are useful to evaluate and diagnose rheumatoid arthritis.

The laboratory studies used in the diagnosis of rheumatoid arthritis fall under three categories such as the hematological parameters, immunological parameters and markers of inflammation [7].

Hence some of such tests include, Erythrocyte Sedimentation Rate, C-reactive protein, complete blood count, Rheumatoid factor assay, anti–nuclear antibody assay, anti-cyclic citrullinated peptide and anti-mutated citrullinated vimentin assay [8].

These biomarkers can not only help in early diagnosis of the disease, but also can help in assessing the prognosis of the disease.

Pericardial Effusion
  • Other extra-articular signs include vasculitis causing leg ulcers or mononeuritis multiplex, pleural or pericardial effusions, pulmonary infiltrates or fibrosis, pericarditis, myocarditis, lymphadenopathy, Felty syndrome, Sjögren syndrome, scleromalacia[merckmanuals.com]
  • Occasionally, a comorbid pericardial effusion may exist. Similarly, pneumothorax is possible, but rare. Pathogenesis A variety of mechanisms have been postulated for pleural effusions occurring in rheumatoid arthritis patients.[err.ersjournals.com]
  • Heart: A collection of fluid around the heart (pericardial effusion) from inflammation is not uncommon in rheumatoid arthritis. This usually causes only mild symptoms, if any, but it can be very severe and lead to poor heart function.[emedicinehealth.com]
Joint Space Narrowing
  • space narrowing: symmetrical or concentric marginal erosions: due to erosion by pannus of the bony “ bare areas ” Hands and wrists Diagnosis and follow-up of patients with RA commonly involve imaging of the hands and wrists.[radiopaedia.org]
Thrombocytosis
  • Similarly, the platelet count is usually normal but thrombocytosis occurs in response to inflammation.[hopkinsarthritis.org]
  • Acute-phase reactants (eg, thrombocytosis, elevated ESR, elevated CRP) reflect disease activity. A mild polyclonal hypergammaglobulinemia often occurs. ESR is elevated in 90% of patients with active disease.[merckmanuals.com]
  • Felty's syndrome is characterized by neutropenia, often with associated anemia and thrombocytosis, with splenomegaly and occasionally with leg ulcers. This closely resembles the large granular lymphocyte (LGL) syndrome in RA.[clevelandclinicmeded.com]
HLA-DR4
  • It is generally considered that a genetic predisposition (HLA-DR B1 which is the most common allele of HLA-DR4 involved in RA) and an environmental trigger (Epstein-Barr virus postulated as a possible antigen, but not proven) lead to an autoimmune response[radiopaedia.org]
  • The gene that influences the likelihood or a tendency to have RA is one of the genes that controls the function of the immune system called the HLA-DR4 gene. However, not everyone who inherits this gene will develop the disease.[orthop.washington.edu]
  • Other HLA-DR4 molecules (eg, HLA-DR beta *0402) lack this epitope and do not confer this risk. Genes other than those of the major histocompatibility complex (MHC) are also involved.[emedicine.medscape.com]
  • […] was estimated that genetics may account for between 40 and 65% of cases of seropositive RA, but only around 20% for seronegative RA. [3] RA is strongly associated with genes of the inherited tissue type major histocompatibility complex (MHC) antigen HLA-DR4[en.wikipedia.org]
HLA-DR1
  • HLA-DR1 (HLA-DR beta *0101) also carries this shared epitope and confers risk, particularly in certain southern European areas. Other HLA-DR4 molecules (eg, HLA-DR beta *0402) lack this epitope and do not confer this risk.[emedicine.medscape.com]
Pleural Effusion
  • Pathogenesis A variety of mechanisms have been postulated for pleural effusions occurring in rheumatoid arthritis patients.[err.ersjournals.com]
  • Effects of rheumatoid arthritis on the lungs Rheumatoid nodules can develop in the lungs resulting in collapsed lung, coughing up blood or pleural effusion .[symptoma.com]
  • "Rheumatoid pleural effusion". Seminars in Arthritis and Rheumatism . 35 (6): 368–378. doi : 10.1016/j.semarthrit.2006.03.002 . ISSN 0049-0172 . PMID 16765714 .[en.wikipedia.org]
  • Systemic disease marked by pleural effusions, pericarditis, pulmonary fibrosis, neuropathies, and ocular disorders may occu. Symptoms usually develop gradually over the course of several months but may begin abruptly in some patients.[medical-dictionary.thefreedictionary.com]
  • Fluid may collect around one or both lungs and is referred to as a pleural effusion . Inflammation of the lining tissues of the lungs is known as pleuritis.[emedicinehealth.com]

Treatment

Treatment of rheumatoid arthritis aims at reducing the inflammation of the joints, relieving pain, preventing joint damage and minimizing disability. Treatment is mostly symptomatic as there is no cure for the disease.

The treatment involves exercise and lifestyle modifications, medications and surgery in some extreme cases. The medications for treating rheumatoid arthritis include, NSAIDs, corticosteroids, DMARDs (Disease Modifying Anti–Rheumatic Drugs) and immunesuppressants [9].

Prognosis

Rheumatoid arthritis is a debilitating disease. Though treatment can delay and reduce the severity of the disability, there is no cure for this condition.

If the disease pattern is not altered by any medication, there is an ultimate destruction of the joints. The bone and the cartilages get eroded and the surface on which the joint moves is destroyed, resulting in rigidity and immobility of the joint, leading to a loss in the range of motion.

It may take years for the disease to progress to this stage, though the process may be hastened in some individuals. In very rare cases, when the organs such as the blood vessels are affected, life-threatening vasculitis may develop  [3].

Usually, the symptoms appear within the first two years of occurrence of the disease and manifests as pain, stiffness and immobility. As the disease progresses it results in 'burnt out' disease where there is severe immobility, deformity but very little inflammation.

Etiology

Etiology of occurrence of rheumatoid arthritis has not yet been identified and various researches are being carried out to identify the cause. It has been suggested that rheumatoid arthritis can be caused by both genetic and environmental factors. The Human Leukocyte Antigen (HLA) type is identified to be the gene linked with rheumatoid arthritis [1]. Of this, the HLA-DRB1 contains a sequence for the shared epitope and is found to be linked with the occurrence of rheumatoid arthritis.

Antibodies like RF and anti-CCP are associated with the occurrence of rheumatoid arthritis [2]. Apart from the genetic cause, it has been documented that various other causes such as smoking, bacteria, endocrinology and reproductive and psychological factors can predispose to the occurrence of rheumatoid arthritis.

Epidemiology

Woman are found to be more prone to be affected by this condition than men. It has been estimated that this disease is prevalent in 1% of women and 0.4% of men and 3.6% of women and 1.7% of men have a lifetime risk of acquiring this disease. The highest incidence is among the individuals between 40 to 75 years of age and the ratio of occurrence of this disease between women and men is 2:1. Rheumatoid arthritis is more common in the northern Europe and Northern America, but less common in Asia and Africa.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of rheumatoid arthritis is complex and is not completely understood.

Initially, the external factors such as smoking, triggers an autoimmune response in susceptible individuals. This results in the hyperplasia of the cells in the synovial joint and activation of the endothelial cells. These are early events that later progresses into bone and cartilage destruction due to uncontrolled inflammation. The mononuclear phagocytes, CD4 T-cells, osteoclasts, fibroblasts and neutrophils play a major role in the development of symptoms while, the B-cells produce autoantibodies.

Moreover there is an abnormal production of inflammatory mediators, cytokines, chemokines and growth factors that result in the further deterioration of bones and cartilages. The inflammation and the abnormal proliferation of the synovia, otherwise known as the pannus, ultimately results in the destruction of cartilage, bones, blood vessels, tendons and ligaments.

Though only the articular structures are the primary sites involved, other structures are also affected as a result of this inflammation.

Prevention

Though rheumatoid arthritis cannot be prevented, because of its genetic influence. The disease can be easily managed by appropriate exercise and avoiding triggering factors such as smoking and infection [10].

Summary

Rheumatoid arthritis is an autoimmune disorder that presents itself as a chronic inflammatory condition. An external trigger such as smoking, drinking, trauma or infection can trigger the immune system resulting in this condition. Rheumatoid arthritis is characterized by synovial hypertrophy and chronic inflammation of the joints. There may be extraarticular manifestations of this condition.

Genetic predisposition for the occurrence of this disease is still a topic of debate. Small joints of the hands and feet are the most affected in this condition and symmetric polyarthritis is its classical presentation. Early intervention of the condition is mandatory to avoid further complications.

Patient Information

Rheumatoid arthritis is a chronic inflammatory condition that affects mainly the joints, though it can also affect other organs. Though the specific cause of the disease is not known, it can triggered by various factors such as smoking.

Treatment of rheumatoid arthritis must be tailored according to individual needs and is usually a combination of drug and non-drug therapies. Early intervention can prevent progression of the disease and can prevent further deterioration of the joints and other associated complications.

References

Article

  1. Lipsky PE. Harrison's Principles of Internal Medicine. In: Isselbacher KJ, Braunwald E, Fauci AS, et al.Rheumatoid arthritis. 17th ed. New York, NY: McGraw-Hill; 1994:1648-55.
  2. Barton A, Worthington J. Genetic susceptibility to rheumatoid arthritis: an emerging picture. Arthritis Rheum. Oct 15 2009;61(10):1441-6.
  3. van Venrooij WJ, van Beers JJ, Pruijn GJ. Anti-CCP antibodies: the past, the present and the future. Nat Rev Rheumatol. Jun 7 2011;7(7):391-8
  4. van der Heijde DM. Radiographic imaging: the ‘gold standard' for assessment of disease progression in rheumatoid arthritis. Rheumatology (Oxford). Jun 2000;39 suppl 1:9-16
  5. Lindhardsen J, Ahlehoff O, Gislason GH, et al. Risk of atrial fibrillation and stroke in rheumatoid arthritis: Danish nationwide cohort study. BMJ. 2012;344:e1257.
  6. Komano Y, Harigai M, Koike R, Sugiyama H, Ogawa J, Saito K. Pneumocystis jiroveci pneumonia in patients with rheumatoid arthritis treated with infliximab: a retrospective review and case-control study of 21 patients. Arthritis Rheum. Mar 15 2009;61(3):305-12
  7. Ahlmén M, Svensson B, Albertsson K, Forslind K, Hafström I. Influence of gender on assessments of disease activity and function in early rheumatoid arthritis in relation to radiographic joint damage. Ann Rheum Dis. Jan 2010;69(1):230-3.
  8. Bang H, Egerer K, Gauliard A, et al. Mutation and citrullination modifies vimentin to a novel autoantigen for rheumatoid arthritis. Arthritis Rheum. 2007;56(8):2503–11
  9. Luqmani R, Hennell S, Estrach C, Basher D, Birrell F, Bosworth A, et al. British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first 2 years). Rheumatology (Oxford). Apr 2009;48(4):436-9.
  10. Macedo AM, Oakley SP, Panayi GS, Kirkham BW. Functional and work outcomes improve in patients with rheumatoid arthritis who receive targeted, comprehensive occupational therapy. Arthritis Rheum. Nov 15 2009;61(11):1522-30.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!