Rheumatoid arthritis (RA) is a chronic inflammatory disorder that potentially affects many tissues and organs of the human body. Amongst the tissues that may become affected are: the skin, blood vessels, heart, lungs and muscles. However, the joints are the primary sites of infection and if left untreated it may results in the destruction of articular cartilage (Robbins, 2008, p.1237). This disease is a condition that affects the physical, societal and financial aspects of the patient's life (Croon et al, 2004).2. What is the aetiology of the injury?
The etiology of RA is unclear and many factors are suspected. Nevertheless, the most widely believed theory is that RA is caused by the contact of a genetically susceptible individual to an arthritogenic antigen that causes a breakdown of the immune system leading to a chronic autoimmune reaction. The continuing autoimmune reaction, activation of CD4+ helper T cells, and local inflammatory mediators are what ultimately destroys the affected tissues (Robbins, 2008, p.1239). Due to the disease distribution, it is thought that the infective agent involved must be ubiquitous and thus mycoplasma, Epstein-Barr virus, cytomegalovirus, parvovirus, or rubella virus might be implicated (Harrison’s, 2008, p.2084). Individuals with the class II MHC allele HLA-DR4 or HLA-DR1 have a higher risk of getting the disease, however twin concordance studies seem to show a strong environmental triggering role as well (Harrison’s, 2008, p.2083)3. How is it usually diagnosed?
There are no specific tests which determine RA. Rheumatoid Factor (RF) is found in 2/3 of adults with the disease, but it is not specific and RF can be found in a small population of healthy people. Aside from RA, SLE, Sjorgen’s syndrome, chronic liver disease, sarcoidosis, interstitial pulmonary fibrosis, infectious mononucleosis, hepatitis B, TB, leprosy, syphilis, subacute bacterial endocarditis, leishmaniasis, schistosomiasis, and malaria may cause a positive RF test (Harrison’s, 2008, p.2088). Antibodies to CCP may be tested, it is about as sensitive but a little more specific than RF. A normocytic, normochromic anemia is often detected in active RA, as is an elevated erythrocyte sedimentation rate. Synovial fluid analysis confirms the presence of inflammatory factors. Initial radiography usually doesn’t reveal disease, but later in the course, combined with characteristic patterns of symmetrical joint involvement the x-rays may support a diagnosis (Harrison’s, 2008, p.2088). Finally, there is a list of 10 diagnostic criteria and patients having 6 or more criteria are classified as diseased (Wasserman, 2011).4. What populations of people is it usually seen in?
Variation in sex, ethnicity and age is well known and accepted globally (Sarmiento-Monroy et al, 2012). The age group it affects is those that are mainly between 25-50 years of age (Anderson, 2012) with the most common development between the 4th and 5th decades of life. The incidence of the disease is slightly less in sub-saharan Africa and among Caribbean blacks (Harrison’s, 2008, p.2083). Smokers have an elevated risk and pregnancy tends to cause remission (Wasserman, 2011).5. What is the injuries prevalence in the general population?
The prevalence of RA is ~0.8% in the general population, is 3x more likely in women, and increases with age (Harrison’s, 2008, p.2083).6. Why is it important to do research on this injury?
Research into RA is important because there is still no identified etiological agent. Furthermore, patients tend to live 3-12 years less than non-diseased individuals due to accelerated cardiovascular disease (Wasserman, 2011). Furthermore, there is still no cure to the disease and a substantial number of people do not benefit from the current medications.7. Why is it interesting?
The disease is interesting for a variety of reasons. The interplay between genetics and environment is interesting, as is the still unknown aeteological basis of the disease. The diagnostic method is rather imprecise too. Archaeological evidence has shown that the disease has been with us since 1500 BC (Hart, 1976). It has been around for a very long time, and remarkably little is known about it.8. What forms of research are usually conducted on this injury and why?
The long-term nature of the disease lends itself to longitudinal studies. There is often correlational research, observational studies, and cohort studies employed.Body9. Present the reviews according to the organisation you have chosen.
10. Outline the research using summaries and paraphrases expressed in your own words.
Ng, B., Chu, A., and Khan, M.M (2012) conducted a cohort study through national databases to determine trends in drug prescribing and their effects on patients. Biological therapy use increased as did methotrexate use. Furthermore, the time from diagnosis to pharmacotherapy also decreased to 28 days. The use of disease modifying anti-rheumatic drugs, and biological therapies is an indicator of quality of care and it is believed that care quality increased in this time.
Prahalad, et al. (2013) was a genetic study investing if child onset and adult onset disease had a similar genetic basis. They found that similar loci, PTPN22, TRAF1/C5 STAT4 and TNFAIP3 loci in both adult and child onset of rheumatic favor. They found that TNFAIP3 is more pronounced in children than in adults with the disease. Ultimately the cumulative effect of these genes is what they believe leads to risk.
Yeoh, N., Burton, J.P., Suppish, P., Reid, G., Stebbings, S. (2013) looked to explore the influence of microbiota in RA. They found that alterations in the commensal flora, the bacteria that naturaly live in the body, may play a significant role in the development of the autoimmune reaction that leads to the disease.
Trieb, K., Machacek, P., Hofstaetter, S.G., Pantotopoulos, J., Wanivenhaus, A. (2013) reviewed the value of surgical techniques in the care of rheumatoid patients. The wrist is a commonly affected articulation in RA patients and this very quickly leads to a reduced quality of life. The authors found that patients had a high-satisfaction rate for a procedure called radio-lunate wrist arthrodesis, of 27 patients sampled, only 1 had poor results in both function and pain relief.
Yazici, Y., Simsek, I. (2013) conducted a review of the testing methods of RA and concluded just as their title says, that there is no further need to do research towards methodology of detecting remission and instead practitioners should just the tools available and that they’re comfortable using.11. Evaluate/analyse the quality of available research on this topic.
The research for all areas of RA tends to be very good. There are many different and varied areas to explore; there is adequate funding, and plenty of peer-reviewed source material. Furthermore, due to the worldwide prevalence of the disease, research articles come from all over the world.
Conclusion12. Summarise what you have written.
RA is a potentially devastating disease that has a major impact on quality of life. The aetiology is unknown but is suspected to be the result of an interplay between genetics and external pathogens causing an autoimmune reaction. Diagnosis is imprecise and mostly clinical, but is usually based on some combination of non-specific tests and radiography, dependent on the clinicians choice. The disease is more common in women than in men, and has a world wide prevalence. There are many potential treatment mechanisms ranging from NSAIDS and pain management, to disease modifying drugs such as methotrexate. Biological agents have been in use in recent years too, and their use has revolutionized therapy. Finally, in cases where there is substantial damage to the articulations, surgery can be performed to attempt to correct the defect.
13. Identify any issues and/or limitations within the research. One of the major limitations is in the small sample sizes for some of the research. Another frequent limitation is that confounding factors and comorbidities are rarely accounted for.
14. Indicate any further research which may be needed.
In the near future the focus should be on conducting research that could help in the identification of some of the remaining genetic variants that might be associated with condition and are yet to be uncovered. Further interesting research would focus on genetic pharmacotherapy.
Anderson et al, (2012). Rheumatoid Arthritis Disease Activity Measures: American
Croon et al, (2004). Predictive factors of work disability in rheumatoid arthritis: a
systemic literature review. Review. The EULAR Journal. Retrieved 7 April, 2013 from http://ard.bmj.com/content/63/11/1362.full
Hart, F.D. (1976). History of the treatment of rheumatoid arthritis. British Medical
Kumar, V., Abbas, A.K., Aster, J.C., Fausto, N. (2009). Diseases of the Immune System.
Robbins and Cotran Pathologic Basis of Disease (8th ed.) (pp. 183-258). New York: Saunder’s
Lipsky, P.E. (2008). Rheumatoid Arthritis. In S. Fauci, D. Kasper, D. Longo, E.
Braunwald, S. Hauser, J.L. Jameson, & J. Loscalzo (Eds.), Harrison’s Principles of Internal Medicine (17th ed.) (pp. 2083-2092). New York: McGraw Hill Medical
Ng, B., Chu, A., Khan, M.M. (2012). A retrospective cohort study: 10-year trend of
disease-modifying antirheumatic drugs and biological agents use in patients with rheumatoid arthritis at Veteran Affairs Medical Centers. BMJ Open Accesible Medical Research. doi:10.1136/bmjopen-2012-002468
Prahalad, S., et al. (2013). Susceptibility to childhood onset rheumatoid arthritis:
Investigation of a weighted genetic risk score that integrates cumulative effects of variants at five genetic loci. Arthriis & Rheumatism. DOI 10.1002/art.37913
Sarmiento-Monroy et al(2012). Cardiovascular Disease in Rheumatoid Arthritis: A
Systematic Literature Review in Latin America. Review Article. Retrieved 7 April, 2013 from http://www.hindawi.com/journals/arth/2012/371909/
Trieb, K., Machacek, P., Hofstaetter, S.G., Panotopolous, J., Wanivenhaus, A. (2012).
Radio-lunate arthrodesis in rheumatoid arthritis: outcome and techniques. Archives of Orthopedic Trauma Surgery. DOI 10.1007/s00402-013-1729-2
Wasserman, A.M. (2011). Diagnosis and management of rheumatoid arthritis. American
Family Physician 84(11). 1245-1252. Retrieved 9 April, 2013 from http://www.aafp.org/afp/2011/1201/p1245.html
Yazici, Y., Simsek, I. (2013). Tools for monitoring remission in rheumatoid arthritis: any
will do, let's just pick one and start measuring. Arthritis Research & Therapy 15(104). doi:10.1186/ar4139
Yeoh, N., Burton, P., Suppiah, P., Reid, G., Stebbings, S. (2013). The Role of the
Microbiome in Rheumatic Diseases. Current Rheumatological Reports 15(314). DOI 10.1007/s11926-012-0314-y