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A 79-year-old woman with late-stage rheumatoid arthritis comes for routine follow-up (Figures 97-1, 97-2, 97-3, and 97-4). She began having hand pain and stiffness approximately 40 years ago. She took nonprescription medications for pain for approximately 10 years before seeing a physician. She was diagnosed with rheumatoid arthritis on the basis of combination of clinical, laboratory, and radiograph findings. She was treated with prednisone and tried most of the disease-modifying agents as they became available; however, her disease progression continued. Approximately 10 years ago, she began having increased foot pain and difficulty walking. Today, she works with a multidisciplinary team to control pain and preserve hand function and independence.
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Rheumatoid arthritis (RA) is a progressive chronic illness that causes significant pain and disability. RA is a polyarticular inflammatory arthritis that causes symmetrical joint pain and swelling and typically involves the hands. Early recognition and treatment with nonbiologic and/or biologic disease-modifying antirheumatologic agents (DMARDs) can induce remission and preserve function.
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- RA is found in 0.8% of the adult population worldwide.1
- It is more than twice as common in women as compared to men (54 per 100,000 vs. 25 per 100,000).1
- Typical age of onset is 30 to 50 years.1
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- Genetic predisposition coupled with an autoimmune or infection-triggering incident.
- Synovial macrophages and fibroblasts proliferate, leading to increased lymphocytes and endothelial cells.
- Increased cellular material occludes small blood vessels, causing ischemia, neovascularization, and inflammatory reactions.
- Inflamed tissue grows irregularly, causing joint damage.
- Damage causes further release of cytokines, interleukins, proteases, and growth factors, resulting in more joint destruction and systemic complications including a higher risk for cardiovascular disease
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Genetic predisposition signified by a positive family history.
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The 2010 American College of Rheumatology/European League Against Rheumatism classification criteria uses a scoring system to designate patients as definite RA. A score of 6 or greater out of 10 meets criteria for definite RA.2
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- Joint involvement—1 large joint (0 ...