Immunological Investigations

A Journal of Molecular and Cellular Immunology

ISSN: 0882-0139 (Print) 1532-4311 (Online) Journal homepage: https://www.tandfonline.com/loi/iimm20

Rheumatoid arthritis: A single-center Egyptian

experience

B. R Sakr, M. M Elfishawi, M. H ElArousy, A. K Hatw, A. N AbdulKarim, A. B

Tammam, A. N Kotp, M. E Hamed, I. E Genedy, E. D. El Desouky & Z. O Nawito

To cite this article: B. R Sakr, M. M Elfishawi, M. H ElArousy, A. K Hatw, A. N AbdulKarim,

A. B Tammam, A. N Kotp, M. E Hamed, I. E Genedy, E. D. El Desouky & Z. O Nawito (2018)
Rheumatoid arthritis: A single-center Egyptian experience, Immunological Investigations, 47:3,
293-302, DOI: 10.1080/08820139.2018.1425700

To link to this article: https://doi.org/10.1080/08820139.2018.1425700

Published online: 16 Jan 2018.

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IMMUNOLOGICAL INVESTIGATIONS
2018, VOL. 47, NO. 3, 293–302
https://doi.org/10.1080/08820139.2018.1425700

Rheumatoid arthritis: A single-center Egyptian experience

B. R Sakra, M. M Elfishawia, M. H ElArousyc, A. K Hatwc, A. N AbdulKarimc, A. B Tammamc,
A. N Kotpc, M. E Hamedc, I. E Genedyc, E. D. El Desoukyb, and Z. O Nawitoa
a
Rheumatology and Rehabilitation Department, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt;
b
Epidemiology and Biostatistics Department, National Cancer Institute, Cairo University, Cairo, Egypt;
c
Medical students, faculty of medicine, Cairo University, Cairo, Egypt

ABSTRACT KEYWORDS
Objective: Demonstration of rheumatoid arthritis (RA) characteristics Egypt; epidemiology;
in a large cohort of Egyptian patients. rheumatoid arthritis
Methods: Retrospective analysis of data of 3219 RA patients attend-
ing the Rheumatology outpatient clinic, Kasr Alainy Hospital, Cairo
University; from January 1995 till December 2015.
Results: Mean age at disease onset was 36.1 ±13.4 years; 2774 (84%)
were females and mean disease duration was 12.9 ±7.9 years.
Regarding number of joint affected at disease onset; polyarticular
pattern was found in 77.1%, pattern of joint involvement; combined
small and large joints involvement was in 83.2%, subcutaneous
nodules in 14.2%, interstitial lung disease in 0.3%, secondary
Sjogren’s syndrome in 10.5%, hand bony erosions at diagnosis in
20.6%. Rheumatoid factor was positive in 52%.
There was annual increase in the newly diagnosed cases
(P = 0.017) reflecting increase in patients’ awareness and improve-
ment of medical service, also annual increase in: mean age of onset
(P < 0.001) reflecting changes in health measures, also in cases with
monoarticular or oligoarticular patterns at disease onset (P = 0.02,
0.01 respectively) reflecting earlier diagnosis of patients and in
patients with small joint involvement (P = 0.001) with a significant
decline in: polyarticular pattern (P = 0.001), combined small and large
joint affection (P < 0.001), and number of cases with hand bony
erosions (P = 0.01) denoting earlier diagnosis, tight disease control.
Conclusion: We found a female predominance, younger age at dis-
ease onset, lower frequency of extra articular manifestations, more
frequent polyarticular pattern at disease onset and less erosive dis-
ease, denoting changing referral patterns, earlier diagnosis, improved
disease control in Egyptian RA patients over 2 decades.
Abbreviations: SNs: Subcutaneous nodules; 2ry SS: 2ry Sjogren’s
syndrome; ILD: Interstitial lung disease; ACPA: Anti-cyclic citrullinated
peptide antibodies; DMARDs: Disease modifying anti-rheumatic
drugs.

Introduction
Rheumatoid arthritis (RA) is a common autoimmune systemic inflammatory disease
with an overall prevalence of 0.5%-1% (Aletaha et al., 2010). The interaction of

CONTACT B. R Sakr Sakrbasma@kasralainy.edu.eg Rheumatology and Rehabilitation Dept, Kasr Al-Ainy hospital,
Kasr Al-Aini St, Cairo, Egypt
This article has been republished with minor changes. These changes do not impact the academic content of the article.
Supplemental data for this article can be accessed here.
© 2018 Taylor & Francis
294 B. R. SAKR ET AL.

genetic and environmental factors results in a cascade of immune reactions (Aletaha

et al., 2010). A number of extra-articular manifestations and comorbidities are
present in RA patients, which result in increased mortality (Gibofsky, 2014). RA is
seen more often in females with an overall female to male ratio of 2:3 (Doran et al.,
2002).
Many risk factors are associated with an increased risk of RA, ranging from infections
and vaccinations to hormonal risk factors, such as breastfeeding and number of pregnan-
cies, as well as lifestyle-related factors, such as diet, smoking, and obesity. In addition,
studies have suggested an association between RA and periodontitis (Gerlag et al., 2016).
Previous studies suggested that RA patients of different ethnic origins may exhibit
different manifestations and outcomes, which enables the development of different tar-
geted treatment modalities (Almeida Mdo et al., 2014). In our country, there are few
reports about disease manifestations and characteristics of RA especially among large
Egyptian cohort along a long term period of follow up; the present study was designed to
describe the demographic, clinical characteristics of patients with RA attending a tertiary
Egyptian medical institute over a period of 20 years.

Material and methods

Study design
This was a retrospective, observational, single center, Egyptian study.

Data source
The data source for the current study was the registration follow-up files of a cohort of
3219 RA patients aged ≥18 years who fulfilled the 1987 ACR revised criteria for diagnosis
of RA (Arnett et al., 1988), attending the outpatient clinic of Rheumatology Department in
Kasr Alainy Hospital, Cairo University from 1995 to 2015. This tertiary medical center
receives around 20,000 case/year with different rheumatic diseases (14,000 case/year as
new cases and 6000 case/year as follow-up patients). The protocol was reviewed and
approved by the Research Ethics Committee (REC) (ethics approval umber N-27–2017).
We did not rely on the new 2010 ACR/EULAR criteria because the studied RA Egyptian
patients were diagnosed from 1995 and we wanted to compare them with RA cases from
previous studies which also relied on the older criteria.

Data collection
Demographic characteristics included: {age at disease onset and age at initial visit which is
the age of diagnosis, sex, residence, marital status, consanguinity, family history of
autoimmune disease, and whether smoker or not}.

– Clinical data included: {disease duration, number of joints affected; in the form of
polyarticular, oligoarticular, or monoarticular at disease onset, types of joint involve-
ment at disease onset as small, large joints, or combined small and large joints}
 IMMUNOLOGICAL INVESTIGATIONS 295

– Presence of extra-articular manifestations (e.g., subcutaneous nodules (SNs), 2ry

Sjogren’s syndrome (2ry SS), skin vasculitis and interstitial lung disease (ILD) were
also documented)
– Serological tests as rheumatoid factor (qualitative rheumatoid factor) and anti-cyclic
citrullinated peptide antibodies (ACPA) were included.
– Plain radiographs of hands and wrists were assessed for the presence or absence of
bony erosions.
– History of drug intake was also reported {disease modifying anti-rheumatic drugs
(DMARDs); methotrexate, leflunomide, antimalarial drugs, and gold therapy and
glucocorticoids.
– History of comorbidities, e.g., hypertension, diabetes.

Procedures to improve case finding

In order to minimize selection bias, patients who missed regular monthly follow up for
more than 5 years were excluded from the study.

Statistical methods
Data management and statistical analysis were performed using Statistical Package for
Social Sciences (SPSS) version 21. Numerical data were summarized using means and
standard deviations. Categorical data were summarized as frequency and percentages.
Time trend analysis was done using linear regression model. All P values are two-sided; P
value ≤ 0.05 were considered significant.

Results
Demographic characteristics
A total of 3219 RA patients were identified in a 20 years’ interval (1995–2015). Their mean
age at disease onset ranged from 18 to 61 with a mean of 36.1 ± 13.4 years. Disease
duration ranged from 0.5 to 53 years with mean of 12.9 ± 7.9 years. Around 24.9% of
patients with subcutaneous nodules were smokers while only 16.4% were nonsmokers
(P = 0.001), moreover 34.5% of patients having hand erosions at diagnosis were smokers
vs 30.5% nonsmokers (P = 0.225), also RF was positive in 66.9% of smokers and negative
in 64% (P = 0.369). Demographic data of our patients are shown in Table 1, while Table 2
describes their disease characteristics.

Drug intake by the studied RA population

Methotrexate was received by 2668 (82.8%) patients, hydroxyl chloroquine by 1641(51%),
leflunomide by 606 (18.8%), Gold therapy by 55(1.7%), and glucocorticoids by1452 (45%)
patients. None of the patients were using biological therapy.
296 B. R. SAKR ET AL.

Table 1. Demographic data of the studied RA population.

Demographic data Frequency (N (%))
Age at initial visit, diagnosis (years) 20–75 (40.5 ± 12.6)
Range [Mean± SD]
Sex (Females) 2774 (84%)
Residency
Great Cairo 2179 (67.8%)
Delta, Lower Egypt 146 (4.5%)
Upper Egypt 241 (7.5%)
Missing 653(20.2%)
Consanguinity 163(5%)
Smokers 303(9.4%)
Marital status
Single 346 (10.7%)
Married 2624 (81.6%)
Divorced 43 (1.3%)
Missing 84 (2.6%)
Widow 122 (3.8%)
Co-morbidities
Hypertension 91 (2.8%)
Diabetes 266 (8.2%)
Positive family history of autoimmune diseases 243 (7.5%)

Figure 1. Variations in newly diagnosed RA patients.

Variations in RA characteristics during the past 20 years

There was a significant statistical annual increase by 0.13% in the newly diagnosed cases
(P = 0.017) throughout the studied period (Figure 1), while there was a significant annual
decrement by 0.4% in female % (P = 0.02). Also, we found a significant annual increase in
the mean age of disease onset by 0.2 year (P < 0.001) (Figure 2).
Concerning the number of joint affection at RA onset in our patients; there was a
statistically significant annual increase in monoarticular and oligoarticular presenta-
tions at disease onsetby 0.1% and 0.9% (P = 0.02, 0.01 respectively). On the contrary,
polyarticular pattern showed significant annual decline by 1.2% (P = 0.001)
(Figure 3).
Regarding types of joints affected at disease onset, there was an annual decrement in
combined small and large joint affection by 0.9% (P < 0.001), while small joint affection
showed a steady annual increment by 0.6% (P = 0.001) (Figure 4).
 IMMUNOLOGICAL INVESTIGATIONS 297

Figure 2. Variations in sex distribution of RA patients.

Figure 3. Variations in pattern of joint involvement.

Figure 4. Variations in type of joint involvement.

298 B. R. SAKR ET AL.

Presence of 2ry Sjogren’s syndrome increased annually by 0.5% (P = 0.03), while

subcutaneous nodules decreased annually by 0.4% (P = 0.068).
Annual decline in the number of cases with bony hand erosions at diagnosis by 0.5%
was detected (P = 0.01). Females were more prone to have erosions (33% versus 29% in
males); although this was not statistically significant (P = 0.39). Also, RF positive cases
were significantly higher in the erosive group (34% versus 28% seronegative) (P = 0.019).

Discussion
To the best of our knowledge, this is the first and largest retrospective study describing
demographic and disease characteristics of RA among a large cohort of Egyptian patients
over a long period of time (20 years).
Our results showed a higher incidence of RA in women (5.2:1), this was comparable to
that reported in Western population (4–5:1) (Kvien et al., 2006) and in Algeria (5.9:1)
(Slimani et al., 2014) but was lower than reported in the Brazilian population (8:1)
(Almeida Mdo et al., 2014).
Females represented 84% of the sample size matching with that observed in the
COMORA (COMOrbidities in Rheumatoid Arthritis) study (81.7%) conducted on 4586
RA patients from 17 different countries (Dougados et al., 2014), also in agreement with a
study conducted by Alian et al, 2017 on 1142 RA Egyptian patients (Monocentric study)
where females represented (79.6%) of cases (Alian et al., 2017).
The mean age of our RA patients at disease onset was 36.1 ±13.4 years and at initial
visit where it was diagnosed was 40.5 ±12.6 years which was comparable to that men-
tioned by Imanaka et al (Imanaka et al., 1997) where it was (37.5 ±14.1 and 42.6 ±14.3,
respectively). While it was lower than that reported in other populations, e.g., Omani RA
patients (44.5 ±14.5 ys) (Al-Temimi, 2010), Algerian (50.1 ±14.5 ys) (Slimani et al., 2014),
Brazilian (47.5 ±11.03 ys) (Almeida Mdo et al., 2014), and that reported in the COMORA
study (56 ±13 ys) (Dougados et al., 2014).
The mean age of our RA patients at disease onset was 36.1 ±13.4 years and at initial
visit where it was diagnosed was 40.5 ±12.6 years, showing that there was time delay
between age of onset and diagnosis which may be attributed to the fact that patients
sought medical advice from primary care physicians or other specialists such as orthope-
dic surgeons, rather than consulting a rheumatologist from the outset. A lack of awareness
of the need to see a rheumatologist from the patient and the primary care physician may
therefore limit early diagnosis of RA. This was also the case in the United Arab of
Emirates (Zafar et al., 2012), this could be overcomed by increasing patients’ awareness
and by anticipation of awareness programs and public campaigns.
Only 9.4% of our patients were smokers which were lower than that reported in the
COMORA study (13.2%) (Dougados et al., 2014); this can be explained by the community
traditions in revulsion of cigarette smoking among females who represented the vast
majority of our patients. 24.9% of patients with subcutaneous nodules were smokers
while only 16.4% were nonsmokers (P = 0.001), this is in agreement with a study on
USA RA patients where Saag KG et al (Saag et al., 1997) reported that Pack cigarette
smoking was associated with subcutaneous nodules (P = 0.051), also this was in line with
Nyhäll-Wåhlin et al (Nyhäll-Wåhlin et al., 2006) who stated that in Sweden RA patients
smoking was associated with rheumatoid nodules (P < 0.001), moreover 34.5% of patients
 IMMUNOLOGICAL INVESTIGATIONS 299

having hand erosions at diagnosis were smokers vs 30.5% nonsmokers (P = 0.225), this is
in line with Yin et al (Yin et al., 2017) who stated that there was no association between
smoking status with the presence of radiographic erosions (P = 0.66).
Regarding comorbidities, 8.2% of patients were diabetics and 2.8% had hypertension
which appear to be lower than frequencies observed in the general Egyptian population
(15.5% for diabetes, 26.3% for hypertension) (Ashour et al., 1995; Hegazi et al., 2015), also
this is lower than frequencies reported by Alian et al, 2017 (Alian et al., 2017) where 32.2%
of the Egyptian RA patients recruited in that study were hypertensive and 20.1% were
diabetic, again our frequency was lower than that reported by Al-Bishri et al, 2013 (Al-
Bishri et al., 2013) in a study conducted on 340 RA patients where 31% of patients were
diabetic and 36% had hypertension, this may be explained by the high percentage of
corticosteroids intake among the patients of the latter 2 studies (87.1% and 80.8%,
respectively), while it was only 45% in our patients, we could not discuss these comorbid-
ities in relation to cardiovascular complications of RA despite its importance in Egyptian
RA patients (Elshereef et al., 2015) due to shortage of data in the registry files regarding
this point which is one of the limitations we faced. In addition, the association between
RA and periodontitis could not be assessed due to lack of documented data regarding this
aspect in the registry files.
The main reported extra-articular manifestations in our RA patients were SNs (14.2%)
and 2ry SS (10.5%), which is lower than other populations, e.g., in the Brazilian population
{SNs (19.4%) and 2ry SS (46.9%)} (Almeida Mdo et al., 2014), in Turkish patients (18.1%
for SNs) (Calguneri et al., 2006), in the United Arab of Emirates (2ry SS 28%) (Badsha
et al., 2008) and in Omani patients (2ry SS 24.4%). ILD was reported in 0.8% of our RA
patients, which was lower than that reported in Saudi Arabian RA patients (2.7%) (Al-
Bishri et al., 2013) and Omani RA patients (3%) (Al-Temimi, 2010); this may be attributed
to our previous relying on the less accurate conventional radiography for diagnosis of ILD
due to high expenses of high resolution CT chest.
Compared to other countries, Egyptian patients seem to have less erosive disease
(20.6%) at disease diagnosis vs. 68.1% in Algeria (Slimani et al., 2014), 62.2% in Brazil
(Almeida Mdo et al., 2014), 55.2% in the United Arab Emirates (Badsha et al., 2008), and
42% in Kuwaiti patients (Al-Salem and Al-Awadhi, 2004) denoting earlier diagnosis and
the effect of anticipation of support groups, awareness programs, and public campaigns
similar to efforts anticipated in the United Arab of Emirates (Zafar et al., 2012).
Around 52% of patients were positive for RF which was close to the Brazilian
population (49.2%) (Almeida Mdo et al., 2014; Da Mota et al, 2010), while it was
less than Kuwaiti, Omani, Saudi Arabian, and Sweden patients, where it was 60%, 76%,
and 73%, respectively (Al-Bishri et al., 2013; Al-Salem and Al-Awadhi, 2004; Al-
Temimi, 2010; Hallert et al., 2014).
Methotrexate was the most commonly used DMARD; where it was received by 82.8%
RA patients while it was in the Saudi Arabian (74.4%) (Al-Bishri et al., 2013), Algerian
patients (72.2%) (Slimani et al., 2014), and in the COMORA study (88.6%) (Dougados
et al., 2014). None of our patients were on biologic therapy that could be attributed to the
financial problems in our country; making treatment with conventional DMARDs com-
pulsory although the rate of biologic use in clinical practice is rising to treat moderate to
severe RA that has not responded to conventional DMARDs .
300 B. R. SAKR ET AL.

In the present study, time trend analysis revealed a significant annual increase by 0.13%
in the newly diagnosed RA cases (P = 0.017) which may reflect increase in patients’
medical awareness and improvement of medical service in our country during the last
20 years.
We detected a significant annual decrement by 0.4% in female RA patients (P = 0.02)
which was less than that recorded in a study done on 446 RA patients from Olmsted
County, Minnesota where there was a modest increase in women from 1995 to 2007 by
2.5% (P = 0.02) (Myasoedova et al., 2010).
Our study revealed a significant annual increase in the mean age of disease onset by
0.2 year (P < 0.001). Concordantly, in a study conducted on 566 Japanese patients from
1960 to 1990; the age of onset increased significantly from 37.5 to 46.9 years. This increase
may reflect changes in health measures (e.g., increase in life span and change in socio-
economic status) (Imanaka et al., 1997).
Polyarticular pattern of joint affection at disease onset was the most commonly detected
(80.3%) among our RA patients who were in concordance with that reported in literature
(Hecht et al., 2015), but it showed significant decline annually. While there was a statistically
significant annual increase in both monoarticular and oligoarticular presentations which may
be explained by the earlier diagnosis of arthritis patients in the last decade.
An interesting finding in our data was the steady annual decline in number of cases with
bony hand erosions at diagnosis by 0.5% (P = 0.01) denoting earlier diagnosis and more tight
disease control and anticipation of support groups, awareness programs, and public cam-
paigns similar to efforts anticipated in the United Arab of Emirates (Zafar et al., 2012).
In our study, there was no statistical difference between males and females regarding
the presence of hand erosions [33% of the studied RA females (n = 2774) had erosions,
while 29% of males had erosions (P = 0.39)], which was statistically comparable with
results of the quantitative standard monitoring of patients with RA (QUEST-RA) program
which was established to include 6004 RA patients from 70 sites in 25 countries where
women had erosions more often than men (P = 0.36) (Sokka et al., 2009). Also, number of
RF positive cases was significantly higher in the erosive group which was in agreement
with previous studies (Hecht et al., 2015; Van Steenbergen et al., 2014).
Our study has several limitations: first, this is a retrospective study where shortage of some
important data documented in the registry files was a major obstacle in our research, second;
patients were included using the 1987 ACR criteria for RA diagnosis instead of the new 2010
ACR/EULAR criteria, this is because we studied patients diagnosed from 1995 and we wanted
to compare RA Egyptian patients with RA cases from previous studies which also relied on the
older criteria. The third limitation was that ACPA test was done for only 269 (8.3%) patients
due to financial causes. Also although cardiovascular disease is an important comorbidity
(Elshereef et al., 2015) we could not document its percentage or correlate it with other
comorbidities as DM, hypertension due to lack of data in the registry files regarding this
point. Furthermore, the association between RA and periodontitis could not be assessed due
to lack of documented data regarding this aspect in the registry files.
The changing referral patterns and change in awareness of the public and primary care
physicians/providers about RA (Zafar et al., 2012) is one of the most important factors
that influenced our research.
 IMMUNOLOGICAL INVESTIGATIONS 301

Conclusion
The present study describes RA characteristics in a tertiary referral hospital, carried on a
large cohort of Egyptian patients over a long period of time (2 decades). We found a
female predominance, younger age at disease onset, lower frequency of extra-articular
manifestations, more frequent polyarticular pattern at disease onset and less erosive
disease.
This 20 year follow-up cohort has demonstrated that during a period of changing
referral patterns and earlier disease recognition, earlier diagnosis, improved disease con-
trol, and fewer signs of disease progression (i.e., erosions) are found in Egyptian RA
patients. Some conclusions about the cultural and ethnic comparisons would be important
as well.

Ethical approval
This article does not contain any studies with human participants or animals performed by any of
the authors.

References
Al-Bishri J, Attar S, Bassuni N, et al. (2013). Comorbidity profile among patients with rheumatoid
arthritis and the impact on prescriptions trend. Clin Med Insights Arthritis Musculoskelet
Disord, 6, 11–18.
Aletaha D, Neogi T, Silman AJ, et al. (2010). Rheumatoid arthritis classification criteria: an
American College of Rheumatology/European League Against Rheumatism collaborative initia-
tive. Arthritis Rheum, 62, 2569–2578.
Alian SM, Zaghlol RS, Khalil SS, et al. (2017). Rheumatoid arthritis severity index and its relation to
comorbidity in Egyptian rheumatoid arthritis patients. Int J Adv Res, 5, 1443–1451.
Almeida Mdo S, Almeida JV, Bertolo MB. (2014). Demographic and clinical features of patients
with rheumatoid arthritis in Piaui, Brazil-evaluation of 98 patients. Rev Bras Reumatol, 54, 360–
365.
Al-Salem IH, Al-Awadhi AM. (2004). The expression of rheumatoid arthritis in Kuwaiti patients in
an outpatient hospital-based practice. Med Princ Pract, 13, 47–50.
Al-Temimi F. (2010). The spectrum of rheumatoid arthritis in patients attending rheumatology
clinic in Nizwa Hospital-Oman. Oman Med J, 25, 184–189.
Arnett FC, Edworthy SM, Bloch DA, et al. (1988). The American Rheumatism Association 1987
revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum, 31, 315–324.
Ashour Z, Ibrahim MM, Appel LJ, et al. (1995). The Egyptian National Hypertension Project
(NHP). Design and rationale. The NHP investigative team. Hypertension, 26, 880–885.
Badsha H, Kong KO, Tak PP. (2008). Rheumatoid arthritis in the United Arab Emirates. Clin
Rheumatol, 27, 739–742.
Calguneri M, Ureten K, Akif Ozturk M, et al. (2006). Extra-articular manifestations of rheumatoid
arthritis: results of a university hospital of 526 patients in Turkey. Clin Exp Rheumatol, 24, 305–
308.
Da Mota LM, Dos Santos Neto LL, Burlingame R, et al. (2010). Laboratory characteristics of a
cohort of patients with early rheumatoid arthritis. Rev Bras Reumatol, 50, 375–388.
Doran MF, Pond GR, Crowson CS, et al. (2002). Trends in incidence and mortality in rheumatoid
arthritis in Rochester, Minnesota, over a forty-year period. Arthritis Rheum, 46, 625–631.
Dougados M, Soubrier M, Antunez A, et al. (2014). Prevalence of comorbidities in rheumatoid
arthritis and evaluation of their monitoring: results of an international, cross-sectional study
(COMORA). Ann Rheum Dis, 73, 62–68.
302 B. R. SAKR ET AL.

Elshereef RR, Darwish A, Ali A, et al. (2015). Asymptomatic atherosclerosis in egyptian rheumatoid
arthritis patients and its relation to disease activity. Int J Rheumatol, 2015, 381931.
Gerlag DM, Norris JM, Tak PP. (2016). Towards prevention of autoantibody-positive rheumatoid
arthritis: fromlifestyle modification to preventive treatment. Rheumatology (Oxford), 55, 607–
614.
Gibofsky A. (2014). Overview of epidemiology, pathophysiology, and diagnosis of rheumatoid
arthriti: A synopsis. Am J Manag Care, 20, S128–35.
Hallert E, Husberg M, Kalkan A, et al. (2014). Early rheumatoid arthritis 6 years after diagnosis is
still associated with high direct costs and increasing loss of productivity: the Swedish TIRA
project. Scand J Rheumatol, 43, 177–183.
Hecht C, Englbrecht M, Rech J, et al. (2015). Additive effect of anti-citrullinated protein antibodies
and rheumatoid factor on bone erosions in patients with RA. Ann Rheum Dis, 74, 2151–2156.
Hegazi R, El-Gamal M, Abdel-Hady N, Hamdy O. (2015). Epidemiology of and risk factors for type
2 diabetes in Egypt. Ann Glob Health, 81, 814–820.
Imanaka T, Shichikawa K, Inoue K, et al. (1997). Increase in age at onset of rheumatoid arthritis in
Japan over a 30 year period. Ann Rheum Dis, 56, 313–316.
Kvien TK, Uhlig T, Ødegård S, Heiberg MS. (2006). Epidemiological aspects of rheumatoid
arthritis: the sex ratio. Ann N Y Acad Sci, 1069, 212–222.
Myasoedova E, Crowson CS, Kremers HM, et al. (2010). Is the incidence of rheumatoid arthritis
rising?: results from Olmsted County, Minnesota, 1955-2007. Arthritis Rheum, 62, 1576–1582.
Nyhäll-Wåhlin BM, Jacobsson LT, Petersson IF, Turesson C. (2006). BARFOT study group.
Smoking is a strong risk factor for rheumatoid nodules in early rheumatoid arthritis. Ann
Rheum Dis, 65, 601–606.
Saag KG, Cerhan JR, Kolluri S, et al. (1997). Cigarette smoking and rheumatoid arthritis severity.
Ann Rheum Dis, 56, 463–469.
Slimani S, Abbas A, Ben Ammar A, et al. (2014). Characteristics of rheumatoid arthritis in Algeria: a
multicenter study. Rheumatol Int, 34, 1235–1239.
Sokka T, Toloza S, Cutolo M, et al. (2009). Women, men, and rheumatoid arthritis: analyses of
disease activity, disease characteristics, and treatments in the QUEST-RA study. Arthritis Res
Ther, 11, R7.
Van Steenbergen HW, Ajeganova S, Forslind K, et al. (2014). The effects of rheumatoid factor and
anticitrullinated peptide antibodies on bone erosions in rheumatoid arthritis. Ann Rheum Dis,
74, 2151–2156.
Yin J, He D, Jiang L, et al. (2017). Influence of cigarette smoking on rheumatoid arthritis risk in the
han chinese population. Front Med (Lausanne), 4, 76.
Zafar S, Badsha H, Mofti A, et al. (2012). Efforts to increase public awareness may result in more
timely diagnosis of rheumatoid arthritis. Clin Rheumatol, 18, 279–282.