Rheumatoid Arthritis

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 Q1 (a) Rheumatoid arthritis (RA) is a chronic, progressive, inflammatory, systemic

autoimmune disease, affecting the joints with varying severity among patients (Bullock et al.,

2018). (b) The global prevalence of rheumatoid arthritis is about 1.4% for women, and 2.0% for

men. It occurs in around 1 in 1000 persons worldwide and most frequent in industrialized

countries. The disease affects people from all social strata, but its occurrence varies greatly from

region to region and country to country (Otón & Carmona, 2019). (c) The prevalence of

rheumatoid arthritis (RA) among adults in the United States is 9 per 100,000 persons. Among

persons aged 18-44 years, incidence rates range from 3 to 8 per 100,000 persons affecting an

estimated 6 to 8 million Americans (Lo et al., 2021).

Q2. (a) Stage I: Synovitis. Here, one may start having mild symptoms, including joint

pain and joint stiffness. This stage affects the hands and fingers, as well as the ankles and knees.

The immune system begins attacking the joint tissue, causing the synovial membrane to swell

and become inflamed. (b) Stage II: Pannus. Here, the continued inflammation leads to a thinning

of the cartilage. Cartilage helps provide some cushion for the bones and makes joint motion more

fluid. Without that cushion, joint pain and stiffness worsens. This also sets the stage for joint

damage and the bones begin to erode at the joint (Mupparapu et al., 2019).

(c) Stage III: Fibrous ankylosis. Ankylosis is a term for when bones start to fuse together

at a joint, causing lack of mobility. Here, the damaged joint area starts to fuse with a connective

fibrous tissue. This severely limit patient’s range of motion, which may make simple tasks more

difficult. The joints start to appear bent and crooked. (d) Stage IV: Bony ankylosis. Here, the

bones fuse together with actual bone tissue instead of a connective fibrous tissue. The pain and

the ability to move actually goes away. The joint is essentially gone, so the patients can’t bend or

flex the area making them unable to do some tasks and hobbies (Cheng et al., 2022).
 Q3. Rheumatoid arthritis is the joint disease that can be found in human body. It causes

inflammation throughout the body, primarily affecting the joints and soft tissues of the hands,

feet, and knees. Synovial inflammation and hyperplasia (“swelling”), autoantibody production

(rheumatoid factor and anti–citrullinated protein antibody [ACPA]), cartilage and bone

destruction and systemic features, including cardiovascular, pulmonary, psychological, and

skeletal disorders. This inflammation results in painful swelling, stiffness (joint pain), fatigue,

weight loss and limited range of motion in the joints (Iwamoto & Kawakami, 2019)

Porphyromonas gingivalis, a bacterium commonly detected in periodontitis, promotes the

endogenous production of recombinant human arginine deiminase 4 (PADI4), which induces

abnormal citrulline levels, promotes the conversion of arginine to citrulline, and ultimately

reduces tissue tolerance to citrulline peptides. It is an autoimmune (The body’s immune system

mistakenly produces antibodies against a specific protein called collagen) condition that affects

multiple organs including the heart and lungs, causing organ damage as well as damage to joints.

The disease can remain stable or progress over time affecting patient’s daily activities such as

dressing, showering or performing housework (Gupta et al., 2022).

Q4. Rheumatoid arthritis is a disease primarily of the synovial joints, but also in other

structures such as the eyes and CNS. The exact cause of RA remains unclear, with possible

triggers including genetic factors, viral infections and environmental exposures. As a result of

these triggers, antibodies (also known as immunoglobulins) develop against the body's own

tissues and are released into the bloodstream in response. These autoantibodies form part of the

pathophysiology of Rheumatoid arthritis since they directly or indirectly damage synovium

fibroblasts leading to collagen reduction, joint destruction and formation of lesions called

erosions blocking blood flow (Florescu et al., 2022).

 The therapeutic efficacy of B-cell depletion in RA demonstrates the impact of B-cell

activity on synovial inflammation and joint damage. IL-6 stimulates B cells to differentiate into

plasma cells to produce immunoglobulins. IL-6 induces B-cell differentiation and has been

shown to induce B-cell antibody production. IL-6 influences T-cell development by stimulating

the proliferation and differentiation of T lymphocytes into TH-17 cells which produce IL-17. In

murine models of autoimmune diseases in the presence of IL-6 and transforming growth factor

beta (TGF-b), T cells develop into Antibody production IL-6 B cell Macrophage Neutrophil T

cell. In the joints IL-6 induces pannus formation, osteoclast activation and mediates chronic

synovitis. In humans this pathway is driven by IL-6 in combination with IL-1b and IL-23 rather

than TGF-b (Ogata et al,. 2019).

Q5. The main symptoms of rheumatoid arthritis are pain weight loss, loss of appetite,

fever, fatigue (tiredness), weakness, swelling and stiffness in the affected joints. Most patients

first experience early morning joint stiffness which lasts for about one hour and joint pain that

worsens at night. Pain is another sensitive symptom; in fact, some kinds of pain can be severe

and difficult to manage. Other symptoms are dry eyes and chest pain. This is basically as a result

of inflammation (Henderson et al., 2021).

Q6. Physical examination may show rheumatoid nodules on the skin, or they may be

observed in other parts of the body such as the abdomen and spine. Rheumatoid nodule is a

group of small bumps under the skin that cannot be scraped off. They are more common in

women than men, particularly those that are at high risk for autoimmune diseases like

rheumatoid arthritis. They often appear in the form of a round or oval lesion with a central area

of raised panniculus and contains small blisters on the surface (Conforti et al., 2021).
 Q7. Risk factors are factors that increase the chance of developing an illness. (a)

Environmental factors have been found to be a risk factor for rheumatoid arthritis. It is believed

that certain factors in the environment, such as dust, smoking, and chemicals, may trigger the

release of auto-antibodies as well as specific cell populations called effector T cells. (b) Gene

markers in the blood of people who have Rheumatoid Arthritis, showed that some genes were

more likely to find arthritis than others. The genes involved were determined, looking at whether

they had different DNA sequences or otherwise differed in their genetic makeup. Proving genes

to be a risk factor (Cheng et al., 2022).

Q8. The Comorbidity for rheumatoid arthritis include inflammation of the heart and other

internal organs, lung disease, thyroid dysfunction and hearing loss. Some cancer types have been

found to co-exist with rheumatoid arthritis. Also, a progressive destruction of joints associated

with proliferation of osteoclast-like cells and deposition of collagen, leading to joint deformity,

pain concomitant diseases such as cancer, cardiovascular diseases and diabetes can also increase

prognosis and treatment intensity. Others are; osteoarthritis – occurs when protective cartilage

that cushions the ends of the bones wears down over time, psoriatic arthritis and ankylosing

spondylitis (Mouliou & Dardiotis, 2022).

Conclusion. Advanced Practice Nurses should learn about these patients’ experiences as

they develop additional knowledge and skills as a Nurse Practitioner. They should also

contribute to quality improvement efforts by implementing guidelines from provider

organizations such as the American College of Rheumatology. In order to optimize patient

outcomes, clinicians should understand the pathophysiology of rheumatoid arthritis as well as

how to manage common comorbidities. They should also be aware of the various treatments

options available for all stages of this disease and their attendant risks and benefits.
 References
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(2018). Rheumatoid arthritis: a brief overview of the treatment. Medical Principles and
Practice, 27(6), 501-507.
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Lo, J., Chan, L., & Flynn, S. (2021). A systematic review of the incidence, prevalence, costs, and
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