I. Concept
Rheumatoid arthritis (RA) is a chronic, symmetrical, polyarthritic autoimmune disease characterized by the involvement of small joints such as the wrist, metacarpophalangeal and proximal interphalangeal joints, and may be accompanied by extra-articular systemic damage. The pathological basis is synovitis, and joint deformity may occur when the cartilage and bone of the joints are involved. the age of onset of RA is 20-40 years old, with 45 years old being the most common, and the ratio of men to women is 1:2-3.
Diagnostic criteria
In 1987, the American College of Rheumatology revised the classification criteria for rheumatoid arthritis.
(1) Morning stiffness lasting at least one hour per day;
(2) Swelling of 3 or more joints;
(3) Swelling of the wrist, metacarpophalangeal, and proximal interphalangeal joints;
(4) Symmetrical joint swelling;
(5) rheumatoid subcutaneous nodules;
(6) Positive rheumatoid factor (titer >1:20);
(7) Hand x-ray changes (at least osteoporosis and narrowing of the joint space).
Items 1-4 above must persist for at least 6 weeks. Those with 4 or more items can be diagnosed with rheumatoid arthritis.
III. Staging criteria
(I) Stage I (early stage) 1X-ray film without destructive changes. ж2X present film may have osteoporosis.
Stage II (middle stage) 1X-ray osteoporosis with or without mild subchondral bone destruction, and mild cartilage destruction. ж2 Restricted joint movement, but no joint deformation. ж3 Muscle atrophy near the affected joint. ж4 Extra-articular soft tissue lesions, such as rheumatoid nodules and tenosynovitis.
Stage III (severe stage) 1 X-rays with cartilage and bone destruction in addition to osteoporosis. ж2 Joint deformation, such as subluxation, ulnar deviation or joint hyperextension, but without osteofibrosis or bony ankylosis. ж3 Extensive muscle atrophy. 4 Extra-articular soft tissue lesions, such as rheumatoid nodules and tenosynovitis may be present.
Stage IV (end-stage) 1 Bone fibrosis or bony ankylosis. ж2 Possession of the criteria in stage III.
Note: ж indicates that must be available in a certain period of the classification.
(B) concise X-ray staging criteria
Stage Ⅰ: there is a swelling shadow of the soft tissue around the joint and osteoporosis of the joint end
Stage II: The joint space becomes narrow due to cartilage destruction
Stage III: Chisel-like destructive changes on the joint surface
Stage IV: joint subluxation and fibrous and bony ankylosis after joint destruction
IV. Functional classification
Grade I: competent in all activities of daily life (including self-care, occupational and non-occupational activities)
Grade II: Self-care and work, but limited non-occupational activities
Grade III: Self-care of life but limited in occupational and non-occupational activities
Grade IV: unable to take care of themselves and incapable of working.
Note: Self-care activities include dressing, eating, bathing. tidying and toileting. Non-occupational refers to recreation and/or leisure, and occupational refers to work, schooling, and homemaking.
V. Routine observation items
Record the patient’s general conditions such as gender, age, disease duration, joint manifestations and extra-articular manifestations (rheumatoid nodules, concurrent vasculitis, Sjogren’s syndrome, etc.) in patients with RA and arthritis/pain, and refer to the observation items recommended by the American College of Rheumatology for the core indicators of regression observation (activity).
1.Time of morning stiffness (hand) in minutes
2.Number of joints with pressure pain
3, the number of swollen joints (38 joints, foreign reports all 68 joints can be simplified to 28 joints, Wilske that the tarsal joint with bone erosion is a poor prognosis indicators []. We also added 10 tarsophalangeal joints to 38 joints, and examined in detail the swelling, pain and pressure changes of distal interphalangeal joints, proximal interphalangeal joints, metacarpophalangeal joints, wrists, elbows, knees, shoulders, tarsophalangeal joints, etc.)
4.Patients’ evaluation of joint pain (take 10cm visual acuity control table method)
5.The patient’s comprehensive evaluation of disease activity (after the patient reads the AIMS, see Appendix 1 for details, he/she will use the 10cm visual acuity chart to mark his/her condition).
6. The physician’s comprehensive evaluation of disease activity (using a 10-cm visual acuity control chart, according to the consultation
The total impression of the patient was observed in the room)
7.Patients’ evaluation of physical function (using Stanford University health assessment questions, see Appendix 2 for details, and calculate the average value)
8, walking time (from 25 feet (7, 62 meters) at the general gait to the recording time)
9.Button test (take a common blouse with five buttons and five button holes, use one hand to button the five buttons and then unbutton the other hand can be fixed lapel, record time in seconds)
10, grip strength (left and right hand each for three times, take the average)
11.The presence and location of rheumatoid nodules, number
12, system damage
13.X-ray hand and foot (once a year, compared with the previous one)
Determine the patient’s x-ray staging, functional classification.
Six, auxiliary examination
1.General items: blood routine, urine routine, stool routine, liver function, kidney function, blood sedimentation, C-reactive protein, rheumatoid factor.
C-reactive protein, rheumatoid factor, ANA profile, ENA peptide, immunoglobulin, serum protein electrophoresis, hand and foot X-ray, ECG, chest X-ray, abdominal ultrasound
2.With or without IISS: salivary flow rate, parotid gland imaging, lip gland biopsy if necessary, and ophthalmology Schrimer test, BUT, corneal fluorescence staining
3. For hematologic abnormalities, such as hemolytic anemia or dystrophic anemia, bone aspiration, iron staining, Coombs test, Rous test, reticulocytes, etc. should be checked. If there are white blood cell and platelet abnormalities, bone aspiration and coagulation should be checked.
4.Psychoneurological symptoms such as headache, convulsions, pathological signs, psychiatric symptoms, perceptual disorders, etc. should be investigated.
Brain CT, MIR, EEG, lumbar puncture, etc.
5.If pericardial effusion, myocardial damage, arrhythmia, etc. are suspected, cardiac ultrasound and ambulatory electrocardiogram should be investigated.
6.If chest X-ray shows pulmonary fibrosis, high resolution CT of lung should be checked.
7, review items: monthly review of routine blood, urine routine, blood sedimentation, C-reactive protein, rheumatoid factor, every three months review of liver function, kidney function, every six months review of hand and foot x-ray
Seven, rheumatoid arthritis treatment routine
(A) early application of slow-acting anti-rheumatic drugs: combined chemotherapy program
1, the condition is mainly joint swelling and pain in the acute phase ESR, CRP normal, immunoglobulin, serum protein electrophoresis normal, no II SS.