Carpal collapse in patients with rheumatoid arthritis

The inflammation of the wrist and carpal collapse play an important role in the deformity of the rheumatoid hand and leads to functional limitation. The aim of this study was to evaluate carpal collapse and related clinical variables in patients with rheumatoid arthritis (RA). Carpal height ratio (CHR) indicating the degree of carpal collapse was measured in 33 female RA patients with a mean age of 41.9±10.3 years and 30 female healthy control subjects with a mean age of 40.5±9.2 years. The normal range of the carpal collapse was defined in our study population and the incidence of carpal collapse was determined. The correlation between carpal collapse and clinical and laboratory variables including pain by visual analog scale, Ritchie articular index, erythrocyte sedimentation rate, C-reactive protein, health assessment questionnaire indicating functional status, and Larsen roentgenological evaluation were determined. Subgroup analyses were also performed in patients with and without carpal collapse. The mean disease duration of the patients was 12.4±5.5 years. The mean CHR index of the patients was significantly lower than in the control group (0.47±4.3 and 0.54±1.4 respectively). CHR <0.48 was defined as carpal collapse in our study group. Seventeen patients (51.5%) had carpal collapse in the patient group. None of the clinical or laboratory variables except levels of disease duration and Larsen score was correlated with carpal collapse as represented by CHR. The best related clinical variable with carpal collapse was found as duration of disease. The mean duration of disease and the Larsen score were significantly higher in patients with carpal collapse than those without collapse. Other clinical parameters and functional status were similar between patients with and without carpal collapse. In conclusion, although various clinical parameters and functional disability in patients with RA may not be correlated with radiological malalignment, the carpal collapse may be more common in RA than is generally recognized.     

Characteristics and medical management of patients with rheumatoid arthritis and ankylosing spondylitis

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are chronic, progressive, systemic inflammatory rheumatic diseases that lead to serious disability. The objective of this study was to investigate the demographic and clinical characteristics of the patients with RA and AS who were treated in tertiary hospitals in Turkey and to analyze their current medical management. A total of 562 RA and 216 AS patients were evaluated. The mean age of RA patients was 52.1 ± 12.6 years. The female to male ratio was 3.7:1. Of the RA patients, 72.2% had positive rheumatoid factor (RF), 62.9% had high C-reactive protein, and 75.2% had radiological erosion. The ratio of patients with Disease Activity Score (DAS) 28 >3.2 was 73.9% and of those with Health Assessment Questionnaire (HAQ) ≥1.5 was 20.9%. There was a statistically significant increase in RF positivity and HAQ scores in the group with higher DAS 28 score. Frequency of extraarticular manifestations was 22.4%. The ratio of the patients receiving disease modifying antirheumatic drugs (DMARD) was 93.1%, and 6.9% of the patients were using anti-tumor necrosis factor (TNF) blocking agents. In AS, the mean age of the patients was 38.1 ± 10.6, and the female to male ratio was 1:2.5. The time elapsed between the first symptom and diagnosis was 4.3 years. The ratio of peripheral joint involvement was 29.4%. Major histocompatibility complex, class I, B 27 was investigated in 31.1% of patients and the rate of positivity was 91%. In 52.4% of the patients, Bath AS Disease Activity Index (BASDAI) was ≥4. The erythrocyte sedimentation rate, Bath AS Functional Index, and peripheral involvement were significantly higher in the group with BASDAI ≥4. Frequency of extraarticular involvement was 21.2% in AS patients. In the treatment schedule, 77.5% of AS patients were receiving sulphasalazine, 15% methotrexate, and 9.9% anti-TNF agents. Despite widespread use of DMARD, we observed high disease activity in more than half of the RA and AS patients. These results may be due to relatively insufficient usage of anti-TNF agents in our patients and therefore these results mostly reflect the traditional treatments. In conclusion, analysis of disease characteristics will inform us about the disease severity and activity in RA and AS patients and could help in selecting candidate patients for biological treatments.     

Anxiety and depression in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) mostly follows a painful, progressively disabling course, and individuals with RA experience more psychological distress than healthy individuals. The objective of the present study is to examine the prevalences of accompanying anxiety and depression in RA cases. The study included 82 RA cases and 41 age- and sex-matched healthy volunteers as the control group. Psychiatric examinations of all cases of the patient and control groups were performed according to DSM-IV criteria. Hamilton Anxiety Scale or Hamilton Depression Scale was applied to those who were found to have anxiety or depression. Total prevalence of anxiety, depression, and mixed anxiety-depressive disorder was found to be 70.8% (n=58) in the patient group and 7.3% (n=3) in the control group, and the difference was significant (p<0.001). Of the RA patients, 41.5% (n=34) was found to have depression, 13.4% (n=11) anxiety, and 15.9% (n=13) mixed anxiety-depressive disorder. The disease duration in patients with anxiety was shorter than the RA patient with depression (p<0.05). The disease duration was positively correlated with the degree of depression and negatively correlated with the degree of anxiety (r=0.341, p<0.05; r=−0.642, p<0.05, respectively). The results of our study suggest that prevalences of anxiety and mainly depression, increase in RA cases. When the clinical picture in RA cases becomes complicated with anxiety or depression, some problems at patients’ adaptation and response to treatment may be possible. RA cases should be monitored for accompanying anxiety or depression during follow-up.     

Hearing difficulties are common in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is well known to affect many different organ systems. Previous work suggests that this includes the auditory system and that measures of hearing may be related to indices of RA disease activity. The aims of this study were to determine whether hearing loss in young subjects with rheumatoid arthritis is greater than would be expected in the normal population and whether disease activity or duration correlate with hearing levels. About 55 patients (less than 50 years old) with RA were sampled from a secondary-care-level population. Pure-tone audiograms, transient evoked otoacoustic emissions (TEOAEs) and rheumatological assessment including disease duration and the DAS28 disease activity score were carried out. Subjective hearing loss was a common symptom with a prevalence of 29.6% (95% CI 17.8–42.2%). The prevalence of conductive hearing loss was 1.9% (95% CI 0.3–9.7%)). Subjects with RA had worse hearing than expected at low and middle frequencies (250 Hz to 2 kHz). TEOAEs were absent in 15 of 84 (18%, 95% CI 11–27%) normal ears. No relationship was demonstrated between hearing thresholds and markers of disease activity or other rheumatological parameters. Hearing loss is common in young people with RA and should be sought by clinicians caring for this patient population. TEOAEs are absent in a higher proportion of patients than expected, and this may be a marker of early asymptomatic hearing loss. It may be conductive or sensorineural and may take any configuration, including low-frequency loss.     

Accelerated atherosclerosis in pre-menopausal female patients with rheumatoid arthritis

Increased mortality due to cardiovascular disease in rheumatoid arthritis (RA) patients was reported. Using B-mode ultrasonography we compared intima-media thickness (IMT) and plaque occurrence (indicators of asymptomatic atherosclerosis) in the carotid arteries in 70 pre-menopausal, female RA patients and 40 controls. Correlations with different risk factors were evaluated. The IMT values were higher in RA patients (0.59 mm vs. 0.47 mm, P < 0.0001) and they had more plaques (P = 0.023). In RA patients higher levels of sensitive CRP (P < 0.0001), ICAM (P < 0.0001), VCAM (P < 0.0001), IL-2 (P < 0.001), IL-6 (P = 0.009) and TNF-alfa (P < 0.01) were found. A correlation between IMT and triglycerides (P = 0.018) and a negative correlation between IMT and HDL cholesterol (P = 0.037) were found. With multiple regression analysis the association between IMT and sensitive CRP (P = 0.027) and presence of plaques and apolipoprotein B (P = 0.028) was established. The results indicate that even pre-menopausal, female RA patients had accelerated atherosclerosis. Chronic systemic inflammation may play an important role in atherogenesis.     

Predictors of functional disability in patients with rheumatoid arthritis

Objective . Using the World Health Organization's classification system of the consequences of disease, this study sought to examine the impact of physical and psychological impairment variables, beyond that contributed by social, demographic, and disease variables, on the functional disability of a rheumatoid arthritis (RA) sample. Data collected during an acute episode were used to predict concurrent and future disability status. Method . A secondary data analysis of 85 adults hospitalized for exacerbations in arthritis was undertaken. Disability was assessed with the Health Assessment Questionnaire. Physical impairment was measured with the Keitel Function Test and Pain Analog Scales, and psychological impairment was measured with the Center for Epidemiologic Studies Depression Scale and the Perceived Self-Efficacy Scale for People with Arthritis. Results . Our findings indicated that physical impairment, demographic, and disease variables accounted for 64% of the explained variance in disability during the concurrent episode. Psychological impairment as well as demographic and disease variables accounted for 49% of the explained variance in future disability status. Conclusion . The combined influence of demographic characteristics and the consequences of the pathology of RA experienced as physical and psychological impairments contributed differentially to disability during concurrent and future time periods.     

Factors affecting drug treatment compliance in patients with rheumatoid arthritis

We prospectively examined 100 rheumatoid arthritis (RA) patients to calculate drug compliance rates, characteristics of compliant and non-compliant patients, and changes in compliance over time. Three assessments were obtained over a one-year follow–up. Detailed drug history of RA and for concomitant disease was queried. Sedimentation rate, C-reactive protein, and rheumatoid factor values, Ritchie articular index, morning stiffness, and health assessment questionnaire were evaluated. Twenty-six patients (30.2%) were consistently compliant and 10 patients (11.6%) were consistently non-compliant. Older age was associated with a greater likelihood of compliance. Comparison of compliant and non-compliant groups revealed no statistically significant difference in distribution of gender, disease duration, and total number of pills taken for RA and/or total number of pills taken for any reason. In conclusion, compliance to drugs in RA patients is a common problem. Clinical and laboratory activity of RA had less influence on drug compliance. Older age is associated with a greater likelihood of compliance.     

Analysis of direct medical and nonmedical costs for care of rheumatoid arthritis patients using the large cohort database,IORRA

Abstract

Objectives Our goal was to determine the annual direct medical and nonmedical costs for the care of patients with rheumatoid arthritis (RA) using data from a large cohort database in Japan.

Methods Direct medical costs [out of pocket to hospitals and pharmacies and for complementary and alternative medicine (CAM)] and nonmedical costs (caregiving, transportation, self-help devices, house modifications) were determined for RA patients who were participants in the Institute of Rheumatology, Rheumatoid Arthritis (IORRA) studies conducted in October 2007 and April 2008. Correlations between these costs and RA disease activity, disability level, and quality of life (QOL) were assessed.

Results Data were analyzed from 5,204 and 5,265 RA patients in October 2007 and April 2008, respectively. The annual direct medical costs were JPY132,000 [out of pocket to hospital (US$1 = JPY90 in 2007)], JPY84,000 (out of pocket to pharmacy), and JPY146,000 (CAM). Annual direct nonmedical costs were JPY105,000 (caregiving), JPY22,000 (transportation), JPY30,000 (self-help devices), and JPY188,000 (house modifications). Based on the utilization rate for each cost component, the annual medical and nonmedical costs for each RA patient were JPY262,136 and JPY61,441, respectively. Costs increased with increasing RA disease activity and disability level or worsening quality of life (QOL).

Conclusions Based on the IORRA database, patients with RA bear heavy economic burdens that increase as the disease is exacerbated. The results also suggest that the increase in medical and nonmedical costs may be ameliorated by the proactive control of disease activity.     

Body image in patients with rheumatoid arthritis

Abstract

We investigated body image in patients with rheumatoid arthritis (RA), correlating it with self-esteem, function, and quality of life. Forty-three RA patients and 39 control individuals from the community between 18 and 70 years of age and paired for gender, age, and body mass index (BMI) were evaluated. Patients were assessed for body image [Body Dysmorphic Disorder Examination (BDDE)], self-esteem (Rosenberg Self-Esteem Scale), function [Health Assessment Questionnaire (HAQ)] and quality of life [Short Form-36 (SF-36)]. The RA group had a mean age of 51.6 years, BMI 26.01, and disease duration 12.2 years. Most participants were categorized in functional class I. The BDDE score of the RA group (51.8) was significantly higher than in the control group (22.6) (p < 0.001). Rosenberg Self-Esteem Scale, HAQ and some SF-36 subscales were worse in the RA group than in the control group. These scores had a direct correlation with body image scores (p < 0.001). Individuals with RA had a worse body image than individuals without this condition. Body image was directly correlated with self-esteem, function, and quality of life.     

Hand disability and related variables in patients with rheumatoid arthritis

Objective: To carry out a cross-sectional study of patients with rheumatoid arthritis (RA) for hand disability, articular damage and to define their relation with demographic, laboratory and clinical parameters. Methods: The study included 105 RA patients with a mean age of 49.4 years. Demographic parameters of the patients were recorded. Clinical parameters including disease duration, duration of morning stiffness, pain assessed by visual analog scale, Ritchie Articular Index, grip strength, lateral, tip and three-fingered pinch, and laboratory parameters comprising C-reactive protein, erythrocyte sedimentation rate and rheumatoid factor were evaluated in all patients. The Rheumatoid Arthritis Articular Damage (RAAD) score was used to assess the irreversible articular damage and deformities of the hand. Hand disability was assessed by the special hand disability index of Standford Health Assessment Questionnaire (HAQ). Results: Hand disabilities of various levels were detected in 81% of the patients. Disease duration, grip strength, pinch measurements, clinical and laboratory activity parameters were strongly correlated with hand disability (p<0.01). Hand disability was more related to disease activity parameters than articular damage (p<0.01 and p<0.05, respectively). Grip strength and pinch measurements were the most related parameters with hand disability. The disability scores were significantly higher in female patients (p<0.01). The RAAD score was correlated with disease duration and grip strength (p<0.01). The clinical and laboratory parameters and seropositivity were not correlated with articular damage assessed by RAAD score (p>0.05). Conclusion: Our data suggest that grip strength and pinch measurements seem to be the most related variables with hand disability and articular damage. Therefore, grip strength and pinch measurement should be included in the evaluation and follow-up of the patients with RA in hand rehabilitation units.     

An 8-year follow-up study of pulmonary function in patients with rheumatoid arthritis

To evaluate longitudinal alterations in pulmonary function, 63 patients suffering from rheumatoid arthritis (RA) with previously reported reduced pulmonary diffusing capacity were re-examined in an 8-year follow-up study. Cross-sectional examination revealed normal values for vital capacity (VC), forced expiratory volume in 1 s (FEV1) and diffusing capacity per litre alveolar volume (KCO). Total diffusing capacity (D_LCO; P>0.0001), maximal expiratory flow at 75% of expired VC (MEF 75; P>0.0001) and MEF 50 (P>0.01) were decreased. Longitudinal evaluation revealed unchanged MEF50, MEF75 and FEV1, whereas increases in D_LCO (P>0.0001) and KCO (P>0.0001) and a decrease in VC (P>0.05) were found. The longitudinal changes in diffusing capacity were unrelated to patient age, disease duration, disease activity in the study period or pulmonary function at the first examination. Thus, in patients suffering from RA, the most prominent functional pulmonary abnormality, decreased diffusing capacity, appeared to improve in the course of time, despite a slight decrease in VC and continued articular disease activity.     

Coordinated individual education with an arthritis passport for patients with rheumatoid arthritis

Objective . To evaluate the effects of a program for individual education in combination with the use of an arthritis passport. Methods . We studied 3 groups of patients with rheumatoid arthritis. The first experimental group received educational materials and followed the program under the guidance of their regular providers of health care whose activities were coordinated through arthritis passports. The second experimental group only received education materials; the control group received only usual care. Results . There were no effects on self-efficacy expectations, knowledge, health status, or behavior in either experimental group. Opinions of general practitioners, physiotherapists, and visiting nurses concerning the arthritis passport were very positive, but rheumatologists' opinions were not. Opinions on coordination of care were more positive among the physiotherapists of the experimental group. Conclusions . Individual education for patients with rheumatoid arthritis by health care providers during routine consultations, as implemented in this program, had no effect on self-efficacy expectations, knowledge, health status, or health behavior. Likewise, the distribution of educational materials by itself without the involvement of health care providers had no effect. The use of the arthritis passport improved coordination of care, especially for physiotherapists.     

Atypical mycobacteriosis in two patients with rheumatoid arthritis

We report two cases of rheumatoid arthritis (RA) with atypical mycobacteriosis. Opportunistic infections are critical complications for rheumatic diseases. The use of steroids or immunosuppressants may increase the risk of opportunistic infections. However, these reports are rare in that they demonstrate atypical mycobacterial infections as complications of RA, even though no immunosuppressive agents were used. We discuss the characteristics of atypical mycobacterial infections of the lung in RA. Received: January 22, 2001 / Accepted: July 21, 2001     

Measuring sensation in the feet of patients with rheumatoid arthritis

Objectives: (1) To determine the test–retest reliability of monofilaments pressed against the skin as a method of assessing sensation in the feet of patients with rheumatoid arthritis (RA) and in controls using two grades of monofilaments; (2) to determine the stability of findings over 6 weeks; and (3) to calculate initial estimates of frequency of loss of sensation and to investigate its association with disease status. Method: Clinical examination of the feet was undertaken in 51 patients with RA and 20 normal controls. Six sites on each foot were tested twice with both 10 g and 3 g research grade monofilaments and this was repeated after 6 weeks. Disease status was measured using the Disease Activity Score, the Health Assessment Questionnaire, visual analogue scales of pain, and the acute phase response using erythrocyte sedimentation rate and plasma viscosity. Results: Reproducibility was high for 3 g (kappa = 0.73) and 10 g (kappa = 0.75) monofilaments. The best balance between sensitivity (58.8%) and specificity (87.5%) for distinguishing the feet of patients from the feet of controls was using the 3 g filament and defining reduced protective sensation as being sensitive to less than 11 of 12 applications. Using this definition, the prevalence of reduced protective sensation is 59% in the patient group and 12.5% in the feet of controls. There was some variation in sensation over 6 weeks in the patient group, but this was not related to measures of clinical status. Conclusion: The use of monofilaments in assessing sensation levels in the RA foot is repeatable and reproducible over a six‐week period and requires only a short time to perform. The frequency of reduced sensation in the feet of patients with RA was greater than previously reported. Future studies should assess relationships with disease duration and inflammatory status. Copyright © 2006 John Wiley & Sons, Ltd.     

Antibodies to rheumatoid arthritis nuclear antigen (RANA) in Japanese patients with rheumatoid arthritis

Summary We studied antibodies to rheumatoid arthritis nuclear antigen (RANA) by the Ouchterlony method in 0.5% agarose plates, using soluble antigen extracted with 0.25 M sucrose solution from cultured Raji cells. Anti-RANA antibody was found in sera from 24 to 40 (60%) patients with rheumatoid arthritis (RA), from 4 of 20 (20%) patients with systemic lupus erythematosus (SLE), and from 2 of 30 (7%) healthy controls. When sucrose extracts from BJAB, Ramos, and JM cells were used as the cellular antigens, no anti-RANA precipitin lines were detected. Indirect immunofluorescence study, using Raji cells or human B lymphocytes transformed by EB virus as substrate tissues, demonstrated anti-RANA antibody as fine speckled nuclear staining. Although RA patients with positive anti-RANA antibody usually had high titers of anti-Epstein-Barr nuclear antigen (EBNA) and anti-viral capsid antigen (VCA) IgG antibodies, the Wilcoxon ranks sum test showed no close statistical correlation between the presence of anti-RANA antibodies and the titers of anti-EBNA or anti-VCA (IgG) antibodies. These data showed that the incidence of positivity of anti-RANA antibodies in Japanese RA patients is almost the same as that in American and European RA patients.     

Systematic review of NSAID-induced adverse reactions in patients with rheumatoid arthritis in Japan

Abstract

A systematic review of randomized controlled clinical trials of nonsteroidal antiinflammatory drugs (NSAIDs) in rheumatoid arthritis (RA) patients was conducted to evaluate the risk of NSAID-induced adverse reactions. Double-blind, randomized, controlled trials with 6-week treatments for RA patients were included in the study. The endpoints for the analysis included any adverse reactions, digestive adverse reactions, and upper gastrointestinal (GI) adverse reactions. A fixed-effect model was used for estimation of the risk. Time-to-event analysis of the incidence of adverse reactions was also conducted. A total of 28 trials was included for the analysis, and a total of 30 NSAIDs were used in the trials. The proportion of patients who experienced any adverse reaction was as follows: piroxicam 18.9% (3 trials), diclofenac 18.8% (4 trials), indomethacin 22.1% (14 trials), and aspirin 25.0% (4 trials). The proportion of patients who experienced digestive adverse reactions was as follows: piroxicam 10.2%, diclofenac 10.6%, indomethacin 13.1%, and aspirin 14.1%. Most withdrawals due to adverse reaction occurred during the first 3 weeks after administration of the NSAID. Although the risk of NSAID-induced adverse reaction was different from drug to drug, the risk of adverse reaction was clinically significant.     

Cardiovascular disease in patients with rheumatoid arthritis

The risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) is 1.5–2-fold higher than age- and sex-matched individuals from the general population. This excess risk is attributed to the systemic chronic inflammation which is a hallmark of RA. Challenges to optimizing CV risk management in RA include the need for improved methods to predict CV risk, and defining the target risk factor(s) to reduce CV risk. Lessons learned from RA studies can also inform CV risk prevention in the general population, where inflammation also has an important role in the pathogenesis of atherosclerosis.     

Heart rate variability in patients with rheumatoid arthritis

Heart rate variability (HRV) is a useful tool for the detection of sympathetic-parasympathetic balance in the autonomic nervous system. Autonomic nervous system involvement in patients with rheumatoid arthritis (RA) has rarely been studied and has shown conflicting results. Our purpose was to determine if HRV showed changes in patients with RA in comparison with the normal population. Short-term analysis of HRV was performed for time-domain frequency in 42 patients with RA and 44 matched controls. In this analysis, patients displayed lower standard deviation of the mean than healthy subjects ( P<0.0001). Patients tended to display higher pNN50 and root-mean-square of successive difference values than did healthy subjects, but these differences were not statistically significant (P >0.05). In frequency domain analysis, the spectral measures of HRV showed reduced high-frequency (HF) values and an higher low-frequency (LF) values; as a result, the ratio between low and high frequencies (LF/HF), representative of sympathovagal modulation, was significantly increased (P=0.001, P=0.012, and P=0.003, respectively). Our data suggest an increase in sympathetic control of the heart rate in patients with RA. This increased sympathetic activity could play a key role in the development of ventricular tachyarrhythmias in RA and may be related to the higher incidence of sudden death in this disorder.     

Mud compress therapy for the hands of patients with rheumatoid arthritis

Objective The aim of this study was to evaluate the efficacy of home treatment with mud compresses for the hands of patients with rheumatoid arthritis (RA).Methods Forty-five patients suffering from RA were enrolled in a double-blind, randomized, controlled study. Twenty-two were treated with true mud compresses (treatment group) and 23 were treated with attenuated mud compresses (control group). The compresses were applied in the patients homes five times a week during a 3-week period. Patients were assessed four times: at baseline, upon completion of the 3-week treatment period, 1 month after the treatment, and 3 months after conclusion of the treatment period. Positive response was defined as reductions of 30% or more in the number of tender and swollen joints, 20% or more in physician global assessment of disease activity, and 20% or more in patient global assessment of the severity of joint pain.Results In the treatment group, significant reductions in the number of swollen and tender joints and patients global assessments of pain severity was observed at all post-treatment assessments. Significant improvement in the scores of physician global assessment was seen at the end of therapy and 1 month later. In the control group, no improvement in the number of swollen and tender joints or physician global assessment was found in any post-treatment evaluation. However, a significant reduction in patient global assessment of joint pain severity was reported at the end of therapy and 3 months after concluding treatment.Conclusion Treatment with mud compresses relieves pain affecting the hands and reduces the number of swollen and tender joints in the hands of patients suffering from RA. This treatment can augment conventional medical therapy in these patients.     

The relationship between disease activity and depression in Egyptian patients with rheumatoid arthritis

Aim of the workTo estimate the prevalence of depression and its relationship with disease activity parameters in Egyptian patients with RA.Patients and methodsA cross sectional study was conducted on 170 patients with RA. The following values were assessed for each patient: erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), swollen and tender joint counts (SJC and TJC), disease activity score 28 (DAS28), health assessment questionnaire score (HAQ), visual analogue scale (VAS) of pain and hospital anxiety and depression scale-depression subscale (HADS-D).ResultsThe prevalence of depression was 15.29% (26 RA patients). In the depressed RA patients, positive significant correlations were found between HADS-D score and age, disease duration, HAQ score, VAS, DAS28 score and CRP. However, no significant correlation was found between HADS-D score and ESR, number of swollen and tender joints. No significant difference (P > 0.05) was found between depressed male and female patients with RA.ConclusionPatients with RA and co-morbid depression have worse health outcomes. RA cases should be monitored for accompanying depression during follow-up. The identification and treatment of depression in RA paramount to the overall management of RA.