Purdue Agr Ability November 13,                                       1
2015.
 >>  Thank you all for joining
us today and we will plan to get
started with our formal
presentation in just a moment.
 >>  Well, good morning to all
of you and welcome to the Agr
Ability Webinar series.  My name
is Paul Jones and I manage the
project that is headquartered
here at the university.  Our
session today is on
understanding Rheumatoid
Arthritis and our presenter is
Dr. Randall Reed.  Before we get
started with our actual
presentation just a few basic
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have any comments or questions                                        2
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some type of ability.  Every                                          3
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there.  At this point I'm going
to turn things over to Dr. Reed
and he will give the body of the
presentation, and then again we
will be back at the end with our
poll questions and with
questions and answers.  Dr. Reed
currently practices at
rheumatology PC in Indianapolis
and have a relationship with
university health as well.  His
appointments include assistant
professorships in medicine and
pediatrics and board certified
for medicine and rheumatology
and pediatrics and he has
specialties in these areas.  At
this point I will deactivate my
camera and microphone and --
 >>  Hello.  I appreciate being
asked to lead this discussion on
Rheumatoid Arthritis today and
we're going to talk about
Rheumatoid Arthritis, how it's
different from other forms of
arthritis, the symptoms and the
treatments and feel free to ask
any questions along the way.  So
arthritis is a general term
meaning joint problems, and it
affects about 60 million
Americans.  It's only second to
heart disease in causing
disability in this country and                                        4
the costs are quite high.  The
U.S. costs are over $80 billion
and that is not only treatment
costs and evaluation, but loss
wages.  We see arthritis more
commonly in women than men, and
it does limit everyday activity
for millions of Americans.  So
there are hundreds of different
types of arthritis.  The most
common arthritis that people are
familiar with is osteoarthritis
and degenerative type and from
wear and tear and more common as
we get older.  Rheumatoid
Arthritis of course is arthritis
due to inflammation in the
joints and we will talk more
about that.  Gout is a form of
inflammatory arthritis that
tends to occur intermittently
and caused by crystals in the
joints and soft tissues and
causes debilitating attacks that
may last a week or two and clear
but it requires treatment,
treatment with medications to
lower the gout levels.
Psoriatic arthritis developed in
ten, 15% of people will develop
that type.  People with lupus
can have arthritis.  Septic is
infection of the joint and comes
from some other place in the
body and the infection spreads
through the body.  Lyme
arthritis is caused by infection
carried by deer ticks and
they're quite small, nearly
impossible to see with the naked
eye, and it's often seen in
certain regions where it's more
prevalent.  The next type is
inflammation of the spine and
CPPD is similar to gout except
it's calcium crystals that
deposit in the joints and then
there's other conditions where
there is inflammation of blood
vessels that can lead to                                              5
arthritis as well but today
we're focusing on Rheumatoid
Arthritis.  Now, Rheumatoid
Arthritis has about a prevalence
of 1% in the U.S. and 2 million
people are affected by this
condition and women out number
men in this and occurs in the
30's through 50's but children
with develop Rheumatoid
Arthritis.  We see many patients
develop Rheumatoid Arthritis
even in their 60's and 70's and
it's a chronic disorder that
causes inflammation primarily in
the joints but can affect other
organ systems and most commonly
the side effects in the skin,
the eyes and the heart and the
glands and it's a systemic
process and not isolated to the
joints, so when we think about -
arthritis our first thing is if
it's in the joints or a
mechanical degenerative process,
so this slide here compares the
normal knee to a knee with
Rheumatoid Arthritis or a knee
with osteoarthritis and I am
trying to get a pointer up here,
so the normal knee has nice
smooth cartilage on the surfaces
that touch each other, and the
joint capsule is thin, the light
pink material there.  Just
inside is the synovial membrane
and with the joint and there is
small amount of fluid in the
joint.  In Rheumatoid Arthritis
what happens is the this
thickens and becomes inflamed
and you will get thickening of
the joint capsule and you will
start having inflammatory cells
inside the synovial cavity and
can lead to cartilage damage.
Now compare that to
osteoarthritis where the lining
doesn't thicken to any great
degree.  The joint capsule is                                         6
fairly normal but you get
cartilage loss and we don't know
what leads to that and get these
spots in the joint and regular
surfaces and occasionally new
bone formation with bone spurs,
but the osteoarthritis joint
doesn't have inflammation cells
in it to any great degree.  So
what exactly is happening in the
joint with Rheumatoid Arthritis?
Well, it's the immune system
that is basically attacking
proteins in the joint.  It's
attacking proteins in the lining
which is then leading to
inflammation of the joint and
that leads to destruction of the
cartilage and then the bone.  So
one question is why do people
get Rheumatoid Arthritis?
What's the root cause of this
condition?  And the actual
epidemiology of the condition is
unknown.  There is a genetic
disposition of it and families
with Rheumatoid Arthritis are at
increased risk for developing
that condition.  There are
certain ethnic populations that
we see it in a greater frequency
and certain Native American
tribes.  There is a genetic
marker with some patients with
Rheumatoid Arthritis and which
puts them at a higher risk for
disease and lots of interest of
looking into environmental
exposures, things that can start
the whole process and bacteria
or things in the diet that may
set things off, but nobody has
been able to identify a
causative organism or exposure.
We know that cigarette smoking
actually increases the risk in
patients and stopping smoking
can reduce that risk.  There
maybe a role of hormones in the
development of Rheumatoid                                             7
Arthritis.  Of course we see the
condition more in women than men
so perhaps that estrogen
exposure has a role and just our
immune system in general puts us
at risk for some patients of
developing Rheumatoid Arthritis
so what are the symptoms?  Well,
this slide describes symptoms
that we see in all forms of
inflammatory arthritis and pain
and swelling in the joints and
it's usually visible.  In
Rheumatoid Arthritis it's a
symmetric condition so the left
side looks like the right side
of the body and the involvement
is symmetric to one side of the
body and another.  Morning
arthritis is a symptom of this
and stiffness is disabling for
an hour or more in the morning
and unable to make a fist and
these are the subcutaneous
nodules under the skin and
commonly on the extensor
surfaces like the elbow or
sometimes around the ankle and
Achilles tendon but sometimes on
the bottom of the feet and some
times they're painful and
sometimes not and larger stages
and joint deformity and of
inflammation and fatigue,
sometimes low grade fever, low
energy.  Some people lose
appetites but fatigue is a
common symptom of chronic
inflammation so morning symptoms
are in Rheumatoid Arthritis
waking up stuff, puffy swollen
joints and many of the symptoms
improve as the day goes on but
not completely clears and this
demonstrates the Rheumatoid
Arthritis and you can see in the
wrist here there is bulging in
that wrist area as well as the
left wrist.  You will see
swelling, particularly in the                                         8
first row of knuckles here and
then the second row of knuckles
is another prominent area of
Rheumatoid Arthritis.  Curiously
the knuckles -- the joints
closest to the nails are
generally unaffected by
Rheumatoid Arthritis.  In this
photo it looks like there maybe
swelling in this joint, but that
probably is more of
osteoarthritis changes.  If I
could examine the hand it would
be hard and bony and these
joints are soft and squishy.
All right.  And then later
stages of the Rheumatoid
Arthritis condition leads to
joint deformities so people will
get this sort of splaying of the
fingers to the pinkie side of
the hand and call it ulnar
deviation and the bone on that
side of the arm, and then you
get progressive thickening of
the synovium and leads to this
thickness all along the knuckles
there.  These fingers you can
see are getting angular changes
and call them swan neck
deformities and changes in
Rheumatoid Arthritis.  It's our
hope as doctors in 2015 we don't
see many people with these
changes.  We count on our
primary care colleagues and
other colleagues to catch things
before it gets to this point.
This is a picture of a
rheumatoid nodule.  It's hard to
tell but it's this lump right
here and that is on someone's
elbow.  Many times they're
symptomatic when they lean on a
table or chair and those can be
surgically removed if causing
symptoms and most of the time
they're relatively symptomatic
so we will move on to a
diagnosis of Rheumatoid                                               9
Arthritis and much is based on
the history that the patient
describes going back to the
symptoms that we discussed
patients will come in and
describe stiffness in the
morning, inability to function
for an hour or longer because of
the stiffness and pain, puffy
swollen joints, fatigue is often
seen.  Sometimes nodules are
present in the presentation and
there are different ways
Rheumatoid Arthritis can start
in patients.  Most patients will
start with a fairly symmetric
onset of multiple joints
involving the hands and the feet
most commonly, but almost any
joint can be involved, and
that's probably the majority of
the time patients have a fairly
rapid onset of joint symptoms.
Some people have more additive
presentation and one joint that
bothers them for a while, may
quiet down, but then another
joint bothers them and more than
one at a time and a fairly
typical pattern of this
arthritis.  There is a small
subset of folks with
intermittent arthritis and have
severe pain and then goes away
and then occurs in another joint
days later and that is happening
and different patterns how it
presents and viral infections
and acute arthritis that can
look like Rheumatoid Arthritis
and those can be quite disabling
as well, but they're self
limited, meaning they get better
on their own.  There is a virus
that affects children usually in
the preschool years that causes
fisk disease and arthritis in
adults and parvo disease and
when evaluating these patients
the length of time the symptoms                                      10
are present is important in
distinguishing from the acute
process from something
developing into a chronic
process so we reserve diagnosing
that until eight weeks after the
symptoms are present and moving
on to the blood testing.  Of
course there are two markers of
Rheumatoid Arthritis in the
blood, one that has been around
for years and the rheumatoid
factor and it's present in the
majority of patients with
Rheumatoid Arthritis.  A newer
marker of Rheumatoid Arthritis
called CCP antibody is only the
last decade or so and we will
generally test both with
patients with Rheumatoid
Arthritis that is suspected and
firms up the diagnoses and not
perfect test and one or more are
present in 80% of patients so
there is still one in five
patients with classical
rheumatoid and without the
marker and important for the
primary care specialists to have
this suspicion of Rheumatoid
Arthritis and not completely
rely on the laboratory testing
but it's fortunate that they do
the tests.  Other tests that are
done in evaluating patients with
inflammatory joint symptoms and
blood markers of inflammation
and there are two and sed rate
and one [INAUDIBLE] protein and
elevated in patients with
Rheumatoid Arthritis but again
many patients present with
obvious joint inflammation and
have normal markers so those are
not perfect tests either.  Many
patients present with anemia in
the blood counts and that can be
a clue and we check chemistries
and kidney and liver function in
anticipation of treating these                                       11
conditions.  X-rays can be
helpful and some patients will
have changes on the X-ray that
are typical features of
Rheumatoid Arthritis and
arthritis and most are the small
joints and hands and feet and
see changes in those than a
larger joint.  MRI can be used
if patients have symptoms but
not obvious findings on
examination.  An MRI will give
very nice pictures of joint
inflammation or even damage
related to chronic inflammation
so there are a number of tools
to help us in diagnosing
Rheumatoid Arthritis but the
most important piece is the
history and the physical exam.
We need a history consistent
with inflammatory joint disease
and physical exam features of
small joint swelling and warm
swollen joints in the larger
joints.  This is an X-ray of a
hand affected by Rheumatoid
Arthritis.  The prominent
features here in the middle
finger you see complete loss of
the joint space.  The adjacent
joint actually looks pretty
normal.  Another soft sign we
see in the X-ray is this darker
change to the bone.  Bone
typically has fairly uniform
white like you see here but
around the joints of patients
with Rheumatoid Arthritis we
will see this sort of darker
change which correlates with
reduced calcium content and what
we call thinning of the bone or
osteopenia.  Over here we have
what is probably an erosion.  It
looks like someone took a bite
out of the bone and these are
features we look on the hand and
foot X-rays to help support the
diagnosis and our hope is we                                         12
don't see the erosions when we
first order the X-rays.  This is
an MRI, and the MRI is
demonstrating some typical
features of Rheumatoid
Arthritis.  Let me get my
pointer here again.  I'm going
to go over to the upper right
one and you can see the bright
bone.  That brightness is what
we call edema or swelling in the
bone.  The joints that are
affected by Rheumatoid Arthritis
will often cause adjacent bone
edema.  This one in the upper
row, the second one from the
left, you can see a loss of the
edge of the bone on the top and
that is probably an erosion in
that bone there.  We don't very
often obtain MRI imagining to
make the diagnoses and the
clinical presentation is obvious
but sometimes we have patients
referred by specialists that
obtained an MRI for an
evaluation of the patient's
joint pain and find these
erosive changes get them to the
rheumatology office for
evaluation.  So if someone is
diagnosed with Rheumatoid
Arthritis and they go on the
internet and start to research
Rheumatoid Arthritis and look at
images and see the images of the
crooked fingers and deformities
and become quite anxious about
the diagnoses and that is a
factor and it's having huge
outcomes on the treatments and
if patients are present early
and treatment is done early
reduces those things and
Rheumatoid Arthritis is a
chronic condition.  Once it
develops it rarely goes into
remission.  5-10% rate is
reported.  We're seeing some
patients that go on early                                            13
treatment especially with
advanced therapies.  After a
couple of years of treatment the
treatment can be withdrawn and
have sustained remission
although most of the patients
will relapse.  If we don't treat
the condition early and
aggressively most patients
develop damage to the joint and
to the bone and usually within
the first two years so it's
critical to have a high index of
[INAUDIBLE] and evaluate the
patients quickly and get them to
rheumatologists quickly and this
next fact is old data and much
lower with early recognition and
treatment.  Many patients have
productive lives and are able to
function the way they did prior
to developing disease if
identified early.  This
condition can be associated with
increased risk of infection.
Chronic inflammatory disorders
like Rheumatoid Arthritis have a
higher risk of cardiovascular
disease and lymphoma is seen at
greater frequency with these
patients even if they're not on
medicines and when you listen to
theads on TV you hear about
lymphoma and the drugs could
have association with it but
with Rheumatoid Arthritis the
risk is increased of this.  So
what's the good news about this
condition?  Well, the best news
is the better treatments that we
have -- then even 15 years ago.
There are advancement with the
new antibodies CCP and more
dense imaging options.  Of
course there is ongoing research
in other ways of manipulating
the immune system, stem cell
transplant.  People are looking
at gene therapies but we're not
there yet so currently we can                                        14
manipulate the immune response
farm logically so treatment is
the biggest thing and our first
goal is to improve symptoms.  We
want patients to have less pain,
less swelling, less stiffness
and function normally and the
secondary goals  are to prevent
damage and prevent erosions and
joint deformities so again we
want to identify people early
and try to get them on
appropriate therapies early on
with the condition, and of
course we always want to
minimize risk of adverse events
from the medications and
balancing the risk of treatments
with the risk of developing
deformity and disability.  So
let's talk about how we treat
Rheumatoid Arthritis.
Rheumatoid Arthritis is a robust
inflammatory process so we have
to use medicines that impact
that inflammation.  We have a
group of agents which are
disease inflammatory drugs and
DMARD and used for about three
decades to control Rheumatoid
Arthritis and done well in
having an impact and slowing
progression and disease and
preventing disability.  Steroids
are used fairly extensive.  They
work the fastest of the agents
that we have but they can have
side effects we would like to
avoid so we're happy to have
medicines like the DMARDs or
other modifiers.  What we call
NSAIDs and non steroidal
anti-inflammatory drugs and they
don't have a role in preventing
Rheumatoid Arthritis and things
like Celebrex, Motrin and Advil
and they help with the pain but
not strong enough to prevent
disease and damage so we use
them but don't see them as an                                        15
important piece in treating the
disease process.  Joint
injections can be used for
severely painful joints and they
work very well.  We basically
inject a steroid right into the
joint and quickly reduces
inflammation and the side
effects and the swelling and
pain and warmth so in patients
that present with a big swollen
knee and can't walk because of
it or an ankle joint injections
can be effective and we use them
even if a patient has a mild
flair of single joint while on
treatment.  The greatest
advances in treating Rheumatoid
Arthritis and other inflammatory
arthritis are the biological
response modifiers and around
for over a decade and
revolutionized the treatment
Rheumatoid Arthritis and changes
the face of patients with
Rheumatoid Arthritis and we will
talk about all of these in more
detail with the next slides, so
let's first start with our
DMARDs, and we have things to
choose and are listed here.  The
first agent is methotrexate and
used to treat cancer but we use
low doses on a once a week
pattern to control inflammation
and inflammatory joint disorders
and works well and many times
patients can be treated with
this all alone and have control
of the disease and can be a shot
or a pill and has long-term
safety.  Sulfalazine and another
one and daily agent.
Hydroxychloroquine is another
one and antimalaria drug and the
next one.  The ones on the
bottom have fallen out of favor
because they're not as effective
as the ones on top.  This shows
the biologic agents and                                              16
advertised on TV now and they're
shaped just like antibodies in
our own system and designed to
attach to certain things that
drive inflammation so on the
right in the middle there that
will attach to a protein which
drives inflammation in patients
with Rheumatoid Arthritis so
here's a list of the different
things that we have that first
the bullet point and the tumor
necrosis inhibitors of around
the longest and these are all
ones that have been for a while.
They block the tumor necrosis
factor.  The ones on the lower
part of the slide block the path
ways and unfortunately it's not
one size fits all with the
patients with Rheumatoid
Arthritis.  Some patients
respond to one agent and not
another.  Nobody understands why
that is.  It's just the
heterogeneity of the condition.
We have to do trials with
individual agents and after
three months we're not seeing a
response we choose something
else to treat patients with.  In
most cases we come across an
agent that helps well with
patients and improve symptoms
and function.  This slide just
demonstrates how effective the
agents are.  The bottom line
with the white open circles is
the placebo treated patients.
The top line are patients
treated with the medication
called Humira and there is a big
difference in treatment
response.  On the bar on the
left you see ACR 20.  That is
20% improvement with treatment
and you can see right away just
in the first four weeks the
patients treated with this drug
have marked improvement in their                                     17
function.  So excellent agents
and as by the doctor here the
data and suggest aggressive
treatment may slow or inhibit
patients' joint damage and
published in 2005 when the
agents were used more widely so
there are risks of treatment and
we always balance the risks with
the risks of not treating.  When
we don't treat Rheumatoid
Arthritis as we discussed the
vast majority of people develops
damage in the first two years
but since we're suppressing this
there is risk of infection and
potential liver toxicity and
many have gastrointestinal
issues and patients with
Rheumatoid Arthritis have to
make sure and other providers
know they're on certain drugs.
Of course there are cancer risks
in the patients treated with the
agents.  We talked about the
lymphoma risk but there is still
concerns about other kinds of
cancer.  To date though it
appears that patients treated
with medications you're not
seeing the developed cancer in
any greater rate than other
treated with certain drugs so
that is good news and we always
have to monitor things long-term
doing lab tests periodically to
make sure that the liver
function is normal that the
blood counts are normal, so we
see patients frequently.  They
get labs periodically and
hopefully we won't see any
problems.  There's always
questions about dietary things
in arthritis.  Unfortunately we
don't have any dietary things to
reduce this and fish oil may
have a role in reducing symptoms
but no studies in showing the
slowing of the progression of                                        18
the disease.  The importance of
exercise is primarily keeping
the joints moving normally.
Exercise doesn't have an impact
on the inflammatory process but
if you don't use your joints can
you lose strength and motion and
so it's always important to do
simple range of motion exercises
and some light weights to keep
the muscles that support the
joints strong.  And surgery for
Rheumatoid Arthritis is
primarily reserved for end-stage
joint problems but rheumatoid
nodules can be removed if
they're symptomatic and joint
replacements can be performed so
surgery is an option for
end-stage disease.  Fortunately
now days with early treatment
we're keeping people from having
to proceed with surgical
interventions.  Our hand surgery
colleagues commented they're
seeing fewer patients with late
stage rheumatoid joint disease.
So this slide is just a summary.
Rheumatoid Arthritis is a
chronic condition causing
inflammation in the joints,
usually the hands wrists and
feet but any joint can be
affected.  If we don't treat
them they develop joint demeanor
and results in disability.
Medical treatments can reduce
the progression and improve the
quality of life and the
increased risk for
cardiovascular disease with
patients with Rheumatoid
Arthritis we have seen studies
that treating this disease
actually reduces that
cardiovascular risk so it's not
just a joint disease.  It's a
systemic disorder affecting
other organ systems and we have
to keep that in mind of the risk                                     19
of the treatment that the
condition has impact on quality
of life, length of life so we
have to treat it aggressively,
identify it early.  I think that
maybe my last slide.  I think we
can probably open things up to
questions.
 >>  Well thank you very much
Dr. Reed.  That was excellent
overview and really laid things
out very well.  So let me --
while we're preparing for the
questions and answers I'm going
to administer our poll
questions.  If you do have
questions please feel free to go
ahead and enter those into the
chat window or have a microphone
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during the question and answer
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first question and that simply
asks about your affiliation.  If
you could let us know which of
the categories you best fall and
which category that you fall
into.  (Captioning is not
working with the poll questions
up)
--  and whether the questions
that you had were appropriate
and met your needs.  Okay.  I'm
having to wait on the system to
close the poll.  Sorry for that
delay.  Okay.  So here are the
poll results.  The next question
asks about the technology.  Was
it useful?  If you had specific
issues and do that in the chat
problem.  I forgot to mention if
you had multiple people viewing
the Webinar at your site it's
helpful to know that also so we
can count them in the attendance
for that if you can make a note
there.  Okay.  Our next question
asks based on today's session
would you attend another session                                     20
in this series?  Okay.  I
appreciate your response on that
and then our final poll asks how
you heard about the session
today and let us know.  All
right.  Thank you very much for
your responses.  At this point
I'm going to turn things back
over to Cliff who is our IT
specialist.  And to Dr. Reed for
our question and answer time.
Let me do a little thing here so
I can get the ball passed.
Cliff can answer the questions.
 >>  Can we ask a question?
Hello.
 >>  Yes, Cliff is going to do
the questions on the screen
there.
 >>  Can we ask a question
please?  Doesn't have the
microphone on to answer or
whatever.
 >>  Okay.  So our first
question is what the correlation
between age and Rheumatoid
Arthritis?
 >>  Okay.  You know we can see
Rheumatoid Arthritis develop at
any age.  We discussed earlier
in the presentation it tends to
develop in the 30's through
50's, but there are children
with Rheumatoid Arthritis.
There are patients over the age
of 60 with Rheumatoid Arthritis
but the peak is in the 30's and
40's.
 >>  The next question what is
the difference and prevalence of
Rheumatoid Arthritis between
agricultural and non
agricultural community?
>>  I'm not aware of any
difference between agricultural
and non agricultural
communities.  There is a
tendency for Rheumatoid
Arthritis to have a prevalence
in cooler climates and hard to                                       21
know if it's a climate issue or
with the ethnic make up of
groups in different parts of the
world.
 >>  The next question is is
there a correlation between
Rheumatoid Arthritis and people
that suffer from neuropathy of
the feet?
>>  No.  People with
neuropathies of the lower
extremities and ankle region can
develop what we call neuropathic
joints, the loss of sensation in
the region can cause deformities
result of losing that sensation
and there's an interesting
phenomenon in patients who had a
prior stroke affecting an
extremity.  For instance, if
someone loses use of the right
arm due to a stroke and develops
Rheumatoid Arthritis for some
reason some of the folks will
only have the Rheumatoid
Arthritis in the normal arm but
not the affected arm and it's
not clear why that is the case.
I actually had a patient like
that years ago and it was a
striking presentation.
 >>  We have a question -- we
have a hand raised by Bud
Wilner.  Bud, you can type the
question or we will enable your
microphone.
 >>  Let me get the mic on here.
 >>  They turn on the mic.
 >>  Okay.  Can you hear me?
>>  We can hear you.
 >>  Yeah.  What about spinal
arthritis?
>>  Well, it's interesting.
Rheumatoid Arthritis can affect
the spine but it's most commonly
affecting the neck region.  We
never see Rheumatoid Arthritis
affecting the lower spine, the
lumbar region as we call it.
Most commonly if people have                                         22
spinal arthritis degenerative.
There is a different form of
arthritis that can affect the
spine and an inflammatory
process and most times presents
in the 20's, 30's, earlier in
life but most people with lower
back pain has degenerative
arthritis and not Rheumatoid
Arthritis and people with
Rheumatoid Arthritis that have
cervical spinal involvement and
other joint involvement with
that so it's a curiosity as to
why the lumbar spine is left
alone in Rheumatoid Arthritis.
 >>  Thank you very much.
 >>  You're welcome.
 >>  The question is a little
bit bigger so I will try to
expand it so you can see the
whole thing.  So the question is
so does a correlation exist for
Rheumatoid Arthritis or
arthritis in general between hot
and cold temperatures?  Because
a common arthritis myth states
that arthritis can be caused
from moving frequently from hot
to cold temperatures.
 >>  Yeah.  So we don't see
necessarily a correlation
between hot and cold
temperatures.  Patients
frequently have an impact on
symptoms from different
environmental temperatures, but
we don't see more severe disease
in certain climates necessarily,
or actual I don't think we don't
see higher prevalence of disease
in different climates and there
are rheumatologists across the
world and we're seeing a similar
group of patients with
Rheumatoid Arthritis and while
temperature changes may affect
symptoms it doesn't necessarily
seem to be having an impact on
the prevalence of the disease at                                     23
this point.
 >>  Okay.  We have a few
minutes for more questions if
they're out there otherwise we
will finish the Webinar.
 >>  Just had another note for
attendees today.  Again if
anybody has another question we
will be on for another minute or
so but we're having the annual
web conference on December 1-3.
That is a series of two webinars
per day and a total of six.
Some of the topics we will look
at.  There's one on working with
migrant seasonal farm workers,
Post Traumatic Stress Disorder
with veterans and another
veterans session and personal
perspective from returning home
from a veteran who is here at
Purdue and covering carpel
tunnel syndrome in agricultural
occupations and selecting
wheelchairs for use and an
update from the USDA leader in
Washington and any other
questions?  An excellent
presentation.  Thank you Dr.
Reed for taking the time to
share the information today.
Again follow up if you have
questions you can send them to
our Agr Ability website.  I'm
going to open a poll here at the
end if you have other comments.
We will leave this open for a
while and let you make comments
you would like to.  Otherwise
thank you again and we hope to
have you participate in an
upcoming Webinar.