JUVENILE ARTHRITIS

1. Rheumatoid Factor - RF is an antibody that is measurable in the blood. - The RF test is the most useful immunologic test for confirming rheumatoid arthritis (RA).

Purpose: To confirm RA when diagnosis is uncertain.

Procedure: Preparation 1. Explain to the patient that this test helps confirm RA. 2. Inform the patient that he need not restrict food and fluids. 3. Tell the patient that test requires a blood sample. Explain who will perform the venipuncture and when. 4. Explain in the patient that he may experience slight discomfort from the needle puncture and the tourniquet. Implementation 1. Perform a venipuncture and collect the sample in a 7-ml clot-activator tube. Patient care 1. Apply direct pressure to the venipuncture site until bleeding stops. 2. Check regularly for signs of infection. 3. Because a patient with RA may be immunologically compromised, keep the venipuncture site clean and dry for 24 hours. Complications o Hematoma at the venipuncture site.

Interpretation Normal results o RF titer is less than 1:20; rheumatoid screening test is nonreactive.

Abnormal results o Non-RA and RA populations arent clearly separated with regard to the presence of RF: 25% of patients with RA have a nonreactive titer; 8% of non-RA patients are reactive at greater than 39 IU/ml, and only 3% of non-RA patients are reactive at greater than 80 IU/ml. Patients with various non-RA disease characterized by chronic inflammation may test positive for RF. These disease include SLE, polymyositis, TB, syphilis and influenza.

2. Erythrocyte sedimentation rate (ESR) - It measures the degree of erythrocyte settling in a blood sample during a specified period. - Sensitive but nonspecific test thats often the earliest indicator of disease when other chemical or physical signs are normal. - Usually increases significantly in widespread inflammatory disorders; prolonged elevations may exist in localized inflammation and malignant disease. Purpose: Procedure Preparation 1. Explain to the patient that the ESR test evaluates the condition for RBC. 2. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. 3. Explain to the patient that he may feel slight discomfort from the tourniquet and needle puncture. 4. Inform the patient that he need not restrict food and fluids. Implementation 1. Perform a venipuncture and collect the sample in a 4.5-ml tube with ethylenediaminetetraacetic acid added or in a tube with sodium citrate added. 2. Completely fill the collection tube and invert it gently several times to thoroughly mix the sample and the anticoagulant. 3. Because prolonged standing decreases ESR, examine the sample for clots or chumps and sent it to the laboratory immediately. It must be tested within 1 to 4 hours. 4. Handle the sample gently to prevent hemolysis. Patient care 1. Ensure that subdermal bleeding has stopped before removing pressure. 2. For large hematoma at the venipuncture site, monitor pulses distal to the pulmonary site. Complication o Hematoma at the venipuncture site. To monitor inflammatory and malignant disease. To aid detection and diagnosis of occult disease, such as TB, tissue necrosis, or connective tissue disease.

Interpretation Normal results o o In men ESR is up to 10 mm/hour; in women up to20 mm/hour. ESR gradually increases with age.

Abnormal results o o ESR rises in pregnancy, anemia, acute or chronic inflammation, TB, rheumatic fever, rheumatoid arthritis, and some cancer. Polycythemia, sickle cell anemia and low plasma fibrinogen or globulin levels tend to depress the ESR.

3. Antinuclear antibodies (ANA) - Measures relative level of ANA in a serum sample through indirect immunofluorescence. Serial dilutions of serum are mixed with either Hep-2 or mouse kidney substrate. - Titer is taken at the greatest dilutions that shows the reaction. Purpose: To screen SLE To monitor the effectiveness of immunosuppressive therapy for SLE. Procedure Preparation 1. Explain to the patient that this test evaluates the immune system and that further testing is usually required for diagnosis. 2. Inform the patient that it may be necessary to repeat the test to monitor his response to therapy. 3. Inform the patient that he need not restrict food and fluids. 4. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. 5. Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture. 6. Check the patients history for drugs that may affect test results, such as isoniazid and procainamide. Note findings on the laboratory request. Implementation 1. Perform a venipuncture and collect the sample in a 7-ml tube without additives. Patient care 1. Because a patient with an autoimmune disease has a compromised immune system, observe the venipuncture site for signs of infection, and report changes to the physician immediately. 2. Keep a clean, dry bandage over the site for at least 24 hours. 3. Apply direct pressure to the venipuncture site until bleeding stops. Complications o Hematoma at the venipuncture site

Interpretation

Normal results o Test results are reported as positive or negative.

Abnormal results

o o

Low titers may occur in patients with viral disease, chronic hepatic disease, collagen vascular disease, and autoimmune disease and in some healthy adults; the incidence increases with age. The higher the titer, the more specific the test is for SLE.

4. Human leukocyte antigen B27 (HLA-B27) Is a blood test that identifies a specific protein located on the surface of your white blood cells called human leukocyte antigen B27. - Human leukocyte antigens (HLAs) are proteins commonly found on white blood cells. These antigens help your immune system identify differences between healthy body tissue and foreign substances that may cause infection. - Although most HLAs protect the body from harm, HLA-B27 is a specific type of protein that contributes to immune system dysfunction. The presence of HLA-B27 on your white blood cells can cause your immune system to attack the healthy cells that contain it. When this occurs, it can result in an autoimmune disease, such as juvenile rheumatoid arthritis. Purpose: Monitoring Disease Progression: The presence of HLA-B27 is associated with a host of autoimmune diseases, including: Ankylosing spondylitis Reactive arthritis (causes inflammation of the joints, urethra, and eyes and sometimes lesions on the skin) juvenile rheumatoid arthritis Anterior uveitis (causes swelling and irritation in the middle layer of the eye) Procedure Preparation 1. Explain to the patient about the test. 2. Inform the patient that he need not restrict food and fluids. 3. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. 4. Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture. 5. Check the patients history for blood transfusions. Implementation

1. Perform a venipuncture and collect the sample in a tube containing anticoagulant acid citrate dextrose solution. 2. Handle the sample gently to prevent hemolysis.

Patient care 1. Apply direct pressure to the venipuncture site until bleeding stops. Complications: The HLA-B27 test carries minimal risks. The following rare complications are common to all blood tests: o o o o o Difficulty obtaining a sample, resulting in multiple needle sticks Excessive bleeding at the puncture site Fainting or light-headedness Accumulation of blood under the skin (hematoma) Infection at the puncture site

Interpretation Normal results o o o Ideally, your test will be negative, indicating the absence of HLA-B27 in your blood. However, if the test is negative, it doesnt mean that you absolutely do not have an autoimmune disorder. In some cases, patients with autoimmune disorders do not have HLA-B27 on their white blood cells. If the test is positive, this means that HLA-B27 is present in your blood. Although a positive result may be cause for concern, the presence of the antigen does not always indicate that an autoimmune disorder will develop. Diagnosis of an autoimmune disorder must be made based on your symptoms and the results of all blood tests and diagnostic exams.