the following are under investigation for treatments for ra, based on preliminary promising results (not recommended for clinical use yet): boswellic acid, curcumin, devil's claw, euonymus alatus, and thunder god vine (tripterygium wilfordii). nccih has noted that, "in particular, the herb thunder god vine (tripterygium wilfordii) can have serious side effects." there is conflicting evidence on the role of erythropoiesis-stimulating agents for treatment of anemia in persons with rheumatoid arthritis. pregnancy more than 75% of women with rheumatoid arthritis have symptoms improve during pregnancy but might have symptoms worsen after delivery. methotrexate and leflunomide are teratogenic (harmful to foetus) and not used in pregnancy. it is recommended women of childbearing age should use contraceptives to avoid pregnancy and to discontinue its use if pregnancy is planned. low dose of prednisolone, hydroxychloroquine and sulfasalazine are considered safe in pregnant women with rheumatoid arthritis. prednisolone should be used with caution as the side effects include infections and fractures. vaccinations people with ra have an increased risk of infections and mortality and recommended vaccinations can reduce these risks. the inactivated influenza vaccine should be received annually. the pneumococcal vaccine should be administered twice for people under the age 65 and once for those over 65. lastly, the live-attenuated zoster vaccine should be administered once after the age 60, but is not recommended in people on a tumor necrosis factor alpha blocker. prognosis disability-adjusted life year for ra per 100,000 inhabitants in 2004. no data <40 40–50 50–60 60–70 70–80 80–90 90–100 100–110 110–120 120–130 130–140 >140 the course of the disease varies greatly. some people have mild short-term symptoms, but in most the disease is progressive for life. around 25% will have subcutaneous nodules (known as rheumatoid nodules); this is associated with a poor prognosis. prognostic factors poor prognostic factors include, persistent synovitis early erosive disease extra-articular findings (including subcutaneous rheumatoid nodules) positive serum rf findings positive serum anti-ccp autoantibodies positive serum 14-3-3η (ywhah) levels above 0.5 ng/ml carriership of hla-dr4 "shared epitope" alleles family history of ra poor functional status socioeconomic factors elevated acute phase response (erythrocyte sedimentation rate , c-reactive protein ) increased clinical severity. mortality ra reduces lifespan on average from three to twelve years. young age at onset, long disease duration, the presence of other health problems, and characteristics of severe ra – such as poor functional ability or overall health status, a lot of joint damage on x-rays, the need for hospitalisation or involvement of organs other than the joints – have been shown to associate with higher mortality. positive responses to treatment may indicate a better prognosis. a 2005 study by the mayo clinic noted that individuals with ra have a doubled risk of heart disease, independent of other risk factors such as diabetes, excessive alcohol use, and elevated cholesterol, blood pressure and body mass index. the mechanism by which ra causes this increased risk remains unknown; the presence of chronic inflammation has been proposed as a contributing factor. it is possible that the use of new biologic drug therapies extend the lifespan of people with ra and reduce the risk and progression of atherosclerosis. this is based on cohort and registry studies, and still remains hypothetical. it is still uncertain whether biologics improve vascular function in ra or not. there was an increase in total cholesterol and hdlc levels and no improvement of the atherogenic index. epidemiology deaths from rheumatoid arthritis per million persons in 2012 0–0 1–1 2–3 4–5 6–6 7–8 9–9 10–12 13–20 21–55 ra affects between 0.5 and 1% of adults in the developed world with between 5 and 50 per 100,000 people newly developing the condition each year. in 2010 it resulted in about 49,000 deaths globally. onset is uncommon under the age of 15 and from then on the incidence rises with age until the age of 80. women are affected three to five times as often as men. the age at which the disease most commonly starts is in women between 40 and 50 years of age, and for men somewhat later. ra is a chronic disease, and although rarely, a spontaneous remission may occur, the natural course is almost invariably one of the persistent symptoms, waxing and waning in intensity, and a progressive deterioration of joint structures leading to deformations and disability. there is an association between periodontitis and rheumatoid arthritis (ra), hypothesised to lead to enhanced generation of ra-related autoantibodies. oral bacteria that invade the blood may also contribute to chronic inflammatory responses and generation of autoantibodies. history the first recognized description of ra in modern medicine was in 1800 by the french physician augustin jacob landré-beauvais (1772–1840) who was based in the famed salpêtrière hospital in paris. the name "rheumatoid arthritis" itself was coined in 1859 by british rheumatologist alfred baring garrod. the art of peter paul rubens may possibly depict the effects of ra. in his later paintings, his rendered hands show, in the opinion of some physicians, increasing deformity consistent with the symptoms of the disease. ra appears to some to have been depicted in 16th-century paintings. however, it is generally recognized in art historical circles that the painting of hands in the 16th and 17th century followed certain stylized conventions, most clearly seen in the mannerist movement. it was conventional, for instance, to show the upheld right hand of christ in what now appears a deformed posture. these conventions are easily misinterpreted as portrayals of disease. historic (though not necessarily effective) treatments for ra have also included: rest, ice, compression and elevation, apple diet, nutmeg, some light exercise every now and then, nettles, bee venom, copper bracelets, rhubarb diet, extractions of teeth, fasting, honey, vitamins, insulin, magnets, and electroconvulsive therapy (ect). etymology rheumatoid arthritis is derived from the greek word ῥεύμα-rheuma (nom.), ῥεύματος-rheumatos (gen.) ("flow, current"). the suffix -oid ("resembling") gives the translation as joint inflammation that resembles rheumatic fever. rhuma which means watery discharge might refer to the fact that the joints are swollen or that the disease may be made worse by wet weather. research meta-analysis found an association between periodontal disease and ra, but the mechanism of this association remains unclear. two bacterial species associated with periodontitis are implicated as mediators of protein citrullination in the gums of people with ra. vitamin d deficiency is more common in people with rheumatoid arthritis than in the general population. however, whether vitamin d deficiency is a cause or a consequence of the disease remains unclear. one meta-analysis found that vitamin d levels are low in people with rheumatoid arthritis and that vitamin d status correlates inversely with prevalence of rheumatoid arthritis, suggesting that vitamin d deficiency is associated with susceptibility to rheumatoid arthritis. the fibroblast-like synoviocytes have a prominent role in the pathogenic processes of the rheumatic joints, and therapies that target these cells are emerging as promising therapeutic tools, raising hope for future applications in rheumatoid arthritis. possible links with intestinal barrier dysfunction are investigated.