128 This work is licensed under a Creative Commons Attribution 4.0 International License IHJPAS. 37 (2) 2024 Ibn Al-Haitham Journal for Pure and Applied Sciences Journal homepage: jih.uobaghdad.edu.iq PISSN: 1609-4042, EISSN: 2521-3407 Evaluation of Several Hematologic and Serological Parameters in Rheumatoid Arthritis Patients Zahraa Jabbar Diwan 1* and Wasan Addai Al- Marsomy 2 1,2 Department of Biology, College of Science for Women, University of Baghdad, Baghdad, Iraq *Corresponding Author. Received: 29 April 2023 Accepted: 31 May 2023 Published: 20 April 2024 doi.org/10.30526/37.2.3451 Abstract Rheumatoid arthritis (RA) is a chronic inflammatory disease that primarily affects the synovial joints and produces recurring inflammation of the synovial membrane, which ultimately causes joint degeneration, deformity, and disability. The current study included 110 blood samples collected from patients infected with rheumatoid arthritis (60) and 50 blood samples from controls. The results showed that investigation of some hematological tests revealed a high significant erythrocyte sedimentation rate (ESR) for the patient group compared to the control group (28.25 ± 2.72, 16.24 ± 1.83), respectively. But it is non-significant for patients for (WBC, RBC, and PLT) was (7.34 ± 0.25, 4.71 ± 0.08, and 248.26 ± 9.18), while the control group was (6.73 ±0.19, 4.96 ±0.10, and 263.64 ±8.26), respectively. As well as the result of the rheumatoid arthritis factor (Rh) level, there was a significant increase in patients with positive RF 45 (75.00%) and negative RF 15 (25.00%). while the result for the C-reactive protein (CRP) test for patients was positive 26 (43.33%) and negative 34 (56.67%). Keywords: Rheumatoid arthritis, serologic test, CBC test, autoimmune disease, RF factor. 1. Introduction Rheumatoid arthritis is a disordered inflammation resulting from a chronic autoimmune response, that affects both small and large joints in the body. Without treatment, this disease significantly shortens the patient's life, so it also indirectly results in death [1-3]. The pathogenesis of rheumatoid arthritis may be heterogeneous and have complex manifestations, as autoantibodies are a feature of positive rheumatoid arthritis, as they are a biomarker of an erosive disorder of the joint surface. Also, many changes may occur before the clinical onset of the disease; this stage may last for several years and may be characterized by the appearance of autoantibodies without any signs of arthritis [4]. We used the measure of the Erythrocyte Sedimentation Rate (ESR), which is a laboratory indicator for disease activity in clinical medicine and is still an important tool for tracking inflammatory diseases, especially rheumatoid arthritis [5, 6]. Therefore, ESR is a vital component of several rheumatic criteria for determining disease activity and improvement, as well as a laboratory activity sign for its treatment [7, 8]. The erythrocyte sedimentation rate (ESR) is used to track the body's heightened inflammatory activity [9, 10]. Although the ESR test lacks specificity, which is the only negative of its use in assessing illness severity, it can be increased in a variety of disorders through infections and https://jih.uobaghdad.edu.iq/index.php/j/index#1609-4042 https://jih.uobaghdad.edu.iq/index.php/j/index#2521-3407 https://orcid.org/0009-0006-1661-3276 mailto:zahraa.gtuf2102m@csw.uobaghdad.edu.iq https://orcid.org/0000-0001-9831-6713 mailto:wasan.a@csw.uobaghdad.edu.iq https://orcid.org/0009-0006-1661-3276 mailto:zahraa.gtuf2102m@csw.uobaghdad.edu.iq https://orcid.org/0000-0001-9831-6713 mailto:wasan.a@csw.uobaghdad.edu.iq https://orcid.org/0009-0006-1661-3276 mailto:zahraa.gtuf2102m@csw.uobaghdad.edu.iq https://orcid.org/0000-0001-9831-6713 mailto:wasan.a@csw.uobaghdad.edu.iq https://orcid.org/0009-0006-1661-3276 mailto:zahraa.gtuf2102m@csw.uobaghdad.edu.iq https://orcid.org/0000-0001-9831-6713 mailto:wasan.a@csw.uobaghdad.edu.iq https://orcid.org/0009-0006-1661-3276 mailto:zahraa.gtuf2102m@csw.uobaghdad.edu.iq https://orcid.org/0000-0001-9831-6713 mailto:wasan.a@csw.uobaghdad.edu.iq https://orcid.org/0009-0006-1661-3276 mailto:zahraa.gtuf2102m@csw.uobaghdad.edu.iq https://orcid.org/0000-0001-9831-6713 mailto:wasan.a@csw.uobaghdad.edu.iq https://orcid.org/0009-0006-1661-3276 mailto:zahraa.gtuf2102m@csw.uobaghdad.edu.iq https://orcid.org/0000-0001-9831-6713 mailto:wasan.a@csw.uobaghdad.edu.iq https://orcid.org/0009-0006-1661-3276 mailto:zahraa.gtuf2102m@csw.uobaghdad.edu.iq https://orcid.org/0000-0001-9831-6713 mailto:wasan.a@csw.uobaghdad.edu.iq IHJPAS. 37 (2) 2024 129 inflammation in addition to autoimmune diseases, as in the present results, this current study is compatible with [11], which concluded that ESR values can be raised in RA and utilized as a screening test to determine the intensity of the disease, although it has considerably poorer specificity than CRP and RF. The reason for elevated levels of ESR in RA may be an increase in fibrinogen levels, which makes the red blood cells sticky and accelerate the sedimentation process [12]. However, the rheumatoid factor (RF) is an autoantibody that targets the immunoglobulin G (IgG) fc, or crystallizable fragment. These autoantibodies target the joints during inflammation. Recently, the presence of anti-citrullinated protein antibodies (ACPAS) has been associated with rheumatoid arthritis. These autoantibodies target the joints during inflammation by modifying proteins in inflamed joints [13-15]. Therefore, one of the most important diagnostic criteria for rheumatoid arthritis, according to the European League Against Rheumatism (EULAR), is RF, in addition to anti-citrullinated protein antibodies (ACCPA) as serological markers. Several studies have suggested these tests as the best predictors of rheumatoid arthritis and also of cartilage and bone destruction [16-19 ]. As well as the C-reactive protein (CRP), is a cyclic protein with five links that is detected in blood plasma and rises in response to inflammation predominantly in the liver, though it can also be made by fat and inflammatory cells because it was initially discovered to be a material in the blood of individuals with acute inflammation that reacts with the carbohydrate (C) antibody in the pneumococcal capsule. The designation name given to CRP is due to the fact that CRP is high in persons with underlying illnesses such as advanced cancer, hepatitis, arthritis, tissue damage, viral or bacterial infection, and several other autoimmune problems [20, 21]. The aim of the current study is to assess the levels of some hematological parameters, including erythrocyte sedimentation rate (ESR), complete blood count (CBC), and blood groups in the studied groups (patients and controls), in addition to the estimated serological tests, including rheumatoid factor (RF) and C- reactive protein in these groups. 2. Materials and Methods The present study included 110,000 blood samples collected from patients with rheumatoid arthritis by a rheumatology clinic in the Baghdad Teaching Hospital of Iraq from October 2022 to December 2022. A medical history was collected from each patient (age, sex, address, and absence of other diseases). The number was 21 males and 39 females. The ages ranged from 20 to 69 years, and 50 healthy persons (21 males and 29 females) were included for comparison. 5 milliliters of blood samples were divided into two test tubes; 3 ml of blood samples were left to clot at room temperature for 10–15 minutes and then centrifuged at 2500 rpm for 15 minutes to obtain serum for CRP, RF tests, and 2 ml EDTA tubes for ESR and blood grouping tests [22]. 3. Results and Discussion 3.1. Erythrocyte Sedimentation Rate (ESR), WBC, RBC and PLT in rheumatoid arthritis patients and control groups The current results show that the hematologic indicators had a highly significant (P≤0.01) value for ESR (28.25 ± 2.72) for patients and (16.24 ±1.83) for control, but there were no significant differences for other parameters (WBC, RBC, and PLT) (7.34 ± 0.25, 4.71 ± 0.08, and 248.26 ±9.18, respectively) for patients compared with the control group (6.73 ±0.19, 4.96 ±0.10, 263.64 ±8.26, respectively) Table 1 IHJPAS. 37 (2) 2024 130 Table 1. Comparison between ESR, WBC, RBC and PLT parameters of patients and control groups. Group Mean ± SE ESR (mm/h ) WBC RBC PLT (%) Patients 28.25 ±2.72 7.34 ±0.25 4.71 ±0.08 248.26 ±9.18 Control 16.24 ±1.83 6.73 ±0.19 4.96 ±0.10 263.64 ±8.26 T-test 6.789 ** 0.643 NS 0.252 NS 24.935 NS P-value 0.0001 0.0624 0.0571 0.224 ** Highly significant at (P≤0.01), NS= Non-Significant. As in the present results, this current study is compatible with [23], which concluded that ESR values can be raised in RA and utilized as a screening test to determine the intensity of the disease, although it has considerably poorer specificity than CRP and RF and corresponds to [11], whose result of the average ESR in the patient group was 42.7 ± 31, while in the control group it was 12.2 ± 3.0. As for the non-significant results of the WBC, RBC, and PLT parameters, they comply with [12]. This may be due to the fact that most of the patients used anti-rheumatic drugs, including MTX, as their primary medication or other treatments to control this disease. Therefore, the percentages of some results for patients remained normal and approached the control group. 3.2. Blood groups in rheumatoid arthritis patients and control groups The results showed that blood groups were highly significant (P≤0.01) in blood group O (28 (46.67%)), which was the most prevalent among rheumatoid patients, followed by blood group B (15 (25.00%)), blood group A (13 (21.67%)), then blood group AB (4 (6.67%)), and highly significant for the control group as 21 (42.00%), 17 (34.00%), 8 (16.00%), and 4 (8.00%), respectively, but there are no differences between the same type for each of the study groups as shown in Tables 1–2. Table 2. Distribution of study samples according to Blood groups in patients and control. Group No A No. (%) B No. (%) AB No. (%) O No. (%) P-value Patients 60 13 (21.67%) 15 (25.00%) 4 (6.67%) 28 (46.67%) 0.0002 ** Control 50 8 (16.00%) 17 (34.00%) 4 (8.00%) 21 (42.00%) 0.0021 ** P-value -- 0.071 NS 0.502 NS 1.00 NS 0.328 NS --- ** Highly significant at (P≤0.01) , NS= Non-Significant. Since blood type O is the largest proportion in these results, this may be because the majority of the Iraqi population has blood group O, so the results showed that the highest incidence of rheumatoid arthritis was in this group. This result conforms to [24]. That showed the study a result: the blood group O has the greatest percentage of patients with rheumatoid arthritis disease. 3.3. Rheumatoid factor (RF) percentage in rheumatoid arthritis patients and control groups The study results showed a highly significant increase (P<0.01) of the rheumatoid factor influence in patients with rheumatoid arthritis; the positive percentage was in 45 (75.00%) and the negative in 15 (25.00%), while the results of the control group were in the positive percentage (0.00%) and the negative in 50 (100%), as shown in Tables 1–3. IHJPAS. 37 (2) 2024 131 Table 3. The percentage of rheumatoid factor in patients and control groups. Group No Positive+ No. (%) Negative- No. (%) P-value Patients 60 45 (75.00%) 15 (25.00%) 0.0001 ** Control 50 0 (0.00%) 50 (100%) 0.0001 ** P-value -- 0.0001 ** 0.0001 ** --- ** Highly significant at (P≤0.01). The current study corresponds to [25], where (76%) were positive, (24%) were negative, and the control group was negative (100%). According to the results, the pathogenic factor played a significant role in infections as a result of the combination of antibodies in the inflammatory position, and this came in conformity with [26]. Therefore, the RF-positive percentage in patients is higher than the RF-negative. Patients with rheumatoid arthritis and many other non-rheumatic disorders, including infections and chronic diseases, might show signs of the immunoglobulin class known as rheumatoid factors [27, 28]. According to numerous studies, the acuteness of rheumatoid arthritis disease and the rheumatic component are strongly correlated because this factor is titer as a measure of the depth of medication response rather than a prediction of the length or severity of the disease, so the value is lower in cases where the clinical symptoms decrease in patients [29]. 3.4. C-reactive protein in rheumatoid arthritis patients and control groups The results of C-reactive protein showed non-significant differences; the positive percentage was in 26 patients (43.33%), and the negative was in 34 (56.67%). While it was not expressed in the healthy group (0.00%), as shown in Table 1-4. Table 4. The percentage of C - reactive protein in patients and control groups. Group No Positive No. (%) Negative No. (%) P-value Patients 60 26 (43.33%) 34 (56.67%) 0.302 NS Control 50 0 (0.00%) 50 (100%) 0.0001 ** P-value -- 0.0001 ** 0.0037 ** --- **Highly significant at (P≤0.01) , NS= Non-Significant. C- reactive protein and serum ferritin are two of the most widely used acute phase indicators and have great value for monitoring disease activity; therefore, CRP was detected in some samples of patients with rheumatoid arthritis [30,31]. Other studies indicated that an increase in its concentration is associated with the severity of rheumatoid arthritis disease, and this illustrated the expression result in some infected patients without the other samples [32]. 4. Conclusion The high levels of ESR in (RA) patients were higher than the control, but no differences were observed in the numbers of WBC, RBC, and PLT in these patients , and There were significant differences in the levels of RF, and CRP for patients compared with the control. IHJPAS. 37 (2) 2024 132 Acknowledgment In the name of God, the Most Gracious, the Most Merciful, and in the salutations and blessings of Muhammad, his servant and messenger, and his pure and pure family, acknowledge the immeasurable thanksgiving to the ever-great God. I extend my sincere gratitude to my supervisor, Assistant Professor Dr. Wasan Addai Mahdi. Many thanks to the staff of Baghdad Teaching Hospital, to Dr. Adnan Sedkhan, to the Martyr Al-Sadr General Hospital, and to the Department of Biology, College of Science for women, University of Baghdad. Conflict of Interest There are no conflicts of interest. Funding There is no funding for the article. Ethical Clearance The samples were gained according to Local Research Ethics Committee approval in Iraqi Ministry of Health No. 135857i on 6 /10/2022. References 1. Yap, H.Y.; Tee, S.Z.; Wong, M.M.; Chow, S.K.; Peh, S.C.; Teow, S.Y. Pathogenic role of immune cells in rheumatoid arthritis: implications in clinical treatment and biomarker development. Cells 2018, 7(10), 161. DOI: https://doi.org/10.3390/cells7100161. 2. Rija, F.F., Hussein, S.Z.; Abdalla, M.A., 2021. Physiological and immunological disturbance in rheumatoid arthritis patients. Baghdad Science Journal 2021, 18(2), 0247-0247. DOI: https://doi.org/10.21123/bsj.2021.18.2.0247. 3. Faiq, M.K.; Kadhim, D.J.; Gorial, F.I. The Belief about Medicines among a Sample of Iraqi Patients with Rheumatoid Arthritis. Iraqi Journal of Pharmaceutical Sciences 2019, 1683-28(2), 134- 141. DOI: https://doi.org/10.31351/vol28iss2pp134-141 4. Lucchino, B.; Spinelli, F.R; Iannuccelli, A. Guzzo, M.P.; Conti, F.; Franco, M.D. Mucosa– Environment Interactions in the Pathogenesis of Rheumatoid Arthritis. Cells 2019, 8(7), 700. DOI: https://doi.org/10.3390/cells8070700 5. Targońska-Stępniak, B.; Zwolak, R.; Piotrowski, M.; Grzechnik, K.; Majdan, M. The relationship between hematological markers of systemic inflammation (Neutrophil-To-Lymphocyte, Platelet-To- Lymphocyte, Lymphocyte-To-Monocyte Ratios) and ultrasound disease activity parameters in patients with rheumatoid arthritis. Journal of Clinical Medicine. 2020, 9(9), 2760. DOI: https://doi.org/10.3390/jcm9092760 6. Jassim, H.H.; Alnassiri, S.H.; Mawlood, A.F.; Shnak, Q.A. Relationship of erythrocyte sedimentation rate with the activity of prolidase and liver enzyme in serum of patients with rheumatoid arthritis. Materials Today: Proceedings 2021, 43, 2069-2075. 7. Buzatu, C.; Moots, R.J. Measuring disease activity and response to treatment in rheumatoid arthritis. Expert Review of Clinical Immunology 2019, 15(2), 135-45. DOI: https://doi.org/10.1080/1744666X.2019.1559050 8. Hale, A.J.; Ricotta, D.N.; Freed, J.A. Evaluating the erythrocyte sedimentation rate. JAMA Diagnostic Test Interpretation 2019, 321(14), 1404-1405. DOI: 10.1001/jama.2019.1178. 9. Tishkowski, K; Gupta, V. Erythrocyte sedimentation rate. In StatPearls [Internet]. StatPearls Publishing 2022. https://pubmed.ncbi.nlm.nih.gov/32491417/ https://doi.org/10.3390/cells7100161 https://doi.org/10.21123/bsj.2021.18.2.0247 https://doi.org/10.31351/vol28iss2pp134-141 https://doi.org/10.3390/cells8070700 https://doi.org/10.3390/jcm9092760 https://doi.org/10.1080/1744666X.2019.1559050 https://pubmed.ncbi.nlm.nih.gov/32491417/ IHJPAS. 37 (2) 2024 133 10. Atere, A.D.; Oseni, B.S.; Adebua, I.P.; Fapohunda, J.S.; Aigbokheo, I.F. Prognostic roles of c-reactive protein and erythrocyte sedimentation rate as acute phase reactants in mentally challenged subjects. Sudan Journal of Medical Sciences 2018, 13(4), 311-323. DOI:10.18502/sjms.v13i4.3641. 11. Assasi, N.; Blackhouse, G.; Campbell, K.; Hopkins, R.B.; Levine, M.; Richter, T.; Budden, A. 2015. Comparative value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) testing in combination versus individually for the diagnosis of undifferentiated patients with suspected inflammatory disease or serious infection: a systematic review and economic analysis. Canadian Agency for Drugs and Technologies in Health 2015, (Internet). 12. Lapić, I.; Padoan, A.; Bozzato, D.; Plebani, M. Erythrocyte sedimentation rate and C-reactive protein in acute inflammation: meta-analysis of diagnostic accuracy studies. American Journal of Clinical Pathology 2020, 153(1), 14-29. DOI: 10.1093/ajcp/aqz142. 13. Falkenburg, W.J.; Van Schaardenburg, D.; Ooijevaar-de Heer, P.; Bultink I.E.; Voskuyl, A. E.; Bentlage, A.E.; Vidarsson, G.; Wolbink, G.; Rispens, T. Anti-hinge antibodies recognize IgG subclass–and protease-restricted neoepitopes. The Journal of Immunology 2017, 198(1), 82-93. https://doi.org/10.4049/jimmunol.1601096. 14. Motta, F.; Bizzaro, N.; Giavarina, D.; Franceschini, F.; Infantino, M.; Palterer, B.; Sebastiani, G.D.; Selmi, C. Rheumatoid factor isotypes in rheumatoid arthritis diagnosis and prognosis: a systematic review and meta-analysis. RMD open. 2023, 9(3), e002817. DOI: 10.1136/rmdopen-2022-002817. 15. Van Hoovels, L.; Vander Cruyssen, B.; Sieghart, D.; Bonroy, C.; Nagy, E.; Pullerits, R.; Čučnik, S.; Dahle, C.; Heijnen, I.; Bernasconi, L.; Benkhadra, F. IgA rheumatoid factor in rheumatoid arthritis. Clinical Chemistry and Laboratory Medicine (CCLM). 2022, 60(10), 1617-1626. DOI: https://doi.org/10.1515/cclm-2022-0244. 16. Elshafie, A.I.; Elbagir, S.; Aledrissy, M.I.; Elagib, E.M.; Nur, M.A.; Rönnelid, J. Occurrence of anti- CCP2 and RF isotypes and their relation to age and disease severity among Sudanese patients with rheumatoid arthritis. Clinical Rheumatology 2019, 1(38), 1545-1553. DOI: https://doi.org/10.1007/s10067-019-04431-6. 17. Shpatz, R.; Braun-Moscovici, Y.; Balbir-Gurman, A. ACPA Antibodies Titer at the Time of Rheumatoid Arthritis Diagnosis Is Not Associated with Disease Severity. The Israel Medical Association Journal: IMAJ. 2021, 23(10), 646-650. https://pubmed.ncbi.nlm.nih.gov/34672447/ 18. Kamiya, H.; Panlaqui, O.M. Systematic review and meta-analysis of the risk of rheumatoid arthritis- associated interstitial lung disease related to anti-cyclic citrullinated peptide (CCP) antibody. BMJ open 2021, 11(3), e040465. 19. Nagy, G.; Roodenrijs, N.M.;Welsing, P.M.; Kedves, M.; Hamar, A.; Van Der Goes, M.C.; Kent, A.; Bakkers, M.; Blaas, E.; Senolt, L.; Szekanecz, Z. EULAR definition of difficult-to-treat rheumatoid arthritis. Annals of the rheumatic diseases 2021, 80(1), 31-35. DOI: https://doi.org/10.1136/bmjopen- 2020-040465. 20. Cleland, D.A.; Eranki, A.P. Procalcitonin. [Updated 2023 Apr 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing 2024. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539794/. 21. Sproston, N.R.; Ashworth, J.J. Role of C-reactive protein at sites of inflammation and infection. Frontiers in Immunology. 2018, 9, 342848. DOI: https://doi.org/10.3389/fimmu.2018.00754. 22. Galeef, E.R; Salloom, D.F. HLA-B genotype and Escherichia coli association in Iraqi patients with reactive arthritis. Iraqi Journal of Science 2016, 1648-1652. https://ijs.uobaghdad.edu.iq/index.php/eijs/article/view/7020. 23. Sultan, M. Biochemical and the Genetic Variations of Apolipoprotein E levels and Correlation with its Isoforms Polymorphism in Patients with Rheumatoid Arthritis. MSc Thesis, College of Medicine, University of Babylon 2021. 24. Baughman, R.P.; Cremers, J.P; Harmon, M.; Lower, E.E; Drent, M. Methotrexate in sarcoidosis: hematologic and hepatic toxicity encountered in a large cohort over a six year period. Sarcoidosis, https://doi.org/10.18502/sjms.v13i4.3641 https://doi.org/10.1093/ajcp/aqz142 https://doi.org/10.4049/jimmunol.1601096 https://doi.org/10.1136%2Frmdopen-2022-002817 https://doi.org/10.1515/cclm-2022-0244 https://doi.org/10.1007/s10067-019-04431-6 https://pubmed.ncbi.nlm.nih.gov/34672447/ https://doi.org/10.1136/bmjopen-2020-040465 https://doi.org/10.1136/bmjopen-2020-040465 https://www.ncbi.nlm.nih.gov/books/NBK539794/ https://doi.org/10.3389/fimmu.2018.00754 https://ijs.uobaghdad.edu.iq/index.php/eijs/article/view/7020 IHJPAS. 37 (2) 2024 134 Vasculitis, and Diffuse Lung Diseases 2020, 37(3), e2020001. DOI: https://doi.org/10.36141/svdld.v37i3.9362. 25. Salih, I.; Omran, R. The Effects of Gene Polymorphisms in Interleukin-4 on the Susceptibility of Rheumatoid Arthritis in a Iraq Population. Journal of Biotechnology Research 2018, 4(10), 76-79. DOI: doi.org/10.32861/jbr.410.76.79. 26. Mohammed, H.A. The Serum Level of DC-SIGN and Mannose Receptor in Rheumatoid Arthritis Patients. MSc. thesis college of Science for Women - University of Baghdad 2021. 27. Wu, C.Y; Yang, H.Y; Luo, S.F.; Lai, J.H. From rheumatoid factor to anti-citrullinated protein antibodies and anti-carbamylated protein antibodies for diagnosis and prognosis prediction in patients with rheumatoid arthritis. International Journal of Molecular Sciences. 2021, 22(2), 686. DOI: https://doi.org/10.3390/ijms22020686. 28. van Delft MA, Huizinga TW. An overview of autoantibodies in rheumatoid arthritis. Journal of autoimmunity. 2020, 110, 102392. DOI: https://doi.org/10.1016/j.jaut.2019.102392. 29. Ramdan, I.M.; Candra, K.P.; Lusiana, D.; Duma, K. Redesign of the Traditional Handloom for Sarong Female-Weavers Based on Anthropometric Data. Indian Journal of Public Health Research & Development 2019, 1(10), 10. DOI: https://doi.org/10.5958/0976-5506.2019.02950. 30. Abdullah, H. Evaluation of some Immunogenetic markers of Rheumatoid Arthritis in samples of Iraqi patients. A thesis Institute of Genetic Engineering and Biotechnology for postgraduate studies at Baghdad University 2010. 31. Bray C.; Bell, L.N.; Liang, H.; Haykal, R.; Kaiksow, F.; Mazza, J.J. Yale, S.H. Erythrocyte sedimentation rate and C-reactive protein measurements and their relevance in clinical medicine. WMJ : official publication of the State Medical Society of Wisconsin 2016, 115(6), 317-21. DOI: 10.18773/austprescr.2015.034. 32. Farag, M.R; Alagawany, M. Physiological alterations of poultry to the high environmental temperature. Journal of Thermal Biology. 2018, 1(76), 101-106. DOI: https://doi.org/10.1016/j.jtherbio.2018.07.012. https://doi.org/10.36141/svdld.v37i3.9362 https://doi.org/10.32861/jbr.410.76.79 https://doi.org/10.3390/ijms22020686 https://doi.org/10.1016/j.jaut.2019.102392 https://doi.org/ https://doi.org/10.18773%2Faustprescr.2015.034 https://doi.org/10.1016/j.jtherbio.2018.07.012