Skip Navigation


Rheumatology Advance Access originally published online on November 3, 2007
Rheumatology 2007 46(12):1804-1807; doi:10.1093/rheumatology/kem246
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
46/12/1804    most recent
kem246v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (9)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Dalbeth, N.
Right arrow Articles by McQueen, F. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dalbeth, N.
Right arrow Articles by McQueen, F. M.
Related Collections
Right arrow Crystal Arthritis
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The Author 2007. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Tophaceous joint disease strongly predicts hand function in patients with gout

N. Dalbeth, J. Collis, K. Gregory, B. Clark, E. Robinson and F. M. McQueen

University of Auckland, Auckland, New Zealand.

Correspondence to: N. Dalbeth, Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, Grafton, Auckland, New Zealand, E-mail: n.dalbeth{at}auckland.ac.nz


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 Acknowledgements
 References
 
Objectives. The functional impact of gout is poorly understood. The aim of this study was to determine predictors of hand function in gout.

Methods. Twenty unselected patients with gout were recruited from rheumatology clinics. No patient had an acute gout flare at assessment. Participants were assessed for clinical characteristics of gout, including the site and number of tophi. Hand function was assessed by the Sollerman hand function test. Fingertip to palm (FTP) distance measurement, grip strength and the Disability Assessment of Shoulder and Hand (DASH) questionnaire scores were also recorded. Data were analysed by simple and multiple linear regression models.

Results. The median Sollerman score was 75.5 (range 31–80). The median hand FTP distance was 2.91 (0.88–6.69) cm, grip strength was 31 (4–71) kg, and DASH score was 28.77 (0–76.47). Of the clinical characteristics measured, the number of joints of the hand with overlying tophi (hand tophus joint count) was the strongest single predictor of the Sollerman score (r2 = 0.59), and also predicted the other measures of hand mobility and function. A multiple regression model including hand tophus joint count, sex, number of gout flares in the preceding 6 months, gout disease duration and hand tender joint count was a better predictor of the Sollerman score than hand tophus joint count alone (r2 = 0.81, F4,14 = 3.94, P = 0.024).

Conclusions. Measures of chronic and poorly controlled disease predict hand function in patients with gout. In particular, tophaceous joint disease has a major impact on functional capacity in gout.

KEY WORDS: Gout, Hand function, Tophus


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 Acknowledgements
 References
 
Gout is a major cause of arthritis worldwide. This disease is characterized by deposition of monosodium urate crystals in joints and soft tissues. In early disease, gout presents as recurrent episodes of self-limiting acute inflammatory attacks (‘flares’) of arthritis. In the presence of prolonged hyperuricaemia, some patients also develop chronic tophaceous disease and erosive polyarthritis.

Numerous studies have investigated the impact of inflammatory arthropathies such as rheumatoid arthritis on functional outcomes. The presence of persistent active inflammatory disease, as indicated by pain, joint tenderness and swelling, raised inflammatory markers and radiographic damage, predicts functional impairment in rheumatoid arthritis [1–4]. In comparison, the functional impact of gout is poorly understood. Furthermore, predictors of poor functional outcome in gout are not well recognized.

Although the feet are most commonly affected by acute and chronic gout, the hands are also frequently affected. Chronic gout may lead to synovitis of the wrists and finger joints, and deposition of intra-articular and subcutaneous tophi. The aim of this study was to understand the impact of gout on objective measures of hand function, and to determine predictors of poor hand function in patients with this disease.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 Acknowledgements
 References
 
Twenty patients with gout were recruited from rheumatology clinics at Auckland District Health Board and Counties Manukau District Health Board, Auckland, New Zealand from November 2005 to February 2006. The inclusion criteria were previous diagnosis of acute gout by a physician as defined by the Wallace classification for gout [5] and ability to provide written informed consent. Women of childbearing age were excluded from the study (due to the potential risks of radiographs in pregnancy). Patients with acute gout flares (as defined by marked tenderness, swelling and erythema of at least one joint) were also excluded. The Northern Regional X Ethics Committee approved this study. All patients provided written informed consent before inclusion into the study.

The patients were assessed to obtain clinical characteristics, including the number of tophi. The number of individual tophi on the hands was counted, and their position recorded on hand diagrams. All visible tophi were recorded, irrespective of size. Digital photographs of the hands were also obtained. Patients reported the level of pain experienced over the past week using a visual analogue scale (100 mm scale). Blood was obtained for measurement of serum urate, C-reactive protein and creatinine.

Plain radiographs of both hands were obtained on the same day as the clinical and hand function assessments. These radiographs were independently scored using a newly developed gout radiographic damage index by a rheumatologist (N.D.) and a radiologist (B.C.), both of whom were blinded to the hand function assessments. Inter-observer intraclass correlation coefficient for this score was 0.965 (0.915–0.986). The two sets of values were averaged to obtain the final scores. We have recently validated this index as an accurate and reliable measure of joint damage in gout [6]. This index includes the Sharp/van der Heijde scoring method for erosion and joint space narrowing in rheumatoid arthritis, with additional scoring of the hand distal interphalangeal joints.

Assessment of hand function was performed by a rheumatology occupational therapist (OT) who was blinded to the clinical and radiology findings. The OT administered the Sollerman hand function test, a validated objective measure of hand function [7]. In this test, patients are examined on their ability to perform 20 everyday tasks, testing seven of the eight most common hand grips. Grip capabilities are tested with simple activities such as turning a door handle, picking up coins, using a screwdriver and doing up a zip. A score of 0–4 is given depending on the time and ease with which each task was completed, with a total score out of 80 (maximum score indicating full hand function). The dominant hand Sollerman score was used for the analysis.

The OT also recorded fingertip to palm (FTP) flexion distance for each finger (to the distal palmar crease). The mean FTP distance for all fingers was used for the analysis. Grip strength was measured using a Jamar hand dynamometer (kindly provided by Surgical Synergies Ltd, NZ). The dominant hand grip strength was used for the analysis.

Subjective hand disability was measured using the Disabilities of Assessment Shoulder and Hand questionnaire (DASH) [8]. This is a validated self-administered questionnaire of 30 questions relating to symptoms and general function of the upper extremities. The questionnaire is scored from 0 to 100, with a score of 100 indicating maximum disability.

All patients completed the 20-item Health Assessment Questionnaire Disability Index (HAQ-DI) in English as described by Fries [9]. This self-report questionnaire examines eight key domains of activities of daily living (dressing and grooming, arising, eating, walking, hygiene, reach, grip, activities). Each domain is scored 0–3, with the sum of all domains divided by 8 to provide a HAQ-DI score ranging from 0 (no disability) to 3 (severe disability) on an ordinal scale.

The Medical Outcomes Study Short Form 36 (SF-36) questionnaire was also completed by all participants [10]. This is a validated self-report questionnaire that measures eight domains (physical functioning, physical roles, emotional roles, bodily pain, general health, vitality, social functioning and mental health). Each domain ranges from 0 (severe disability) to 100 (no disability).

Medians with ranges and percentages are used to describe the clinical characteristics and hand function of participants. Spearman correlations were used to describe the associations between variables. The Sollerman score was transformed to satisfy the assumptions of normality in regression models. Multiple regression was used to investigate the clinical variables that predicted hand function variables in this sample of patients. The r2-values were used to compare models with subsets with the same number of predictors and F-test statistics were calculated to compare nested models. Variables included in the model were selected based on three separate criteria. First, variables that influence hand function in the general population: age, sex, diagnosis of diabetes mellitus and renal function (as represented by serum creatinine) [11, 12]. Second, variables representing severity of gout disease activity: gout disease duration, number of gout flares in the preceding 6 months, number of tophi overall, the number of joints of the hand with overlying tophi (hand tophus joint count) and serum urate level. Finally, variables that have been associated with poor functional status in other forms of arthritis were selected; tender joint count, pain visual analogue score, radiographic erosion scores and C-reactive protein [2, 13, 14].


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 Acknowledgements
 References
 
Baseline characteristics and hand function assessments
The clinical characteristics of the patients have been reported previously [15] and are summarized in Table 1. The majority of patients (16/20, 80%) had some tophaceous disease. Most (14/16, 88%) of the patients with tophaceous disease had at least one hand tophus. The overall hand function assessments are also summarized in Table 1. There was impairment of hand function in the study group overall, with a median Sollerman score measuring 75.5 (range 31–80).


View this table:
[in this window]
[in a new window]

  		TABLE 1. Baseline data and functional assessments

 
Relationship between hand mobility and function measures in gout
Spearman correlation analysis indicated that the measures of hand mobility and function were strongly related to each other (Table 2). In addition, these measures were strongly associated with measures of overall physical disability, such as the HAQ-DI and the SF-36 physical function score (Table 2).


View this table:
[in this window]
[in a new window]

  		TABLE 2. Spearman correlations among measures of hand scores and overall measures of physical disability

 
Predictors of hand mobility and function scores
Initial correlation analysis showed that a number of clinical variables were associated with the Sollerman score. These variables were gout disease severity measures such as serum urate concentration (rs = –0.59, P = 0.006), number of gout flares in the preceding 6 months (rs = –0.61, P = 0.004), the total number of tophi (rs = –0.86, P < 0.0001) and the number of joints of the hand with overlying tophi (hand tophus joint count) (rs = –0.88, P < 0.0001) (Fig. 1). Arthritis severity measures were also correlated with the Sollerman score; pain visual analogue scale (rs = –0.71, P = 0.0004), hand tender joint count (rs = –0.67, P = 0.001) and radiographic damage score (rs = –0.71, P = 0.0005). In univariate correlation analysis, age, sex, serum creatinine, diabetes mellitus, gout disease duration and C-reactive protein did not correlate with hand function as measured by the Sollerman test.


Figure 1
View larger version (7K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		FIG. 1. Correlations between hand tophus joint count and hand function measures.

 
The number of joints of the hand with overlying tophi (hand tophus joint count) was found to be the best single predictor of the Sollerman score (r2 = 0.59, Table 3). There was a relationship between the hand tophus joint count and other measures of gout severity such as serum urate concentration (rs = 0.53, P = 0.016), number of gout flares in the preceding 6 months (rs = 0.63, P = 0.003) and the total number of tophi (rs = 0.95, P < 0.001), and also measures of arthritis severity such as pain visual analogue scale (rs = 0.83, P < 0.001), hand tender joint count (rs = 0.77, P < 0.001) and radiographic damage (rs = 0.71, P < 0.001). However, in multiple regression analysis, the hand tophus joint count predicted the Sollerman score after adjusting for each of these variables.


View this table:
[in this window]
[in a new window]

  		TABLE 3. Regression models to predict the Sollerman score

 
Although the hand tophus joint count was the best single predictor of the Sollerman score, a multiple regression model including hand tophus joint count, sex, number of gout flares in the preceding 6 months, gout disease duration and hand tender joint count was a better predictor than hand tophus joint count alone (Table 3, F4,14 = 3.94, P = 0.024). Adding further variables did not increase the fit of the model.

Similar results were found with the other measures of hand mobility and function (Fig. 1). The hand tophus joint count was the strongest single predictor of both the FTP distance measurement and grip strength (r2 = 0.66 and 0.55, respectively). For the DASH, hand tender joint count and the pain visual analogue scale were better single predictors (r2 = 0.49 and 0.48, respectively). The hand tophus joint count was a weaker single predictor of the DASH score (r2 = 0.36).


   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
Acknowledgements
 References
 
This work has demonstrated that tophaceous joint disease is a major independent predictor of hand function in patients with gout. Furthermore, other measures of gout disease severity such as disease duration and frequency of gout flares further contribute to hand function. In this study, most patients with tophaceous disease had tophi involving the hands. This observation, together with the analysis of hand function in this patient group, suggests that impairment of hand function is a frequent occurrence in patients with chronic tophaceous gout.

The key predictor of hand function was the number of joints of the hand with overlying tophi (hand tophus joint count). This finding may indicate that individuals with fewer tophi in the hand retain a greater diversity of grips, greater grip strength and can adapt by using unaffected fingers or the contralateral hand. As tophi increase in size and number and more joints become involved, the ability to adapt diminishes. Tophi may influence joint function in a number of ways; by joint damage, associated synovitis and/or mechanical obstruction to joint movement. Although radiographic damage did correlate with the Sollerman score in this study, the hand tophus joint count independently predicted the Sollerman score, even after adjusting for radiographic damage scores. Similarly, it is unlikely that synovitis related to intra-articular uric acid deposits completely explains the observed relationship, as the hand tophus joint count independently predicted the Sollerman score, even after adjusting for pain scores and tender joint counts. Furthermore, patients with signs of active synovitis were excluded from the study, and there was no significant relationship between C-reactive protein and Sollerman scores.

The observation that mean FTP measurements are strongly associated with other measures of hand function and also the hand tophus joint count is in keeping with the clinical observation that tophaceous involvement of the hands frequently leads to fixed contractures of the fingers that in turn impact on hand function. Mechanical obstruction to joint movement by tophi may lead to subsequent reduced grip strength, loss of dexterity and poor in-hand manipulation. Fixed contractures result in stiff extended fingers that are unable to conform to the shape of objects when grasping (for example, the ability to hold a hammer, pick up a glass, grasp cutlery or carry a bag would be impeded). With loss of finger flexion pinch grips are also affected; these grips are essential for dexterous tasks such as writing, undoing lids, picking up and holding small objects.

As in patients with RA [16], the measures of hand mobility and function used in this study of patients with gout generally correlated well with one another, and with measures of overall physical function. Although hand tophus joint count strongly predicted all measures of hand mobility and function, there were some differences in the predictors of objective measures of hand function and mobility (Sollerman score, FTP distance and grip strength), and the subjective measure of hand disability (DASH score). In particular, pain and joint tenderness were stronger predictors of subjective hand disability. This finding may be due to the guarding and protective strategies that are employed by individuals with joint pain. It is interesting to note that tender joint count was a contributor to hand function, despite the exclusion of patients with acute gout flares. This observation may be explained by low-grade chronic inflammation present in patients with chronic tophaceous disease.

We recognize that this study has some limitations, particularly the small sample size and recruitment from secondary care clinics. Although this is a small study, the relationship between hand function measures and tophaceous joint disease was clearly and consistently demonstrated, emphasizing the strength of the relationship. The patients were recruited from secondary care rheumatology clinics, rather than primary care where many patients with gout are treated, and thus may not be representative of the overall population of gout patients. The serum urate concentrations in the study patients were high despite urate-lowering therapy, consistent with severe treatment-resistant gout that is more often observed in secondary care clinics. Despite this, we believe that the results have relevance to specialist rheumatologists working in secondary care and also primary care physicians treating patients with gout.

In addition to the development of tophaceous disease, gout is characterized by recurrent episodes of severe joint inflammation. In this study, patients with acute gout flares were excluded, in an attempt to explore the impact of gout on usual joint function. It is likely that further deterioration of joint function occurs at the time of gout flares. Further work to understand the impact of gout flares on hand and general musculoskeletal function will be of great interest.

Lowering of serum urate levels to <0.36 mmol/l is key in achieving tophus regression and also reducing the frequency of gout flares [17, 18]. However, the impact of effective urate-lowering therapy on musculoskeletal function has not been demonstrated. Measures of chronic and poorly controlled gout were major predictors of hand function in this study. Although this study did not specifically address the impact of therapy on hand function, our data suggest that intensive early treatment of gout with effective urate-lowering medication may play a major role in preventing the functional consequences of gout. Further prospective studies are needed to specifically address this issue.

In summary, tophaceous disease of the hand strongly predicts impairment of hand mobility and function. These data emphasize the impact of tophaceous gout on functional capacity, and argue for intensive treatment to prevent development of tophaceous disease and its associated functional consequences.

Formula


   Acknowledgements
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Acknowledgements
References
 
We wish to acknowledge Sharon Rudkin from Surgical Synergies Ltd for the loan of the Jamar hand dynamometer. N.D. is funded by the Health Research Council of New Zealand. K.G. was the recipient of a Maurice and Phyllis Paykel Summer Studentship.

Funding: This project was funded by the Auckland Regional Rheumatology Trust.

Disclosure statement: The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Acknowledgements
 References
 

  1. Vliet Vlieland TP, van der Wijk TP, Jolie IM, Zwinderman AH, Hazes JM. Determinants of hand function in patients with rheumatoid arthritis. J Rheumatol (1996) 23:835–40.[Web of Science][Medline]
  2. Fraser A, Vallow J, Preston A, Cooper RG. Predicting ‘normal’ grip strength for rheumatoid arthritis patients. Rheumatology (1999) 38:521–8.[Abstract/Free Full Text]
  3. Combe B, Cantagrel A, Goupille P, et al. Predictive factors of 5-year health assessment questionnaire disability in early rheumatoid arthritis. J Rheumatol (2003) 30:2344–9.[Abstract/Free Full Text]
  4. Molenaar ET, Voskuyl AE, Dijkmans BA. Functional disability in relation to radiological damage and disease activity in patients with rheumatoid arthritis in remission. J Rheumatol (2002) 29:267–70.[Abstract/Free Full Text]
  5. Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yu TF. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum (1977) 20:895–900.[Web of Science][Medline]
  6. Dalbeth N, Clark B, McQueen FM, Doyle A, Taylor WJ. Validation of a radiographic damage index in chronic gout; a modified Sharp/van der Heijde score accurately and reliably represents joint damage. Arthritis Rheum (2007) 57:1067–73.[CrossRef][Web of Science][Medline]
  7. Sollerman C, Ejeskar A. Sollerman hand function test. A standardised method and its use in tetraplegic patients. Scand J Plast Reconstr Surg Hand Surg (1995) 29:167–76.[Web of Science][Medline]
  8. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C. Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. J Hand Ther (2001) 14:128–46.[Medline]
  9. Fries JF, Spitz PW, Young DY. The dimensions of health outcomes: the health assessment questionnaire, disability and pain scales. J Rheumatol (1982) 9:789–93.[Web of Science][Medline]
  10. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care (1992) 30:473–83.[Web of Science][Medline]
  11. Cetinus E, Buyukbese MA, Uzel M, Ekerbicer H, Karaoguz A. Hand grip strength in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract (2005) 70:278–86.[CrossRef][Web of Science][Medline]
  12. Limaye V, Frankham A, Disney A, Pile K. Evaluation of hand function in patients undergoing long term haemodialysis. Ann Rheum Dis (2001) 60:278–80.[Abstract/Free Full Text]
  13. Bagis S, Sahin G, Yapici Y, Cimen OB, Erdogan C. The effect of hand osteoarthritis on grip and pinch strength and hand function in postmenopausal women. Clin Rheumatol (2003) 22:420–4.[CrossRef][Web of Science][Medline]
  14. Zheng S, Robinson E, Yeoman S, et al. MRI bone oedema predicts eight year tendon function at the wrist but not the requirement for orthopaedic surgery in rheumatoid arthritis. Ann Rheum Dis (2006) 65:607–11.[Abstract/Free Full Text]
  15. Dalbeth N, Clark B, Gregory K, Gamble GD, Doyle A, McQueen FM. Computed tomography measurement of tophus volume: comparison with physical measurement. Arthritis Rheum (2007) 57:461–5.[CrossRef][Web of Science][Medline]
  16. Dellhag B, Burckhardt CS. Predictors of hand function in patients with rheumatoid arthritis. Arthritis Care Res (1995) 8:16–20.[Medline]
  17. Shoji A, Yamanaka H, Kamatani N. A retrospective study of the relationship between serum urate level and recurrent attacks of gouty arthritis: evidence of reduction of recurrent gouty arthritis with antihyperuricemic therapy. Arthritis Rheum (2004) 51:321–5.[CrossRef][Web of Science][Medline]
  18. Perez-Ruiz F, Calabozo M, Pijoan JI, Herrero-Beites AM, Ruibal A. Effect of urate-lowering therapy on the velocity of size reduction of tophi in chronic gout. Arthritis Rheum (2002) 47:356–60.[CrossRef][Web of Science][Medline]
Submitted 28 June 2007; Accepted 9 August 2007


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Therapeutic Advances in Musculoskeletal DiseasesHome page
L. X. Chen and H. R. Schumacher
Febuxostat treatment for gout: what the clinician needs to know
Therapeutic Advances in Musculoskeletal Diseases, December 1, 2009; 1(2): 67 - 69.
[Abstract] [PDF]

Home page
 Rheumatology (Oxford)Home page
J. D. Carter, R. P. Kedar, S. R. Anderson, A. H. Osorio, N. L. Albritton, S. Gnanashanmugam, J. Valeriano, F. B. Vasey, and L. R. Ricca
An analysis of MRI and ultrasound imaging in patients with gout who have normal plain radiographs
Rheumatology, November 1, 2009; 48(11): 1442 - 1446.
[Abstract] [Full Text] [PDF]

Home page
 The Journal of RheumatologyHome page
R. GRAINGER, W. J. TAYLOR, N. DALBETH, F. PEREZ-RUIZ, J. A. SINGH, R. W. WALTRIP, N. SCHLESINGER, R. EVANS, N. L. EDWARDS, F. SIVERA, et al.
Progress in Measurement Instruments for Acute and Chronic Gout Studies
J Rheumatol, October 1, 2009; 36(10): 2346 - 2355.
[Abstract] [Full Text] [PDF]

Home page
 Rheumatology (Oxford)Home page
N. Dalbeth and T. Merriman
Crystal ball gazing: new therapeutic targets for hyperuricaemia and gout
Rheumatology, March 1, 2009; 48(3): 222 - 226.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
46/12/1804    most recent
kem246v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (9)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Dalbeth, N.
Right arrow Articles by McQueen, F. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dalbeth, N.
Right arrow Articles by McQueen, F. M.
Related Collections
Right arrow Crystal Arthritis
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?