Overview : The vulva is a part of the female reproductive system and is also part of the external genitalia. The vulva consists of labia minora, labia majora, mons pubis, clitoris, vestibular bulb, vulval vestibule, urinary meatus the vaginal opening, hymen, and Bartholin's glands. other parts of the vulva include sebaceous glands, urogenital triangle, and pudendal cleft. Pelvic floor muscles support the structures of the vulva and vulva including the entrance to the vagina. Vulva goes through changes during childhood, puberty, menopause, and post-menopause. Structure: A) Mons pubis: it is present in both sexes and act as a cushion during sexual intercourse and is more pronounced in female. the mons pubis is a soft fatty tissue at the front of the vulva in the pubic region covering the pubic bone. the lower part of the mons pubis is divided by a fissure called pudendal cleft. it separates mons pubis and labia majora, the mons pubis, and labia majora get covered by pubic hair at pu...
Overview -
Rheumatoid arthritis is an autoimmune disorder that is characterized by inflammation of the joints. Rheumatoid arthritis typically affects smaller joints in the initial stages mainly of the hands and feet. It can affect the neck but spare the other parts of the spine and never affect the sacroiliac joints.
Rheumatoid arthritis is more common in females with a female: male ratio of 3:1. It can occur at any age but the peak incidence is in a fourth or fifth decade for females and sixth or eighth decade for males. Rheumatoid arthritis is passed on to the generations(genetic) with males being carriers of the disease in many cases. Untreated cases of rheumatoid arthritis can cause joint erosions and consequent disability of the joint.
Quick facts about rheumatoid arthritis -
1) Rheumatoid arthritis has no cure.
2)It significantly decreases life expectancy.
3)The exact cause of rheumatoid arthritis is unknown.
4)Rheumatoid arthritis is a genetic disease.
5)Heart disease is the most common cause of death in rheumatoid arthritis patients.
Symptoms of rheumatoid arthritis -
A) Joint symptoms: the symptoms of rheumatoid arthritis are variable but the joint symptoms always predominate and are often the first symptom that drives your attention. To start with a person often experience pain, tenderness, and inflammation of the affected joint followed by stiffness and swelling. joints symptoms in rheumatoid arthritis shows some specific pattern as follows:
1)Stiffness lasting for more than 30 minutes especially in the morning and after strenuous activity or long periods of inactivity is a classical sign of rheumatoid arthritis.
2)Involvement of smaller joints (joints of fingers, toes, and wrist joint) occurs first.
3)The joint involvement is symmetric in rheumatoid arthritis.
4)Rheumatoid arthritis can involve the neck but spares other parts of the spine and never affects the sacroiliac joints.
5)Nerve entrapment syndromes like carpal tunnel syndrome is a common complication that occurs in joints in rheumatoid arthritis.
B)Rheumatoid nodules: this is a relatively uncommon symptom as it is seen in only 20% of patients. Rheumatoid nodules are small nodules/masses situated over the bony surfaces under the skin. Nodules also indicate the presence of rheumatoid factors in the blood and their severity is in proportion to the levels of rheumatoid factors in the blood. Occasionally rheumatoid nodules are also seen in the lungs, sclera, and other tissues.
C)Eyes in rheumatoid arthritis: Eyes are also one of the important organs affected by rheumatoid arthritis. Typically dryness of eyes and inflammation of sclera(scleritis) are the most common manifestations. Scleral nodules are also seen in some patients.
D)Pericarditis (inflammation of the pericardium) and interstitial lung disease are the symptoms of severe rheumatoid arthritis.
E)Felty's syndrome: is the occurrence of splenomegaly(increase in the size of the spleen) and neutropenia, usually is the sign of a severe, destructive form of rheumatoid arthritis.
F)Aortitis (inflammation of the aorta) is a late and rare symptom that results in aortic regurgitation (a form of heart disease), which is also the most common cause of death in rheumatoid arthritis patients.
Diagnosis of rheumatoid arthritis -
Diagnosis of rheumatoid arthritis is made on the basis of clinical examination and laboratory findings, as there is no specific test to detect rheumatoid arthritis. following are the tests used in the diagnosis of rheumatoid arthritis:
1)Rheumatoid factor(RA factor) test - RA factor is an antibody found in 70-80% of patients with rheumatoid arthritis and is the first test advised when rheumatoid arthritis is suspected. However, it is not specific to rheumatoid arthritis.RA factor can occur in other autoimmune diseases and in some infections like hepatitis C, syphilis, and tuberculosis. Its level is directly proportional to the severity of the
disease.
2)Anti-CCP antibodies test - This is the most specific blood test for rheumatoid arthritis out of all the other tests with 95% accuracy. anti-CCP is an IgM antibody found in rheumatoid arthritis.
3)ESR and C-reactive protein - ESR and C-reactive protein levels are raised in rheumatoid arthritis. Levels of these two entities are in proportion to the disease activity.
4)X-ray changes in rheumatoid arthritis - X-ray is more sensitive than MRI and ultrasonography in the initial stages of the disease and X-ray signs in rheumatoid arthritis are more specific than the blood tests. However,x-rays taken in the first 6 months after the appearance of symptoms are normal in most cases and the earliest changes occur in hands and feet. The classical X-ray findings in rheumatoid arthritis are as follows:
a)Soft tissues swelling(swelling of tissue around the joint)
b)Decreased bone density of affected joints.
c)Joint-space narrowing
d)Joint erosion
Treatment of rheumatoid arthritis-
Treatment of rheumatoid arthritis is mainly medical and surgical treatment is needed in a small fraction of patients. Early diagnosis of the disease and prompt medical treatment play a vital role in preventing the complications. however, rheumatoid arthritis is an autoimmune disease and there is no cure for it. The medications can only give symptomatic relief and may reduce the progression of the disease to some extent if the patient is receiving regular treatment. There are some measures to understand the response of the treatment in a particular individual, the most preferred score is Disease activity score 28 joints (DAS28) by the American college of rheumatology. The objectives of treatment are :
a)Reduction of inflammation and pain in joints.
b)Reduction of the swelling and stiffness of joints.
c)Prevention of the function of a joint.
d)Prevention of joint deformity.
Surgical treatment is reserved for intractable cases and can help to improve the function of damaged joints and can also be useful in relieving pain.
Medical management is the mainstay treatment of rheumatoid arthritis, the two main classes of the drug used in the treatment are corticosteroids and the DMRDs and are used either alone or in combination.
a)Reduction of inflammation and pain in joints.
b)Reduction of the swelling and stiffness of joints.
c)Prevention of the function of a joint.
d)Prevention of joint deformity.
Surgical treatment is reserved for intractable cases and can help to improve the function of damaged joints and can also be useful in relieving pain.
Medical management is the mainstay treatment of rheumatoid arthritis, the two main classes of the drug used in the treatment are corticosteroids and the DMRDs and are used either alone or in combination.
A)Corticosteroids (steroids) -corticosteroids in the treatment of rheumatoid arthritis :
1)These are the drugs in the initial treatment plan of rheumatoid arthritis(as soon as the disease is diagnosed).
2)Started in low doses and then adjusted as per the response of the patient.
3)Steroids can never be used alone and always used in combination with the DMARDs.
4) They are used as a bridge to reduce the disease activity until the slower-acting DMRDs take effect or are used as the supportive treatment in progressing rheumatoid arthritis despite the treatment with DMARDs.
5)Intra-articular injections of steroids can be helpful when one or two joints are the chief source of the difficulty. Triamcinolone is the steroid of choice for this but, intra-articular injections should not be given more than 4 times a year.
6) Prednisone is the preferred steroid for oral use and started at low doses of 5-10mg/day.
7)When steroids are to be discontinued, they should be tapered on a planned schedule appropriate to the duration of treatment.
4) They are used as a bridge to reduce the disease activity until the slower-acting DMRDs take effect or are used as the supportive treatment in progressing rheumatoid arthritis despite the treatment with DMARDs.
5)Intra-articular injections of steroids can be helpful when one or two joints are the chief source of the difficulty. Triamcinolone is the steroid of choice for this but, intra-articular injections should not be given more than 4 times a year.
6) Prednisone is the preferred steroid for oral use and started at low doses of 5-10mg/day.
7)When steroids are to be discontinued, they should be tapered on a planned schedule appropriate to the duration of treatment.
B) DMRDs (Disease-modifying antirheumatic drugs) -
DMARDs are the most effective drugs in the treatment of rheumatoid arthritis and should be started as soon as the diagnosis is certain.DMARDs are started with the aim of suppressing the disease activity and the doses are adjusted accordingly to achieve the best results. Following DMRs are used in the treatment of rheumatoid arthritis :
1)Methotrexate: it is the DMRD of choice for patients of rheumatoid arthritis and is the best-tolerated DMRD.
# Duration of action: DMRDs are slow-acting drugs and methotrexate is no exception. Ideally, methotrexate takes 2-6 weeks to show beneficial effects.
# Dose of methotrexate: the drug is started at a dose of 7.5mg orally weekly, if there is no desired response but the patient has tolerated the drug then the dose is increased to 15mg/wk. However, the maximum dose per week should not exceed 20-25mg/wk.
# Side effects of methotrexate: Methotrexate is generally well-tolerated however, there are some side effects-
1)Gastric irritation and stomatitis
2)Leukopenia or thrombocytopenia
3)Hepatotoxicity with cirrhosis(liver)
4)Hypersensitivity to the drug
5)Interstitial pneumonitis
#Contraindications of methotrexate: Methotrexate is contraindicated (not recommended) in the following conditions -
1)Chronic hepatitis: it causes drugs to accumulate in the body and reduces the patient's response to the drug.
2)Pregnant women; as the drug can cross the placental barrier and cause serious fetal malformations.
All the patients with rheumatoid arthritis should be tested for liver function tests(LFT) before starting the LFT should be repeated every 12 weeks to monitor liver function.
# Drugs not to be given with methotrexate :
1)Amoxicillin
2)Probenecid
# Other DMARDs used in the treatment of rheumatoid arthritis are :
1)Sulfasalazine
2)Leflunomide
3)Minocycline
4)Tofacitinib
5)TNF(Tumour necrosis factor) inhibitor: eg. Etanercept, Infliximab
6)Abatacept
7)Rituximab
# DMRD combinations :7)Rituximab
Combinations of some DMRDs are generally more effective than either alone, the most preferred combination is methotrexate and TNF inhibitors.
Prognosis of rheumatoid arthritis :
Rheumatoid arthritis is a progressive disorder, drugs used in the treatment of the disease can suppress the disease activity but can not achieve remission. The disease activity is highest in the first 4-5 years and is evident in blood investigations. however, deformities occur after several years of the diagnosis and the disease is more aggressive in untreated patients. In most cases, cardiovascular disease is the final cause of death and is responsible for increased mortality rates in rheumatoid arthritis patients.
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