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http://www.medicinenet.com/rheumatoid_arthritis/article.htm

What is rheumatoid arthritis?

Rheumatoid arthritis is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body tissues are mistakenly attacked by its own immune system. The immune system is a complex organization of cells and antibodies designed normally to “seek and destroy” invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.

While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. Typically, however, rheumatoid arthritis is a progressive illness that has the potential to cause joint destruction and functional disability.

Normal and Arthritic Joints Illustration - Rheumatoid ArthritisA joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles.

In some patients with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early in the disease and be progressive. Moreover, studies have shown that the progressive damage to the joints does not necessarily correlate with the degree of pain, stiffness, or swelling present in the joints.

Rheumatoid arthritis is a common rheumatic disease, affecting approximately 1.3 million people in the United States, according to current census data. The disease is three times more common in women as in men. It afflicts people of all races equally. The disease can begin at any age, but it most often starts after age 40 and before 60. In some families, multiple members can be affected, suggesting a genetic basis for the disorder.

What causes rheumatoid arthritis?

The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. Some scientists believe that the tendency to develop rheumatoid arthritis may be genetically inherited. It is suspected that certain infections or factors in the environment might trigger the immune system to attack the body’s own tissues, resulting in inflammation in various organs of the body such as the lungs or eyes.

Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF and interleukin-1/IL-1) are expressed in the inflamed areas.

Environmental factors also seem to play some role in causing rheumatoid arthritis. Recently, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.

What are the symptoms of rheumatoid arthritis?

The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment, and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and patients generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies from patient to patient, and periods of flares and remissions are typical.

When the disease is active, symptoms can include fatigue, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).

In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs and opening jars can become difficult during flares. The small joints of the feet are also commonly involved. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of voice.

Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren’s syndrome. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing or coughing. The lung tissue itself can also become inflamed, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with an enlarged spleen (referred to as Felty’s syndrome) and can increase the risk of infections. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected. A rare, serious complication, usually with long-standing rheumatoid disease, is blood-vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.

How is rheumatoid arthritis diagnosed?

The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. The doctor reviews the history of symptoms, examines the joints for inflammation and deformity, the skin for rheumatoid nodules, and other parts of the body for inflammation. Certain blood and x-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and x-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis and related diseases is called a rheumatologist.

The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above), most often around the elbows and fingers, can suggest the diagnosis.

Abnormal blood antibodies can be found in patients with rheumatoid arthritis. A blood antibody called “rheumatoid factor” can be found in 80% of patients. Citrulline antibody (also referred to as anti-citrulline antibody, anti-cyclic citrullinated peptide antibody, and anti-CCP) is present in most patients with rheumatoid arthritis. It is useful in the diagnosis of rheumatoid arthritis when evaluating patients with unexplained joint inflammation. A test for citrulline antibodies is most helpful in looking for the cause of previously undiagnosed inflammatory arthritis when the traditional blood test for rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies have been felt to represent the earlier stages of rheumatoid arthritis in this setting. Another antibody called “the antinuclear antibody” (ANA) is also frequently found in patients with rheumatoid arthritis.

A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is used as a crude measure of the inflammation of the joints. The sed rate is usually faster during disease flares and slower during remissions. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis.

Joint x-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses x-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint x-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive test procedure, can demonstrate the inflamed joints.

The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. Analysis of the joint fluid, in the laboratory, can help to exclude other causes of arthritis, such as infection and gout. Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally, cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms.

How is rheumatoid arthritis treated?

There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as seen on x-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.

Two classes of medications are used in treating rheumatoid arthritis: fast-acting “first-line drugs” and slow-acting “second-line drugs” (also referred to as disease-modifying antirheumatic drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate and hydroxychloroquine (Plaquenil) promote disease remission and prevent progressive joint destruction, but they are not antiinflammatory agents.

The degree of destructiveness of rheumatoid arthritis varies from patient to patient. Patients with uncommon, less destructive forms of the disease or disease that has quieted after years of activity (“burned out” rheumatoid arthritis) can be managed with rest, pain and antiinflammatory medications alone. In general, however, patients improve function and minimize disability and joint destruction when treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis. Most patients require more aggressive second-line drugs, such as methotrexate, in addition to antiinflammatory agents. Sometimes these second-line drugs are used in combination. In some patients with severe joint deformity, surgery may be necessary.

“First-line” drugs

Acetylsalicylate (Aspirin), naproxen (Naprosyn), ibuprofen (Advil, Medipren, Motrin), and etodolac (Lodine) are examples of nonsteroidal antiinflammatory drugs (NSAIDs). NSAIDs are medications that can reduce tissue inflammation, pain, and swelling. NSAIDs are not cortisone. Aspirin, in doses higher than that used in treating headaches and fever, is an effective antiinflammatory medication for rheumatoid arthritis. Aspirin has been used for joint problems since the ancient Egyptian era. The newer NSAIDs are just as effective as aspirin in reducing inflammation and pain and require fewer dosages per day. Patients’ responses to different NSAID medications vary. Therefore, it is not unusual for a doctor to try several NSAID drugs in order to identify the most effective agent with the fewest side effects. The most common side effects of aspirin and other NSAIDs include stomach upset, abdominal pain, ulcers, and even gastrointestinal bleeding. In order to reduce stomach side effects, NSAIDs are usually taken with food. Additional medications are frequently recommended to protect the stomach from the ulcer effects of NSAIDs. These medications include antacids, sucralfate (Carafate), proton-pump inhibitors (Prevacid, and others), and misoprostol (Cytotec).

Corticosteroid medications can be given orally or injected directly into tissues and joints. They are more potent than NSAIDs in reducing inflammation and in restoring joint mobility and function. Corticosteroids are useful for short periods during severe flares of disease activity or when the disease is not responding to NSAIDs. However, corticosteroids can have serious side effects, especially when given in high doses for long periods of time. These side effects include weight gain, facial puffiness, thinning of the skin and bone, easy bruising, cataracts, risk of infection, muscle wasting, and destruction of large joints, such as the hips. Corticosteroids also carry some increased risk of contracting infections. These side effects can be partially avoided by gradually tapering the doses of corticosteroids as the patient achieves improvement of the disease. Abruptly discontinuing corticosteroids can lead to flares of the disease or other symptoms of corticosteroid withdrawal and is discouraged. Thinning of the bones due to osteoporosis may be prevented by calcium and vitamin D supplements. For further information on corticosteroids, please read the article on prednisone.

“Second-line” or “slow-acting” drugs
(Disease-modifying anti-rheumatic drugs or DMARDs)

While “first-line” medications (NSAIDs and corticosteroids) can relieve joint inflammation and pain, they do not necessarily prevent joint destruction or deformity. Rheumatoid arthritis requires medications other than NSAIDs and corticosteroids to stop progressive damage to cartilage, bone, and adjacent soft tissues. The medications needed for ideal management of the disease are also referred to as disease-modifying anti-rheumatic drugs or DMARDs. They come in a variety of forms and are listed below. These “second-line” or “slow-acting” medicines may take weeks to months to become effective. They are used for long periods of time, even years, at varying doses. If effective, DMARDs can promote remission, thereby retarding the progression of joint destruction and deformity. Sometimes a number of second-line medications are used together as combination therapy. As with the first-line medications, the doctor may need to use different second-line medications before treatment is optimal.

Recent research suggests that patients who respond to a DMARD with control of the rheumatoid disease may actually decrease the known risk (small but real) of lymphoma that exists from simply having rheumatoid arthritis. The DMARDs are reviewed next.

Hydroxychloroquine (Plaquenil) is related to quinine and is also used in the treatment of malaria. It is used over long periods for the treatment of rheumatoid arthritis. Possible side effects include upset stomach, skin rashes, muscle weakness, and vision changes. Even though vision changes are rare, patients taking Plaquenil should be monitored by an eye doctor (ophthalmologist).

Sulfasalazine (Azulfidine) is an oral medication traditionally used in the treatment of mild to moderately severe inflammatory bowel diseases, such as ulcerative colitis and Crohn’s colitis. Azulfidine is used to treat rheumatoid arthritis in combination with antiinflammatory medications. Azulfidine is generally well tolerated. Common side effects include rash and upset stomach. Because Azulfidine is made up of sulfa and salicylate compounds, it should be avoided by patients with known sulfa allergies.

Methotrexate has gained popularity among doctors as an initial second-line drug because of both its effectiveness and relatively infrequent side effects. It also has an advantage in dose flexibility (dosages can be adjusted according to needs). Methotrexate is an immune-suppression drug. It can affect the bone marrow and the liver, even rarely causing cirrhosis. All patients taking methotrexate require regular blood-test monitoring of blood counts and liver function blood tests.

Gold salts have been used to treat rheumatoid arthritis throughout most of the past century. Gold thioglucose (Solganal) and gold thiomalate (Myochrysine) are given by injection, initially on a weekly basis for months to years. Oral gold, auranofin (Ridaura), was introduced in the 1980s. Side effects of gold (oral and injectable) include skin rash, mouth sores, kidney damage with leakage of protein in the urine, and bone marrow damage with anemia and low white-cell count. Patients receiving gold treatment are regularly monitored with blood and urine tests. Oral gold can cause diarrhea. These gold drugs have lost such favor that many companies no longer manufacture them.

D-penicillamine (Depen, Cuprimine) can be helpful in selected patients with progressive forms of rheumatoid arthritis. Side effects are similar to those of gold. They include fever, chills, mouth sores, a metallic taste in the mouth, skin rash, kidney and bone marrow damage, stomach upset, and easy bruising. Patients on this medication require routine blood and urine tests. D-penicillamine can rarely cause symptoms of other autoimmune diseases.

Immunosuppressive medicines are powerful medications that suppress the body’s immune system. A number of immunosuppressive drugs are used to treat rheumatoid arthritis. They include methotrexate (Rheumatrex, Trexall) as described above, azathioprine (Imuran), cyclophosphamide (Cytoxan), chlorambucil (Leukeran), and cyclosporine (Sandimmune). Because of potentially serious side effects, immunosuppressive medicines (other than methotrexate) are generally reserved for patients with very aggressive disease or those with serious complications of rheumatoid inflammation, such as blood vessel inflammation (vasculitis). The exception is methotrexate, which is not frequently associated with serious side effects and can be carefully monitored with blood testing. Methotrexate has become a preferred second-line medication as a result.

Immunosuppressive medications can depress bone-marrow function and cause anemia, a low white-cell count, and low platelet counts. A low white count can increase the risk of infections, while a low platelet count can increase the risk of bleeding. Methotrexate rarely can lead to liver cirrhosis and allergic reactions in the lung. Cyclosporin can cause kidney damage and high blood pressure. Because of potentially serious side effects, immunosuppressive medications are used in low doses, usually in combination with antiinflammatory agents.

Newer treatments

Newer “second-line” drugs for the treatment of rheumatoid arthritis include leflunomide (Arava) and the “biologic” medications etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), adalimumab (Humira), rituximab (Rituxan), and abatacept (Orencia).

Leflunomide (Arava) is available to relieve the symptoms and halt the progression of the disease. It seems to work by blocking the action of an important enzyme that has a role in immune activation. Arava can cause liver disease, diarrhea, hair loss, and/or rash in some patients. It should not be taken just before or during pregnancy because of possible birth defects.

Other medications that represent a novel approach to the treatment of rheumatoid arthritis and are the products of modern biotechnology. These are referred to as the biologic medications or biological response modifiers. In comparison with traditional DMARDs, the biologic medications have a much more rapid onset of action and can have powerful effects on stopping progressive joint damage. In general, their methods of action are also more directed, defined, and targeted.

Etanercept, infliximab, and adalimumab are biologic medications. These medications intercept a protein in the joints (tumor necrosis factor or TNF) that causes inflammation before it can act on its natural receptor to “switch on ” inflammation. This effectively blocks the TNF inflammation messenger from calling out to the cells of inflammation. Symptoms can be significantly, and often rapidly, improved in patients using these drugs. Etanercept must be injected subcutaneously once or twice a week. Infliximab is given by infusion directly into a vein (intravenously). Adalimumab is injected subcutaneously either every other week or weekly. Each of these medications will be evaluated by doctors in practice to determine what role they may have in treating various stages of rheumatoid arthritis. Research has shown that biological response modifiers also prevent the progressive joint destruction of rheumatoid arthritis. They are currently recommended for use after other second-line medications have not been effective. The biological response modifiers (TNF-inhibitors) are expensive treatments. They are also frequently used in combination with methotrexate and other DMARDs. Furthermore, it should be noted that the TNF-blocking biologics all are more effective when combined with methotrexate.

Anakinra is another biologic treatment that is used to treat moderate to severe rheumatoid arthritis. Anakinra works by binding to a cell messenger protein (IL-1, a proinflammation cytokine). Anakinra is injected under the skin daily. Anakinra can be used alone or with other DMARDs. The response rate of anakinra does not seem to be as high as with other biologic medications.

Rituxan is an antibody that was first used to treat lymphoma, a cancer of the lymph nodes. Rituxan can be effective in treating autoimmune diseases like rheumatoid arthritis because it depletes B-cells, which are important cells of inflammation and in producing abnormal antibodies that are common in these conditions. Rituxan is now available to treat moderate to severely active rheumatoid arthritis in patients who have failed the TNF-blocking biologics. Preliminary studies have shown that Rituxan was also found to be beneficial in treating severe rheumatoid arthritis complicated by blood vessel inflammation (vasculitis) and cryoglobulinemia.

Orencia is a recently developed biologic medication that blocks T-cell activation. Orencia is now available to treat adult patients who have failed a traditional DMARD or TNF-blocking biologic medication.

While biologic medications are often combined with traditional DMARDs in the treatment of rheumatoid arthritis, they are generally not used with other biologic medications because of unacceptable risk for serious infections.

The Prosorba column therapy involves pumping blood drawn from a vein in the arm into an apheresis machine or cell separator. This machine separates the liquid part of the blood (the plasma) from the blood cells. The Prosorba column is a plastic cylinder about the size of a coffee mug that contains a sand-like substance coated with a special material called Protein A. Protein A is unique in that it binds unwanted antibodies from the blood that promote the arthritis. The Prosorba column works to counter the effect of these harmful antibodies. The Prosorba column is indicated to reduce the signs and symptoms of moderate to severe rheumatoid arthritis in adult patients with long-standing disease who have failed or are intolerant to disease-modifying anti-rheumatic drugs (DMARDs). The exact role of this treatment is being evaluated by doctors, and it is not commonly used currently.

Newer treatments

Newer “second-line” drugs for the treatment of rheumatoid arthritis include leflunomide (Arava) and the “biologic” medications etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), adalimumab (Humira), rituximab (Rituxan), and abatacept (Orencia).

Leflunomide (Arava) is available to relieve the symptoms and halt the progression of the disease. It seems to work by blocking the action of an important enzyme that has a role in immune activation. Arava can cause liver disease, diarrhea, hair loss, and/or rash in some patients. It should not be taken just before or during pregnancy because of possible birth defects.

Other medications that represent a novel approach to the treatment of rheumatoid arthritis and are the products of modern biotechnology. These are referred to as the biologic medications or biological response modifiers. In comparison with traditional DMARDs, the biologic medications have a much more rapid onset of action and can have powerful effects on stopping progressive joint damage. In general, their methods of action are also more directed, defined, and targeted.

Etanercept, infliximab, and adalimumab are biologic medications. These medications intercept a protein in the joints (tumor necrosis factor or TNF) that causes inflammation before it can act on its natural receptor to “switch on ” inflammation. This effectively blocks the TNF inflammation messenger from calling out to the cells of inflammation. Symptoms can be significantly, and often rapidly, improved in patients using these drugs. Etanercept must be injected subcutaneously once or twice a week. Infliximab is given by infusion directly into a vein (intravenously). Adalimumab is injected subcutaneously either every other week or weekly. Each of these medications will be evaluated by doctors in practice to determine what role they may have in treating various stages of rheumatoid arthritis. Research has shown that biological response modifiers also prevent the progressive joint destruction of rheumatoid arthritis. They are currently recommended for use after other second-line medications have not been effective. The biological response modifiers (TNF-inhibitors) are expensive treatments. They are also frequently used in combination with methotrexate and other DMARDs. Furthermore, it should be noted that the TNF-blocking biologics all are more effective when combined with methotrexate.

Anakinra is another biologic treatment that is used to treat moderate to severe rheumatoid arthritis. Anakinra works by binding to a cell messenger protein (IL-1, a proinflammation cytokine). Anakinra is injected under the skin daily. Anakinra can be used alone or with other DMARDs. The response rate of anakinra does not seem to be as high as with other biologic medications.

Rituxan is an antibody that was first used to treat lymphoma, a cancer of the lymph nodes. Rituxan can be effective in treating autoimmune diseases like rheumatoid arthritis because it depletes B-cells, which are important cells of inflammation and in producing abnormal antibodies that are common in these conditions. Rituxan is now available to treat moderate to severely active rheumatoid arthritis in patients who have failed the TNF-blocking biologics. Preliminary studies have shown that Rituxan was also found to be beneficial in treating severe rheumatoid arthritis complicated by blood vessel inflammation (vasculitis) and cryoglobulinemia.

Orencia is a recently developed biologic medication that blocks T-cell activation. Orencia is now available to treat adult patients who have failed a traditional DMARD or TNF-blocking biologic medication.

While biologic medications are often combined with traditional DMARDs in the treatment of rheumatoid arthritis, they are generally not used with other biologic medications because of unacceptable risk for serious infections.

The Prosorba column therapy involves pumping blood drawn from a vein in the arm into an apheresis machine or cell separator. This machine separates the liquid part of the blood (the plasma) from the blood cells. The Prosorba column is a plastic cylinder about the size of a coffee mug that contains a sand-like substance coated with a special material called Protein A. Protein A is unique in that it binds unwanted antibodies from the blood that promote the arthritis. The Prosorba column works to counter the effect of these harmful antibodies. The Prosorba column is indicated to reduce the signs and symptoms of moderate to severe rheumatoid arthritis in adult patients with long-standing disease who have failed or are intolerant to disease-modifying anti-rheumatic drugs (DMARDs). The exact role of this treatment is being evaluated by doctors, and it is not commonly used currently.

Future treatments

Scientists throughout the world are studying many promising areas of new treatment approaches for rheumatoid arthritis. These areas include treatments that block the action of the special inflammation factors, such as tumor necrosis factor (TNFalpha) and interleukin-1 (IL-1), as described above. Also, biologic medications that block interleukin-6 (IL-6) have been shown by researchers to be of benefit in treating rheumatoid arthritis. Many other drugs are being developed that act against certain critical white blood cells involved in rheumatoid inflammation. Also, new NSAIDs with mechanisms of action that are different from current drugs are on the horizon.

Better methods of more accurately defining which patients are more likely to develop more aggressive disease are becoming available. Recent antibody research has found that the presence of citrulline antibodies in the blood (see above in diagnosis) has been associated with a greater tendency toward more destructive forms of rheumatoid arthritis.

Studies involving various types of the connective tissue collagen are in progress and show encouraging signs of reducing rheumatoid disease activity. Finally, genetic research and engineering is likely to bring forth many new avenues of earlier diagnosis and accurate treatment in the near future. Gene profiling, also known as gene array analysis, is being identified as a helpful method of defining which people will respond to which medications. Studies are underway that are using gene array analysis to determine which patients will be at more risk for more aggressive disease. This is all occurring because of technology improvements. We are at the threshold of tremendous improvements in the way rheumatoid arthritis is managed.

Rheumatoid Arthritis At A Glance
  • Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body.
  • Rheumatoid arthritis can affect persons of all ages.
  • The cause of rheumatoid arthritis is not known.
  • Rheumatoid arthritis is a chronic disease, characterized by periods of disease flares and remissions.
  • In rheumatoid arthritis, multiple joints are usually, but not always, affected in a symmetrical pattern.
  • Chronic inflammation of rheumatoid arthritis can cause permanent joint destruction and deformity.
  • Damage to joints can occur early and does not correlate with symptoms.
  • The “rheumatoid factor” is an antibody blood test that can be found in 80% of patients with rheumatoid arthritis.
  • There is no known cure for rheumatoid arthritis.
  • The treatment of rheumatoid arthritis optimally involves a combination of patient education, rest and exercise, joint protection, medications, and occasionally surgery.
  • Early treatment of rheumatoid arthritis results in better outcomes.
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http://familydoctor.org/online/famdocen/home/women/reproductive/gynecologic/279.printerview.html

http://www.nlm.nih.gov/medlineplus/tutorials/ovariancysts/htm/index.htm

http://www.mayoclinic.com/print/ovarian-cysts/DS00129/DSECTION=all&METHOD=print

Ovarian cysts

Definition

Ovarian cysts are fluid-filled sacs or pockets within or on the surface of an ovary. The ovaries are two organs — each about the size and shape of an almond — located on each side of your uterus. Eggs (ova) develop and mature in the ovaries and are released in monthly cycles during your childbearing years.

Many women have ovarian cysts at some time during their lives. Most ovarian cysts present little or no discomfort and are harmless. The majority of ovarian cysts disappear without treatment within a few months.

However, ovarian cysts — especially those that have ruptured — sometimes produce serious symptoms. The best way to protect your health is to know the symptoms and types of ovarian cysts that may signal a more significant problem, and to schedule regular pelvic examinations.

Symptoms

CLICK TO ENLARGE

Illustration of female reproductive system Female reproductive system

You can’t depend on symptoms alone to tell you if you have an ovarian cyst. In fact, you’ll likely have no symptoms at all. Or if you do, the symptoms may be similar to those of other conditions, such as endometriosis, pelvic inflammatory disease, ectopic pregnancy or ovarian cancer. Even appendicitis and diverticulitis can produce signs and symptoms that mimic a ruptured ovarian cyst.

Still, it’s important to be watchful of any symptoms or changes in your body and to know which symptoms are serious. If you have an ovarian cyst, you may experience the following signs and symptoms:

  • Menstrual irregularities
  • Pelvic pain — a constant or intermittent dull ache that may radiate to your lower back and thighs
  • Pelvic pain shortly before your period begins or just before it ends
  • Pelvic pain during intercourse (dyspareunia)
  • Pain during bowel movements or pressure on your bowels
  • Nausea, vomiting or breast tenderness similar to that experienced during pregnancy
  • Fullness or heaviness in your abdomen
  • Pressure on your rectum or bladder — difficulty emptying your bladder completely

The signs and symptoms that signal the need for immediate medical attention include:

  • Sudden, severe abdominal or pelvic pain
  • Pain accompanied by fever or vomiting

Causes

Your ovaries normally grow cyst-like structures called follicles each month. Follicles produce the hormones estrogen and progesterone and release an egg when you ovulate.

Sometimes a normal monthly follicle just keeps growing. When that happens, it becomes known as a functional cyst. This means it started during the normal function of your menstrual cycle. There are two types of functional cysts:

  • Follicular cyst. Around the midpoint of your menstrual cycle, your brain’s pituitary gland releases a surge of luteinizing hormone (LH), which signals the follicle holding your egg to release it. When everything goes according to plan, your egg bursts out of its follicle and begins its journey down the fallopian tube in search of fertilization.

    A follicular cyst begins when the LH surge doesn’t occur. The result is a follicle that doesn’t rupture or release its egg. Instead it grows and turns into a cyst. Follicular cysts are usually harmless, rarely cause pain and often disappear on their own within two or three menstrual cycles.

  • Corpus luteum cyst. When LH does surge and your egg is released, the ruptured follicle begins producing large quantities of estrogen and progesterone in preparation for conception. This changed follicle is now called the corpus luteum. Sometimes, however, the escape opening of the egg seals off and fluid accumulates inside the follicle, causing the corpus luteum to expand into a cyst.

    Although this cyst usually disappears on its own in a few weeks, it can grow to almost 4 inches in diameter and has the potential to bleed into itself or twist the ovary, causing pelvic or abdominal pain. If it fills with blood, the cyst may rupture, causing internal bleeding and sudden, sharp pain. The fertility drug clomiphene citrate (Clomid, Serophene), which is used to induce ovulation, increases the risk of a corpus luteum cyst developing after ovulation. These cysts don’t prevent or threaten a resulting pregnancy.

When to seek medical advice

If you experience severe or spasmodic pain in your lower abdomen, accompanied by fever and vomiting, see your doctor. These signs and symptoms — or those of shock such as cold, clammy skin, rapid breathing, and lightheadedness or weakness — indicate an emergency and require immediate medical attention.

Tests and diagnosis

A cyst on your ovary may be found during a pelvic exam. If a cyst is suspected, doctors often advise further testing to determine its type and whether you need treatment.

Typically, doctors address several questions to determine a diagnosis and to aid in management decisions:

  • Shape. Is your cyst irregularly shaped?
  • Size. What size is it?
  • Composition. Is it filled with fluid, solid or mixed? Fluid-filled cysts aren’t likely to be cancerous. Those that are solid or mixed — filled with fluid and solid — may require further evaluation to determine if cancer is present.

To identify the type of cyst, your doctor may perform the following procedures:

  • Pregnancy test. A positive pregnancy test may suggest that your cyst is a corpus luteum cyst, which can develop when the ruptured follicle that released your egg reseals and fills with fluid.
  • Pelvic ultrasound. In this painless procedure, a wand-like device (transducer) is used to send and receive high-frequency sound waves (ultrasound). The transducer can be moved over your abdomen and inside your vagina, creating an image of your uterus and ovaries on a video screen. This image can then be photographed and analyzed by your doctor to confirm the presence of a cyst, help identify its location and determine whether it’s solid, filled with fluid or mixed.
  • Laparoscopy. Using a laparoscope — a slim, lighted instrument inserted into your abdomen through a small incision — your doctor can see your ovaries and remove the ovarian cyst.
  • CA 125 blood test. Blood levels of a protein called cancer antigen 125 (CA 125) often are elevated in women with ovarian cancer. If you develop an ovarian cyst that is partially solid and you are at high risk of ovarian cancer, your doctor may test the level of CA 125 in your blood to determine whether your cyst could be cancerous. Elevated CA 125 levels can also occur in noncancerous conditions, such as endometriosis, uterine fibroids and pelvic inflammatory disease.

Complications

A large ovarian cyst can cause abdominal discomfort. If a large cyst presses on your bladder, you may need to urinate more frequently because its capacity is reduced.

Some women develop less common types of cysts that may not produce symptoms, but that your doctor may find during a pelvic examination. Cystic ovarian masses that develop after menopause may be cancerous (malignant). These factors make regular pelvic examinations important.

The following types of cysts are much less common than functional cysts:

  • Dermoid cysts. These cysts may contain tissue such as hair, skin or teeth because they form from cells that produce human eggs. They are rarely cancerous, but they can become large and cause painful twisting of your ovary.
  • Endometriomas. These cysts develop as a result of endometriosis, a condition in which uterine cells grow outside your uterus. Some of that tissue may attach to your ovary and form a growth.
  • Cystadenomas. These cysts develop from ovarian tissue and may be filled with a watery liquid or a mucous material. They can become large — 12 inches or more in diameter — and cause twisting of your ovary.

Treatments and drugs

Treatment depends on your age, the type and size of your cyst, and your symptoms. Your doctor may suggest:

  • Watchful waiting. You can wait and be re-examined in one to three months if you’re in your reproductive years, you have no symptoms and an ultrasound shows you have a simple, fluid-filled cyst. Your doctor will likely recommend that you get follow-up pelvic ultrasounds at periodic intervals to see if your cyst has changed in size.

    Watchful waiting, including regular monitoring with ultrasound, is also a common treatment option recommended for postmenopausal women if a cyst is filled with fluid and is less than 2 centimeters in diameter.

  • Birth control pills. Your doctor may recommend birth control pills to reduce the chance of new cysts developing in future menstrual cycles. Oral contraceptives offer the added benefit of significantly reducing your risk of ovarian cancer — the risk decreases the longer you take birth control pills.
  • Surgery. Your doctor may suggest removal of a cyst if it is large, doesn’t look like a functional cyst, is growing or persists through two or three menstrual cycles. Cysts that cause pain or other symptoms may be removed.

    Some cysts can be removed without removing the ovary in a procedure known as a cystectomy. Your doctor may also suggest removing the affected ovary and leaving the other intact in a procedure known as oophorectomy. Both procedures may allow you to maintain your fertility if you’re still in your childbearing years. Leaving at least one ovary intact also has the benefit of maintaining a source of estrogen production.

    If a cystic mass is cancerous, however, your doctor will advise a hysterectomy to remove both ovaries and your uterus. After menopause, the risk of a newly found cystic ovarian mass being cancerous increases. As a result, doctors more commonly recommend surgery when a cystic mass develops on the ovaries after menopause.

Prevention

Although there’s no definite way to prevent the growth of ovarian cysts, regular pelvic examinations are a way to help ensure that changes in your ovaries are diagnosed as early as possible. In addition, be alert to changes in your monthly cycle, including symptoms that may accompany menstruation that aren’t typical for you or that persist over more than a few cycles. Be sure to talk with your doctor about any concerns relating to menstruation.

http://jama.ama-assn.org/cgi/reprint/297/5/554.pdf

http://www.mayoclinic.com/print/polycystic-ovary-syndrome/DS00423/DSECTION=all&METHOD=print

Polycystic ovary syndrome

Definition

Polycystic ovary syndrome (PCOS) is a common condition characterized by irregular menstrual periods, excess hair growth and obesity, though it can affect women in a variety of ways.

The exact cause of polycystic ovary syndrome is unknown, but the condition stems from a disruption in the monthly reproductive cycle. The name polycystic ovary syndrome comes from the appearance of the ovaries in some women with the disorder — large and studded with numerous cysts (polycystic).

Polycystic ovary syndrome affects about one in 10 women in the United States and is the leading cause of infertility in women. Early diagnosis and treatment of polycystic ovary syndrome can help reduce the risk of long-term complications, which include diabetes and heart disease.

Symptoms

CLICK TO ENLARGE

Illustration showing normal ovary and polycystic ovary Polycystic ovary syndrome

Women with polycystic ovary syndrome usually have at least several of the many signs and symptoms associated with PCOS, including:

  • Irregular or no menstruation. This is the most common characteristic. Irregular menstruation means having menstrual cycles that occur at intervals longer than 35 days or fewer than eight times a year. The condition may begin in adolescence with the onset of menstruation, or it may appear later after a weight gain.
  • Signs of excess androgen. Elevated levels of male hormones may result in physical signs, such as long, coarse hair on your face, chest, lower abdomen, back, upper arms or upper legs (hirsutism); acne; and male-pattern baldness (alopecia). However, not all women who have polycystic ovary syndrome have physical signs of androgen excess.
  • Enlarged ovaries with multiple cysts. Your doctor may detect ovarian cysts by ultrasound. However, you may have ovaries with multiple cysts but still not have polycystic ovary syndrome. And you may have PCOS but have ovaries that appear normal.
  • Infertility. Polycystic ovary syndrome is the most common cause of female infertility in the United States.
  • Obesity. It’s estimated that about half of women with polycystic ovary syndrome are obese.
  • Skin tags. These small, excess growths of skin that are usually found on your neck or in your armpit are common in women with PCOS.
  • Prediabetes or type 2 diabetes. The ability to use insulin effectively is impaired in PCOS and can result in high blood sugar levels and diabetes. Prediabetes is also called impaired glucose tolerance.
  • Acanthosis nigricans. This is the medical term for darkened, velvety skin on the nape of your neck, armpits, inner thighs, vulva or under your breasts.

Additionally, the following are more likely to occur in women with PCOS:

  • High blood pressure
  • High blood cholesterol
  • Elevated levels of C-reactive protein, which may be associated with cardiovascular problems
  • Nonalcoholic steatohepatitis, a liver disease
  • Sleep apnea

Causes

The intricate process of a woman’s reproductive cycle is regulated by fluctuating levels of hormones produced by the pituitary gland in your brain, including luteinizing hormone (LH) and follicle-stimulating hormone (FSH), and by your ovaries.

The ovaries secrete the female hormones estrogen and progesterone and also produce some androgens, the so-called male hormones. Androgens include testosterone, androstenedione and dehydroepiandrosterone (DHEA).

In polycystic ovary syndrome, your body produces an excess of androgens, and your ratio of LH to FSH is often abnormally high. The process of ovaries releasing eggs (ovulation) occurs less frequently than normal (oligo-ovulation), or the ovaries don’t release eggs at all (anovulation). In the absence of ovulation, the menstrual cycle is irregular or absent.

Doctors don’t know the cause of polycystic ovary syndrome, but research suggests a link to excess insulin, the hormone produced in the pancreas that allows cells to use sugar (glucose), your body’s primary energy supply. By several mechanisms, excess insulin is thought to boost androgen production by your ovaries. Studies also indicate that genetic factors may play a role in PCOS.

When to seek medical advice

Early diagnosis and treatment of polycystic ovary syndrome may help reduce your risk of long-term complications, such as diabetes and heart disease.

Talk with your doctor if you have irregular, scant or no menstrual periods, are overweight, and have acne or excess facial hair growth. Your doctor may refer you to a doctor who specializes in hormonal disorders (endocrinologist).

Tests and diagnosis

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Illustration showing pelvic examination Pelvic examination

There’s no specific test to definitively diagnose polycystic ovary syndrome. The diagnosis is one of exclusion, which means your doctor considers all of your signs and symptoms and then rules out other possible disorders.

Besides a complete physical examination, including a pelvic examination, other tests you may have include:

  • Blood tests. Your blood may be drawn for laboratory tests to measure levels of several hormones. These may include testosterone, DHEA sulfate, luteinizing hormone (LH), follicle-stimulating hormone (FSH), 17-hydroxy progesterone, prolactin, and thyroid-stimulating hormone (TSH), which triggers the release of thyroid hormone from the thyroid gland. Additional blood testing may include fasting glucose, cholesterol and triglyceride levels.
  • Ultrasound. Your doctor may request a pelvic ultrasound to check your ovaries and the thickness of the lining of your uterus. Ultrasound exams are painless. While you relax on a bed or examining table, a wand-like device (transducer) is placed on your body or in your vagina (transvaginal ultrasound). It emits inaudible sound waves that are translated into images on a computer.

Complications

Having polycystic ovary syndrome puts you at increased risk of:

  • Type 2 diabetes
  • High blood pressure
  • Increased triglycerides
  • Decreased high-density lipoprotein (HDL) cholesterol, the so-called “good” cholesterol
  • Cardiovascular disease
  • Metabolic syndrome, a cluster of signs and symptoms that indicate a significantly increased risk of cardiovascular disease

Because PCOS disrupts the reproductive cycle and exposes the uterus to a constant supply of estrogen, women with PCOS are at risk of:

  • Abnormal uterine bleeding
  • Cancer of the uterine lining (endometrial cancer)

Pregnancy concerns
You may need treatment with fertility medications to become pregnant if you have polycystic ovary syndrome. During pregnancy, you may be at increased risk of gestational diabetes and pregnancy-induced high blood pressure.

Treatments and drugs

Polycystic ovary syndrome treatment generally focuses on management of your individual main concerns, such as infertility, hirsutism, acne or obesity.

Long term, the most important aspect of treatment is managing cardiovascular risks, such as obesity, high blood cholesterol, diabetes and high blood pressure. To help guide ongoing treatment decisions, your doctor will likely want to see you for regular visits to perform a physical examination, measure your blood pressure and obtain fasting glucose and lipid levels.

You may benefit from counseling about healthy-eating choices and regular exercise. This is particularly important if you’re overweight. Obesity makes insulin resistance worse. Weight loss can reduce both insulin and androgen levels, and may restore ovulation. Ask your doctor to recommend a weight-control program, and meet regularly with a dietitian.

Your doctor may prescribe one or more medications to help manage the symptoms and risks associated with PCOS.

Medications for regulating your menstrual cycle
If you’re not trying to become pregnant, your doctor may prescribe low-dose oral contraceptives that combine synthetic estrogen and progesterone. They decrease androgen production and give your body a break from the effects of continuous estrogen. This decreases your risk of endometrial cancer and corrects abnormal bleeding.

An alternative approach is taking progesterone for seven to 10 days each month. This regulates your menstrual cycle and offers protection against endometrial cancer, but it doesn’t improve androgen levels.

Your doctor also may prescribe metformin (Glucophage, Glucophage XR), an oral medication for type 2 diabetes that treats insulin resistance. This drug is still being studied as a treatment for polycystic ovary syndrome, but research has demonstrated that it improves ovulation and may reduce androgen levels. However, doctors don’t yet know if metformin offers the same protection against endometrial cancer as does treatment with oral contraceptives or with progesterone alone.

Medications for reducing excessive hair growth
Your doctor may add a medication specifically targeted at countering the effects of excess androgen. Spironolactone (Aldactone) blocks the effects of androgen and reduces new androgen production. For those reasons, the drug isn’t recommended if you’re pregnant or planning to become pregnant. Spironolactone is also a diuretic and may cause you to urinate more frequently.

Your doctor might also prescribe eflornithine (Vaniqa), a prescription cream that slows facial hair growth in women. This medication is effective for about one-third of the women who use it. Avoid using this medication during pregnancy.

Medications for achieving pregnancy
To become pregnant, you may need a medication to trigger ovulation. Clomiphene (Clomid, Serophene) is an oral anti-estrogen medication that you take in the first part of your menstrual cycle. If clomiphene alone isn’t effective, your doctor may add metformin to help trigger ovulation.

A study published in the New England Journal of Medicine compared the use of clomiphene and metformin, as well as a combination of the two medications, for achieving pregnancy. The study found that clomiphene was significantly more effective at helping women conceive than was metformin alone. About 80 percent of women are able to conceive using clomiphene, and it’s estimated that 50 percent of women taking clomiphene have a baby.

If you don’t become pregnant using clomiphene and metformin, your doctor may recommend using gonadotropins — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) medications that are administered by injection. Because many women with PCOS have elevated levels of LH, your doctor may recommend treatment with FSH alone.

With clomiphene or gonadotropins, the risk of multiple births — twins or more — is increased.

Surgery
If medications don’t help you become pregnant, your doctor rarely may recommend an outpatient surgery called laparoscopic ovarian drilling.

In this procedure, a surgeon makes a small incision in your abdomen and inserts a tube attached to a tiny camera (laparoscope). The camera provides the surgeon with detailed images of your ovaries and neighboring pelvic organs. The surgeon then inserts surgical instruments through other small incisions and uses electrical or laser energy to burn holes in enlarged follicles on the surface of the ovaries. The goal is to stimulate ovulation by reducing levels of LH and androgen hormones.

Hair removal
Several options besides prescription medications exist for hair removal. They include shaving, plucking and over-the-counter remedies such as waxes, gels, creams and lotions (depilatories). However, depilatories may irritate your skin, so follow package directions and on first use, apply the product to an inconspicuous area to determine if it’s suitable for you. The results may last several weeks, then you must repeat treatment.

Options for longer lasting hair removal include:

  • Electrolysis. To permanently remove excess hair, some women undergo electrolysis in addition to medical therapy. A fine needle is inserted into the hair follicle and electric current is applied to kill the follicle. Because only one follicle can be treated at a time, this method isn’t useful for large areas of the body. Several treatments are usually necessary. Scarring or, rarely, skin infections may occur. Home electrolysis kits usually are ineffective because the hair follicle is deep in the skin, so seek care with an experienced, certified electrologist.
  • Laser therapy. Laser hair removal systems use laser light — an intense, pulsating beam of light — to remove unwanted hair. Laser hair removal is effective on short, visible hair. Before the procedure, you shave the area to be treated, and allow it to grow to a stubble. Your doctor may use multiple treatments to target the affected areas. After several months, laser procedures permanently reduce one-third or more of the hair in the targeted area. Even after multiple treatments, however, you may experience some hair regrowth, although the new hair may be finer and lighter in color.

Lifestyle and home remedies

You may hear conflicting advice from media, support groups and health care professionals on the role of diet in weight management. Much of the disagreement focuses on carbohydrates.

Carbohydrates are long chains of glucose, a type of sugar. Your digestive system splits these chains into small sugar molecules that enter your bloodstream and trigger the release of insulin.

Low-fat, high-carbohydrate diets that have been popular in recent years may increase insulin levels, so some health and nutrition advocates advise women with polycystic ovary syndrome to follow a low-carbohydrate diet. However, a diet that calls for increased protein to compensate for decreased carbohydrates may spike your intake of saturated fats, elevating your blood cholesterol levels and increasing your risk of cardiovascular disease. Research hasn’t demonstrated that a diet high in protein offers more benefit to women with PCOS than does a diet high in carbohydrates.

Choose complex carbohydrates
Carbohydrates provide many important nutrients, so don’t severely restrict them. Instead, choose complex carbohydrates, which are high in fiber. The more fiber in a food, the more slowly it’s digested and the more slowly your blood sugar levels rise. High-fiber carbohydrates include whole-grain breads and cereals, whole-wheat pasta, bulgur, barley, brown rice and beans. Limit less healthy, simple carbohydrates such as soda, excess fruit juice, cake, candy, ice cream, pies, cookies and doughnuts.

Additional research may determine which specific dietary approach is best, but it’s clear that losing weight by reducing total calorie intake benefits the overall health of women with polycystic ovary syndrome. Work with your doctor and registered dietitian to determine the best dietary plan for you.

Get your exercise
Exercise helps lower your blood sugar levels. For women with polycystic ovary syndrome, an increase in daily physical activity and participation in a regular exercise regimen are essential for treating or preventing insulin resistance and for helping weight-control efforts.

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More mosquitos found with killer virus

Health authorities are warning people to protect themselves against virus-carrying mosquitos in the western Riverina in southern NSW

Health authorities are warning people to protect themselves against virus-carrying mosquitos in the western Riverina in southern NSW. (AAP Image: Dave Hunt)

A second batch of mosquitos has been found in the western Riverina region, in southern New South Wales, with a disease that can be fatal to humans.

The result comes just over a week after the first positive test in the region for Murray Valley encephalitis, which can also cause permanent brain damage.

Greater Southern Area Health public health director Tracey Oakman says there is no cure or vaccine for the virus.

Ms Oakman is urging residents and visitors to protect themselves by avoiding being outdoors in the evenings, installing mosquito screens and wearing insect repellent and suitable clothing.

She says the symptoms of the virus include headaches, nausea, vomiting, neck stiffness and fever.

“There is no evidence of human infections to date,” she said.

“However, the mosquito monitoring results means there may be the potential for people to become infected if bitten by mosquitoes.”

The last human case of Murray Valley encephalitis in the Riverina was around 30 years ago.

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Roxon ready to come to table with states

Nicola Roxon says the Federal and State Governments are driven by what is best for patients.

Nicola Roxon says the Federal and State Governments are driven by what is best for patients. (AFP: William West)

Federal Health Minister Nicola Roxon insists she is optimistic about today’s meeting with the states and territories over the next healthcare agreement, despite serious tensions surfacing.

The states want an extra $3 billion a year over the next five years to address what they say was a funding shortfall under the previous government.

There is also disagreement over what conditions the Commonwealth might attach to any funding.

But Ms Roxon says there is nothing unusual about these arguments before such an important meeting.

“Of course there is going to be disagreement and argument, that’s what good negotiations are about,” she said.

“But we’re all driven by what will deliver the best outcomes for patients. That will be the measure.”

“And if we can convince the states that this is a measure that will help patients, if the states can convince us that some different investment from the Commonwealth will help patients, then those will be the things that will be on the table at the end of the day.”

Ms Roxon is not committing to a figure but says any money will come with strings.

“We will be making sure that there are serious performance monitoring measures attached to any money we provide,” she said.

New South Wales’ Health Minister Reba Meagher is demanding the Commonwealth lift its split of hospital funding from around 40 per cent to 50.

“Reform will only be successful if there is genuine investment in change,” she said.

But Tasmania’s Health Minister Lara Giddings is not hopeful.

“It’s starting to look like it will be unrealistic to have all the detail by June on a new healthcare agreement,” she said.

Ms Roxon says she will keep meeting with the states until agreement is reached.

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What is Xerostomia

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Xerostomia

From Wikipedia, the free encyclopedia

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ICD10 K11.7, R68.2
ICD9 527.7
DiseasesDB 17880

Xerostomia is the medical term for a dry mouth due to a lack of saliva. Xerostomia is sometimes colloquially called pasties or cottonmouth.

Xerostomia can cause difficulty in speech and eating. It also leads to halitosis and a dramatic rise in the number of cavities, as the protective effect of saliva is no longer present, and can make the mucosa of the mouth more vulnerable to infection. Notably, a symptom of methamphetamine abuse usually called “meth mouth” is largely caused by xerostomia.

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[edit] Causes

It may be a sign of an underlying disease, such as Sjögren’s syndrome, poorly controlled diabetes, or Eaton-Lambert syndrome, but this is not always so.

Other causes of insufficient saliva include anxiety, medications, or alcohol, trauma to the salivary glands or their ducts or nerves, dehydration, excessive mouth breathing, previous radiation therapy, and also a natural result of aging. The vast majority of elderly individuals will suffer xerostomia to some degree. Playing or exercising a long time outside on a hot day will often cause your saliva glands to simply dry up as your bodily fluids are concentrated elsewhere. Xerostomia is a common side-effect of various drugs, such as cannabis, dextromethorphan, and several antidepressants.

[edit] Treatment

Treatment involves finding any correctable causes and fixing those if possible. In many cases it is not possible to correct the xerostomia itself, and treatment focuses on relieving the symptoms and preventing cavities. Patients who have endured chemotherapy usually suffer from this post- treatment. Patients with xerostomia should avoid the use of decongestants and antihistamines, and pay careful attention to oral hygiene. Sipping sugarless fluids frequently, chewing xylitol-containing gum[1], and using a carboxymethyl cellulose saliva substitute as a mouthwash may help. Aquoral may be prescribed to treat xerostomia. Non-systemic relief can be found using an oxidized glycerol triesters treatment used to coat the mouth.

[edit] References

  1. ^ Jensen JL, Langberg CW (1997): Temporary hyposalivation induced by radiation therapy in a child. Tidsskr Nor Loegeforen 21:3077-9

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Klinefelter syndrome

Klinefelter syndrome is a chromosome disorder that affects males. Normally, a male has two chromosomes that determine his sex: an X inherited from his mother and a Y inherited from his father. A male with Klinefelter syndrome has an additional X chromosome. The effects vary and may include:

* Infertility – the condition may be diagnosed when an apparently normal male is seen because they have fertility problems.
* Reduced testicle size – the testicle may not develop properly.
* Late puberty – not enough of the male hormone testosterone is produced and puberty may be late. These boys may be given testosterone treatment so they develop normal male physical characteristics like facial hair and a deeper voice.

Klinefelter syndrome occurs in around one in every 500 male babies, which makes it one of the most common abnormalities of the sex chromosomes. This condition is also known as XXY syndrome. The additional X chromosome does not influence sexual orientation.

Symptoms at birth
The condition isn’t usually diagnosed at birth, because the baby looks healthy and normal. However, certain physical characteristics of Klinefelter syndrome may be apparent, including:

* Small penis
* Undescended testicles
* Hypospadias (the urethra is located on the underside of the penis instead of the tip).

Signs at puberty
Klinefelter syndrome is usually diagnosed at puberty, when the expected physical changes don’t occur. Some of the signs and symptoms of the condition include:

* Small penis
* Small testicles (hypogonadism)
* Difficulties with sexual functioning
* Lack of facial, pubic and underarm hair
* Taller than average height
* Enlarged breasts (gynaecomastia)
* Slim physique
* Disproportionately long legs compared to the length of the body
* Single crease in the palm (simian crease)
* Slightly impaired IQ
* Sometimes, the boy may have speech and hearing difficulties.

The cause is unknown and not inherited
Humans have 46 paired chromosomes, made up of two sex chromosomes that determine gender and 44 chromosomes that dictate other factors. The mother always passes on an X chromosome. If the father provides an X chromosome, the child will be female; a Y chromosome makes the child male. A boy with Klinefelter syndrome has an additional X chromosome. This is thought to be caused by an error within the fertilised egg or the dividing cells as the baby develops. The presence of the Y chromosome ensures male sexual characteristics but, because the testicles are underdeveloped, there may not be enough testosterone production. This is why the penis and testicles are smaller than average, and why most men with Klinefelter syndrome are infertile. Some researchers suspect that advanced maternal age may be a risk factor.

Possible complications
Klinefelter syndrome is associated with an increased risk of certain diseases and conditions, including:

* Breast cancer
* Diabetes mellitus
* Infertility
* Leukaemia
* Non-Hodgkin’s lymphoma
* Osteoporosis
* Pulmonary disease
* Thyroid disease
* Tooth decay
* Varicose veins.

Diagnosis methods
Klinefelter syndrome is diagnosed using a number of tests, including:

* Physical examination – including rectal exam of the prostate gland (most males with Klinefelter syndrome have an enlarged prostate).
* Chromosome analysis – to confirm diagnosis.
* Blood tests – to check for hormone levels.
* Semen examination – to check fertility.

Treatment options
There is no cure for Klinefelter syndrome. Treatment aims to correct some of the abnormalities and provide emotional support. Options may include:

* Cosmetic surgery – to remove enlarged breast tissue.
* Hormone therapy – such as testosterone, to help bring on the normal changes of puberty. Hormone therapy will need to be lifelong.
* Counselling – to help the boy come to terms with his condition.
* Educational support – if necessary.
* Speech therapy – if necessary.
* Frequent screening tests – to ensure the early diagnosis of any associated complications (such as diabetes or breast cancer).
* Reproductive technologies – such as IVF, to help men with Klinefelter syndrome become fathers of their own biological children.

Where to get help

* Your doctor
* Klinefelter Syndrome Support Group Tel. (02) 9836 2970 or email: klinefeltersaus@hotmail.com
* XXY Support Group Tel. (08) 9279 6440
* Genetic Support Network Victoria Tel. (03) 8341 6315

Things to remember

* Klinefelter syndrome is a chromosome disorder that affects males. It is not an inherited disorder.
* A male with Klinefelter syndrome has an additional X chromosome, which causes infertility and other characteristics such as slim build and development of breast tissue.
* The chromosomes are present in every cell of the body and the extra X chromosome cannot be removed.
* Treatment options include cosmetic surgery to remove enlarged breast tissue and lifelong testosterone therapy.

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Study finds brain power better at night

 

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Science award

PhD student Martin Sale of the University of Adelaide uses magnetic brain stimulation to investigate how the brain learns. It seems that learning is better in the evening. (Fresh Science)

An Adelaide University PhD student has found part of the brain which learns best at night.

Martin Sale has been named Young Scientist of the Year as part of National Science Week.

He was awarded the prize for his research which found that the cerebral cortex, the area of the brain which controls movement, is able to learn more effectively in the evening than in the morning.

Mr Sale says his findings could have implications for people who are recovering from brain injuries.

“[In] rehabilitation therapy for people who have had a stroke, for example, we can maybe identify a time of day when their brain is most receptive to therapy and they can potentially get better quicker,” he said.

But Mr Sale says, before the research has practical application, more study is needed to understand why this part of the brain is more receptive at night.

“There are many hormones that fluctuate throughout the day and these can certainly have an effect on learning and memory,” he said.

“We think possibly one, or a combination of these hormones, is influencing our results.”

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