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Rheumatoid arthritis is an autoimmune disease that causes inflammation of the joints, tendons, and bones, resulting in pain, swelling, stiffness, and destruction of joints. It is the most common inflammatory arthritis, affecting approximately 1% of the population. The disease is characterized by persistent inflammatory synovitis that leads to damage of cartilage, bone erosion, joint deformity, and disability. It commonly involves small joints of the hands and feet but can also affect larger joints like knees, ankles, and wrists. Symptoms include pain, swelling, and morning stiffness lasting over an hour. Extra-articular manifestations may occur in 30-40% of patients and include rheumatoid nodules, anemia, lung involvement
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Rheumatic disorders summary
Rheumatoid arthritis is a chronic inflammatory disease that affects the joints, causing swelling and stiffness, eventually resulting in deterioration of bone and cartilage. It is caused by an autoimmune response and is characterized by symmetric inflammation of multiple small joints of the hands and feet. Symptoms progress from early inflammation to joint destruction and deformity if left untreated.
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Rheumatoid arthritis is a chronic autoimmune disease that causes inflammation of the synovium lining the joints, leading to pain, stiffness, and eventual joint damage and loss of function. It is characterized by symmetric inflammation of small joints of the hands and feet. While the exact cause is unknown, genetic and environmental factors are thought to play a role. Diagnosis is based on symptoms and serological markers like rheumatoid factor. Treatment aims to reduce inflammation and prevent further joint damage through medications like DMARDs and biologics, with the goal of improving quality of life and physical function.
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- Evaluation of geriatric trauma patients should consider their baseline functional status and medical history. Vitals should be closely monitored as they can decompensate quickly. Early intubation may be needed.
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Birth period, socioeconomical status, nutritional and intrauterine environment are the factors influencing low birth weight
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Breast cancer: Post menopausal endocrine therapy
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
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- 2. ARTHRITIS “arthro” = joint “itis” = inflammation “Arthritis can affect babies and children, as well as people in the prime of their lives” • Rheumatoid arthritis is an autoimmune disease in which the normal immune response is directed against an individual's own tissue, including the joints, tendons, and bones, resulting in inflammation and destruction of these tissues. • Commonest inflammatory joint disease seen in clinical practice affecting approx 1% of population. • Characterized by persistent inflammatory synovitis leading to cartilage damage, bone erosions, joint deformity and disability.
- 3. Anatomy of the Joint Articular/hyaline cartilage -acts as a shock absorber - allows for friction-free movement - not innervated! Synovial membrane/synovium -secretes synovial fluid -nourishes cartilage -cushions the bones
- 4. OVERVIEW • AGE: ANY AGE, COMMONLY 3RD TO 6TH DECADE • FEMALE:MALE 3:1 • PATTERN OF JOINT INVOLVEMENT COULD BE:- 1) POLYARTICULAR : MOST COMMON 2) OLIGOARTICULAR 3) MONOARTICULAR • MORNING JOINT STIFFNESS > 1 HOUR AND EASING WITH PHYSICAL ACTIVITY IS CHARACTERISTIC. • SMALL JOINTS OF HAND AND FEET ARE TYPICALLY INVOLVED.
- 5. CLINICAL MANIFESTATIONS • ARTICULAR • EXTRA-ARTICULAR
- 6. ARTICULAR MANIFESTATION • PAIN AND SWELLING IN AFFECTED JOINT AGGRAVATED BY MOVEMENT IS THE MOST COMMON SYMPTOM. • MORNING STIFFNESS ≥1 HR • JOINTS INVOLVED -
- 7. RELATIVE INCIDENCE OF JOINT INVOLVEMENT IN RA • MCP AND PIP JOINTS OF HANDS & MTP OF FEET 90% • KNEES, ANKLES & WRISTS- 80% • SHOULDERS- 60% • ELBOWS- 50% • TM, ACROMIO - CLAVICULAR & SC JOINTS- 30%
- 8. JOINTS INVOLVED IN RA • DON’T FORGET THE CERVICAL SPINE!! INSTABILITY AT CERVICAL SPINE CAN LEAD TO IMPINGEMENT OF THE SPINAL CORD. • THORACOLUMBAR, SACROILIAC, AND DISTAL INTERPHALANGEAL JOINTS (DIP)OF THE HAND ARE NOT INVOLVED.
- 9. PIP Swelling
- 10. Ulnar Deviation, MCP Swelling, Left Wrist Swelling
- 11. EXTRA-ARTICULAR MANIFESTATIONS • PRESENT IN 30-40% • MAY OCCUR PRIOR TO ARTHRITIS • PATIENTS THAT ARE MORE LIKELY TO GET ARE: • HIGH TITRES OF RF/ ANTI-CCP • HLA DR4+ • MALE • EARLY ONSET DISABILITY • HISTORY OF SMOKING
- 12. EXTRAARTICULAR INVOLVEMENT • CONSTITUTIONAL SYMPTOMS ( MOST COMMON) • RHEUMATOID NODULES(30%) • HEMATOLOGICAL- • NORMOCYTIC NORMOCHROMIC ANEMIA • LEUCOCYTOSIS /LEUCOPENIA • THROMBOCYTOSIS • FELTY’S SYNDROME- • CHRONIC NODULAR RHEUMATOID ARTHRITIS • SPLEENOMEGALY • NEUTROPENIA
- 13. • RESPIRATORY- PLEURAL EFFUSION, PNEUMONITIS , PLEURO-PULMONARY NODULES, ILD • CVS-ASYMPTOMATIC PERICARDITIS , PERICARDIAL EFFUSION, CARDIOMYOPATHY • RHEUMATOID VASCULITIS- MONONEURITIS MULTIPLEX, CUTANEOUS ULCERATION, DIGITAL GANGRENE, VISCERAL INFARCTION • CNS- PERIPHERAL NEUROPATHY, CORD-COMPRESSION FROM ATLANTOAXIAL/MIDCERVICAL SPINE SUBLUXATION, ENTRAPMENT NEUROPATHIES • EYE- KERATO-CONJUNCTIVITIS SICCA, EPISCLERITIS, SCLERITIS
- 14. RHEUMATOID NODULE •These are small subcutaneous nodules present at the extensor surfaces of hand, wrist, elbow and back in rheumatoid arthritis patients. •Characteristics feature of rheumatoid arthritis •A marker of disease activity •Can be present even if other features of rheumatoid Arthritis are absent