Rheumatoid arthritis is the inflammatory form of arthritis. It is a chronic disease affecting connective tissue, mainly of joints, and can be very painful. It is thought to be an autoimmune disease, where the immune system attacks its own body, instead of defending it. The disease affects about one person in 20 in Britain at some time, and the figure rises dramatically after the age of 65. Some people are seriously crippled by the condition.
Put very simply, the problem with rheumatoid arthritis is that the body is producing too many of the wrong kind of prostaglandins, which have an inflammatory effect. These are the 2 series prostaglandins.
There are plenty of 2 series prostaglandins in people with rheumatoid arthritis, but not enough of the 1 series.2 The 2 series PGs are made from arachidonic acid in the diet, especially meat and dairy produce, whereas the 1 series PGs are made only from essential fatty acids. If there are not enough essential fatty acids, either because not enough are eaten or not enough are getting through the system, then not enough 1 series prostaglandins will be manufactured.
When PGE1 is in short supply, the immune system is one of the first things to feel the pinch. PGE1 has a very important job in controlling T-lymphocyte production, and the T-lymphocytes are the crack troops of the body. When the front line is absent, mayhem ensues.
Modern drugs used to treat arthritis, steroids and non-steroidal anti-inflammatory drugs (NSAIDs) work by inhibiting all prostaglandins, both the good and the bad, and in the case of steroids, other substances called leukotrienes, which are thought to cause inflammation.
Steroids inhibit the mobilization of arachidonic acid from phospholipids,   and   so   reduce   the   formation   of   both leukotrienes and prostaglandins.
Most NSAIDs reduce the formation of prostaglandins by blocking cyclo-oxygenase, which gives rise to prostaglandins.
But the trouble with conventional drug treatment is that the drugs not only suppress inflammatory substances, but they also suppress anti-inflammatory ones as well. They knock out all prostaglandins, thehelpfulPGElsaswellastheunhelpfulPGE2s.

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Sometimes people with BDD don’t directly question others because they’re afraid people will think they’re vain or that their question is strange. So instead of directly asking, they bring up the topic in a more indirect way. A man concerned with his body build explained, “I wanted to ask other people how I looked, but I didn’t want them to know I cared so much about it. I thought it would seem like a sign of weakness that I was bothered by it. Instead, I hinted around the subject, talking about appearance or body size in a more general way, hoping to get them to say ‘You look big.’”
A teacher directly asked her husband about her “sagging” eyes, saying “Do you see it? How bad is it?” “But when I’m around friends or at social events, I can’t directly ask,” she said. “It would be too embarrassing. So I switch into philosophizing. I talk about things like how society overvalues appearance, and all the cosmetic surgery that’s done. I’m somehow hoping I’ll be told I look okay.”
Sometimes, the intent is to get others to confirm that the defect is bad. One woman tried to get her husband to comment positively on other women’s breasts, which was a way of affirming that hers were unattractive. “The point was to get him to agree with me because I’m right.” Another woman, in great desperation, dragged her three young children to the mirror each day, pointing to invisible marks on her face and insisting that they agree that they saw them and how awful they looked. She told me “I’d harangue them and harangue them, and they’d just cry.”
Some people use photos to convince others of how much they’ve changed and how bad they now look. One of the first people with BDD whom I met handed me a several-year-old photo within a few minutes of my meeting her. “Can’t you see how much I’ve changed?” she asked jabbing the photograph with her finger. She implored me to agree with her, pointing out how much hair had fallen out, how much fuller her cheeks used to be, and how different her eyes were—how lifeless and dull they’d become. She described at length how the photograph clearly demonstrated these changes, although I couldn’t see them. A young man showed me a year-old photo of himself, pleading with me. “Can’t you see how I’ve changed? Physically, I’ve changed drastically in the past few years. My whole face is different! Can’t you see that?!” He seemed desperate for me to agree with him. At the same time, I sensed he feared I might.
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The only systematic research I know of on early family experiences of people with BDD comes from the Parental Bonding Instrument. This scale is a validated and widely used self-report measure of a person’s perceptions of parental care and overprotection before the age of 16. I found that average scores of 40 consecutive people with BDD were notably lower than published norms on parental care and were in the average range on parental overprotection. These findings are consistent with how many patients describe their early life experiences, which often emphasize feelings of rejection and neglect. It’s important to note, however, it’s unclear whether these individuals actually received less love and care from their parents than the average person, or whether they were unusually sensitive to criticism or rejection at a young age and therefore felt unloved and neglected, even though their parents gave them lots of love and care.
Some people believe their family’s or peers’ emphasis on appearance contributed to their concern. One woman told me, “In my childhood people doted on my appearance. So I fear if I look bad, people won’t like me.” Another said, “Appearance was very important in our family, and it became very important to me. The only area of positive feedback from my parents was for my attractiveness. So destroying my appearance was the most destructive thing I could do.” Experiences such as these could in theory lead to some of the cognitive distortions (distorted ways of thinking) that I’ll discuss in Chapter 14—for example, that one’s worth as a person is based only on one’s appearance. Occasionally, BDD symptoms seem to begin with a parent’s excessive preoccupation with their child’s appearance—what mieht be called “RDD hv mnn ” Some people with BDD, however, report none of these things. Whether particular family experiences or other early life experiences contribute to BDD isn’t clear at this time. This important question needs to be studied.
Another very important question is whether physical or sexual trauma or abuse contributes to BDD’s development. In a small preliminary study, Dr. Caron Zlotnick and I found that 20% of 55 women with a history of sexual abuse had BDD—a fairly high rate. Conversely, in my interview study of 200 people with BDD, 9% had post-traumatic stress disorder (PTSD) at some point in their life (see the Glossary for a definition). However, this rate is about the same as the PTSD rate in the general U.S. population, suggesting that people with BDD may not have unusually high trauma rates. To my knowledge, no published studies have assessed what percentage of people with BDD have a childhood history of abuse per se and whether this rate is higher than in people with another psychiatric disorder or in the general population.
Based on my clinical experience, it’s clear that some people with BDD have been sexually or physically abused but that some haven’t. So it can’t be assumed that everyone with BDD has been abused. Nor can it be assumed that if someone is abused, they’ll develop BDD. However, sexual abuse may contribute to bodily shame and dislike of one’s body. It also makes sense that feeling neglected as a child could contribute to feelings of worthlessness and low self-esteem, including feeling badly about how one looks.
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Symptoms
The symptoms are as varied as the causes. Any kind of physical or emotional stress – anger, fear, fatigue, illness, family or school problems – often provokes the allergic reaction or makes it more severe.
There may be only one symptom such as a skin rash or headache, or a combination of symptoms such as itching, diarrhea, and asthma. The response is almost immediate in those who are severely allergic, but is delayed for hours or even days in persons who are mildly allergic.
The skin, the eyes, the respiratory, gastrointestinal, urinary, or nervous systems may be affected. Changes observed in the skin include hives, eczema, fever blisters, itching, and edema. The eyes could be red, swollen, itchy, or burning. If the mucous membranes of the gastrointestinal tract are affected, symptoms such as bad breath, nausea, vomiting, stomatitis, abdominal distention, cramps, diarrhea, or constipation might be present. Nervous system changes include migraine, anxiety, fatigue, and muscle and joint aching.

Diagnosis
Diet history. Severe, immediate reactions can usually be identified readily, but the more mild, delayed reactions are often not diagnosed for relatively long periods of time, and only after detailed study of the diet. Whenever food allergy is suspected, a comprehensive diet history is essential. The patient, or the patient’s parent, should keep a complete food diary for a period of time as well as a record of the occurrence of symptoms. Sometimes the correlation of the dietary record and the symptoms establishes the cause of the allergy. More often these records help to determine which elirpination diets might be most useful.
Skin tests. Suspected substances may be exposed to the skin to determine whether they cause redness or swelling at the point of contact. By themselves, skin tests are not too reliable for they may give false-positive or false-negative reactions. They can be useful for indicating the elimination diets to be tried first.
Elimination diets. Based upon the dietary history, food diary, and/or skin tests, a diet that eliminates the foods likely to produce allergy is tried. One of the widely used systems of elimination diets is that developed by Dr. Albert Rowe. The cereal-free elimination diet excludes all cereal grains, milk, eggs, beef, pork (except bacon), fish, and some fruits and vegetables. If the patient is symptom free on this diet, foods are added, one at a time, every three to five days in this sequence: fruits and vegetables, rice, oats, corn, rye, wheat, beef. If any food produces a symptom, it is removed from the list of permitted foods. The fruit-free, cereal-free diet eliminates all cereal grains, fruits, spices, and condiments.
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In common parlance the term allergy is used to describe an unusual sensitivity but, strictly speaking, it should be confined to an altered reactivity on a second or subsequent exposure to a stimulus.
Some patients get headaches in response to an allergic reaction, possibly due to release of histamine. With the implication that food allergy plays a part in producing migraine, attempts have been made to desensitize patients to offending substances. This involves testing for allergy by using small amounts of suspected materials and noting those to which there is a response. This substance is then prepared in minute concentrations and increasing amounts are injected under the skin at frequent intervals in order to increase gradually the body’s tolerance to it. This approach works well in hay fever and some cases of asthma, where there are definite identifiable allergic responses, but the situation in migraine is not as clear-cut. Although some migraine sufferers may have demonstrable food allergy, desensitizing them to the offending food does not always confer benefit. A trial of this form of treatment in a large number of people is needed, comparing results with those in another group of people who had been ‘desensitized’ with an ineffective substance. This sort of trial has not been undertaken and, in the present unsatisfactory situation, those with demonstrable allergy to a particular substance should take advice from specialists in the field, because of the possibility that they will experience some benefit from desensitization.

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The vagina, which extends upwards above part of the cervix, is also in contact with the bladder here. This is not always too good for the women who have borne babies. Often in later years they find that the tissues lose their elasticity and give way and the bladder bulges down into the vagina. This is called a cystocele.   Since the urethra runs down from the bladder in the anterior wall of the vagina, injury to this organ may cause urinary difficulty.
The vagina is about three inches long on the anterior wall and somewhat longer on the posterior one, which is in close juxtaposition to the rectum. At the lower end of the vagina is a membrane, called the hymen, which rarely may close the vagina of a young girl. If it does, it is necessary to cut it before puberty that the menstrual fluid may escape. The popular impression is that the presence or absence of a hymen is a test of virginity, but on the contrary it may be entirely missing at birth or it may be so elastic as to persist even after childbirth. The hymen, in development, is for protection of the vagina, because this is easily irritated in the immature female. Usually it is broken at the first intercourse, and slight bleeding results.
The vulva, at the outer opening, consists of the labia majora, or outer lips; and the labia minora, or inner lips. Between them anteriorly is the clitoris, usually a minute prominence but which in a so-called hermaphrodite may be so enlarged that it suggests a penis. It seems to have no function except as the seat of sensation.
Every married woman, at least, should expect a vaginal examination. A tremendous lot of information may be got from it. Scores of possibilities are surveyed, but what we are concerned with now is only the reproductive system. The normal ovaries are small, soft affairs, which feel like oysters under a blanket. Contrariwise, the uterus is definite and easily examined, just against the anterior abdominal wall.
With two fingers in the vagina and the other hand on the abdominal wall the uterus should be picked up by what we call bimanual examination. The experienced examiner can pretty well judge just what he is feeling between these two hands. Having found what is normal we may recognize the abnormal, such as enlarged ovaries or uterus and tumors where they do not belong. We must remember, however, that the wise examiner may use considerable latitude in judging what is normal. In the past, too many ovaries were removed because they were larger than the textbook dimensions. A vaginal examination, if carefully done, should be painless, so tender areas may mean there is something wrong. But be sure you differentiate between nervousness and painfulness.
Examination by feel is not enough. Direct vision must be used. This is aided by a speculum. This instrument is made in numerous designs, all intended to open the vagina so that the physician may see clear to the cervix, or neck of the womb. Abnormal conditions may be recognized or, to take a more optimistic attitude, we may reassure ourselves that they are not present. Nowadays the careful physician supplements the vaginal examination with a rectal one, which just on general principles is a valuable part of a physical examination.
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Pregnancy is a highly demanding period nutritionally. This period takes care of the mother and the foetus both, where extra food is required to take care of baby’s weight followed by lactation, where once again extra nutrition is required for the production of milk. The nutrients that require special attention are; increase in total calories by 300; increase in proteins by 15 g and increase in fat by 10 g. Calories are further increased to 500, proteins and fat by 20 g for lactation. Other nutrients are folic acid, which reduces the risk of congenital malformations and helps in foetus weight gain. Iron and calcium are also required in excess for blood and bone formation. Other nutrients required are iodine, vitamin A, B|2 and C.
Additional intake of nutritious food should result in weight gain of 10-12 kg during pregnancy. Fibre rich foods like whole grains, pulses and vegetables along with 8-10 glasses of water should be taken to avoid constipation.

Breast-feeding
Breast milk is a natural and perfect food for new born infants. Colostrum is especially rich in anti-infective properties and transfers immunity to the baby and breast-feeding reduces the risk of infections. Breast milk provides good quality proteins, fats, vitamins, calcium and other minerals for the infant which are sufficient till the age of 4 months, after which weaning foods can be introduced along with breast milk to prevent malnutrition.
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Etiology
Cellulitis is a bacterial infection of the skin and subcutaneous tissues characterized by pain and erythema. The most common pathogens are Staphylococcus aureus and group A streptococci. Escherichia coli, Proteus mirabilis, Acinetobacter, Enterobacter, and Pseudomonas aeruginosa are more common in immunocompromised patients. Children younger than 3 years of age may develop Haemophilus influenzae group В infections in the skin of the head and neck, commonly related to an underlying ear or sinus infection.
The most common site for cellulitis is the lower leg, which may be exposed to minor trauma. It also occurs in intact skin.

Signs and Symptoms
Patients with cellulitis generally complain of a very painful, red rash of acute onset. A prodrome of fever, chills, and malaise occasionally precedes the rash.
Cellulitic skin appears as a well demarcated, irregularly shaped, erythematous, and edematous plaque. Affected skin may be tender, warm, and indurated. Fluctuance suggests an abscess or furuncle (discussed later). Lymphatic streaks and lymphadenopathy may be noted proximally and reflect the spread of the infection.

Laboratory Tests
Wound cultures are low yield (approximately 45%) in cellulitis and are generally reserved for patients who are immunocompromised or have poor response to treatment. Wound culture is performed by aspirating subcutaneous fluid with a 20-gauge needle (22-gauge for the face) on a tuberculin syringe. Some clinicians inject a small amount of sterile preservative-free saline before aspirating. It is best to aspirate at the point of maximum inflammation. Blood cultures yield a pathogen in only about 11 % of cases of cellulitis.
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