Achilles Tendinitis 

Achilles tendinitis is an overuse injury of the Achilles (uh-KIL-eez) tendon, the band of tissue that connects calf muscles at the back of the lower leg to your heel bone.

Achilles tendinitis most commonly occurs in runners who have suddenly increased the intensity or duration of their runs. It's also common in middle-aged people who play sports, such as tennis or basketball, only on the weekends.

Most cases of Achilles tendinitis can be treated with relatively simple, at-home care under your doctor's supervision. Self-care strategies are usually necessary to prevent recurring episodes. More-serious cases of Achilles tendinitis can lead to tendon tears (ruptures) that may require surgical repair.

SYMPTOMS

The pain associated with Achilles tendinitis typically begins as a mild ache in the back of the leg or above the heel after running or other sports activity. Episodes of more severe pain may occur after prolonged running, stair climbing or sprinting.

You might also experience tenderness or stiffness, especially in the morning, which usually improves with mild activity.

When to see a doctor ?

If you experience persistent pain around the Achilles tendon, call your doctor. Seek immediate medical attention if the pain or disability is severe. You may have a torn (ruptured) Achilles tendon.

CAUSES

Achilles tendinitis is caused by repetitive or intense strain on the Achilles tendon, the band of tissue that connects your calf muscles to your heel bone. This tendon is used when you walk, run, jump or push up on your toes.

The structure of the Achilles tendon weakens with age, which can make it more susceptible to injury — particularly in people who may participate in sports only on the weekends or who have suddenly increased the intensity of their running programs.

RISK FACTORS

A number of factors may increase your risk of Achilles tendinitis, including:

1. Your sex and age. Achilles tendinitis occurs most commonly in middle-aged men.

2. Physical problems. A naturally flat arch in your foot can put more strain on the Achilles tendon. Obesity and tight calf muscles also can increase tendon strain.

3. Training choices. Running in worn-out shoes can increase your risk of Achilles tendinitis. Tendon pain occurs more frequently in cold weather than in warm weather, and running on hilly terrain also can predispose you to Achilles injury.

4. Medical conditions. People who have diabetes or high blood pressure are at higher risk of developing Achilles tendinitis.

5. Medications. Certain types of antibiotics, called fluoroquinolones, have been associated with higher rates of Achilles tendinitis.

COMPLICATIONS

Achilles tendinitis can weaken the tendon, making it more vulnerable to a tear (rupture) — a painful injury that usually requires surgical repair.

PREPARING FOR YOUR APPOINTMENT

You'll likely first bring your symptoms to the attention of your family doctor. He or she might refer you to a doctor specializing in sports medicine or physical and rehabilitative medicine (physiatrist). If your Achilles tendon has ruptured, you may need to see an orthopedic surgeon.

What you  can do ?

Before your appointment, you may want to write a list of answers to the following questions:

1. Did the pain begin suddenly or gradually?

2. Are symptoms worse at certain times of day or after certain activities?

3. What types of shoes do you wear during exercise?

4. What medications and supplements do you take regularly?

What to expect from your doctor

Be prepared to answer the following questions regarding your symptoms and factors that may be contributing to your condition:

1. Where exactly does it hurt?

2. Does the pain lessen with rest?

3. What is your normal exercise routine?

4. Have you recently made changes to your exercise routine, or have you recently started participating in a new sport?

5. What have you done for pain relief?

TESTS AND DIAGNOSIS

During the physical exam, your doctor will gently press on the affected area to determine the location of pain, tenderness or swelling. He or she will also evaluate the flexibility, alignment, range of motion and reflexes of your foot and ankle.

Imaging tests

Your doctor may order one or more of the following tests to assess your condition:

X-rays. While X-rays can't visualize soft tissues such as tendons, they may help rule out other conditions that can cause similar symptoms.

Ultrasound. This device uses sound waves to visualize soft tissues like tendons. Ultrasound can also produce real-time images of the Achilles tendon in motion.

Magnetic resonance imaging (MRI). Using radio waves and a very strong magnet, MRI machines can produce very detailed images of the Achilles tendon.

TREATMENTS AND DRUGS

Tendinitis usually responds well to self-care measures. But if your signs and symptoms are severe or persistent, your doctor might suggest other treatment options.

Medications

If over-the-counter pain medications — such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve) — aren't enough, your doctor might prescribe stronger medications to reduce inflammation and relieve pain.

Physical therapy. A physical therapist might suggest some of the following treatment options:

Exercises. Therapists often prescribe specific stretching and strengthening exercises to promote healing and strengthening of the Achilles tendon and its supporting structures.

Orthotic devices. A shoe insert or wedge that slightly elevates your heel can relieve strain on the tendon and provide a cushion that lessens the amount of force exerted on your Achilles tendon.

Surgery. If several months of more-conservative treatments don't work or if the tendon has torn, your doctor may suggest surgery to repair your Achilles tendon.

LIFESTYLE AND HOME REMEDIES

While it may not be possible to prevent Achilles tendinitis, you can take measures to reduce your risk:

Increase your activity level gradually. If you're just beginning an exercise regimen, start slowly and gradually increase the duration and intensity of the training.

Take it easy. Avoid activities that place excessive stress on your tendons, such as hill running. If you participate in a strenuous activity, warm up first by exercising at a slower pace. If you notice pain during a particular exercise, stop and rest.

Choose your shoes carefully. The shoes you wear while exercising should provide adequate cushioning for your heel and should have a firm arch support to help reduce the tension in the Achilles tendon. Replace your worn-out shoes. If your shoes are in good condition but don't support your feet, try arch supports in both shoes.

Stretch daily. Take the time to stretch your calf muscles and Achilles tendon in the morning, before exercise and after exercise to maintain flexibility. This is especially important to avoid a recurrence of Achilles tendinitis.

Strengthen your calf muscles. Strong calf muscles enable the calf and Achilles tendon to better handle the stresses they encounter with activity and exercise.

Cross-train. Alternate high-impact activities, such as running and jumping, with low-impact activities, such as cycling and swimming.

Achilles Tendon Rupture 

Achilles (uh-KILL-eez) tendon rupture is an injury that affects the back of your lower leg. It most commonly occurs in people playing recreational sports.

The Achilles tendon is a strong fibrous cord that connects the muscles in the back of your calf to your heel bone. If you overstretch your Achilles tendon, it can tear (rupture) completely or just partially.

If your Achilles tendon ruptures, you might feel a pop or snap, followed by an immediate sharp pain in the back of your ankle and lower leg that is likely to affect your ability to walk properly. Surgery is often the best option to repair an Achilles tendon rupture. For many people, however, nonsurgical treatment works just as well.

SYMPTOMS

Although it's possible to have no signs or symptoms with an Achilles tendon rupture, most people experience:

Pain, possibly severe, and swelling near your heel

An inability to bend your foot downward or "push off" the injured leg when you walk

An inability to stand on your toes on the injured leg

A popping or snapping sound when the injury occurs

When to see your doctor

Seek medical advice immediately if you feel a pop or snap in your heel, especially if you can't walk properly afterward.

CAUSES

Your Achilles tendon helps you point your foot downward, rise on your toes and push off your foot as you walk. You rely on it virtually every time you move your foot.

Rupture usually occurs in the section of the tendon located within 2 1/2 inches (about 6 centimeters) of the point where it attaches to the heel bone. This section may be predisposed to rupture because it gets less blood flow, which also may impair its ability to heal.

Ruptures often are caused by a sudden increase in the amount of stress on your Achilles tendon. Common examples include:

Increasing the intensity of sports participation, especially in sports that involve jumping

Falling from a height

Stepping into a hole

RISK FACTORS

Factors that may increase your risk of Achilles tendon rupture include:

Age. The peak age for Achilles tendon rupture is 30 to 40.

Sex. Achilles tendon rupture is up to five times more likely to occur in men than in women.

Recreational sports. Achilles tendon injuries occur more often during sports that involve running, jumping, and sudden starts and stops — such as soccer, basketball and tennis.

Steroid injections. Doctors sometimes inject steroids into an ankle joint to reduce pain and inflammation. However, this medication can weaken nearby tendons and has been associated with Achilles tendon ruptures.

Certain antibiotics. Fluoroquinolone antibiotics, such as ciprofloxacin (Cipro) or levofloxacin (Levaquin), increase the risk of Achilles tendon rupture.

PREPARING FOR YOUR APPOINTMENT

Because an Achilles tendon rupture can impair your ability to walk, it's common to seek immediate treatment at a hospital's emergency department. You may also need to consult with doctors specializing in sports medicine or orthopedic surgery.

What you can do

You may want to write a list that includes:

Detailed descriptions of the symptoms and the precipitating event

Information about past medical problems

All the medications and dietary supplements you take

Questions you want to ask the doctor

What to expect from your doctor

The doctor may ask you some of the following questions:

How did this injury occur?

Did you feel or hear a popping or snapping sound when it happened?

Can you stand on tiptoe on that foot?

TESTS AND DIAGNOSIS

During the physical exam, your doctor will inspect your lower leg for tenderness and swelling. In many cases, doctors can feel a gap in your tendon if it has ruptured completely.

The doctor may also ask you to kneel on a chair or lie on your stomach with your feet hanging over the end of the exam table. He or she may then squeeze your calf muscle to see if your foot will automatically flex. If it doesn't, you probably have ruptured your Achilles tendon.

If there's a question about the extent of your Achilles tendon injury — whether it's completely or only partially ruptured — your doctor may order an ultrasound or MRI scan. These painless procedures create images of the tissues of your body.

TREATMENTS AND DRUGS

Treatment for a ruptured Achilles tendon often depends on your age, activity level and the severity of your injury. In general, younger and more active people often choose surgery to repair a completely ruptured Achilles tendon, while older people are more likely to opt for nonsurgical treatment. Recent studies, however, have shown fairly equal effectiveness of both operative and nonoperative management.

Nonsurgical treatment

This approach typically involves wearing a cast or walking boot with wedges to elevate your heel, which allows your torn tendon to heal. This method avoids the risks associated with surgery, such as infection. However, the likelihood of re-rupture may be higher with a nonsurgical approach, and recovery can take longer. If re-rupture occurs, surgical repair may be more difficult.

Surgery

The procedure generally involves making an incision in the back of your lower leg and stitching the torn tendon together. Depending on the condition of the torn tissue, the repair may be reinforced with other tendons. Surgical complications can include infection and nerve damage. Infection rates are reduced in surgeries that employ smaller incisions.

Rehabilitation

After treatment, whether surgical or nonsurgical, you'll go through a rehabilitation program involving physical therapy exercises to strengthen your leg muscles and Achilles tendon. Most people return to their former level of activity within four to six months.

LIFESTYLE AND HOME REMEDIES

To reduce your chance of developing Achilles tendon problems, follow these tips:

Stretch and strengthen calf muscles. Stretch your calf to the point at which you feel a noticeable pull but not pain. Don't bounce during a stretch. Calf-strengthening exercises can also help the muscle and tendon absorb more force and prevent injury.

Vary your exercises. Alternate high-impact sports, such as running, with low-impact sports, such as walking, biking or swimming. Avoid activities that place excessive stress on your Achilles tendons, such as hill running and jumping activities.

Choose running surfaces carefully. Avoid or limit running on hard or slippery surfaces. Dress properly for cold-weather training and wear well-fitting athletic shoes with proper cushioning in the heels.

Increase training intensity slowly. Achilles tendon injuries commonly occur after abruptly increasing training intensity. Increase the distance, duration and frequency of your training by no more than 10 percent each week.

GERD (Acid Reflux)

Gastroesophageal reflux disease (GERD) is a chronic digestive disease. GERD occurs when stomach acid or, occasionally, stomach content, flows back into your food pipe (esophagus). The backwash (reflux) irritates the lining of your esophagus and causes GERD.

Both acid reflux and heartburn are common digestive conditions that many people experience from time to time. When these signs and symptoms occur at least twice each week or interfere with your daily life, or when your doctor can see damage to your esophagus, you may be diagnosed with GERD.

Most people can manage the discomfort of GERD with lifestyle changes and over-the-counter medications. But some people with GERD may need stronger medications, or even surgery, to reduce symptoms.

SYMPTOMS

GERD signs and symptoms include:

A burning sensation in your chest (heartburn), sometimes spreading to your throat, along with a sour taste in your mouth

Chest pain

Difficulty swallowing (dysphagia)

Dry cough

Hoarseness or sore throat

Regurgitation of food or sour liquid (acid reflux)

Sensation of a lump in your throat

When to see a doctor ?

Seek immediate medical attention if you experience chest pain, especially if you have other signs and symptoms, such as shortness of breath or jaw or arm pain. These may be signs and symptoms of a heart attack.

Make an appointment with your doctor if you experience severe or frequent GERD symptoms. If you take over-the-counter medications for heartburn more than twice a week, see your doctor.

CAUSES

GERD is caused by frequent acid reflux — the backup of stomach acid or bile into the esophagus.

When you swallow, the lower esophageal sphincter — a circular band of muscle around the bottom part of your esophagus — relaxes to allow food and liquid to flow down into your stomach. Then it closes again.

However, if this valve relaxes abnormally or weakens, stomach acid can flow back up into your esophagus, causing frequent heartburn. Sometimes this can disrupt your daily life.

This constant backwash of acid can irritate the lining of your esophagus, causing it to become inflamed (esophagitis). Over time, the inflammation can wear away the esophageal lining, causing complications such as bleeding, esophageal narrowing or Barrett's esophagus (a precancerous condition).

RISK FACTORS

Conditions that can increase your risk of GERD include:

1. Obesity

2. Bulging of top of stomach up into the diaphragm (hiatal hernia)

3. Pregnancy

4. Smoking

5. Dry mouth

6. Asthma

7. Diabetes

8. Delayed stomach emptying

9. Connective tissue disorders, such as scleroderma

COMPLICATIONS

Over time, chronic inflammation in your esophagus can lead to complications, including:

Narrowing of the esophagus (esophageal stricture). Damage to cells in the lower esophagus from acid exposure leads to formation of scar tissue. The scar tissue narrows the food pathway, causing difficulty swallowing.

An open sore in the esophagus (esophageal ulcer). Stomach acid can severely erode tissues in the esophagus, causing an open sore to form. The esophageal ulcer may bleed, cause pain and make swallowing difficult.

Precancerous changes to the esophagus (Barrett's esophagus). In Barrett's esophagus, the tissue lining the lower esophagus changes. These changes are associated with an increased risk of esophageal cancer. The risk of cancer is low, but your doctor will likely recommend regular endoscopy exams to look for early warning signs of esophageal cancer.

PREPARING FOR YOUR APPOINTMENT

If you think you have GERD, you're likely to start by first seeing your family doctor or a general practitioner. Your doctor may recommend you see a doctor who specializes in treating digestive diseases (gastroenterologist).

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well-prepared. Here's some information to help you get ready, and what to expect from your doctor.

What you can do ?

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.

1. Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.

2. Write down key personal information, including any major stresses or recent life changes.

3. Make a list of all medications, vitamins or supplements that you're taking.

4. Consider taking a family member or friend along. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Write down questions to ask your doctor?

Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. 

For gastroesophageal reflux disease, some basic questions to ask your doctor include:

1. What is likely causing my symptoms?

2. What kinds of tests do I need?

3. Do I need an endoscopy?

4. Is my GERD likely temporary or chronic?

5. What is the best course of action?

6. What are the alternatives to the primary approach that you're suggesting?

7. I have other health conditions. How can I best manage them while managing GERD?

8. Are there any restrictions that I need to follow?

9. Should I see a specialist? What will that cost, and will my insurance cover it?

10. Is there a generic alternative to the medicine you're prescribing for me?

11. Are there brochures or other printed material that I can take with me? What websites do you recommend?

12. Should I schedule a follow-up visit?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment anytime you don't understand something.

What to expect from your doctor ?

Your doctor is likely to ask you a number of questions. Being ready to answer them may allow more time later to cover points you want to address. Your doctor may ask:

1. What are your symptoms?

2. When did you first notice these symptoms?

3. Have your symptoms been continuous or occasional?

4. How severe are your symptoms?

5. What, if anything, seems to improve your symptoms?

6. What, if anything, appears to worsen your symptoms?

7. Do your symptoms wake you up at night?

8. Are your symptoms worse after meals or after lying down?

9. Do your symptoms include nausea or vomiting?

10. Does food or sour material ever come up in the back of your throat?

11. Do you have difficulty swallowing?

12. Have you gained or lost weight?

13. Do you experience nausea and vomiting?

What you can do in the meantime ?

Try lifestyle changes to control your symptoms until you see your doctor. For instance, avoid foods that trigger your heartburn and avoid eating at least two hours before bedtime.

TESTS AND DIAGNOSIS

Diagnosis of GERD is based on:

Your symptoms. Your doctor may be able to diagnose GERD based on frequent heartburn and other symptoms.

A test to monitor the amount of acid in your esophagus. Ambulatory acid (pH) probe tests use a device to measure acid for 24 hours. The device identifies when, and for how long, stomach acid regurgitates into your esophagus. One type of monitor is a thin, flexible tube (catheter) that's threaded through your nose into your esophagus. The tube connects to a small computer that you wear around your waist or with a strap over your shoulder.

Another type is a clip that's placed in your esophagus during endoscopy. The probe transmits a signal, also to a small computer that you wear. After about two days, the probe falls off to be passed in your stool. Your doctor may ask that you stop taking GERD medications to prepare for this test.

If you have GERD and you're a candidate for surgery, you may also have other tests, such as:

An X-ray of your upper digestive system. Sometimes called a barium swallow or upper GI series, this procedure involves drinking a chalky liquid that coats and fills the inside lining of your digestive tract. Then X-rays are taken of your upper digestive tract. The coating allows your doctor to see a silhouette of your esophagus, stomach and upper intestine (duodenum).

A flexible tube to look inside your esophagus. Endoscopy is a way to visually examine the inside of your esophagus and stomach. During endoscopy, your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat.

Your doctor may also use endoscopy to collect a sample of tissue (biopsy) for further testing. Endoscopy is useful in looking for complications of reflux, such as Barrett's esophagus.

A test to measure the movement of the esophagus. Esophageal motility testing (manometry) measures movement and pressure in the esophagus. The test involves placing a catheter through your nose and into your esophagus.

TREATMENTS AND DRUGS

Treatment for heartburn and other signs and symptoms of GERD usually begins with over-the-counter medications that control acid. If you don't experience relief within a few weeks, your doctor may recommend other treatments, including medications and surgery.

Initial treatments to control heartburn

Over-the-counter treatments that may help control heartburn include:

1. Antacids that neutralize stomach acid. Antacids, such as Maalox, Mylanta, Gelusil, Gaviscon, Rolaids and Tums, may provide quick relief. But antacids alone won't heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or constipation.

2. Medications to reduce acid production. Called H-2-receptor blockers, these medications include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) or ranitidine (Zantac). H-2-receptor blockers don't act as quickly as antacids do, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours. Stronger versions of these medications are available in prescription form.

3. Medications that block acid production and heal the esophagus. Proton pump inhibitors are stronger blockers of acid production than are H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24 HR) and omeprazole (Prilosec, Zegerid OTC).

Contact your doctor if you need to take these medications for longer than two to three weeks or your symptoms are not relieved.

Prescription-strength medications

If heartburn persists despite initial approaches, your doctor may recommend prescription-strength medications, such as:

Prescription-strength H-2-receptor blockers. These include prescription-strength cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid) and ranitidine (Zantac).

Prescription-strength proton pump inhibitors. Prescription-strength proton pump inhibitors include esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid), pantoprazole (Protonix), rabeprazole (Aciphex) and dexlansoprazole (Dexilant).

These medications are generally well-tolerated, but long-term use may be associated with a slight increase in risk of bone fracture and vitamin B-12 deficiency.

Medications to strengthen the lower esophageal sphincter. Baclofen may decrease the frequency of relaxations of the lower esophageal sphincter and therefore decrease gastroesophageal reflux. It has less of an effect than do proton pump inhibitors, but it might be used in severe reflux disease. Baclofen can be associated with significant side effects, most commonly fatigue or confusion.

GERD medications are sometimes combined to increase effectiveness.

Surgery and other procedures used if medications don't help

Most GERD can be controlled through medications. In situations where medications aren't helpful or you wish to avoid long-term medication use, your doctor may recommend more-invasive procedures, such as:

Surgery to reinforce the lower esophageal sphincter (Nissen fundoplication). This surgery involves tightening the lower esophageal sphincter to prevent reflux by wrapping the very top of the stomach around the outside of the lower esophagus. Surgeons usually perform this surgery laparoscopically. In laparoscopic surgery, the surgeon makes three or four small incisions in the abdomen and inserts instruments, including a flexible tube with a tiny camera, through the incisions.

Surgery to strengthen the lower esophageal sphincter (Linx). The Linx device is a ring of tiny magnetic titanium beads that is wrapped around the junction of the stomach and esophagus. The magnetic attraction between the beads is strong enough to keep the opening between the two closed to refluxing acid, but weak enough so that food can pass through it. It can be implanted using minimally invasive surgery methods. This newer device has been approved by the Food and Drug Administration and early studies with it appear promising.

LIFESTYLE AND HOME REMEDIES

Lifestyle changes may help reduce the frequency of heartburn. Consider trying to:

Maintain a healthy weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus. If your weight is healthy, work to maintain it. If you are overweight or obese, work to slowly lose weight — no more than 1 or 2 pounds (0.5 to 1 kilogram) a week. Ask your doctor for help in devising a weight-loss strategy that will work for you.

Avoid tight-fitting clothing. Clothes that fit tightly around your waist put pressure on your abdomen and the lower esophageal sphincter.

Avoid foods and drinks that trigger heartburn. Everyone has specific triggers. Common triggers such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine may make heartburn worse. Avoid foods you know will trigger your heartburn.

Eat smaller meals. Avoid overeating by eating smaller meals.

Don't lie down after a meal. Wait at least three hours after eating before lying down or going to bed.

Elevate the head of your bed. If you regularly experience heartburn at night or while trying to sleep, put gravity to work for you. Place wood or cement blocks under the feet of your bed so that the head end is raised by 6 to 9 inches. If it's not possible to elevate your bed, you can insert a wedge between your mattress and box spring to elevate your body from the waist up. Wedges are available at drugstores and medical supply stores. Raising your head with additional pillows is not effective.

Don't smoke. Smoking decreases the lower esophageal sphincter's ability to function properly.

ALTERNATIVE MEDICINE

No alternative medicine therapies have been proved to treat GERD or to reverse damage to the esophagus. Still, some complementary and alternative therapies may provide some relief, when combined with your doctor's care.

Talk to your doctor about what alternative GERD treatments may be safe for you. Options may include:

Herbal remedies. Herbal remedies sometimes used for GERD symptoms include licorice, slippery elm, chamomile, marshmallow and others. Herbal remedies can have serious side effects, and they may interfere with medications. Ask your doctor about a safe dosage before beginning any herbal remedy.

Relaxation therapies. Techniques to calm stress and anxiety may reduce signs and symptoms of GERD. Ask your doctor about relaxation techniques, such as progressive muscle relaxation or guided imagery.

Acupuncture. Acupuncture involves inserting thin needles into specific points on your body. Limited evidence suggests it may help people with heartburn, but major studies have not proved a benefit. Ask your doctor whether acupuncture is safe for you.

Acid Reflux Infant

Infant reflux (sometimes called infant acid reflux) is the condition where the contents of the stomach are spit out, usually shortly after feeding. Spitting up (infant reflux) becomes less common as a baby gets older, and it's unusual if it's still occurring after 18 months of age.

In a small number of cases, reflux can be a sign of a more serious problem, such as gastroesophageal reflux disease (GERD), an allergy or a blockage.

SYMPTOMS

Spitting up and vomiting are the main symptoms of infant reflux. As long as your baby is healthy, content and growing well, the reflux is not a cause for concern. Your child will in all likelihood outgrow it.

While your baby may act fussy or seem to be uncomfortable, it is very unusual for the stomach contents to be acidic enough to irritate the esophagus or throat, as happens with acid reflux.

When to see a doctor

Contact your baby's doctor if your baby:

Isn't gaining weight

Spits up forcefully, causing stomach contents to shoot out of his or her mouth (projectile vomiting)

Spits up green or yellow fluid

Spits up blood or a material that looks like coffee grounds

Refuses food

Has blood in his or her stool

Has difficulty breathing

Begins vomiting at age 6 months or older

Some of these signs may indicate more-serious conditions, such as gastroesophageal reflux disease (GERD) or pyloric stenosis. In GERD, the reflux contains stomach acid which damages the lining of the esophagus. Pyloric stenosis is a rare condition in which a narrowed valve between the stomach and the small intestine keeps stomach contents from emptying into the small intestine.

CAUSES

Infant reflux is related to a number of factors, often in combination with one another.

In infants, the ring of muscle between the esophagus and the stomach — the lower esophageal sphincter (LES) — is not yet fully mature, allowing stomach contents to flow backward. Eventually, the LES will open only when baby swallows and will remain tightly closed the rest of the time, keeping stomach contents where they belong.

Babies are lying flat most of the time, which makes reflux more likely. Moreover, their diet is completely liquid, also favoring infant reflux. Sometimes air bubbles in the stomach may push liquids backward. In other cases, your baby may simply drink too much, too fast.

Although infant reflux most often occurs after a feeding, it can happen anytime your baby coughs, cries or strains.

In a small number of cases, the symptoms of infant reflux are caused by something else. Among the possibilities:

Allergic gastroenteritis is an intolerance to something in food, usually a protein in cow's milk.

Gastroesophael reflux disease (GERD) is a more severe condition where the reflux is acidic enough to actually irritate and damage the lining of the esophagus.

Eosinophilic esophagitis is a condition where a particular type of white blood cell (eosinophil) builds up and injures the lining of the esophagus.

Obstruction is a blockage or narrowing in the esophagus (esophageal stricture) or between the stomach and small intestine (pyloric stenosis).

COMPLICATIONS

Most cases of infant reflux clear up on their own without causing problems for your baby.

If the condition is not normal reflux, but is GERD or some other condition (much less common), the baby may show signs of poor growth or problems with breathing. Some research indicates that babies who have frequent episodes of spitting up may be more likely to develop gastroesophageal reflux disease during later childhood.

PREPARING FOR YOUR APPOINTMENT

If you're worried about infant reflux, you'll likely start by seeing your child's family doctor or pediatrician. If the reflux is persisting past your child's first birthday or if your child is having some worrisome symptoms such as lack of weight gain and breathing problems, you may be referred to a specialist in digestive diseases in children (pediatric gastroenterologist).

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

Write down any symptoms your baby is experiencing. Note when the baby spits up. Is it every time he or she feeds? How much liquid is your baby spitting up? Does it seem like he or she is throwing up everything eaten?

Make a list of key information. How often do you feed your baby? How long do feeding sessions last? How often do you burp your baby during feedings? Are you breast-feeding? If not, what type of formula are you using? How do you prepare the formula? Have you recently switched formulas?

Write down questions to ask your doctor.

Questions to ask your doctor

Some basic questions you might want to ask your doctor include:

What's the most likely cause of my baby's symptoms?

Does my baby need any tests?

What treatments are available?

What can I do to help my baby?

Am I feeding my baby too much? Or am I feeding my baby too often?

Are there any brochures or other printed material that I can take with me? What websites do you recommend?

What to expect from your doctor

Be ready to respond to questions your doctor is likely to ask you:

When did your baby first begin experiencing symptoms?

Does your baby spit up with every feeding or only occasionally?

How is your baby's temperament? Is he or she content between feedings?

Have you recently switched from breast-feeding to bottle-feeding? Or have you switched infant formulas?

How often do you feed your baby?

How much does your baby eat at each feeding?

Does the same person feed your baby every time?

If you have different caregivers, does everyone feed the baby the same way each time?

In what position does your baby sleep?

Does anything seem to improve your baby's symptoms?

What, if anything, appears to worsen the symptoms?

TESTS AND DIAGNOSIS

Diagnosis of infant reflux is typically based on your baby's symptoms and a physical exam. If your baby is healthy, growing as expected and seems content, then further testing usually isn't needed.

If your baby's doctor suspects a more serious problem, diagnostic tests could include:

Ultrasound. This test is used to detect an obstruction in the opening between the stomach and small intestine (pyloric stenosis).

Lab tests. Various blood and urine tests can help identify or rule out possible causes of recurring vomiting and poor weight gain.

Esophageal pH monitoring. To determine if irritability, sleep disturbances or other symptoms are associated with reflux of acid, it may be helpful to measure the acidity in your baby's esophagus. The doctor will insert a thin tube through your baby's nose or mouth into the esophagus. The tube is attached to a device that monitors acidity. Your baby may need to remain in the hospital while being monitored.

Upper GI series. If the doctor suspects a gastrointestinal obstruction, he or she may recommend a series of X-rays known as an upper gastrointestinal (GI) series. Before the X-rays, your baby is given a white, chalky liquid (barium) to drink. The barium coats the stomach, which helps any abnormalities show up more clearly on the X-rays.

Upper endoscopy. Your baby's doctor may use this procedure to identify or rule out problems in the esophagus, such as narrowing (stricture) or inflammation (esophagitis). The doctor will insert a special tube equipped with a camera lens and light through your baby's mouth into the esophagus, stomach and first part of the small intestine. Samples of any suspicious tissue may be taken for analysis. For infants and children, endoscopy is usually done under general anesthesia.

TREATMENTS AND DRUGS

Most cases of infant reflux clear up on their own, helped by simple changes in feeding techniques, such as:

Smaller, more frequent feedings

Interrupting feedings to burp the baby

Holding your baby upright during and after feedings

To test to see if the reflux is caused by an allergy to a protein in cow's milk, your baby's doctor may suggest that you eliminate dairy products or beef from your diet if you're breast-feeding.

If you feed your baby formula, sometimes switching types can help.

Medication. Acid-blocking medications are not recommended in cases of uncomplicated infant reflux. A short-term trial of an H-2 blocker such as ranitidine, or perhaps a proton pump inhibitor such as omeprazole (Prilosec) or lansoprazole (Prevacid), may be worth trying for babies who have poor weight gain, refuse to feed, have evidence of esophagitis or who have chronic asthma and reflux.

It's important to note that otherwise healthy children taking these medications may face an increased risk of certain intestinal and respiratory infections. In addition, prolonged use of proton pump inhibitors has been linked to problems in iron and calcium absorption in infants.

Surgery. In rare instances, the muscle that relaxes to let food into the stomach (the lower esophageal sphincter) needs to be surgically tightened to prevent acid from flowing back into the esophagus. This fundoplication procedure is usually reserved for the few babies who have reflux severe enough to interfere with breathing or prevent growth.

LIFESTYLE AND HOME REMEDIES

To minimize reflux, consider these tips:

Keep baby upright. Feed your baby in an upright position, and hold your baby in a sitting position for 30 minutes afterward, if possible. Gravity can help stomach contents stay where they belong. Be careful not to jostle or jiggle your baby while the food is settling.

Try smaller, more frequent feedings. Feed your baby slightly less than usual if you're bottle-feeding or cut back a little on the amount of nursing time if you're breast-feeding.

Take time to burp your baby. Frequent burps during and after feeding can keep air from building up in your baby's stomach. To burp, sit your baby upright, supporting his or her head with your hand. Avoid burping your baby over your shoulder, which puts pressure on your baby's abdomen.

Put baby to sleep on his or her back. Most babies should be placed on their backs (supine) to sleep, even if they have reflux.

Thickening formula or expressed breast milk with rice cereal is an older remedy for infant reflux. It isn't universally recommended today.

If you thicken your baby's formula, you might notice less spitting up — but some research suggests that the number of reflux episodes actually remains the same. Thickening formula also adds potentially unnecessary calories to your baby's diet, and might lead to choking or other problems during feeding.

Thickening expressed breast milk with rice cereal isn't likely to be effective because the enzymes in breast milk break down the starch in the cereal — which quickly thins the milk.

Remember, infant reflux is usually little cause for concern. Just keep plenty of burp cloths handy as you ride it out.

ACL Injury

An ACL injury is the tearing of the anterior cruciate ligament, or ACL, inside your knee joint. An ACL injury most commonly occurs during sports that involve sudden stops and changes in direction — such as basketball, soccer, tennis and volleyball.

Immediately after an ACL injury, your knee may swell, feel unstable and become too painful to bear weight. Many people hear or feel a "pop" in their knee when an ACL injury occurs.

Depending on the severity of your ACL injury, treatment may include surgery to replace the torn ligament followed by rehabilitation exercises to help you regain strength and stability. If your favorite sport involves pivoting or jumping, a proper training program may help reduce your chances of an ACL injury.

SYMPTOMS

At the time of an ACL injury, signs and symptoms may include:

A loud "pop" sound

Severe pain and inability to continue activity

Knee swelling that usually worsens for hours after the injury occurs

A feeling of instability or "giving way" with weight bearing

When to see a doctor

Most people seek immediate medical attention after an ACL injury.

CAUSES

Ligaments are strong bands of tissue that connect one bone to another. The ACL, one of two ligaments that cross in the middle of the knee, connects your thighbone (femur) to your shinbone (tibia) and helps stabilize your knee joint.

Most ACL injuries happen during sports and fitness activities. The ligament may tear when you slow down suddenly to change direction or pivot with your foot firmly planted, twisting or hyperextending your knee.

Landing awkwardly from a jump can also injure your ACL, as can falls during downhill skiing. A football tackle or motor vehicle accident also can cause an ACL injury. However, most ACL injuries occur without such contact.

RISK FACTORS

Women are significantly more likely to have an ACL tear than are men participating in the same sports. Women tend to have a strength imbalance, with the muscles at the front of the thigh (quadriceps) being stronger than the muscles at the back of the thigh (hamstrings). The hamstrings help prevent the shinbone from moving too far forward during activities. When landing from a jump, some women may land in a position that increases stress on their ACL.

COMPLICATIONS

People who experience an ACL injury are at higher risk of developing knee osteoarthritis, in which joint cartilage deteriorates and its smooth surface roughens. Arthritis may occur even if you have surgery to reconstruct the ligament.

PREPARING FOR YOUR APPOINTMENT

The pain and disability associated with an ACL injury prompt many people to seek immediate medical attention. Others may make an appointment with their family doctors. Depending upon the severity of your injury, you may be referred to a doctor specializing in sports medicine or orthopedic surgery.

What you can do

Before the appointment, you may want to write down the answers to the following questions:

When did the injury occur?

What were you doing at the time?

Did you initially hear a loud "pop" sound?

Was there much swelling afterward?

What to expect from your doctor

Your doctor may ask some of the following questions:

Have your symptoms been continuous or occasional?

Do any specific movements seem to improve or worsen your symptoms?

Does your knee ever "lock" or feel blocked when you're trying to move it?

Do you ever feel that your knee is unstable or unable to support your weight?

TESTS AND DIAGNOSIS

During the physical exam, your doctor will check your knee for swelling and tenderness — comparing your injured knee to your uninjured knee. He or she also may move your knee into a variety of positions, to help determine if your ACL is torn.

Often the diagnosis can be made on the basis of the physical exam alone, but you may need tests to rule out other causes and to determine the severity of the injury. These tests may include:

X-rays. X-rays may be needed to rule out a bone fracture. However, X-rays can't visualize soft tissues such as ligaments and tendons.

Magnetic resonance imaging (MRI). An MRI uses radio waves and a strong magnetic field to create images of both hard and soft tissues within your body. An MRI can show the extent of an ACL injury and whether other knee ligaments or joint cartilage also are injured.

Ultrasound. Using sound waves to visualize internal structures, ultrasound may be used to check for injuries in the ligaments, tendons and muscles of the knee.

TREATMENTS AND DRUGS

Initial treatment for an ACL injury aims to reduce pain and swelling in your knee, regain normal joint movement and strengthen the muscles around your knee.

You and your doctor will then decide if you need surgery plus rehabilitation, or rehabilitation alone. The choice depends on several factors, including the extent of damage to your knee and your willingness to modify your activities.

Athletes who wish to return to sports involving cutting, pivoting or jumping usually pursue surgical reconstruction to prevent episodes of instability. More-sedentary people without significant injury to the cartilage or other ligaments usually can maintain knee stability with rehabilitation alone.

Therapy

Whether or not you have surgery on your knee, you'll need rehabilitation. Therapy will include:

The use of crutches and, possibly, a knee brace

Range-of-motion exercises to regain your full knee motion

Muscle-strengthening and stability exercises

Surgery

A torn ACL can't be successfully sewn back together, so the ligament is usually replaced with a piece of tendon from another part of your knee or leg. A tendon graft from a deceased donor also may be an option. This surgery is usually performed through small incisions around your knee joint. A narrow, fiber-optic viewing scope is used to guide the placement of the ACL graft.

LIFESTYLE AND HOME REMEDIES

To reduce your chance of an ACL injury, follow these tips:

Improve your conditioning. Training programs that have been shown to be effective in helping to reduce the risk of ACL injuries typically include strengthening and stability exercises, aerobic conditioning, plyometric exercises, "jump training," and risk-awareness training. Exercises that improve balance also can help when done in conjunction with other training exercises.

Strengthen your hamstrings. Women athletes in particular should make sure to strengthen their hamstring muscles as well as their quadriceps.

Use proper techniques. If your sport involves jumping, learn how to land safely. Studies have shown that if your knee collapses inward when you land from a jump, you are more likely to sustain an ACL injury. Technique training along with strengthening of some of the hip muscles can help to reduce this risk.

Check your gear. In downhill skiing, make sure your ski bindings are adjusted correctly by a trained professional so that your skis will release appropriately when you fall.

Wearing a knee brace has not been found to be helpful in preventing ACL injuries.

Acne

Acne is a skin condition that occurs when your hair follicles become plugged with oil and dead skin cells. Acne usually appears on your face, neck, chest, back and shoulders. Effective treatments are available, but acne can be persistent. The pimples and bumps heal slowly, and when one begins to go away, others seem to crop up.

Acne is most common among teenagers, with a reported prevalence of 70 to 87 percent. Increasingly, younger children are getting acne as well.

Depending on its severity, acne can cause emotional distress and scar the skin. The earlier you start treatment, the lower your risk of lasting physical and emotional damage.

SYMPTOMS

Acne signs and symptoms vary depending on the severity of your condition:

Whiteheads (closed plugged pores)

Blackheads (open plugged pores — the oil turns brown when it is exposed to air)

Small red, tender bumps (papules)

Pimples (pustules), which are papules with pus at their tips

Large, solid, painful lumps beneath the surface of the skin (nodules)

Painful, pus-filled lumps beneath the surface of the skin (cystic lesions)

When to see a doctor

If home care remedies don't work to clear up your acne, see your primary care doctor. He or she can prescribe stronger medications. If acne persists or is severe, you may want to seek medical treatment from a doctor who specializes in the skin (dermatologist).

The Food and Drug Administration warns that some popular nonprescription acne lotions, cleansers and other skin products can cause a serious reaction. This type of reaction is quite rare, so don't confuse it with the redness, irritation or itchiness where you've applied medications or products.

Seek emergency medical help if after using a nonprescription skin product you experience:

Faintness

Difficulty breathing

Swelling of the eyes, face, lips or tongue

Tightness of the throat

CAUSES

Four main factors cause acne:

Oil production

Dead skin cells

Clogged pores

Bacteria

Acne typically appears on your face, neck, chest, back and shoulders. These areas of skin have the most oil (sebaceous) glands. Acne occurs when hair follicles become plugged with oil and dead skin cells.

Hair follicles are connected to oil glands. These glands secrete an oily substance (sebum) to lubricate your hair and skin. Sebum normally travels along the hair shafts and through the openings of the hair follicles onto the surface of your skin.

When your body produces an excess amount of sebum and dead skin cells, the two can build up in the hair follicles. They form a soft plug, creating an environment where bacteria can thrive. If the clogged pore becomes infected with bacteria, inflammation results.

The plugged pore may cause the follicle wall to bulge and produce a whitehead. Or the plug may be open to the surface and may darken, causing a blackhead. A blackhead may look like dirt stuck in pores. But actually the pore is congested with bacteria and oil, which turns brown when it's exposed to the air.

Pimples are raised red spots with a white center that develop when blocked hair follicles become inflamed or infected. Blockages and inflammation that develop deep inside hair follicles produce cyst-like lumps beneath the surface of your skin. Other pores in your skin, which are the openings of the sweat glands, aren't usually involved in acne.

Factors that may worsen acne

These factors can trigger or aggravate an existing case of acne:

Hormones. Androgens are hormones that increase in boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormonal changes related to pregnancy and the use of oral contraceptives also can affect sebum production. And low amounts of androgens circulate in the blood of women and can worsen acne.

Certain medications. Drugs containing corticosteroids, androgens or lithium can worsen acne.

Diet. Studies indicate that certain dietary factors, including dairy products and carbohydrate-rich foods — such as bread, bagels and chips — may trigger acne. Chocolate has long been suspected of making acne worse. A recent study of 14 men with acne showed that eating chocolate was related to an increase in acne. Further study is needed to examine why this happens or whether acne patients need to follow specific dietary restrictions.

Stress. Stress can make acne worse.

Acne myths

These factors have little effect on acne:

Greasy foods. Eating greasy food has little to no effect on acne. Though working in a greasy area, such as a kitchen with fry vats, does because the oil can stick to the skin and block the hair follicles. This further irritates the skin or promotes acne.

Dirty skin. Acne isn't caused by dirt. In fact, scrubbing the skin too hard or cleansing with harsh soaps or chemicals irritates the skin and can make acne worse. Though it does help to gently remove oil, dead skin and other substances.

Cosmetics. Cosmetics don't necessarily worsen acne, especially if you use oil-free makeup that doesn't clog pores (noncomedogenics) and remove makeup regularly. Nonoily cosmetics don't interfere with the effectiveness of acne drugs.

RISK FACTORS

Risk factors for acne include:

Hormonal changes. Such changes are common in teenagers, women and girls, and people using certain medications, including those containing corticosteroids, androgens or lithium.

Family history. Genetics plays a role in acne. If both parents had acne, you're likely to develop it, too.

Greasy or oily substances. You may develop acne where your skin comes into contact with oily lotions and creams or with grease in a work area, such as a kitchen with fry vats.

Friction or pressure on your skin. This can be caused by items such as telephones, cellphones, helmets, tight collars and backpacks.

Stress. This doesn't cause acne, but if you have acne already, stress may make it worse.

PREPARING FOR YOUR APPOINTMENT

If you have acne that's not responding to self-care and over-the-counter treatments, make an appointment with your doctor. Early, effective treatment of acne reduces the risk of scarring and of lasting damage to your self-esteem. After an initial examination, your doctor may refer you to a specialist in the diagnosis and treatment of skin conditions (dermatologist).

Here's some information to help you get ready for your appointment.

What you can do

List your key medical information, such as other conditions with which you've been diagnosed and any prescription or over-the-counter products you're using, including vitamins and supplements.

List key personal information, including any major stresses or recent life changes.

List questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.

Below are some basic questions to ask your doctor about acne. If any additional questions occur to you during your visit, don't hesitate to ask.

What treatment approach do you recommend for me?

If the first treatment doesn't work, what will you recommend next?

What are the possible side effects of the medications you're prescribing?

How long can I safely use the medications you're prescribing?

How soon after beginning treatment should my symptoms start to improve?

When will you see me again to evaluate whether my treatment is working?

Is it safe to stop my medications if they don't seem to be working?

What self-care steps might improve my symptoms?

Do you recommend any changes to my diet?

Do you recommend any changes to the over-the-counter products I'm using on my skin, including soaps, lotions, sunscreens and cosmetics?

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to talk about in-depth. Your doctor may ask:

When did you first develop this problem?

Does anything in particular seem to trigger an acne flare, such as stress or — in girls and women — your menstrual cycle?

What medications are you taking, including over-the-counter and prescription drugs as well as vitamins and supplements?

In girls and women: Do you use oral contraceptives?

In girls and women: Do you have regular menstrual periods?

In girls and women: Are you pregnant, or do you plan to become pregnant soon?

What types of soaps, lotions, sunscreens, hair products or cosmetics do you use?

How is acne affecting your self-esteem and your confidence in social situations?

Do you have a family history of acne?

What treatments and self-care steps have you tried so far? Have any been effective?

TREATMENTS AND DRUGS

If over-the-counter (nonprescription) products haven't cleared up your acne, your doctor can prescribe stronger medications or other therapies. A dermatologist can help you:

Control your acne

Avoid scarring or other damage to your skin

Make scars less noticeable

Acne medications work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection or reducing inflammation — which helps prevent scarring. With most prescription acne drugs, you may not see results for four to eight weeks, and your skin may get worse before it gets better. It can take many months or years for your acne to clear up completely.

The drug your doctor recommends depends on the type and severity of your acne. It might be something you apply to your skin (topical medication) or take by mouth (oral medication). Often, drugs are used in combination. Pregnant women will not be able to use oral prescription medications for acne.

Talk with your doctor about the risks and benefits of medications and other treatments you are considering.

Topical medications

These products work best when applied to clean, dry skin about 15 minutes after washing. You may not see the benefit of this treatment for a few weeks. And you may notice skin irritation at first, such as redness, dryness and peeling.

Your doctor may recommend steps to minimize these side effects, including using a gradually increased dose, washing off the medication after a short application or switching to another medication.

The most common topical prescription medications for acne are:

Retinoids. These come as creams, gels and lotions. Retinoid drugs are derived from vitamin A and include tretinoin (Avita, Retin-A, others), adapalene (Differin) and tazarotene (Tazorac, Avage). You apply this medication in the evening, beginning with three times a week, then daily as your skin becomes used to it. It works by preventing plugging of the hair follicles.

Antibiotics. These work by killing excess skin bacteria and reducing redness. For the first few months of treatment, you may use both a retinoid and an antibiotic, with the antibiotic applied in the morning and the retinoid in the evening. The antibiotics are often combined with benzoyl peroxide to reduce the likelihood of developing antibiotic resistance. Examples include clindamycin with benzoyl peroxide (Benzaclin, Duac, Acanya) and erythromycin with benzoyl peroxide (Benzamycin).

Dapsone (Aczone). This gel is most effective when combined with a topical retinoid. Skin side effects include redness and dryness.

Oral medications

Antibiotics. For moderate to severe acne, you may need oral antibiotics to reduce bacteria and fight inflammation. Choices for treating acne include tetracyclines, such as minocycline and doxycycline.

Your doctor likely will recommend tapering off these medications as soon as your symptoms begin to improve or as soon as it becomes clear the drugs aren't helping — usually, within three to four months. Tapering helps prevent antibiotic resistance by minimizing undue exposure to these medications over a long time.

You will likely use topical medications and oral antibiotics together. Studies have found that using topical benzoyl peroxide along with oral antibiotics may reduce the risk of developing antibiotic resistance.

Antibiotics may cause side effects, such as an upset stomach and dizziness. These drugs also increase your skin's sun sensitivity. They can cause discoloration of developing permanent teeth and reduced bone growth in children born to women who took tetracyclines while pregnant.

Combined oral contraceptives. Combined oral contraceptives are useful in treating acne in women and adolescent girls. The Food and Drug Administration approved three products that combine estrogen and progestin (Ortho Tri-Cyclen, Estrostep and Yaz).

The most common side effects of these drugs are headache, breast tenderness, nausea, weight gain and breakthrough bleeding. A serious potential complication is a slightly increased risk of blood clots.

Anti-androgen agent. The drug spironolactone (Aldactone) may be considered for women and adolescent girls if oral antibiotics aren't helping. It works by blocking the effect of androgen hormones on the sebaceous glands. Possible side effects include breast tenderness, painful periods and the retention of potassium.

Isotretinoin. This medicine is reserved for people with the most severe acne. Isotretinoin (Amnesteem, Claravis, Sotret) is a powerful drug for people whose acne doesn't respond to other treatments.

Oral isotretinoin is very effective. But because of its potential side effects, doctors need to closely monitor anyone they treat with this drug. The most serious potential side effects include ulcerative colitis, an increased risk of depression and suicide, and severe birth defects.

In fact, isotretinoin carries such serious risk of side effects that women of reproductive age must participate in a Food and Drug Administration-approved monitoring program to receive a prescription for the drug.

Therapies

These therapies may be suggested in select cases, either alone or in combination with medications.

Light therapy. A variety of light-based therapies have been tried with success. But further study is needed to determine the ideal method, light source and dose. Light therapy targets the bacteria that cause acne inflammation. Some types of light therapy are done in a doctor's office. Blue-light therapy can be done at home with a hand-held device.

Possible side effects of light therapy include pain, temporary redness and sensitivity to sunlight.

Chemical peel. This procedure uses repeated applications of a chemical solution, such as salicylic acid. It is most effective when combined with other acne treatments, except oral retinoids. Chemical peels aren't recommended for people taking oral retinoids because together these treatments can significantly irritate the skin.

Chemicals peels may cause temporary, severe redness, scaling and blistering, and long-term discoloration of the skin.

Extraction of whiteheads and blackheads. Your dermatologist uses special tools to gently remove whiteheads and blackheads (comedos) that haven't cleared up with topical medications. This technique may cause scarring.

Steroid injection. Nodular and cystic lesions can be treated by injecting a steroid drug directly into them. This improves their appearance without the need for extraction. The side effects of this technique include thinning of the skin, lighter skin and the appearance of small blood vessels on the treated area.

Treating acne scars

Procedures used to diminish scars left by acne include the following:

Soft tissue fillers. Injecting soft tissue fillers, such as collagen or fat, under the skin and into indented scars can fill out or stretch the skin. This makes the scars less noticeable. Results are temporary, so you would need to repeat the injections periodically. Side effects include temporary swelling, redness and bruising.

Chemical peels. High-potency acid is applied to your skin to remove the top layer and minimize deeper scars.

Dermabrasion. This procedure is usually reserved for more severe scarring. It involves sanding (planing) the surface layer of skin with a rotating brush. This helps blend acne scars into the surrounding skin.

Laser resurfacing. This is a skin resurfacing procedure that uses a laser to improve the appearance of your skin.

Light therapy. Certain lasers, pulsed light sources and radiofrequency devices that don't injure the epidermis can be used to treat scars. These treatments heat the dermis and cause new skin to form. After several treatments, acne scars may appear less noticeable. This treatment has shorter recovery times than some other methods. But you may need to repeat the procedure more often and results are subtle.

Skin surgery. Using a minor procedure called punch excision, your doctor cuts out individual acne scars and repairs the hole at the scar site with stitches or a skin graft.

Treating children

Most studies of acne drugs have involved people 12 years of age or older. Increasingly, younger children are getting acne as well. In one study of 365 girls ages 9 to 10, 78 percent of them had acne lesions. If your child has acne, you may want to consult a pediatric dermatologist. Ask about drugs to avoid in children, appropriate doses, drug interactions, side effects, and how treatment may affect a child's growth and development.

Treatment of children with acne is often complicated by their family situation. For example, if a child moves between two homes due to divorced parents, it may help to use two sets of medications, one in each home.

LIFESTYLE AND HOME REMEDIES

Once your acne improves, you may need to continue your acne medication or other treatment to prevent new breakouts. You might need to use a topical medication on acne-prone areas, continue taking oral contraceptives or attend ongoing light therapy sessions. Talk to your doctor about how you can keep your skin clear.

You can also use these acne-prevention tips:

Wash acne-prone areas only twice a day. Washing removes excess oil and dead skin cells. But too much washing can irritate the skin. Wash affected areas with a gentle cleanser and use oil-free, water-based skin care products.

Use an over-the-counter acne cream or gel to help dry excess oil. Look for products containing benzoyl peroxide or salicylic acid as the active ingredient.

Use nonoily makeup. Choose oil-free cosmetics that won't clog pores (noncomedogenics).

Remove makeup before going to bed. Going to sleep with cosmetics on your skin can clog your pores. Also, it's a good idea to throw out old makeup and regularly clean your cosmetic brushes and applicators with soapy water.

Wear loosefitting clothing. Tightfitting clothing traps heat and moisture and can irritate your skin. When possible, avoid tightfitting straps, backpacks, helmets, hats and sports equipment to prevent friction against your skin.

Shower after strenuous activities. Oil and sweat on your skin can lead to breakouts.

Avoid touching or picking at the problem areas. Doing so can trigger more acne.

ALTERNATIVE MEDICINE

Some studies suggest that using the following supplements may help treat acne. More research is needed to establish the potential effectiveness and long-term safety of these and other natural acne treatments, traditional Chinese medicine, and ayurvedic herbs.

Talk with your doctor about the pros and cons of specific treatments before you try them.

Tea tree oil. Gels containing 5 percent tea tree oil may be as effective as are lotions containing 5 percent benzoyl peroxide, although tea tree oil might work more slowly. Possible side effects include contact dermatitis and, if you have rosacea, a worsening of those symptoms. One study reported that a young boy experienced breast development after using a combination lavender and tea tree oil hair product. Tea tree oil should be used only topically.

Alpha hydroxy acid. This natural acid is found in citrus fruit and other foods. When applied to your skin, it helps remove dead skin cells and unclog pores. It may also improve the appearance of acne scars. Side effects include increased sensitivity to the sun, redness, mild stinging and skin irritation.

Azelaic acid. This natural acid is found in whole-grain cereals and animal products. It has antibacterial properties. A 20 percent azelaic acid cream seems to be as effective as many other conventional acne treatments when used twice a day for at least four weeks. It is even more effective when used in combination with erythromycin. Prescription azelaic acid (Azelex, Finacea) is an option during pregnancy and while breastfeeding.

Bovine cartilage. Creams containing 5 percent bovine cartilage, applied to the affected skin twice a day, may be effective in reducing acne.

Zinc. Zinc in lotions and creams may reduce acne breakouts.

Green tea extract. A lotion of 2 percent green tea extract helped reduce acne in two studies of adolescents and young adults with mild to moderate acne.

Aloe vera. A 50 percent aloe vera gel was combined with a conventional acne drug (tretinoin) and tested for 8 weeks on 60 people with moderate acne. The combination approach was significantly more effective than tretinoin alone.

Brewer's yeast. A specific strain of brewer's yeast, called CBS 5926, seems to help decrease acne. Brewer's yeast is the only item in this list that's taken orally. It may cause flatulence.

COPING AND SUPPORT

Acne and the scars it can cause may affect your social relationships and self-esteem. Sometimes it can help to talk with your family, a support group or a counselor.

Acoustic Neuroma (Hearing Loss, ringing in ear and balance issue)

Acoustic neuroma is an uncommon, noncancerous (benign) and usually slow-growing tumor that develops on the main nerve leading from your inner ear to your brain. Because branches of this nerve directly influence your balance and hearing, pressure from an acoustic neuroma can cause hearing loss, ringing in your ear and unsteadiness.

Also known as vestibular schwannoma, acoustic neuroma usually grows slowly or not at all. However, in a few cases, it may grow rapidly and become large enough to press against the brain and interfere with vital functions.

Treatments for acoustic neuroma include regular monitoring, radiation and surgical removal.

SYMPTOMS

The signs and symptoms of acoustic neuroma develop from direct effects on the main nerve or from the tumor pressing on adjacent nerves, nearby blood vessels or brain structures.

As the tumor grows, it may be more likely to cause signs and symptoms, although tumor size doesn't always determine effects. It's possible for a small tumor to cause significant signs and symptoms.

You may experience signs and symptoms such as:

Hearing loss, usually gradual — although in some cases sudden — and occurring on only one side or more pronounced on one side

Ringing (tinnitus) in the affected ear

Unsteadiness, loss of balance

Dizziness (vertigo)

Facial numbness and very rarely, weakness

In rare cases, an acoustic neuroma may grow large enough to compress the brainstem and threaten your life.

When to see your doctor

See your doctor if you notice hearing loss in one ear, ringing in your ear or trouble with your balance. Early diagnosis of an acoustic neuroma may help keep the tumor from growing large enough to cause serious consequences, such as total hearing loss or a life-threatening buildup of fluid within your skull.

CAUSES

The cause of acoustic neuromas — tumors on the main balance nerves leading from your inner ear to your brain (eighth cranial nerve) — appears to be a malfunctioning gene on chromosome 22. Normally, this gene produces a protein that helps control the growth of Schwann cells covering the nerves. What makes this gene malfunction isn't clear, and currently there are no known risk factors for getting an acoustic neuroma.

Scientists do know the faulty gene is inherited in neurofibromatosis type 2, a rare disorder that usually involves the growth of tumors on balance nerves on both sides of your head (bilateral vestibular schwannomas).

RISK FACTORS

The only known risk factor for acoustic neuroma is having a parent with the rare genetic disorder neurofibromatosis type 2, but this accounts for only a small number of cases. A hallmark characteristic of neurofibromatosis type 2 is the development of benign tumors on the balance nerves on both sides of your head, as well as on other nerves.

Neurofibromatosis type 2 (NF2) is known as an autosomal dominant disorder, meaning that the mutation can be passed on by just one parent (dominant gene). Each child of an affected parent has a 50-50 chance of inheriting it.

Another possible risk factor that may be associated with acoustic neuroma includes childhood exposure to low-dose radiation of the head and neck.

COMPLICATIONS

An acoustic neuroma may cause a variety of permanent complications, including:

Hearing loss

Facial numbness and weakness

Difficulties with balance

Ringing in the ear

Large tumors may press on your brainstem, preventing the normal flow of fluid between your brain and spinal cord (cerebrospinal fluid). In this case, fluid can build up in your head (hydrocephalus), increasing the pressure inside your skull.

PREPARING FOR YOUR APPOINTMENT

You're likely to start by seeing your family doctor or a general practitioner. Your doctor may then refer you to a doctor trained in ear, nose and throat conditions (otorhinolaryngologist) or a doctor trained in brain and nervous system surgery (neurosurgeon).

Because there's often a lot to talk about during your appointment, it's a good idea to be well-prepared. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.

Make a list of all medications, vitamins or supplements that you're taking.

Ask a family member or friend to join you, if possible. Sometimes it can be difficult to remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Write down questions to ask your doctor.

Preparing a list of questions will help you make the most of your time with your doctor. For acoustic neuroma, some basic questions to ask your doctor include:

What is likely causing my symptoms?

Are there any other possible causes for my symptoms?

What kinds of tests do I need?

What treatment options are available?

Which one do you recommend for me?

What is the likelihood of side effects from each treatment option?

What happens if I do nothing?

Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

When did you first begin experiencing symptoms?

Have your symptoms been continuous or occasional?

How severe are your symptoms?

Do you have any family members with an acoustic neuroma?

At its current level, do you feel the hearing in the affected ear is useful to you in any way? For example, can you use that ear on the telephone, or does that ear help you tell where sound is coming from?

Do you have regular headaches currently or have you had them in the past?

TESTS AND DIAGNOSIS

Because signs and symptoms of acoustic neuroma are likely to develop gradually and because symptoms such as hearing loss can be indicators of other middle and inner ear problems, it may be difficult for your doctor to detect the tumor in its early stages.

After asking questions about your symptoms, your doctor will conduct an ear exam. Your doctor may order the following tests:

Hearing test (audiometry). In this test, conducted by a hearing specialist (audiologist), you hear sounds directed to one ear at a time. The audiologist presents a range of sounds of various tones and asks you to indicate each time you hear the sound. Each tone is repeated at faint levels to find out when you can barely hear.

The audiologist may also present various words to determine your hearing ability.

Scans. Contrasted magnetic resonance imaging (MRI) or computerized tomography (CT) scans of your head can provide images that confirm the presence of an acoustic neuroma.

TREATMENTS AND DRUGS

Your acoustic neuroma treatment may vary, depending on the size and growth of the acoustic neuroma and if you're experiencing symptoms. To treat acoustic neuroma, your doctor may suggest several possible treatments.

Monitoring

If you have a small acoustic neuroma that isn't growing or is growing slowly and causes few or no signs or symptoms, you and your doctor may decide to monitor it, especially if you're an older adult or otherwise not a good candidate for treatment.

Your doctor may recommend that you have regular imaging and hearing tests, usually every six to 12 months, to determine whether the tumor is growing and how quickly. If the scans show the tumor is growing or if the tumor causes progressive symptoms or other difficulties, you may need to undergo treatment.

Stereotactic radiosurgery

Your doctor may recommend stereotactic radiosurgery (ster-e-oh-TAK-tik ray-dee-oh-SUR-jur-e) if you have an acoustic neuroma. Some very large tumors can't be treated with stereotactic radiosurgery.

The goal of stereotactic radiosurgery is to stop the growth of a tumor, preserve the facial nerve's function and possibly preserve hearing. However, a study has found that many people gradually lose their hearing within 10 years after stereotactic radiosurgery.

In stereotactic radiosurgery, such as Gamma Knife radiosurgery, doctors deliver radiation precisely to a tumor without making an incision. The doctor attaches a lightweight head frame to your scalp, which has been numbed, to keep your head still during the procedure. Using imaging scans, your doctor pinpoints the tumor and then plots where to direct the radiation beams.

It may take weeks, months or years before the effects of radiosurgery become evident. Your doctor will monitor your progress with follow-up imaging studies and hearing tests.

Risks of radiosurgery include hearing loss, ringing in the ear, facial weakness, facial numbness, balance problems and treatment failure (continued tumor growth). Very rarely, the radiation could cause a cancer in the treated area in the future.

Surgical removal

You may need surgery to remove an acoustic neuroma. Your surgeon may use one of several techniques for removing an acoustic neuroma, depending on the size of your tumor, preoperative hearing status and other factors. The goal of surgery is to remove the tumor, preserve the facial nerve to prevent facial paralysis and preserve hearing when possible.

Surgery for an acoustic neuroma is performed during general anesthesia and involves removing the tumor through the inner ear or through a window in your skull. The entire tumor may not be able to be completely removed in some cases. For example, if the tumor is too close to important parts of the brain or the facial nerve.

Surgery can create complications, including worsening of symptoms, if certain nerve or cranial structures are affected during the operation. These risks are often based on the size of the tumor and the surgical approach used.

Complications may include:

Leakage of cerebrospinal fluid through the wound

Hearing loss

Facial weakness

Facial numbness

Ringing in the ear

Balance problems

Persistent headache

Infection of the cerebrospinal fluid (meningitis)

Stroke or brain bleeding

COPING AND SUPPORT

Dealing with the possibility of hearing loss and facial paralysis and deciding which treatment would be best for you can be quite stressful. Here are some suggestions you may find helpful:

Educate yourself about acoustic neuroma. The more you know, the better prepared you'll be to make good choices about treatment. Besides talking to your doctor and your audiologist, you may want to talk to a counselor or social worker. Or you may find it helpful to talk to other people who've had an acoustic neuroma and learn more about their experiences during and after treatment.

Maintain a strong support system. Family and friends can help you as you go through this difficult time. Sometimes, though, you may find the concern and understanding of other people with acoustic neuroma especially comforting.

Your doctor or a social worker may be able to put you in touch with a support group. Or you may find an in-person or online support group through the Acoustic Neuroma Association.

ACS

Acute coronary syndrome is a term used for any condition brought on by sudden, reduced blood flow to the heart. Acute coronary syndrome symptoms may include the type of chest pressure that you feel during a heart attack, or pressure in your chest while you're at rest or doing light physical activity (unstable angina). The first sign of acute coronary syndrome can be sudden stopping of your heart (cardiac arrest). Acute coronary syndrome is often diagnosed in an emergency room or hospital.

Acute coronary syndrome is treatable if diagnosed quickly. Acute coronary syndrome treatments vary, depending on your signs, symptoms and overall health condition.

SYMPTOMS

Acute coronary syndrome symptoms are the same as those of a heart attack. And if acute coronary syndrome isn't treated quickly, a heart attack will occur. It's important to take acute coronary syndrome symptoms very seriously as this is a life-threatening condition. Call 911 or your local emergency number right away if you have these signs and symptoms and think you're having a heart attack:

Chest pain (angina) that feels like burning, pressure or tightness

Pain elsewhere in the body, such as the left upper arm or jaw (referred pain)

Nausea

Vomiting

Shortness of breath (dyspnea)

Sudden, heavy sweating (diaphoresis)

If you're having a heart attack, the signs and symptoms may vary depending on your sex, age and whether you have an underlying medical condition, such as diabetes.

Some additional heart attack symptoms include:

Abdominal pain

Pain similar to heartburn

Clammy skin

Lightheadedness, dizziness or fainting

Unusual or unexplained fatigue

Feeling restless or apprehensive

When to see a doctor

If you're having chest pain and you believe it's an emergency situation, call 911 or your local emergency number immediately. Whenever possible, get emergency medical assistance rather than driving yourself to the hospital. You could be having a heart attack.

If you have recurring chest pain, talk to your doctor. It could be a form of angina, and your doctor can help you choose the best treatment. Stable angina occurs predictably. For example, if you jog, you may experience chest pain that goes away when you rest. In unstable angina, chest pain isn't predictable and often occurs at rest. It may also be more intense pain than stable angina.

CAUSES

Acute coronary syndrome is most often a complication of plaque buildup in the arteries in your heart (coronary atherosclerosis) These plaques, made up of fatty deposits, cause the arteries to narrow and make it more difficult for blood to flow through them.

Eventually, this buildup means that your heart can't pump enough oxygen-rich blood to the rest of your body, causing chest pain (angina) or a heart attack. Most cases of acute coronary syndrome occur when the surface of the plaque buildup in your heart arteries ruptures and causes a blood clot to form. The combination of the plaque buildup and the blood clot dramatically limits the amount of blood flowing to your heart muscle. If the blood flow is severely limited, a heart attack will occur.

RISK FACTORS

The risk factors for acute coronary syndrome are similar to those for other types of heart disease. Acute coronary syndrome risk factors include:

Older age (older than 45 for men and older than 55 for women)

High blood pressure

High blood cholesterol

Cigarette smoking

Lack of physical activity

Type 2 diabetes

Family history of chest pain, heart disease or stroke. For women, a history of high blood pressure, preeclampsia or diabetes during pregnancy

PREPARING FOR YOUR APPOINTMENT

Acute coronary syndrome is often diagnosed in emergency situations, and your doctor will perform a number of tests to figure out the cause of your symptoms.

If you're having chest pain or pressure regularly, tell your doctor about it. Your doctor will probably order several tests to figure out the cause of your chest pain. These tests may include a blood draw to check your cholesterol and blood sugar levels. If you need these tests, you'll need to fast to get the most accurate results. Your doctor will tell you if you need to fast before having these tests, and for how long.

Your doctor may also want to perform imaging tests to check for blockages in your heart and the blood vessels leading to it.

TESTS AND DIAGNOSIS

If you have signs and symptoms of acute coronary syndrome, your doctor may run several tests to see if your symptoms are caused by a heart attack or another form of chest discomfort. If your doctor thinks you're having a heart attack, the first two tests you have are:

Electrocardiogram (ECG). This is the first test done to diagnose a heart attack. It's often done while you're being asked questions about your symptoms. This test records the electrical activity of your heart via electrodes attached to your skin. Impulses are recorded as "waves" displayed on a monitor or printed on paper. Because injured heart muscle doesn't conduct electrical impulses normally, the ECG may show that a heart attack has occurred or is in progress.

Blood tests. Certain heart enzymes slowly leak into your blood if your heart has been damaged by a heart attack. Emergency room staff will take samples of your blood to test for the presence of these enzymes.

Your doctor will look at these test results and determine the seriousness of your condition. If your blood tests show no markers of a heart attack and your chest pain has gone away, you'll likely be given tests to check the blood flow through your heart. If your test results reveal that you've had a heart attack or that you may be at high risk to have a heart attack, you'll likely be admitted to the hospital. You may then have more-invasive tests, such as a coronary angiogram.

Your doctor may also order additional tests, either to figure out if your heart's been damaged by a heart attack, or if your symptoms have been brought on by another cause:

Echocardiogram. If your doctor decides you haven't had a heart attack and your risk of having a heart attack is low, you'll likely have an echocardiogram before you leave the hospital. This test uses sound waves to produce an image of your heart. During an echocardiogram, sound waves are directed at your heart from a transducer, a wand-like device, held on your chest. The sound waves bounce off your heart and are reflected back through your chest wall and processed electronically to provide video images of your heart. An echocardiogram can help identify whether an area of your heart has been damaged by a heart attack and isn't pumping normally.

Chest X-ray. An X-ray image of your chest allows your doctor to check the size and shape of your heart and its blood vessels.

Nuclear scan. This test helps identify blood flow problems to your heart. Small amounts of radioactive material are injected into your bloodstream. Special cameras can detect the radioactive material as it is taken up by your heart muscle. Areas of reduced blood flow to the heart muscle — through which less of the radioactive material flows — appear as dark spots on the scan. Nuclear scans are occasionally done while you're having chest pain to check the blood flow to your heart muscle, but more often, are done as part of a stress test.

Computerized tomography (CT) angiogram. A CT angiogram allows your doctor to check your arteries to see if they're narrowed or blocked. In this minimally invasive test, you'll change into a hospital gown and lie on a table that's part of the CT scanning machine. You'll receive an injection of a radioactive dye, and the doughnut-shaped CT scanner will be moved to take images of the arteries in your heart. The images are then sent to a computer screen for your doctor to view. This test is usually only done if your blood tests and electrocardiogram don't reveal the cause of your symptoms.

Coronary angiogram (cardiac catheterization). This test can show if your coronary arteries are narrowed or blocked. A liquid dye is injected into the arteries of your heart through a long, thin tube (catheter) that's fed through an artery, usually in your leg, to the arteries in your heart. As the dye fills your arteries, the arteries become visible on X-ray, revealing areas of blockage. Additionally, while the catheter is in position, your doctor may treat the blockage by performing an angioplasty. Angioplasty uses tiny balloons threaded through a blood vessel and into a coronary artery to widen the blocked area. Often, a mesh tube (stent) also is placed inside the artery to hold it open more widely and prevent re-narrowing in the future.

Exercise stress test. In the days or weeks following your heart symptoms, you may also undergo a stress test. Stress tests measure how your heart and blood vessels respond to exertion. You may walk on a treadmill or pedal a stationary bike while attached to an ECG machine. Or you may receive a drug intravenously that stimulates your heart in a manner that's similar to the way you heart would be stimulated during exercise. Stress tests help doctors decide the best long-term treatment for you. Your doctor also may order a nuclear stress test, which is similar to an exercise stress test, but uses an injected dye and special imaging techniques to produce detailed images of your heart while you're exercising.

TREATMENTS AND DRUGS

Treatment for acute coronary syndrome varies, depending on your symptoms and how blocked your arteries are.

Medications

It's likely that your doctor will recommend medications that can relieve chest pain and improve flow through the heart. These could include:

Aspirin. Aspirin decreases blood clotting, helping to keep blood flowing through narrowed heart arteries. Aspirin is one of the first things you may be given in the emergency room for suspected acute coronary syndrome. You may be asked to chew the aspirin so that it's absorbed into your bloodstream more quickly. If your doctor diagnoses your symptoms as acute coronary syndrome, he or she may recommend taking an 81-milligram dose of aspirin daily.

Thrombolytics. These drugs, also called clotbusters, help dissolve a blood clot that's blocking blood flow to your heart. If you're having a heart attack, the earlier you receive a thrombolytic drug after a heart attack, the greater the chance you will survive and lessen the damage to your heart. However, if you are close to a hospital with a cardiac catheterization laboratory, you'll usually be treated with emergency angioplasty and stenting instead of thrombolytics. Clotbuster medications are generally used when it will take too long to get to a cardiac catheterization laboratory, such as in rural communities.

Nitroglycerin. This medication for treating chest pain and angina temporarily widens narrowed blood vessels, improving blood flow to and from your heart.

Beta blockers. These drugs help relax your heart muscle, slow your heart rate and decrease your blood pressure, which decreases the demand on your heart. These medications can increase blood flow through your heart, decreasing chest pain and the potential for damage to your heart during a heart attack.

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These drugs allow blood to flow from your heart more easily. Your doctor may prescribe ACE inhibitors or ARBs if you've had a moderate to severe heart attack that has reduced your heart's pumping capacity. These drugs also lower blood pressure and may prevent a second heart attack.

Calcium channel blockers. These medications relax the heart and allow more blood to flow to and from the heart. Calcium channel blockers are generally given if symptoms persist after you've taken nitroglycerin and beta blockers.

Cholesterol-lowering drugs. Commonly used drugs known as statins can lower your cholesterol levels, making plaque deposits less likely, and they can stabilize plaque, making it less likely to rupture.

Clot-preventing drugs. Medications such as clopidogrel (Plavix) and prasugrel (Effient) can help prevent blood clots from forming by making your blood platelets less likely to stick together. However, clopidogrel increases your risk of bleeding, so be sure to let everyone on your health care team know that you're taking it, particularly if you need any type of surgery.

Surgery and other procedures

If medications aren't enough to restore blood flow through your heart, your doctor may recommend one of these procedures:

Angioplasty and stenting. In this procedure, your doctor inserts a long, thin tube (catheter) into the blocked or narrowed part of your artery. A wire with a deflated balloon is passed through the catheter to the narrowed area. The balloon is then inflated, compressing the deposits against your artery walls. A mesh tube (stent) is usually left in the artery to help keep the artery open.

Coronary bypass surgery. This procedure creates an alternative route for blood to go around a blocked coronary artery.

LIFESTYLE AND HOME REMEDIES

The same lifestyle changes that help reduce the symptoms of acute coronary syndrome also can help prevent it from happening in the first place. Eat a healthy diet, exercise most days of the week for at least 30 minutes each day, see your doctor regularly for checks of your blood pressure and cholesterol levels, and don't smoke.

Acute kidney failure

Acute kidney failure occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood's chemical makeup may get out of balance.

Acute kidney failure — also called acute renal failure or acute kidney injury — develops rapidly over a few hours or a few days. Acute kidney failure is most common in people who are already hospitalized, particularly in critically ill people who need intensive care.

Acute kidney failure can be fatal and requires intensive treatment. However, acute kidney failure may be reversible. If you're otherwise in good health, you may recover normal or nearly normal kidney function.

SYMPTOMS

Signs and symptoms of acute kidney failure may include:

Decreased urine output, although occasionally urine output remains normal

Fluid retention, causing swelling in your legs, ankles or feet

Drowsiness

Shortness of breath

Fatigue

Confusion

Nausea

Seizures or coma in severe cases

Chest pain or pressure

Sometimes acute kidney failure causes no signs or symptoms and is detected through lab tests done for another reason.

When to see a doctor

Make an appointment with your doctor if you have any signs or symptoms of acute kidney failure.

CAUSES

Acute kidney failure can occur when:

You have a condition that slows blood flow to your kidneys

You experience direct damage to your kidneys

Your kidneys' urine drainage tubes (ureters) become blocked and wastes can't leave your body through your urine

Impaired blood flow to the kidneys

Diseases and conditions that may slow blood flow to the kidneys and lead to kidney failure include:

Blood or fluid loss

Blood pressure medications

Heart attack

Heart disease

Infection

Liver failure

Use of aspirin, ibuprofen (Advil, Motrin IB, others), naproxen (Aleve, others) or related drugs

Severe allergic reaction (anaphylaxis)

Severe burns

Severe dehydration

Damage to the kidneys

These diseases, conditions and agents may damage the kidneys and lead to acute kidney failure:

Blood clots in the veins and arteries in and around the kidneys

Cholesterol deposits that block blood flow in the kidneys

Glomerulonephritis (gloe-mer-u-loe-nuh-FRY-tis), inflammation of the tiny filters in the kidneys (glomeruli)

Hemolytic uremic syndrome, a condition that results from premature destruction of red blood cells

Infection

Lupus, an immune system disorder causing glomerulonephritis

Medications, such as certain chemotherapy drugs, antibiotics, dyes used during imaging tests and zoledronic acid (Reclast, Zometa), used to treat osteoporosis and high blood calcium levels (hypercalcemia)

Multiple myeloma, a cancer of the plasma cells

Scleroderma, a group of rare diseases affecting the skin and connective tissues

Thrombotic thrombocytopenic purpura, a rare blood disorder

Toxins, such as alcohol, heavy metals and cocaine

Vasculitis, an inflammation of blood vessels

Urine blockage in the kidneys

Diseases and conditions that block the passage of urine out of the body (urinary obstructions) and can lead to acute kidney failure include:

Bladder cancer

Blood clots in the urinary tract

Cervical cancer

Colon cancer

Enlarged prostate

Kidney stones

Nerve damage involving the nerves that control the bladder

Prostate cancer

RISK FACTORS

Acute kidney failure almost always occurs in connection with another medical condition or event. Conditions that can increase your risk of acute kidney failure include:

Being hospitalized, especially for a serious condition that requires intensive care

Advanced age

Blockages in the blood vessels in your arms or legs (peripheral artery disease)

Diabetes

High blood pressure

Heart failure

Kidney diseases

Liver diseases

COMPLICATIONS

Potential complications of acute kidney failure include:

Fluid buildup. Acute kidney failure may lead to a buildup of fluid in your lungs, which can cause shortness of breath.

Chest pain. If the lining that covers your heart (pericardium) becomes inflamed, you may experience chest pain.

Muscle weakness. When your body's fluids and electrolytes — your body's blood chemistry — are out of balance, muscle weakness can result. Elevated levels of potassium in your blood are particularly dangerous.

Permanent kidney damage. Occasionally, acute kidney failure causes permanent loss of kidney function, or end-stage renal disease. People with end-stage renal disease require either permanent dialysis — a mechanical filtration process used to remove toxins and wastes from the body — or a kidney transplant to survive.

Death. Acute kidney failure can lead to loss of kidney function and, ultimately, death. The risk of death is higher in people who had kidney problems before acute kidney failure.

PREPARING FOR YOUR APPOINTMENT

Most people are already hospitalized when they develop acute kidney failure. If you or a loved one develops signs and symptoms of kidney failure, bring up your concerns with your doctor or nurse.

If you aren't in the hospital, but have signs or symptoms of kidney failure, make an appointment with your family doctor or a general practitioner. If your doctor suspects you have kidney problems, you may be referred to a doctor who specializes in kidney disease (nephrologist).

Before your meeting with the doctor, write down your questions. Consider asking:

Are my kidneys working properly?

Do I have kidney failure?

What's causing my kidney problems?

What kinds of tests do I need?

Will my kidneys recover?

What are my treatment options?

What are the potential risks of each treatment option?

Do I need dialysis?

Do I need to go to the hospital?

How long will I need to stay in the hospital?

I have these other health conditions. How can I best manage them together?

Do I need to follow any restrictions?

Do I need to eat a special diet?

Can you refer me to a dietitian to help me plan my diet?

Should I see a specialist? Will my insurance cover that?

Is there a generic alternative to the medicine you're prescribing me?

Do you have any printed materials that I can take with me? What websites do you recommend?

TESTS AND DIAGNOSIS

If your signs and symptoms suggest that you have acute kidney failure, your doctor may recommend certain tests and procedures to verify your diagnosis. These may include:

Urine output measurements. The amount of urine you excrete in a day may help your doctor determine the cause of your kidney failure.

Urine tests. Analyzing a sample of your urine, a procedure called urinalysis, may reveal abnormalities that suggest kidney failure.

Blood tests. A sample of your blood may reveal rapidly rising levels of urea and creatinine — two substances used to measure kidney function.

Imaging tests. Imaging tests such as ultrasound and computerized tomography may be used to help your doctor see your kidneys.

Removing a sample of kidney tissue for testing. In some situations, your doctor may recommend a kidney biopsy to remove a small sample of kidney tissue for lab testing. Your doctor inserts a needle through your skin and into your kidney to remove the sample.

TREATMENTS AND DRUGS

Treatment for acute kidney failure typically requires a hospital stay. Most people with acute kidney failure are already hospitalized. How long you'll stay in the hospital depends on the reason for your acute kidney failure and how quickly your kidneys recover.

In some cases, you may be able to recover at home.

Treating the underlying cause of your kidney failure

Treatment for acute kidney failure involves identifying the illness or injury that originally damaged your kidneys. Your treatment options depend on what's causing your kidney failure.

Treating complications until your kidneys recover

Your doctor will also work to prevent complications and allow your kidneys time to heal. Treatments that help prevent complications include:

Treatments to balance the amount of fluids in your blood. If your acute kidney failure is caused by a lack of fluids in your blood, your doctor may recommend intravenous (IV) fluids. In other cases, acute kidney failure may cause you to have too much fluid, leading to swelling in your arms and legs. In these cases, your doctor may recommend medications (diuretics) to cause your body to expel extra fluids.

Medications to control blood potassium. If your kidneys aren't properly filtering potassium from your blood, your doctor may prescribe calcium, glucose or sodium polystyrene sulfonate (Kayexalate, Kionex) to prevent the accumulation of high levels of potassium in your blood. Too much potassium in the blood can cause dangerous irregular heartbeats (arrhythmias) and muscle weakness.

Medications to restore blood calcium levels. If the levels of calcium in your blood drop too low, your doctor may recommend an infusion of calcium.

Dialysis to remove toxins from your blood. If toxins build up in your blood, you may need temporary hemodialysis — often referred to simply as dialysis — to help remove toxins and excess fluids from your body while your kidneys heal. Dialysis may also help remove excess potassium from your body. During dialysis, a machine pumps blood out of your body through an artificial kidney (dialyzer) that filters out waste. The blood is then returned to your body.

LIFESTYLE AND HOME REMEDIES

Acute kidney failure is often difficult to predict or prevent. But you may reduce your risk by taking care of your kidneys. Try to:

Pay attention to labels when taking over-the-counter (OTC) pain medications. Follow the instructions for OTC pain medications, such as aspirin, acetaminophen (Tylenol, others) and ibuprofen (Advil, Motrin IB, others). Taking too much of these medications may increase your risk of acute kidney failure. This is especially true if you have pre-existing kidney disease, diabetes or high blood pressure.

Work with your doctor to manage kidney problems. If you have kidney disease or another condition that increases your risk of acute kidney failure, such as diabetes or high blood pressure, stay on track with treatment goals and follow your doctor's recommendations to manage your condition.

Make a healthy lifestyle a priority. Be active; eat a sensible, balanced diet; and drink alcohol only in moderation — if at all.

Acute Lymphocytic Leukemia 

Acute lymphocytic leukemia (ALL) is a type of cancer of the blood and bone marrow — the spongy tissue inside bones where blood cells are made.

The word "acute" in acute lymphocytic leukemia comes from the fact that the disease progresses rapidly and creates immature blood cells, rather than mature ones. The "lymphocytic" in acute lymphocytic leukemia refers to the white blood cells called lymphocytes, which ALL affects. Acute lymphocytic leukemia is also known as acute lymphoblastic leukemia.

Acute lymphocytic leukemia is the most common type of cancer in children, and treatments result in a good chance for a cure. Acute lymphocytic leukemia can also occur in adults, though the chance of a cure is greatly reduced.

SYMPTOMS

Signs and symptoms of acute lymphocytic leukemia may include:

Bleeding from the gums

Bone pain

Fever

Frequent infections

Frequent or severe nosebleeds

Lumps caused by swollen lymph nodes in and around the neck, underarm, abdomen or groin

Pale skin

Shortness of breath

Weakness, fatigue or a general decrease in energy

When to see a doctor

Make an appointment with your doctor or your child's doctor if you notice any persistent signs and symptoms that concern you. Many signs and symptoms of acute lymphocytic leukemia mimic those of the flu. However, flu signs and symptoms eventually improve. If signs and symptoms don't improve as expected, make an appointment with your doctor.

CAUSES

Acute lymphocytic leukemia occurs when a bone marrow cell develops errors in its DNA. The errors tell the cell to continue growing and dividing, when a healthy cell would normally stop dividing and die. When this happens, blood cell production becomes abnormal. The bone marrow produces immature cells that develop into leukemic white blood cells called lymphoblasts. These abnormal cells are unable to function properly, and they can build up and crowd out healthy cells.

It's not clear what causes the DNA mutations that can lead to acute lymphocytic leukemia. But doctors have found that most cases of acute lymphocytic leukemia aren't inherited.

RISK FACTORS

Factors that may increase the risk of acute lymphocytic leukemia include:

Previous cancer treatment. Children and adults who've had certain types of chemotherapy and radiation therapy for other kinds of cancer may have an increased risk of developing acute lymphocytic leukemia.

Exposure to radiation. People exposed to very high levels of radiation, such as survivors of a nuclear reactor accident, have an increased risk of developing acute lymphocytic leukemia.

Genetic disorders. Certain genetic disorders, such as Down syndrome, are associated with an increased risk of acute lymphocytic leukemia.

Having a brother or sister with ALL. People who have a sibling, including a twin, with acute lymphocytic leukemia have an increased risk of ALL.

PREPARING FOR YOUR APPOINTMENT

Make an appointment with your family doctor or a general practitioner if you or your child has signs and symptoms that worry you. If your doctor suspects acute lymphocytic leukemia, you'll likely be referred to a doctor who specializes in treating diseases and conditions of the blood and bone marrow (hematologist).

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared. Here's some information to help you get ready, and what to expect from the doctor.

What you can do

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.

Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.

Write down key personal information, including any major stresses or recent life changes.

Make a list of all medications, vitamins or supplements that you're taking.

Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together. List your questions from most important to least important in case time runs out. For acute lymphocytic leukemia, some basic questions to ask the doctor include:

What is likely causing these symptoms?

What are other possible causes for these symptoms?

What kinds of tests are necessary?

Is this condition likely temporary or chronic?

What is the best course of action?

What are the alternatives to the primary approach that you're suggesting?

How can other existing health conditions be best managed with ALL?

Are there any restrictions that need to be followed?

Is it necessary to see a specialist? What will that cost, and will my insurance cover it?

Is there a generic alternative to the medicine you're prescribing me?

Are there brochures or other printed material that I can take with me? What websites do you recommend?

What will determine whether I should plan for a follow-up visit?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions that occur to you.

What to expect from the doctor

The doctor is likely to ask you a number of questions. Being ready to answer them may allow time to cover other points you want to address. Your doctor may ask:

When did symptoms begin?

Have these symptoms been continuous or occasional?

How severe are these symptoms?

What, if anything, seems to improve these symptoms?

What, if anything, appears to worsen these symptoms?

What you can do in the meantime

Avoid activity that seems to worsen any signs and symptoms. For instance, if you or your child is feeling fatigued, allow for more rest. Determine which of the day's activities are most important, and focus on accomplishing those tasks.

TESTS AND DIAGNOSIS

Tests and procedures used to diagnose acute lymphocytic leukemia include:

Blood tests. A blood test may reveal too many white blood cells, not enough red blood cells and not enough platelets. A blood test may also show the presence of blast cells — immature cells normally found in the bone marrow but not circulating in the blood.

Bone marrow test. During bone marrow aspiration, a needle is used to remove a sample of bone marrow from the hipbone. The sample is sent to a lab for testing to look for leukemia cells. Doctors in the lab will classify blood cells into specific types based on their size, shape and other features. They also look for certain changes in the cancer cells and determine whether the leukemia cells began from the B lymphocytes or T lymphocytes. This information helps your doctor develop a treatment plan.

Imaging tests. Imaging tests such as X-ray, computerized tomography (CT) scan or ultrasound scan may help determine whether cancer has spread to the brain and spinal cord or other parts of the body.

Spinal fluid test. A lumbar puncture test, also called a spinal tap, may be used to collect a sample of spinal fluid — the fluid that surrounds the brain and spinal cord. The sample is tested to see whether cancer cells have spread to the spinal fluid.

TREATMENTS AND DRUGS

In general, treatment for acute lymphocytic leukemia falls into separate phases:

Induction therapy. The purpose of the first phase of treatment is to kill most of the leukemia cells in the blood and bone marrow and to restore normal blood cell production.

Consolidation therapy. Also called post-remission therapy, this phase of treatment is aimed at destroying any remaining leukemia in the body, such as in the brain or spinal cord.

Maintenance therapy. The third phase of treatment prevents leukemia cells from regrowing. The treatments used in this stage are often given at much lower doses over a long period of time, often years.

Preventive treatment to the spinal cord. People with acute lymphocytic leukemia may also receive treatment to kill leukemia cells located in the central nervous system during each phase of therapy. In this type of treatment, chemotherapy drugs are often injected directly into the fluid that covers the spinal cord.

Depending on your situation, the phases of treatment for acute lymphocytic leukemia can span two to three years.

Treatments may include:

Chemotherapy. Chemotherapy, which uses drugs to kill cancer cells, is typically used as an induction therapy for children and adults with acute lymphocytic leukemia. Chemotherapy drugs can also be used in the consolidation and maintenance phases.

Targeted drug therapy. Targeted drugs attack specific abnormalities present in cancer cells that help them grow and thrive. A certain abnormality called the Philadelphia chromosome is found in some people with acute lymphocytic leukemia. For these people, targeted drugs may be used to attack cells that contain that abnormality. Targeted drugs include imatinib (Gleevec), dasatinib (Sprycel) and nilotinib (Tasigna). These drugs are approved only for people with the Philadelphia chromosome-positive form of ALL and can be taken during or after chemotherapy.

Radiation therapy. Radiation therapy uses high-powered beams, such as X-rays, to kill cancer cells. If the cancer cells have spread to the central nervous system, your doctor may recommend radiation therapy.

Stem cell transplant. A stem cell transplant may be used as consolidation therapy in people at high risk of relapse or for treating relapse when it occurs. This procedure allows someone with leukemia to re-establish healthy stem cells by replacing leukemic bone marrow with leukemia-free marrow from a healthy person.

A stem cell transplant begins with high doses of chemotherapy or radiation to destroy any leukemia-producing bone marrow. The marrow is then replaced by bone marrow from a compatible donor (allogeneic transplant).

Clinical trials. Clinical trials are experiments to test new cancer treatments and new ways of using existing treatments. While clinical trials give you or your child a chance to try the latest cancer treatment, treatment benefits and risks may be uncertain. Discuss the benefits and risks of clinical trials with your doctor.

ALL in older adults

Older adults, such as those older than 60, tend to experience more complications from ALL treatments. And older adults generally have a worse prognosis than children who are treated for ALL. Discuss your options with your doctor. Based on your overall health and your goals and preferences, you may decide to undergo treatment for your ALL. Some people may choose to forgo treatment for the cancer, instead focusing on treatments that improve their symptoms and help them make the most of the time they have remaining.

ALTERNATIVE MEDICINE

No alternative treatments have been proved to cure acute lymphocytic leukemia. But some alternative therapies may help ease the side effects of cancer treatment and make you or your child more comfortable. Discuss your options with your doctor, as some alternative treatments could interfere with cancer treatments, such as chemotherapy.

Alternative treatments that may ease signs and symptoms include:

Acupuncture

Aromatherapy

Massage

Meditation

Relaxation exercises

COPING AND SUPPORT

Although treatment for acute lymphocytic leukemia is typically very successful, it can be a long road. Treatment often lasts 2 1/2 to 3 1/2 years, although the first three to six months are the most intense. During maintenance phases, children can usually live a relatively normal life and go back to school. And adults may be able to continue working. To help you cope, try to:

Learn enough about leukemia to feel comfortable making treatment decisions. Ask your doctor to write down as much information about your specific disease as possible. Then narrow your search for information accordingly. Write down questions you want to ask your doctor before each appointment, and look for information in your local library and on the Internet. Good sources include the National Cancer Institute, the American Cancer Society, and the Leukemia & Lymphoma Society.

Lean on your whole health care team. At major medical centers and pediatric cancer centers, your health care team may include psychologists, psychiatrists, recreation therapists, child-life workers, teachers, dietitians, chaplains and social workers. These professionals can help with a whole host of issues, including explaining procedures to children, finding financial assistance and arranging for housing during treatment. Don't hesitate to rely on their expertise.

Explore programs for children with cancer. Major medical centers and nonprofit groups offer numerous activities and services specifically for children with cancer and their families. Examples include summer camps, support groups for siblings and wish-granting programs. Ask your health care team about programs in your area.

Help family and friends understand your situation. Set up a free, personalized Web page at the not-for-profit website CaringBridge. This allows you to tell the whole family about appointments, treatments, setbacks and reasons to celebrate — without the stress of calling everyone every time there's something new to report.

Acute Liver Failure 

Acute liver failure is loss of liver function that occurs rapidly — in days or weeks —usually in a person who has no pre-existing liver disease. Acute liver failure is less common than chronic liver failure, which develops more slowly.

Acute liver failure, also known as fulminant hepatic failure, can cause serious complications, including excessive bleeding and increasing pressure in the brain. It's a medical emergency that requires hospitalization.

Depending on the cause, acute liver failure can sometimes be reversed with treatment. In many situations, though, a liver transplant may be the only cure.

SYMPTOMS

Signs and symptoms of acute liver failure may include:

Yellowing of your skin and eyeballs (jaundice)

Pain in your upper right abdomen

Abdominal swelling

Nausea

Vomiting

A general sense of feeling unwell (malaise)

Disorientation or confusion

Sleepiness

When to see a doctor

Acute liver failure can develop quickly in an otherwise healthy person, and it is life-threatening. If you or someone you know suddenly develops a yellowing of the eyes or skin; tenderness in the upper abdomen; or any unusual changes in mental state, personality or behavior, seek medical attention right away.

CAUSES

Acute liver failure occurs when liver cells are damaged significantly and are no longer able to function. Potential causes include:

Acetaminophen overdose. Taking too much acetaminophen (Tylenol, others) is the most common cause of acute liver failure in the United States. Acute liver failure can occur after one very large dose of acetaminophen, or after higher than recommended doses every day for several days.

If you suspect that you or someone you know has taken an overdose of acetaminophen, seek medical attention as quickly as possible. Do not wait for the signs of liver failure.

Prescription medications. Some prescription medications, including antibiotics, nonsteroidal anti-inflammatory drugs and anticonvulsants, can cause acute liver failure.

Herbal supplements. Herbal drugs and supplements, including kava, ephedra, skullcap and pennyroyal, have been linked to acute liver failure.

Hepatitis and other viruses. Hepatitis A, hepatitis B and hepatitis E can cause acute liver failure. Other viruses that can cause acute liver failure include Epstein-Barr virus, cytomegalovirus and herpes simplex virus.

Toxins. Toxins that can cause acute liver failure include the poisonous wild mushroom Amanita phalloides, which is sometimes mistaken for edible species.

Autoimmune disease. Liver failure can be caused by autoimmune hepatitis — a disease in which your immune system attacks liver cells, causing inflammation and injury.

Diseases of the veins in the liver. Vascular diseases, such as Budd-Chiari syndrome, can cause blockages in the veins of the liver, leading to acute liver failure.

Metabolic disease. Rare metabolic diseases, such as Wilson's disease and acute fatty liver of pregnancy, infrequently cause acute liver failure.

Cancer. Cancer that either begins in or spreads to your liver can cause your liver to fail.

Many cases of acute liver failure have no apparent cause.

COMPLICATIONS

Acute liver failure often causes complications, including:

Excessive fluid in the brain (cerebral edema). Excessive fluid causes pressure to build in your brain, which can displace brain tissue outside of the space it normally occupies (herniation). Cerebral edema can also deprive your brain of oxygen.

Bleeding and bleeding disorders. A failing liver isn't able to produce sufficient amounts of clotting factors, which help blood to clot. People with acute liver failure often develop bleeding from the gastrointestinal tract. Bleeding may be difficult to control.

Infections. People with acute liver failure are at an increased risk of developing a variety of infections, particularly in the blood and in the respiratory and urinary tracts.

Kidney failure. Kidney failure often occurs following liver failure, especially in cases of acetaminophen overdose, which damages both your liver and your kidneys.

PREPARING FOR YOUR APPOINTMENT

If your doctor suspects you have acute liver failure, you'll likely be admitted to a hospital for treatment. Most people with acute liver failure are treated in an intensive care unit.

Questions to expect from your doctor

Your doctor will ask you or your family members questions to try to determine the cause of your acute liver failure. Your doctor may ask:

When did symptoms begin?

What prescription medications do you take?

What over-the-counter medications do you take?

What herbal supplements do you take?

Do you use illegal drugs?

Have you been diagnosed with hepatitis?

Do you have a history of depression or suicidal thoughts?

How much alcohol do you drink?

Have you recently started taking new medications?

Do you take acetaminophen? How much?

Do liver problems run in your family?

Questions to ask your doctor

If you have been diagnosed with acute liver failure, here are some questions to ask the doctor:

What caused my acute liver failure?

Can it be reversed?

What are the treatments?

Will I need a liver transplant?

Does this hospital have a liver transplant unit?

Should I transfer to a hospital that performs liver transplants?

TESTS AND DIAGNOSIS

Tests and procedures used to diagnose acute liver failure include:

Blood tests. Blood tests to determine how well your liver is functioning may include the prothrombin time test, which measures how long it takes your blood to clot. With acute liver failure, blood won't clot as quickly as it should.

Imaging tests. Your doctor may recommend imaging tests, such as ultrasound, to evaluate your liver. Imaging tests may show liver damage and may help your doctor determine the cause of your liver problems.

Examination of liver tissue. Your doctor may recommend a procedure to remove a small piece of liver tissue (liver biopsy). Tests of the liver tissue may help your doctor understand why your liver is failing.

Because people with acute liver failure are at risk of bleeding during biopsy, the doctor may perform a transjugular liver biopsy. Through a tiny incision on the right side of your neck, your doctor passes a thin tube (catheter) into a large vein in your neck, through your heart and into a vein exiting your liver. Your doctor then inserts a needle down through the catheter and retrieves a sample of liver tissue.

TREATMENTS AND DRUGS

People with acute liver failure are often treated in the intensive care unit of a hospital —and when possible, in a facility that can perform a liver transplant if necessary. Your doctor may try to treat the liver damage itself, but in many cases, treatment involves controlling complications and giving your liver time to heal.

Treatments for acute liver failure

Acute liver failure treatments may include:

Medications to reverse poisoning. Acute liver failure caused by acetaminophen overdose or mushroom poisoning is treated with drugs that can reverse the effects of the toxin and may reduce liver damage.

Liver transplant. When acute liver failure can't be reversed, the only treatment may be a liver transplant. During a liver transplant, a surgeon removes your damaged liver and replaces it with a healthy liver from a donor.

Treatments for complications

Your doctor will work to control signs and symptoms you're experiencing and try to prevent complications caused by acute liver failure. This care may include:

Relieving pressure caused by excess fluid in the brain. Cerebral edema caused by acute liver failure can increase pressure on your brain. Medications can help reduce the fluid buildup in your brain.

Screening for infections. Your medical team will take periodic samples of your blood and urine to be tested for infection. If your doctor suspects that you have an infection, you'll receive medications to treat the infection.

Preventing severe bleeding. Your doctor can give you medications to reduce the risk of bleeding. If you lose a lot of blood, your doctor may perform tests to find the source of the blood loss, and you may require blood transfusions.

LIFESTYLE AND HOME REMEDIES

Reduce your risk of acute liver failure by taking care of your liver.

Follow instructions on medications. If you take acetaminophen or other medications, check the package insert for the recommended dosage, and don't take more than that.

Tell your doctor about all your medicines. Even over-the-counter and herbal medicines can interfere with prescription drugs you're taking.

Drink alcohol in moderation, if at all. Limit the amount of alcohol you drink to no more than one drink a day for women of all ages and men older than 65 and no more than two drinks a day for younger men.

Avoid risky behavior. Get help if you use illicit intravenous drugs. Don't share needles. Use condoms during sex. If you get tattoos or body piercings, make sure the shop you choose is clean and safe. Don't smoke.

Get vaccinated. If you're at increased risk of contracting hepatitis, if you've been infected with any form of the hepatitis virus or if you have chronic liver disease, talk to your doctor about getting the hepatitis B vaccine. A vaccine is also available for hepatitis A.

Avoid contact with other people's blood and body fluids. Accidental needle sticks or improper cleanup of blood or body fluids can spread hepatitis viruses. Sharing razor blades or toothbrushes can also spread infection.

Don't eat wild mushrooms. It can be difficult to distinguish an edible mushroom from a poisonous one.

Take care with aerosol sprays. When you use an aerosol cleaner, make sure the room is ventilated, or wear a mask. Take similar protective measures when spraying insecticides, fungicides, paint and other toxic chemicals. Follow manufacturers' instructions.

Watch what gets on your skin. When using insecticides and other toxic chemicals, cover your skin with gloves, long sleeves, a hat and a mask.

Maintain a healthy weight. Obesity can cause a condition called nonalcoholic fatty liver disease, which may include fatty liver, hepatitis and cirrhosis.

ARDS

Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. More fluid in your lungs means less oxygen can reach your bloodstream. This deprives your organs of the oxygen they need to function.

ARDS typically occurs in people who are already critically ill or who have significant injuries. Severe shortness of breath — the main symptom of ARDS — usually develops within a few hours to a few days after the original disease or trauma.

Many people who develop ARDS don't survive. The risk of death increases with age and severity of illness. Of the people who do survive ARDS, some recover completely while others experience lasting damage to their lungs.

SYMPTOMS

The signs and symptoms of ARDS can vary in intensity, depending on its cause and severity, as well as the presence of underlying heart or lung disease. They include:

Severe shortness of breath

Labored and unusually rapid breathing

Low blood pressure

Confusion and extreme tiredness

When to see a doctor

ARDS usually follows a major illness or injury, and most people who are affected are already hospitalized.

CAUSES

The mechanical cause of ARDS is fluid leaked from the smallest blood vessels in the lungs into the tiny air sacs where blood is oxygenated. Normally, a protective membrane keeps this fluid in the vessels. Severe illness or injury, however, can cause inflammation that undermines the membrane's integrity, leading to the fluid leakage of ARDS.

The most common underlying causes of ARDS include:

Sepsis. The most common cause of ARDS is sepsis, a serious and widespread infection of the bloodstream.

Inhalation of harmful substances. Breathing high concentrations of smoke or chemical fumes can result in ARDS, as can inhaling (aspirating) vomit.

Severe pneumonia. Severe cases of pneumonia usually affect all five lobes of the lungs.

Head, chest or other major injury. Accidents, such as falls or car crashes, can directly damage the lungs or the portion of the brain that controls breathing.

RISK FACTORS

Most people who develop ARDS are already hospitalized for another condition, and many are critically ill. You're especially at risk if you have a widespread infection in your bloodstream (sepsis).

People who have a history of chronic alcoholism are at higher risk of developing ARDS. They're also more likely to die of ARDS.

COMPLICATIONS

ARDS is extremely serious, but thanks to improved treatments, more people are surviving it. However, many survivors end up with potentially serious — and sometimes lasting — complications, including:

Scarring in the lungs (pulmonary fibrosis). Scarring and thickening of the tissue between the air sacs can occur within a few weeks of the onset of ARDS. This stiffens your lungs, making it even more difficult for oxygen to flow from the air sacs into your bloodstream.

Collapsed lung (pneumothorax). In most ARDS cases, a breathing machine called a ventilator is used to increase oxygen in the body and force fluid out of the lungs. However, the pressure and air volume of the ventilator can force gas to go through a small hole in the very outside of a lung and cause that lung to collapse.

Blood clots. Lying still in the hospital while you're on a ventilator can increase your risk of developing blood clots, particularly in the deep veins in your legs. If a clot forms in your leg, a portion of it can break off and travel to one or both of your lungs (pulmonary embolism) — where it blocks blood flow.

Infections. Because the ventilator is attached directly to a tube inserted in your windpipe, this makes it much easier for germs to infect and further injure your lungs.

Abnormal lung function. Many people with ARDS recover most of their lung function within several months to two years, but others may have breathing problems for the rest of their lives. Even people who do well usually have shortness of breath and fatigue and may need supplemental oxygen at home for a few months.

Memory, cognitive and emotional problems. Sedatives and low levels of oxygen in the blood can lead to memory loss and cognitive problems after ARDS. In some cases, the effects may lessen over time, but in others, the damage may be permanent. Most ARDS survivors also report going through a period of depression, which is treatable.

TESTS AND DIAGNOSIS

There's no specific test to identify ARDS. The diagnosis is based on the physical exam, chest X-ray and oxygen levels and by ruling out other diseases and conditions — for example, certain heart problems — that can produce similar symptoms.

Imaging

Chest X-ray. A chest X-ray can reveal which parts of your lungs and how much of the lungs have fluid in them and whether your heart is enlarged.

Computerized tomography (CT). A CT scan combines X-ray images taken from many different directions into cross-sectional views of internal organs. CT scans can provide detailed information about the structures within the heart and lungs.

Lab tests

A test using blood from an artery in your wrist can measure your oxygen level. Other types of blood tests can check for signs of infection or anemia. If your doctor suspects that you have a lung infection, secretions from your airway may be tested to determine the cause of the infection.

Heart tests

Because the signs and symptoms of ARDS are similar to those of certain heart problems, your doctor may recommend heart tests such as:

Electrocardiogram. This painless test tracks the electrical activity in your heart. It involves attaching several wired sensors to your body.

Echocardiogram. A sonogram of the heart, this test can reveal problems with the structures and the function of your heart.

TREATMENTS AND DRUGS

The first goal in treating ARDS is to improve the levels of oxygen in your blood. Without oxygen, your organs can't function properly.

Oxygen

To get more oxygen into your bloodstream, your doctor will likely use:

Supplemental oxygen. For milder symptoms or as a temporary measure, oxygen may be delivered through a mask that fits tightly over your nose and mouth.

Mechanical ventilation. Most people with ARDS will need the help of a machine to breathe. A mechanical ventilator pushes air into your lungs and forces some of the fluid out of the air sacs.

Fluids

Carefully managing the amount of intravenous fluids is crucial. Too much fluid can increase fluid buildup in the lungs. Too little fluid can put a strain on your heart and other organs and lead to shock.

Medication

People with ARDS usually are given medication to:

Prevent and treat infections

Relieve pain and discomfort

Prevent clots in the legs and lungs

Minimize gastric reflux

Sedate

LIFESTYLE AND HOME REMEDIES

If you're recovering from ARDS, the following suggestions can help protect your lungs:

Quit smoking. If you smoke, seek help to quit, and avoid secondhand smoke whenever possible.

Quit alcohol. Alcohol can relax the portion of your upper airway that keeps foreign material from entering your lungs (aspiration).

Get vaccinated. The yearly flu (influenza) shot, as well as the pneumonia vaccine every five years, can reduce your risk of lung infections.

COPING AND SUPPORT

Recovery from ARDS can be a long road, and you'll need plenty of support. Although everyone's recovery is different, being aware of common physical and mental difficulties encountered by others with the disorder can help. Consider these tips:

Ask for help. Particularly after you're released from the hospital, be sure you have help with everyday tasks until you know what you can manage on your own.

Attend pulmonary rehabilitation. Many medical centers now offer pulmonary rehabilitation programs, which incorporate exercise training, education and counseling to help you learn how to return to your normal activities and achieve your ideal weight.

Join a support group. There are support groups for people with chronic lung problems. Discover what's available in your community or online and consider joining others with similar experiences.

Seek professional help. If you have symptoms of depression, such as hopelessness and loss of interest in your usual activities, tell your doctor or contact a mental health professional. Depression is common in people who have had ARDS, and treatment can help.

Adrenal insufficiency 

Addison's disease is a disorder that occurs when your body produces insufficient amounts of certain hormones produced by your adrenal glands. In Addison's disease, your adrenal glands produce too little cortisol and often insufficient levels of aldosterone as well.

Also called adrenal insufficiency, Addison's disease occurs in all age groups and affects both sexes. Addison's disease can be life-threatening.

Treatment for Addison's disease involves taking hormones to replace the insufficient amounts being made by your adrenal glands, in order to mimic the beneficial effects produced by your naturally made hormones.

SYMPTOMS

Addison's disease symptoms usually develop slowly, often over several months, and may include:

Muscle weakness and fatigue

Weight loss and decreased appetite

Darkening of your skin (hyperpigmentation)

Low blood pressure, even fainting

Salt craving

Low blood sugar (hypoglycemia)

Nausea, diarrhea or vomiting

Muscle or joint pains

Irritability

Depression

Body hair loss or sexual dysfunction in women

Acute adrenal failure (addisonian crisis)

Sometimes, however, the signs and symptoms of Addison's disease may appear suddenly. In acute adrenal failure (addisonian crisis), the signs and symptoms may also include:

Pain in your lower back, abdomen or legs

Severe vomiting and diarrhea, leading to dehydration

Low blood pressure

Loss of consciousness

High potassium (hyperkalemia)

When to see a doctor

See your doctor if you have signs and symptoms that commonly occur in people with Addison's disease, such as:

Darkening areas of skin (hyperpigmentation)

Severe fatigue

Unintentional weight loss

Gastrointestinal problems, such as nausea, vomiting and abdominal pain

Dizziness or fainting

Salt cravings

Muscle or joint pains

Your doctor can help determine whether Addison's disease or some other medical condition may be causing these problems.

CAUSES

Addison's disease results when your adrenal glands are damaged, producing insufficient amounts of the hormone cortisol and often aldosterone as well. These glands are located just above your kidneys. As part of your endocrine system, they produce hormones that give instructions to virtually every organ and tissue in your body.

Your adrenal glands are composed of two sections. The interior (medulla) produces adrenaline-like hormones. The outer layer (cortex) produces a group of hormones called corticosteroids, which include glucocorticoids, mineralocorticoids and male sex hormones (androgens).

Some of the hormones the cortex produces are essential for life — the glucocorticoids and the mineralocorticoids.

Glucocorticoids. These hormones, which include cortisol, influence your body's ability to convert food fuels into energy, play a role in your immune system's inflammatory response and help your body respond to stress.

Mineralocorticoids. These hormones, which include aldosterone, maintain your body's balance of sodium and potassium to keep your blood pressure normal.

Androgens. These male sex hormones are produced in small amounts by the adrenal glands in both men and women. They cause sexual development in men and influence muscle mass, libido and a sense of well-being in both men and women.

Primary adrenal insufficiency

Addison's disease occurs when the cortex is damaged and doesn't produce its hormones in adequate quantities. Doctors refer to the condition involving damage to the adrenal glands as primary adrenal insufficiency.

The failure of your adrenal glands to produce adrenocortical hormones is most commonly the result of the body attacking itself (autoimmune disease). For unknown reasons, your immune system views the adrenal cortex as foreign, something to attack and destroy.

Other causes of adrenal gland failure may include:

Tuberculosis

Other infections of the adrenal glands

Spread of cancer to the adrenal glands

Bleeding into the adrenal glands

Secondary adrenal insufficiency

Adrenal insufficiency can also occur if your pituitary gland is diseased. The pituitary gland makes a hormone called adrenocorticotropic hormone (ACTH), which stimulates the adrenal cortex to produce its hormones. Inadequate production of ACTH can lead to insufficient production of hormones normally produced by your adrenal glands, even though your adrenal glands aren't damaged. Doctors call this condition secondary adrenal insufficiency.

Another more common cause of secondary adrenal insufficiency occurs when people who take corticosteroids for treatment of chronic conditions, such as asthma or arthritis, abruptly stop taking the corticosteroids.

Addisonian crisis

If you have untreated Addison's disease, an addisonian crisis may be provoked by physical stress, such as an injury, infection or illness.

PREPARING FOR YOUR APPOINTMENT

You're likely to start by seeing your family doctor or a general practitioner. However, in some cases when you call to set up an appointment, you may be referred to an endocrinologist.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet.

Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.

Write down key personal information, including any major stresses or recent life changes.

Make a list of all medications, vitamins or supplements that you're taking.

Take a family member or friend along, if possible. Sometimes it can be difficult to recall all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your time together. List your questions from most important to least important in case time runs out. For Addison's disease, some basic questions to ask your doctor include:

What is likely causing my symptoms or condition?

Other than the most likely cause, what are possible causes for my symptoms or condition?

What kinds of tests do I need?

Is my condition likely temporary or chronic?

What is the best course of action?

What are the alternatives to the primary approach that you're suggesting?

I have these other health conditions. How can I best manage them together?

Are there any restrictions that I need to follow?

Should I see a specialist?

Is there a generic alternative to the medicine you're prescribing me?

Are there any brochures or other printed material that I can take home with me? What websites do you recommend?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

When did you first begin experiencing symptoms?

Have your symptoms been continuous or occasional?

How severe are your symptoms?

What, if anything, seems to improve your symptoms?

What, if anything, appears to worsen your symptoms?

TESTS AND DIAGNOSIS

Your doctor will talk to you first about your medical history and your signs and symptoms. If your doctor thinks that you may have Addison's disease, you may undergo some of the following tests:

Blood test. Measuring your blood levels of sodium, potassium, cortisol and ACTH gives your doctor an initial indication of whether adrenal insufficiency may be causing your signs and symptoms. A blood test can also measure antibodies associated with autoimmune Addison's disease.

ACTH stimulation test. This test involves measuring the level of cortisol in your blood before and after an injection of synthetic ACTH. ACTH signals your adrenal glands to produce cortisol. If your adrenal glands are damaged, the ACTH stimulation test shows that your output of cortisol in response to synthetic ACTH is limited or nonexistent.

Insulin-induced hypoglycemia test. Occasionally, doctors suggest this test if pituitary disease is a possible cause of adrenal insufficiency (secondary adrenal insufficiency). The test involves checking your blood sugar (blood glucose) and cortisol levels at various intervals after an injection of insulin. In healthy people, glucose levels fall and cortisol levels increase.

Imaging tests. Your doctor may have you undergo a computerized tomography (CT) scan of your abdomen to check the size of your adrenal glands and look for other abnormalities that may give insight to the cause of the adrenal insufficiency. Your doctor may also suggest a MRI scan of your pituitary gland if testing indicates you might have secondary adrenal insufficiency.

TREATMENTS AND DRUGS

All treatment for Addison's disease involves hormone replacement therapy to correct the levels of steroid hormones your body isn't producing. Some options for treatment include:

Oral corticosteroids. Your doctor may prescribe fludrocortisone to replace aldosterone. Hydrocortisone (Cortef), prednisone or cortisone acetate may be used to replace cortisol.

Corticosteroid injections. If you're ill with vomiting and can't retain oral medications, injections may be needed.

Androgen replacement therapy. To treat androgen deficiency in women, dehydroepiandrosterone can be prescribed. Some studies suggest that this therapy may improve overall sense of well-being, libido and sexual satisfaction.

An ample amount of sodium is recommended, especially during heavy exercise, when the weather is hot, or if you have gastrointestinal upsets, such as diarrhea. Your doctor will also suggest a temporary increase in your dosage if you're facing a stressful situation, such as an operation, an infection or a minor illness.

Addisonian crisis

An addisonian crisis is a life-threatening situation that results in low blood pressure, low blood levels of sugar and high blood levels of potassium. This situation requires immediate medical care. Treatment typically includes intravenous injections of:

Hydrocortisone

Saline solution

Sugar (dextrose)

COPING AND SUPPORT

These steps may help you cope better with a medical emergency if you have Addison's disease:

Carry a medical alert card and bracelet at all times. In the event you're incapacitated, emergency medical personnel know what kind of care you need.

Keep extra medication handy. Because missing even one day of therapy may be dangerous, it's a good idea to keep a small supply of medication at work, at a vacation home and in your travel bag, in the event you forget to take your pills. Also, have your doctor prescribe a needle, syringe and injectable form of corticosteroids to have with you in case of an emergency.

Stay in contact with your doctor. Keep an ongoing relationship with your doctor to make sure that the doses of replacement hormones are adequate but not excessive. If you're having persistent problems with your medications, you may need adjustments in the doses or timing of the medications.

Adenomyosis

Adenomyosis (ad-uh-no-my-O-sis) occurs when endometrial tissue, which normally lines the uterus, exists within and grows into the muscular wall of the uterus. The displaced endometrial tissue continues to act as it normally would — thickening, breaking down and bleeding — during each menstrual cycle. An enlarged uterus and painful, heavy periods can result.

Symptoms most often start late in the childbearing years after having children.

The cause of adenomyosis remains unknown, but the disease typically disappears after menopause. For women who experience severe discomfort from adenomyosis, certain treatments can help, but hysterectomy is the only cure.

SYMPTOMS

Sometimes, adenomyosis is silent — causing no signs or symptoms — or only mildly uncomfortable. In other cases, adenomyosis may cause:

Heavy or prolonged menstrual bleeding

Severe cramping or sharp, knifelike pelvic pain during menstruation (dysmenorrhea)

Menstrual cramps that last throughout your period and worsen as you get older

Pain during intercourse

Blood clots that pass during your period

Your uterus may get bigger. Although you might not know if your uterus is enlarged, you may notice that your lower abdomen seems bigger or feels tender.

When to see a doctor

If you have prolonged, heavy bleeding or severe cramping during your periods — and it interferes with your regular activities — make an appointment to see your doctor.

CAUSES

The cause of adenomyosis isn't known. Expert theories about a possible cause include:

Invasive tissue growth. Some experts believe that adenomyosis results from the direct invasion of endometrial cells from the lining of the uterus into the muscle that forms the uterine walls. Uterine incisions made during an operation such as a cesarean section (C-section) may promote the direct invasion of the endometrial cells into the wall of the uterus.

Developmental origins. Other experts speculate that adenomyosis originates within the uterine muscle from endometrial tissue deposited there when the uterus first formed in the fetus.

Uterine inflammation related to childbirth. Another theory suggests a link between adenomyosis and childbirth. An inflammation of the uterine lining during the postpartum period might cause a break in the normal boundary of cells that line the uterus. Surgical procedures on the uterus may have a similar effect.

Stem cell origins. A recent theory proposes that bone marrow stem cells may invade the uterine muscle, causing adenomyosis.

Regardless of how adenomyosis develops, its growth depends on the circulating estrogen in a woman's body. When estrogen production decreases at menopause, adenomyosis eventually goes away.

RISK FACTORS

Risk factors for adenomyosis include:

Prior uterine surgery, such as a C-section or fibroid removal

Childbirth

Middle age

Most cases of adenomyosis — which depends on estrogen — are found in women in their 40s and 50s. Adenomyosis in middle-aged women could relate to longer exposure to estrogen compared with that of younger women. Until recently, adenomyosis was most often diagnosed only when a woman had a hysterectomy. Current research suggests that the condition may also be common, but often undetected, in younger women.

COMPLICATIONS

If you often have prolonged, heavy bleeding during your periods, chronic anemia may result. Anemia causes fatigue and other health problems. See your doctor if you suspect you may have anemia.

Although not harmful, the pain and excessive bleeding associated with adenomyosis can disrupt your lifestyle. You may find yourself avoiding activities that you've enjoyed in the past because you have no idea when or where you might start bleeding.

Painful periods can cause you to miss work or school and can strain relationships. Recurring pain can lead to depression, irritability, anxiety, anger and feelings of helplessness. That's why it's important to see a doctor if you suspect you may have adenomyosis.

PREPARING FOR YOUR APPOINTMENT

Your first appointment will be with either your primary care provider or your gynecologist. To save time and make sure you cover everything you want to discuss, it's a good idea to prepare for your appointment.

What you can do

Before your appointment:

Write down any symptoms you're experiencing. Include those that may seem unrelated to your condition.

Make a list of any medications or vitamin supplements you take. Write down doses and how often you take them.

Take a notebook or electronic notepad with you. Use it to write down important information during your visit.

Think about questions to ask your doctor. Write down any questions, listing the most important ones first.

For adenomyosis, some basic questions to ask your doctor include:

How is adenomyosis diagnosed?

How much experience do you have in diagnosing and treating adenomyosis?

Are there any medications I can take to improve my symptoms?

What side effects can I expect from medication use?

Under what circumstances do you recommend surgery?

Will I take a medication before or after surgery?

Could my condition affect my ability to become pregnant?

Are there any alternative treatments I might try?

Don't hesitate to ask your doctor to repeat information or to ask follow-up questions.

What to expect from your doctor

Some questions your doctor might ask include:

How long have you been experiencing symptoms?

When do symptoms typically occur?

How severe are your symptoms?

When was your last period?

Could you be pregnant?

Are you using a birth control method?

Do your symptoms seem to be related to your menstrual cycle?

Does anything seem to improve your symptoms?

Does anything make your symptoms worse?

TESTS AND DIAGNOSIS

Your doctor may suspect adenomyosis based on:

Signs and symptoms

A pelvic exam that reveals an enlarged, tender uterus

Ultrasound imaging of the uterus

Magnetic resonance imaging (MRI) of the uterus

In some instances, your doctor may collect a sample of uterine tissue for testing (endometrial biopsy) to verify that your abnormal uterine bleeding isn't associated with any other serious condition. But, an endometrial biopsy won't help your doctor confirm a diagnosis of adenomyosis. The only way to be certain of adenomyosis is to examine the uterus after surgery to remove it (hysterectomy).

Other uterine diseases can cause signs and symptoms similar to adenomyosis, making adenomyosis difficult to diagnose. Such conditions include fibroid tumors (leiomyomas), uterine cells growing outside the uterus (endometriosis) and growths in the uterine lining (endometrial polyps). Your doctor may conclude that you have adenomyosis only after determining there are no other possible causes for your signs and symptoms.

TREATMENTS AND DRUGS

Adenomyosis usually goes away after menopause, so treatment may depend on how close you are to that stage of life.

Treatment options for adenomyosis include:

Anti-inflammatory drugs. If you're nearing menopause, your doctor may have you try anti-inflammatory medications, such as ibuprofen (Advil, Motrin IB, others), to control the pain. By starting an anti-inflammatory medicine two to three days before your period begins and continuing to take it during your period, you can reduce menstrual blood flow and help relieve pain.

Hormone medications. Combined estrogen-progestin birth control pills or hormone-containing patches or vaginal rings may lessen heavy bleeding and pain associated with adenomyosis. Progestin-only contraception, such as an intrauterine device, or continuous-use birth control pills often lead to amenorrhea — the absence of your menstrual periods — which may provide symptom relief.

Hysterectomy. If your pain is severe and menopause is years away, your doctor may suggest surgery to remove your uterus (hysterectomy). Removing your ovaries isn't necessary to control adenomyosis.

LIFESTYLE AND HOME REMEDIES

To ease pelvic pain and cramping related to adenomyosis:

Soak in a warm bath.

Use a heating pad on your abdomen.

Take an over-the-counter anti-inflammatory medication, such as ibuprofen (Advil, Motrin IB, others).

Attention-deficit/hyperactivity disorder (ADHD) is a chronic condition that affects millions of children and often persists into adulthood. ADHD includes a combination of problems, such as difficulty sustaining attention, hyperactivity and impulsive behavior.

Children with ADHD also may struggle with low self-esteem, troubled relationships and poor performance in school. Symptoms sometimes lessen with age. However, some people never completely outgrow their ADHD symptoms. But they can learn strategies to be successful.

While treatment won't cure ADHD, it can help a great deal with symptoms. Treatment typically involves medications and behavioral interventions. Early diagnosis and treatment can make a big difference in outcome.

SYMPTOMS

Attention-deficit/hyperactivity disorder (ADHD) has been called attention-deficit disorder (ADD) in the past. But ADHD is now the preferred term because it describes both of the primary features of this condition: inattention and hyperactive-impulsive behavior. In some children, signs of ADHD are noticeable as early as 2 or 3 years of age.

Signs and symptoms of ADHD may include:

Difficulty paying attention

Frequently daydreaming

Difficulty following through on instructions and apparently not listening

Frequently has problems organizing tasks or activities

Frequently forgetful and loses needed items, such as books, pencils or toys

Frequently fails to finish schoolwork, chores or other tasks

Easily distracted

Frequently fidgets or squirms

Difficulty remaining seated and seemly in constant motion

Excessively talkative

Frequently interrupts or intrudes on others' conversations or games

Frequently has trouble waiting for his or her turn

ADHD occurs more often in males than in females, and behaviors can be different in boys and girls. For example, boys may be more hyperactive and girls may tend to be quietly inattentive.

Normal behavior vs. ADHD

Most healthy children are inattentive, hyperactive or impulsive at one time or another. It's normal for preschoolers to have short attention spans and be unable to stick with one activity for long. Even in older children and teenagers, attention span often depends on the level of interest.

The same is true of hyperactivity. Young children are naturally energetic — they often wear their parents out long before they're tired. In addition, some children just naturally have a higher activity level than others do. Children should never be classified as having ADHD just because they're different from their friends or siblings.

Children who have problems in school but get along well at home or with friends are likely struggling with something other than ADHD. The same is true of children who are hyperactive or inattentive at home, but whose schoolwork and friendships remain unaffected.

When to see a doctor

If you're concerned that your child shows signs of ADHD, see your pediatrician or family doctor. Your doctor may refer you to a specialist, but it's important to have a medical evaluation first to check for other possible causes of your child's difficulties.

If your child is already being treated for ADHD, he or she should see the doctor regularly until symptoms have largely improved, and then every three to four months if symptoms are stable. Call the doctor if your child has any medication side effects, such as loss of appetite, trouble sleeping, increased irritability, or if your child's ADHD has not shown much improvement with initial treatment.

CAUSES

While the exact cause of ADHD is not clear, research efforts continue.

Multiple factors have been implicated in the development of ADHD. It can run in families, and studies indicate that genes may play a role. Certain environmental factors also may increase risk, as can problems with the central nervous system at key moments in development.

RISK FACTORS

Risk factors for ADHD may include:

Blood relatives (such as a parent or sibling) with ADHD or another mental health disorder

Exposure to environmental toxins — such as lead, found mainly in paint and pipes in older buildings

Maternal drug use, alcohol use or smoking during pregnancy

Maternal exposure to environmental poisons — such as polychlorinated biphenyls (PCBs) — during pregnancy

Premature birth

Although sugar is a popular suspect in causing hyperactivity, there's no reliable proof of this. Many things in childhood can lead to difficulty sustaining attention, but that is not the same as ADHD.

COMPLICATIONS

ADHD can make life difficult for children. Children with ADHD:

Often struggle in the classroom, which can lead to academic failure and judgment by other children and adults

Tend to have more accidents and injuries of all kinds than children who don't have the disorder

Have poor self-esteem

Are more likely to have trouble interacting with and being accepted by peers and adults

Are at increased risk of alcohol and drug abuse and other delinquent behavior

Coexisting conditions

ADHD doesn't cause other psychological or developmental problems. However, children with ADHD are more likely than are other children to also have conditions such as:

Learning disabilities, including problems with understanding and communicating

Anxiety disorders, which may cause overwhelming worry, nervousness and worsening of ADHD symptoms until the anxiety is treated and under control

Depression, which frequently occurs in children with ADHD

Bipolar disorder, which includes depression as well as manic behavior

Oppositional defiant disorder (ODD), generally defined as a pattern of negative, defiant and hostile behavior toward authority figures

Conduct disorder, marked by antisocial behavior such as stealing, fighting, destroying property, and harming people or animals

Tourette syndrome, a neurological disorder characterized by repetitive muscle or vocal tics

PREPARING FOR YOUR APPOINTMENT

You're likely to start by taking your child to a family doctor or pediatrician. Depending on the results of the initial evaluation, your doctor may refer you to a specialist, such as a developmental-behavioral pediatrician, psychologist, psychiatrist or pediatric neurologist.

What you can do

To prepare for your child's appointment:

Make a list of any symptoms and difficulties your child has at home or at school.

Prepare key personal information, including any major stresses or recent life changes.

Make a list of all medications, as well as any vitamins, herbs or supplements, that your child is taking.

Bring any past evaluations and results of formal testing with you, if you have them.

Make a list of questions to ask your child's doctor.

Some basic questions to ask your doctor include:

Other than ADHD, what are possible causes for my child's symptoms?

What kinds of tests does my child need?

What treatments are available, and which do you recommend?

What are the alternatives to the primary approach that you're suggesting?

My child has these other health conditions. How can I best manage these conditions together?

Should my child see a specialist?

Is there a generic alternative to the medicine you're prescribing for my child?

What types of side effects can we expect from the medication?

Are there any printed materials that I can have? What websites do you recommend?

Don't hesitate to ask questions anytime you don't understand something.

What to expect from your doctor

Be ready to answer questions your doctor may ask, such as:

When did you first notice your child's behavior issues?

Do the troubling behaviors occur all the time or only in certain situations?

How severe are your child's difficulties?

What, if anything, appears to worsen your child's behavior?

What, if anything, seems to improve your child's behavior?

Does your child consume caffeine? How much?

What are your child's sleep hours and patterns?

How is your child's current and past academic performance?

Does your child read at home? Does he or she have trouble reading?

What discipline methods have you used at home? Which ones are effective?

Describe who lives at home and a typical daily routine.

TESTS AND DIAGNOSIS

In general, a child shouldn't receive a diagnosis of ADHD unless the core symptoms of ADHD start early in life and create significant problems at home and at school on an ongoing basis.

There's no specific test for ADHD, but making a diagnosis will likely include:

Medical exam, to help rule out other possible causes of symptoms

Information gathering, such as any current medical issues, personal and family medical history and school records

Interviews or questionnaires for family members, your child's teachers or other people who know your child well, such as baby sitters and coaches

ADHD rating scales to help collect and evaluate information about your child

Diagnostic criteria for ADHD

To be diagnosed with ADHD, your child must meet the criteria in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. For a diagnosis of ADHD, a child must have six or more signs and symptoms from one or both of the two categories below.

Inattention

Often fails to give close attention to details or makes careless mistakes in schoolwork and other activities

Often has difficulty sustaining attention in tasks or play activities

Often doesn't seem to listen when spoken to directly

Often doesn't follow through on instructions and fails to finish schoolwork or chores

Often has difficulty organizing tasks and activities

Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort, such as schoolwork or homework

Often loses items necessary for tasks or activities (for example, toys, school assignments, pencils, books)

Is often easily distracted

Is often forgetful in daily activities

Hyperactivity and impulsivity

Often fidgets with hands or feet or squirms in seat

Often leaves seat in classroom or in other situations when remaining seated is expected

Often runs about or climbs excessively in situations when it's inappropriate

Often has difficulty playing or engaging in leisure activities quietly

Is often "on the go" or often acts as if "driven by a motor"

Often talks too much

Often blurts out answers before questions have been completed

Often has difficulty awaiting turn

Often interrupts or intrudes on others' conversations or games

In addition to having at least six signs or symptoms from these two categories, a child with ADHD:

Has inattentive or hyperactive-impulsive signs and symptoms that cause impairment

Has behaviors that aren't normal for children the same age who don't have ADHD

Has symptoms for at least six months

Has symptoms that affect school, home life or relationships in more than one setting (such as at home and at school)

A child diagnosed with ADHD is often given a more specific diagnosis (a subtype), such as:

Predominantly inattentive type ADHD. A child has at least six signs and symptoms from the inattention list above. This child may sit quietly and appear to get along with others, but he or she is not paying attention.

Predominantly hyperactive-impulsive type ADHD. A child has at least six signs and symptoms from the hyperactivity and impulsivity list above. This may be misjudged as an emotional or disciplinary problem.

Combined-type ADHD. A child has six or more signs and symptoms from each of the two lists above.

Other conditions that resemble ADHD

A number of medical conditions or their treatments may cause signs and symptoms similar to those of ADHD, or exist along with ADHD. Examples include:

Learning or language problems

Mood disorders (such as depression)

Anxiety disorders

Seizure disorders

Vision or hearing problems

Tourette syndrome

Sleep disorders

Thyroid medication

Substance abuse

Brain injury

Diagnosing ADHD in young children

Although signs of ADHD can sometimes appear in preschoolers or children even younger, diagnosing the disorder in very young children is difficult. That's because developmental problems such as language delays can be mistaken for ADHD. For that reason, children preschool age or younger suspected of having ADHD are more likely to need evaluation by a specialist, such as a psychologist or psychiatrist, speech pathologist, or developmental pediatrician.

TREATMENTS AND DRUGS

Standard treatments for ADHD in children include medications, education, training and counseling. These treatments can relieve many of the symptoms of ADHD, but they don't cure it. It may take some time to determine what works best for your child.

Stimulant medications

Currently, stimulant drugs (psychostimulants) are the most commonly prescribed medications for ADHD. Stimulants appear to boost and balance levels of brain chemicals called neurotransmitters. These medications help improve the signs and symptoms of inattention and hyperactivity — sometimes dramatically.

Examples include methylphenidate (Concerta, Metadate, Ritalin, others), dextroamphetamine (Dexedrine), dextroamphetamine-amphetamine (Adderall XR) and lisdexamfetamine (Vyvanse).

Stimulant drugs are available in short-acting and long-acting forms. A long-acting patch is available that can be worn on the hip.

The right dose varies from child to child, so it may take some time to find the correct dose. And the dose may need to be adjusted if significant side effects occur or as your child matures. Ask your doctor about possible side effects of stimulants.

Stimulant medications and heart problems

Although rare, several heart-related deaths occurred in children and teenagers taking stimulant medications. The possibility of increased risk of sudden death is still unproved, but if it exists, it's believed to be in people who already have underlying heart disease or a heart defect. Your child's doctor should make sure your child doesn't have any signs of a heart condition and should ask about family risk factors for heart disease before prescribing a stimulant medication.

Other medications

Other medications used to treat ADHD include atomoxetine (Strattera) and antidepressants such as bupropion (Wellbutrin, others) and desipramine (Norpramin). Clonidine (Catapres) and guanfacine (Intuniv, Tenex) have also been shown to be effective. Atomoxetine and antidepressants work slower than stimulants and may take several weeks before they take full effect. These may be good options if your child can't take stimulants because of health problems or if stimulants cause severe side effects.

Ask your doctor about possible side effects of any medications.

Suicide risk

Although it remains unproved, concerns have been raised that there may be a slightly increased risk of suicidal thinking in children and teenagers taking nonstimulant ADHD medication or antidepressants. Contact your child's doctor if you notice any signs of suicidal thinking or other signs of depression.

Giving medications safely

Making sure your child takes the right amount of the prescribed medication is very important. Parents may be concerned about stimulants and the risk of abuse and addiction. Dependence hasn't been shown in children who take these drugs for appropriate reasons and at the proper dose.

On the other hand, there's concern that siblings and classmates of children and teenagers with ADHD might abuse stimulant medications. To keep your child's medications safe and to make sure your child is getting the right dose at the right time:

Administer medications carefully. Children and teens shouldn't be in charge of their own ADHD medication without proper supervision.

At home, keep medication locked in a childproof container. An overdose of stimulant drugs is serious and potentially fatal.

Don't send supplies of medication to school with your child. Deliver any medicine yourself to the school nurse or health office.

ADHD behavior therapy and counseling

Children with ADHD often benefit from behavior therapy and counseling, which may be provided by a psychiatrist, psychologist, social worker or other mental health care professional. Some children with ADHD may also have other conditions such as anxiety disorder or depression. In these cases, counseling may help both ADHD and the coexisting problem.

Examples of therapy include:

Behavior therapy. Teachers and parents can learn behavior-changing strategies for dealing with difficult situations. These strategies may include token reward systems and timeouts.

Psychotherapy. This allows older children with ADHD to talk about issues that bother them, explore negative behavioral patterns and learn ways to deal with their symptoms.

Parenting skills training. This can help parents develop ways to understand and guide their child's behavior.

Family therapy. Family therapy can help parents and siblings deal with the stress of living with someone who has ADHD.

Social skills training. This can help children learn appropriate social behaviors.

The best results usually occur when a team approach is used, with teachers, parents, and therapists or physicians working together. Educate yourself about ADHD, and then work with your child's teachers and refer them to reliable sources of information to support their efforts in the classroom.

LIFESTYLE AND HOME REMEDIES

To help reduce your child's risk of ADHD:

During pregnancy, avoid anything that could harm fetal development. Don't drink alcohol, smoke cigarettes or use drugs. Avoid exposure to environmental toxins, such as polychlorinated biphenyls (PCBs).

Protect your child from exposure to pollutants and toxins, including cigarette smoke, agricultural or industrial chemicals, and lead paint (found in some old buildings).

Limit screen time. Although still unproved, it may be prudent for children to avoid excessive exposure to TV and video games in the first five years of life.

If your child has ADHD, to help reduce problems or complications:

Be consistent, set limits and have clear consequences for your child's behavior.

Put together a daily routine for your child with clear expectations that include such things as bedtime, morning time, mealtime, simple chores and TV.

Avoid multitasking yourself when talking with your child, make eye contact when giving instructions, and set aside a few minutes every day to praise your child.

Work with teachers and caregivers to identify problems early, to decrease the impact of the condition on your child's life.

ALTERNATIVE MEDICINE

There's little research that indicates that alternative medicine treatments can reduce ADHD symptoms. Before considering any alternative interventions, talk with your doctor to determine if the therapy will be safe. Some alternative medicine treatments that have been tried, but are not yet fully proved scientifically, include:

Yoga or meditation. Doing regular yoga routines or meditation and relaxation techniques may help children relax and learn discipline, which may help them manage their symptoms of ADHD.

Special diets. Most diets that have been promoted for ADHD involve eliminating foods thought to increase hyperactivity, such as sugar, and common allergens such as wheat, milk and eggs. Some diets recommend eliminating artificial food colorings and additives. So far, studies haven't found a consistent link between diet and improved symptoms of ADHD, though there is some anecdotal evidence that suggests diet changes might make a difference. Limiting sugar, however, doesn't seem to help. Caffeine use as a stimulant for children with ADHD can have risky effects and is not recommended.

Vitamin or mineral supplements. While certain vitamins and minerals are necessary for good health, there's no evidence that supplemental vitamins or minerals can reduce symptoms of ADHD. "Megadoses" of vitamins — doses that far exceed the Recommended Dietary Allowance (RDA) — can be harmful.

Herbal supplements. There is no evidence to suggest that herbal remedies help with ADHD, and some may be harmful.

Proprietary formulations. These are products made from vitamins, micronutrients and other ingredients that are sold as possible treatment supplements for children with ADHD. These products have had little or no research and are exempt from FDA oversight, making them possibly ineffective or potentially harmful.

Essential fatty acids. These fats, which include omega-3 oils, are necessary for the brain to function properly. Researchers are still investigating whether these may improve ADHD symptoms.

Neurofeedback training. Also called electroencephalographic (EEG) biofeedback, this treatment involves regular sessions in which a child focuses on certain tasks while using a machine that shows brain wave patterns. Theoretically, a child can learn to keep brain wave patterns active in the front of the brain — improving symptoms of ADHD. While this treatment looks very promising, more research is needed to see whether it works.

Other techniques. These can include sensory integration therapy and interactive metronome training. At this time there is not enough research to support their effectiveness.

COPING AND SUPPORT

Caring for a child with ADHD can be challenging for the whole family. Parents may be hurt by their child's behavior as well as by the way other people respond to it. The stress of dealing with ADHD can lead to marital conflict. These problems may be compounded by the financial burden that ADHD can place on families.

Siblings of a child with ADHD also may have special difficulties. They can be affected by a brother or sister who is demanding or aggressive, and they may also receive less attention because the child with ADHD requires so much of a parent's time.

Resources

Many resources are available, such as social services or support groups. Support groups often can provide helpful information about coping with ADHD. Ask your child's doctor if he or she knows of any support groups in your area.

There also are excellent books and guides for both parents and teachers, and Internet sites dealing exclusively with ADHD. But be careful of websites or other resources that focus on risky or unproved remedies or those that conflict with your health care team's recommendations.

Techniques for coping

Many parents notice patterns in their child's behavior as well as in their own responses to that behavior. Both you and your child may need to change behavior. But substituting new habits for old ones isn't easy — it takes a lot of hard work. It's important to have realistic expectations. Set small goals for both yourself and your child and don't try to make a lot of changes all at once.

To help manage ADHD:

Structure your child's life. Structure doesn't mean rigidity or iron discipline. Instead, it means arranging things so that a child's life is as predictable, calm and organized as possible. Children with ADHD don't handle change well, and having predictable routines can make them feel safe as well as help improve behavior. Give your child a few minutes warning — with a countdown — when it's necessary to change from one activity or location to another.

Provide positive discipline. Firm, loving discipline that rewards good behavior and discourages destructive actions is the best place to start. Also, children with ADHD usually respond well to positive reinforcement, as long as it's earned. Rewarding or reinforcing a new good behavior every time it occurs can encourage new habits.

Stay calm and set a good example. Set a good example by acting the way you want your child to act. Try to remain patient and in control — even when your child is out of control. If you speak quietly and calmly, your child is more likely to calm down too. Learning stress management techniques can help you deal with your own frustrations.

Strive for healthy family relationships. The relationship among all family members plays a large part in managing or changing the behavior of a child with ADHD. Couples who have a strong bond often find it easier to face the challenges of parenting than those whose bond isn't as strong. That'