ABSENCE SEIZURE
ABSENCE SEIZURE
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Absence Seizure
Absence seizures involve brief, sudden lapses of consciousness. They're more common in children than adults. Someone having an absence seizure may look like he or she is staring into space for a few seconds. This type of seizure usually doesn't lead to physical injury.
Absence seizures usually can be controlled with anti-seizure medications. Some children who have them also develop other seizures. Many children outgrow absence seizures in their teens.
SYMPTOMS
An indication of simple absence seizure is a vacant stare, which may be mistaken for a lapse in attention that lasts 10 to 15 seconds, without any subsequent confusion, headache or drowsiness.
Signs and symptoms of absence seizures include:
Sudden stop in motion without falling
Lip smacking
Eyelid flutters
Chewing motions
Finger rubbing
Small movements of both hands
Absence seizures generally last 10 to 15 seconds, followed immediately by full recovery. Afterward, there's no memory of the incident. Some people have dozens of episodes daily, which interfere with school or daily activities.
A child may have absence seizures for some time before an adult notices the seizures, because they're so brief. A decline in a child's learning ability may be the first sign of this disorder. Teachers may comment about a child's inability to pay attention.
When to see a doctor
Contact your doctor:
The first time you notice a seizure
If this is a new type of seizure
If the seizures continue to occur despite being placed on anti-seizure medication
Seek immediate medical attention:
If you observe prolonged automatic behaviors — activities such as eating or moving without awareness — or prolonged confusion, possible symptoms of a condition called absence status epilepticus
After any seizure lasting more than five minutes
CAUSES
Often, no underlying cause can be found for absence seizures. Many children appear to have a genetic predisposition to them. Rapid breathing (hyperventilation) can trigger an absence seizure.
In general, seizures are caused by abnormal electrical impulses from nerve cells (neurons) in the brain. The brain's nerve cells normally send electrical and chemical signals across the synapses that connect them.
In people who have seizures, the brain's usual electrical activity is altered. During an absence seizure, these electrical signals repeat themselves over and over in a three-second pattern.
People who have seizures may also have altered levels of the chemical messengers that help the nerve cells communicate with one another (neurotransmitters).
Absence seizures are more prevalent in children. Many children gradually outgrow them over months to years. Some children with absence seizures may also experience full seizures (tonic-clonic seizures).
RISK FACTORS
Certain factors are common to children who have absence seizures, including:
Age. Absence seizures are more common in children between the ages of 4 and 10.
Sex. In general, most seizures are more common in boys, but absence seizures are more common in girls.
History of febrile seizures. Infants and children who have seizures brought on by fever are at greater risk of absence seizures.
Family members who have seizures. Nearly half of children with absence seizures have a close relative who has seizures.
COMPLICATIONS
While most children outgrow absence seizures, some:
Have seizures throughout life
Eventually have full convulsions, such as generalized tonic-clonic seizures
Other complications can include:
Learning difficulties
Behavior problems
Social isolation
PREPARING FOR YOUR APPOINTMENT
You're likely to start by seeing your family doctor or a general practitioner. However, you'll probably be referred to a doctor who specializes in nervous system disorders (neurologist).
Here's some information to help you get ready for the appointment.
What you can do
Write down any symptoms your child is experiencing, including any that may seem unrelated to seizures.
Make a list of all medications, vitamins and supplements you or your child takes.
Write down questions to ask the doctor.
Preparing a list of questions will help you make the most of your time with your doctor.
For absence seizure, some basic questions to ask your doctor include:
What's the most likely cause of these symptoms?
Are there other possible causes?
What tests are needed? Do these tests require special preparation?
Is this condition temporary or long lasting?
What treatments are available, and which do you recommend?
What side effects might I expect from treatment?
Are there alternatives to the treatment you're suggesting?
Is there a generic alternative to the medicine you're prescribing?
Can my child also develop the grand mal type of seizure?
How long will my child need to take medication?
Do I need to restrict activities? Can my child participate in physical activities, such as soccer, football and swimming?
Do you have brochures or other printed material I can take? What websites do you recommend?
Don't hesitate to ask any other questions you have.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, such as:
When did the symptoms begin?
How often have the symptoms occurred?
Can you describe a typical seizure?
How long do the seizures last?
Is your child aware of what happened after the seizure?
TESTS AND DIAGNOSIS
Your doctor will ask for a detailed description of the seizures and conduct a physical exam. Tests may include:
Electroencephalography (EEG). This painless procedure measures waves of electrical activity in the brain. Brain waves are transmitted to the EEG machine via small electrodes attached to the scalp with paste or an elastic cap.
Your child may be asked to breathe rapidly or look at flickering lights, an attempt to provoke a seizure. During a seizure, the pattern on the EEG differs from the normal pattern.
Brain scans. Tests such as magnetic resonance imaging (MRI) can produce detailed images of the brain, which can help rule out other problems, such as a stroke or a brain tumor. Because your child will need to hold still for long periods, talk with your doctor about the possible use of sedation.
TREATMENTS AND DRUGS
Your doctor likely will start at the lowest dose of anti-seizure medication possible and increase the dosage as needed to control the seizures. Most children can taper off anti-seizure medications, under a doctor's supervision, after they've been seizure-free for two years.
Drugs prescribed for absence seizure include:
Ethosuximide (Zarontin). This is the drug most doctors start with for absence seizures. In most cases, seizures respond well to this drug.
Valproic acid (Depakene). Because this drug has been associated with higher risk of birth defects in babies, doctors advise women against using it while trying to conceive or during pregnancy. Women who can't achieve seizure control on other medications should discuss potential risks with their doctors.
Lamotrigine (Lamictal). Some studies show this drug to be less effective than ethosuximide or valproic acid, but has fewer side effects.
LIFESTYLE AND HOME REMEDIES
A person with absence seizures may elect to wear a medical bracelet for identification for emergency medical reasons. The bracelet should state whom to contact in an emergency and what medications you use. It's also a good idea to let teachers, coaches and child care workers know about the seizures.
COPING AND SUPPORT
Even after they've been controlled with medication, seizures may affect areas of your child's life, such as attention span and learning. He or she will have to be seizure-free for reasonable lengths of time (intervals vary from state to state) before being able to drive.
You may find it helpful to talk with other people who are in the same situation as you. Besides offering support, they may have advice or tips for coping that you haven't considered.
The Epilepsy Foundation has a network of support groups, as well as online forums for teens and adults who have seizures and parents of children who have seizures. You can call the Epilepsy Foundation at 1-800-332-1000 or visit its website. Also, your doctor may know of support groups in your area.
ACHILLES TENDINITIS
ACHILLES TENDINITIS
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:
Your sex and age. Achilles tendinitis occurs most commonly in middle-aged men.
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.
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.
Medical conditions. People who have diabetes or high blood pressure are at higher risk of developing Achilles tendinitis.
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:
Did the pain begin suddenly or gradually?
Are symptoms worse at certain times of day or after certain activities?
What types of shoes do you wear during exercise?
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:
Where exactly does it hurt?
Does the pain lessen with rest?
What is your normal exercise routine?
Have you recently made changes to your exercise routine, or have you recently started participating in a new sport?
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 TENDON RUPTURE
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.
ACID REFLUX (GERD)
ACID REFLUX (GERD)
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:
Obesity
Bulging of top of stomach up into the diaphragm (hiatal hernia)
Pregnancy
Smoking
Dry mouth
Asthma
Diabetes
Delayed stomach emptying
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.
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 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:
What is likely causing my symptoms?
What kinds of tests do I need?
Do I need an endoscopy?
Is my GERD 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 other health conditions. How can I best manage them while managing GERD?
Are there any restrictions that I need to follow?
Should I see a specialist? What will that cost, and will my insurance cover it?
Is there a generic alternative to the medicine you're prescribing for me?
Are there brochures or other printed material that I can take with me? What websites do you recommend?
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:
What are your symptoms?
When did you first notice these 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?
Do your symptoms wake you up at night?
Are your symptoms worse after meals or after lying down?
Do your symptoms include nausea or vomiting?
Does food or sour material ever come up in the back of your throat?
Do you have difficulty swallowing?
Have you gained or lost weight?
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:
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.
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.
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
ACID REFLUX INFANT
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
ACL INJURY
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
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)
ACOUSTIC NEUROMA (HEARING LOSS)
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
ACS (ACUTE CORONARY SYNDROME
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
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
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
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.
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
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.
ADDISON'S DISEASE
ADDISON'S DISEASE
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
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).
ADHD
ADHD
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's one reason it's important for partners to take time to nurture their own relationship.
Give yourself a break. If your child has ADHD, give yourself a break now and then. Don't feel guilty for spending a few hours apart from your child. You'll be a better parent if you're rested and relaxed. And don't hesitate to ask relatives and friends for help. Make sure that baby sitters or other caretakers are knowledgeable about ADHD and mature enough for the task.
ADJUSTMENT DISORDER
ADJUSTMENT DISORDER
Adjustment Disorder
Work problems, going away to school, an illness — any number of life changes can cause stress. Most of the time, people adjust to such changes within a few months. But if you continue to feel down or self-destructive, you may have an adjustment disorder.
An adjustment disorder is a type of stress-related mental illness. You may feel anxious or depressed, or even have thoughts of suicide. Your normal daily routines may feel overwhelming. Or you may make reckless decisions. In essence, you have a hard time adjusting to change in your life, and it has serious consequences.
You don't have to tough it out on your own, though. Adjustment disorder treatment — usually brief — is likely to help you regain your emotional footing.
SYMPTOMS
Adjustment disorders symptoms vary from person to person. The symptoms you have may be different from those of someone else with an adjustment disorder. But for everyone, symptoms of an adjustment disorder begin within three months of a stressful event in your life.
Emotional symptoms of adjustment disorders
Signs and symptoms of adjustment disorder may affect how you feel and think about yourself or life, including:
Sadness
Hopelessness
Lack of enjoyment
Crying spells
Nervousness
Jitteriness
Anxiety, which may include separation anxiety
Worry
Desperation
Trouble sleeping
Difficulty concentrating
Feeling overwhelmed
Thoughts of suicide
Behavioral symptoms of adjustment disorders
Signs and symptoms of adjustment disorder may affect your actions or behavior, such as:
Fighting
Reckless driving
Ignoring bills
Avoiding family or friends
Performing poorly in school or at work
Skipping school
Vandalizing property
Length of symptoms
How long you have symptoms of an adjustment disorder also can vary:
6 months or less (acute). In these cases, symptoms should ease once the stressor is removed. Brief professional treatment may help symptoms disappear.
More than 6 months (chronic). In these cases, symptoms continue to bother you and disrupt your life. Professional treatment may help symptoms improve and prevent the condition from continuing to get worse.
When to see a doctor
Sometimes the stressful change in your life goes away, and your symptoms of adjustment disorder get better because the stress has eased. But often, the stressful event remains a part of your life. Or a new stressful situation comes up, and you face the same emotional struggles all over again.
Talk to your doctor if you're having trouble getting through each day. You can get treatment to help you cope better with stressful events and feel better about life again.
If you have suicidal thoughts
If you or someone you know has thoughts of suicide, get help right away. Consider talking to your doctor, nurse, a mental health professional, a trusted family member or friend, or your faith leader.
If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately. Or call a suicide hot line number. In the United States, you can call the 24-hour National Suicide Prevention Lifeline at 800-273-8255 (toll-free) to talk with a trained counselor.
CAUSES
Researchers are still trying to figure out what causes adjustment disorders. As with other mental disorders, the cause is likely complex and may involve genetics, your life experiences, your temperament and even changes in the natural chemicals in the brain.
RISK FACTORS
Although the cause of adjustment disorders is unknown, some things make you more likely to have an adjustment disorder. Among children and teenagers, both boys and girls have about the same chance of having adjustment disorders. Among adults, women are twice as likely to be diagnosed with adjustment disorders.
Stressful events
One or more stressful life events may put you at risk of developing an adjustment disorder. It may involve almost any type of stressful event in your life. Both positive and negative events can cause extreme stress. Some common examples include:
Being diagnosed with a serious illness
Problems in school
Divorce or relationship breakup
Job loss
Having a baby
Financial problems
Physical assault
Surviving a disaster
Retirement
Death of a loved one
Going away to school
In some cases, people who face an ongoing stressful situation — such as living in a crime-ridden neighborhood — can reach a breaking point and develop an adjustment disorder.
Your life experiences
If you generally don't cope well with change or you don't have a strong support system, you may be more likely to have an extreme reaction to a stressful event.
Your risk of an adjustment disorder may be higher if you experienced stress in early childhood. Overprotective or abusive parenting, family disruptions, and frequent moves early in life may make you feel like you're unable to control events in your life. When difficulties then arise, you may have trouble coping.
Other risk factors may include:
Other mental health problems
Exposure to wars or violence
Difficult life circumstances
COMPLICATIONS
Most adults with adjustment disorder get better within six months and don't have long-term complications. However, people who also have another mental health disorder, a substance abuse problem or a chronic adjustment disorder are more likely to have long-term mental health problems, which may include:
Depression
Alcohol and drug addiction
Suicidal thoughts and behavior
Compared with adults, teenagers with adjustment disorder — especially chronic adjustment disorder marked by behavioral problems — are at significantly increased risk of long-term problems. In addition to depression, substance abuse and suicidal behavior, teenagers with adjustment disorder are at risk of developing psychiatric disorders such as:
Schizophrenia
Bipolar disorder
Antisocial personality disorder
PREPARING FOR YOUR APPOINTMENT
If you have symptoms of an adjustment disorder, make an appointment with your primary care doctor. While adjustment disorders resolve on their own in most cases, your doctor may be able to recommend coping strategies or treatments that help you feel better sooner.
What you can do
To prepare for your appointment, make a list of:
Any symptoms you've been experiencing, and for how long
Key personal information, including any major stresses or recent life changes, both positive and negative
Medical information, including other physical or mental health conditions, and names and dosages of any medications or supplements you're taking
Questions to ask your doctor so that you can make the most of your appointment
Ask a family member or friend to go with you to the appointment, if possible. Someone who accompanies you can help remember what the doctor says.
For adjustment disorder, some basic questions to ask your doctor include:
What do you think is causing my symptoms?
Are there any other possible causes?
How will you determine my diagnosis?
Is my condition likely temporary or long term (chronic)?
Do you recommend treatment? If yes, with what approach?
How soon do you expect my symptoms to improve?
Should I see a mental health specialist?
Do you recommend any temporary changes at home, work or school to help me recover?
Should people at my work or school be made aware of my diagnosis?
Are there any brochures or other printed material that I can have? What websites do you recommend?
Don't hesitate to ask questions during your appointment anytime you don't understand something.
What to expect from your doctor
Be ready to answer your doctor's questions so you have time to focus on your priorities. Your doctor may ask:
What are your symptoms?
When did you or your loved ones first notice your symptoms?
What major changes have recently occurred in your life, both positive and negative?
Have you talked with friends or family about these changes?
How often do you feel sad or depressed?
Do you have thoughts of suicide?
How often do you feel anxious or worried?
Are you having trouble sleeping?
Do you have difficulty finishing tasks at home, work or school that previously felt manageable to you?
Are you avoiding social or family events?
Have you been having any problems at school or work?
Have you made any impulsive decisions or engaged in reckless behavior that doesn't seem like you?
What other symptoms or behaviors are causing you or your loved ones distress?
Do you drink alcohol or use illegal drugs? How often?
Have you been treated for other psychiatric symptoms or mental illness in the past? If yes, what type of therapy was most helpful?
TESTS AND DIAGNOSIS
Adjustment disorders are diagnosed based on signs and symptoms and a thorough psychological evaluation. To be diagnosed with adjustment disorder, you must meet criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual, published by the American Psychiatric Association, is used by mental health professionals to diagnose mental conditions and by insurance companies to reimburse for treatment.
For an adjustment disorder to be diagnosed, several criteria must be met, including:
Having emotional or behavioral symptoms within three months of a specific stressor occurring in your life
Experiencing more stress than would normally be expected in response to the stressor, or having stress that causes significant problems in your relationships, at work or at school — or having both of these criteria
An improvement of symptoms within six months after the stressful event ends
The symptoms are not the result of another diagnosis
Types of adjustment disorders
Your doctor may ask detailed questions about how you feel and how you spend your time. This will help pinpoint which type of adjustment disorder you have. There are six main types. Although they're all related, each type has certain signs and symptoms:
Adjustment disorder with depressed mood. Symptoms mainly include feeling sad, tearful and hopeless, and experiencing a lack of pleasure in the things you used to enjoy.
Adjustment disorder with anxiety. Symptoms mainly include nervousness, worry, difficulty concentrating or remembering things, and feeling overwhelmed. Children who have adjustment disorder with anxiety may strongly fear being separated from their parents and loved ones.
Adjustment disorder with mixed anxiety and depressed mood. Symptoms include a mix of depression and anxiety.
Adjustment disorder with disturbance of conduct. Symptoms mainly involve behavioral problems, such as fighting or reckless driving. Youths may skip school or vandalize property.
Adjustment disorder with mixed disturbance of emotions and conduct. Symptoms include a mix of depression and anxiety as well as behavioral problems.
Adjustment disorder unspecified. Symptoms don't fit the other types of adjustment disorders, but often include physical problems, problems with family or friends, or work or school problems.
TREATMENTS AND DRUGS
Most people find treatment of adjustment disorder helpful, and they often need only brief treatment. Others may benefit from longer treatment. There are two main types of treatment for adjustment disorder — psychotherapy and medications.
Psychotherapy
The main treatment for adjustment disorders is psychotherapy, also called counseling or talk therapy. You may attend individual therapy, group therapy or family therapy. Therapy can provide emotional support and help you get back to your normal routine. It can also help you learn why the stressful event affected you so much. As you understand more about this connection, you can learn healthy coping skills to help you deal with other stressful events that may arise.
Medications
In some cases, medications may help, too. Medications can help with such symptoms as depression, anxiety and suicidal thoughts. Antidepressants and anti-anxiety medications are the medications most often used to treat adjustment disorders. As with therapy, you may need medications only for a few months, but don't stop taking any medication without talking with your doctor first. If stopped suddenly, some medications, such as certain antidepressants, may cause withdrawal symptoms.
LIFESTYLE AND HOME REMEDIES
There are no guaranteed ways to prevent adjustment disorder. But developing healthy coping skills and learning to be resilient may help you during times of high stress. Resilience is the ability to adapt well to stress, adversity, trauma or tragedy. Some of the ways you can improve your resilience are:
Having a good support network
Seeking out humor or laughter
Living a healthy lifestyle
Learning how to think positively about yourself
If you know that a stressful situation is coming up — such as a move or retirement — call on your inner strength in advance. Remind yourself that you can get through it. In addition, consider checking in with your doctor or mental health provider to review healthy ways to manage your stress.
STILL's DISEASE
STILL's DISEASE
Still’s Disease
Adult Still's disease is a rare type of arthritis that features a sore throat, a salmon-colored rash and a high fever that spikes once or twice a day. Joint pain tends to develop a few weeks after these initial signs and symptoms.
The cause of adult Still's disease is unknown, but researchers are investigating the possibility that it might be triggered by some type of infection. Some people experience just one episode of adult Still's disease. In other people, the condition persists or recurs.
Adult Still's disease is an inflammatory type of arthritis, similar to rheumatoid arthritis. This inflammation can destroy affected joints, particularly the wrists. Treatment involves medications, such as prednisone, that help control inflammation.
SYMPTOMS
Most people with adult Still's disease experience a combination of the following signs and symptoms:
Sore throat. One of the very first symptoms of adult Still's disease is a sore throat. The lymph nodes in your neck also might be swollen and tender.
Fever. You may experience a daily fever of at least 102 F (38.9 C) for a week or longer. The fever usually peaks in the late afternoon or early evening. Sometimes, you may experience two fever spikes daily. Between episodes, your temperature will likely return to normal.
Rash. A salmon-pink rash may come and go with the fever. The rash usually appears on your trunk, arms or legs. Physical contact, such as rubbing your skin, may provoke the rash to appear.
Achy and swollen joints. You may find that your joints — especially your knees, wrists, ankles, elbows, hands and shoulders — are stiff, painful and inflamed. Usually, the joint discomfort lasts at least two weeks.
Muscle pain. Muscular pain associated with adult Still's disease usually ebbs and flows with the fever, but the pain may be severe enough to disrupt your daily activities.
Having any of these signs or symptoms doesn't necessarily mean that you have adult Still's disease. The signs and symptoms of this disorder may mimic those of other conditions, including mononucleosis and a type of cancer called lymphoma.
When to see a doctor
If you have a high fever, rash and achy joints, see your doctor to determine what may be the cause. Also, if you have adult Still's disease and develop a cough, difficulty breathing, chest pain or any other unusual symptoms, call your doctor.
CAUSES
Although it's not certain what causes adult Still's disease, the condition may be triggered by a viral or bacterial infection.
RISK FACTORS
Age is the main risk factor for adult Still's disease, with incidence in adults peaking twice: once from 15 to 25 years and again from 36 to 46 years. Males and females are equally at risk of acquiring the disorder. Multiple cases of adult Still's disease in families are uncommon, so it's unlikely that this disorder is inherited.
COMPLICATIONS
Most complications from adult Still's disease arise from chronic inflammation of your body organs and joints.
Joint destruction. Chronic inflammation can damage your joints. The most commonly involved joints are your knees and wrists. Your neck, foot, finger and hip joints also may be affected, but much less frequently.
Inflammation of your heart. Adult Still's disease can lead to an inflammation of the sac-like covering of your heart (pericarditis) or of the muscular portion of your heart (myocarditis).
Excess fluid around your lungs. Inflammation may cause fluid to build up around your lungs, which can make it hard to breathe deeply.
PREPARING FOR YOUR APPOINTMENT
You're likely to first seek advice from your family doctor, but he or she might refer you to a specialist in joint diseases (rheumatologist).
Because appointments can be brief and 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
Write down your symptoms, including when they first started and how often they flare up.
Write down your key medical information, including any other health conditions with which you've been diagnosed.
List all the medications you're currently taking, including prescription and over-the-counter drugs, vitamins, or supplements.
Take a family member or friend along, if possible. Someone who accompanies you can help remember information that you missed or forgot.
Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.
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:
What are your symptoms, and when did they first develop?
Do your symptoms come and go, or are they continuous?
When are your symptoms most likely to flare up?
What treatments or self-care measures have you tried so far?
Have any treatments or self-care measures helped?
Have you been diagnosed with any other medical conditions?
TESTS AND DIAGNOSIS
There's no single test used to diagnose adult Still's disease. Imaging tests can reveal the damage that has been caused by adult Still's disease, while blood tests can help rule out other conditions that have similar symptoms.
TREATMENTS AND DRUGS
Doctors use a variety of drugs to treat adult Still's disease. The type of drug you'll take depends on the severity of your symptoms and whether you experience side effects.
Nonsteroidal anti-inflammatory drugs (NSAIDs). Over-the-counter NSAIDs, such as ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve), may help with mild joint pain and inflammation. Stronger NSAIDs are available by prescription. NSAIDs can damage the liver, so you may need regular blood tests to check liver function.
Steroids. Most people who have adult Still's disease require treatment with steroids, such as prednisone. These powerful drugs reduce inflammation, but may lower your body's resistance to infections and increase your risk of developing osteoporosis.
Methotrexate. The medication methotrexate (Rheumatrex, Trexall) is often used in combination with prednisone, which allows the prednisone dose to be reduced.
Biologic response modifiers. Drugs such as infliximab (Remicade), adalimumab (Humira) and etanercept (Enbrel) have shown some promise, but their long-term benefit is still unknown. If other medications haven't worked, your doctor may suggest trying anakinra (Kineret) or rituximab (Rituxan).
LIFESTYLE AND HOME REMEDIES
Here are a few ways to help you make the most of your health if you have adult Still's disease:
Understand your medications. Even if you're symptom-free some days, it's important to take your medications as your doctor recommends. Controlling inflammation helps reduce the risk of complications.
Supplement your diet. If you're taking high doses of prednisone, talk to your doctor about taking more calcium and vitamin D supplements to help prevent osteoporosis.
Keep moving. While you might not feel up to a workout if your joints ache, exercise can help you maintain your range of motion and relieve pain and stiffness.
AGORAPHOBIA
AGORAPHOBIA
Agoraphobia
Agoraphobia is a type of anxiety disorder in which you fear and often avoid places or situations that might cause you to panic and make you feel trapped, helpless or embarrassed.
With agoraphobia, you fear an actual or anticipated situation, such as using public transportation, being in open or enclosed spaces, standing in line or being in a crowd. The anxiety is caused by fear that there's no easy way to escape or seek help if intense anxiety develops. Most people who have agoraphobia develop it after having one or more panic attacks, causing them to fear another attack and avoid the place where it occurred.
People with agoraphobia often have a hard time feeling safe in any public place, especially where crowds gather. You may feel that you need a companion, such as a relative or friend, to go with you to public places. The fears can be so overwhelming that you may feel unable to leave your home.
Agoraphobia treatment can be challenging because it usually means confronting your fears. But with talk therapy (psychotherapy) and medications, you can escape the trap of agoraphobia and live a more enjoyable life.
SYMPTOMS
Typical agoraphobia symptoms include:
Fear of being alone in any situation
Fear of being in crowded places
Fear of losing control in a public place
Fear of being in places where it may be hard to leave, such as an elevator or train
Inability to leave your home (housebound) or only able to leave it if someone else goes with you
Sense of helplessness
Overdependence on others
In addition, you may have signs and symptoms of a panic attack, such as:
Rapid heart rate
Excessive sweating
Trouble breathing
Feeling shaky, numb or tingling
Chest pain or pressure
Lightheadedness or dizziness
Sudden flushing or chills
Upset stomach or diarrhea
Feeling a loss of control
Fear of dying
Panic disorder and agoraphobia
Some people have a panic disorder in addition to agoraphobia. Panic disorder is a type of anxiety disorder in which you experience sudden attacks of extreme fear that reach a peak within a few minutes and trigger intense physical symptoms (panic attacks). You might think that you're totally losing control, having a heart attack or even dying.
Fear of another panic attack can lead to avoiding similar circumstances or the place where it occurred in an attempt to prevent future panic attacks.
When to see a doctor
Agoraphobia can severely limit your ability to socialize, work, attend important events and even manage the details of daily life, such as running errands.
Don't let agoraphobia make your world smaller. Call your health care provider if you have symptoms.
CAUSES
Having panic disorder or other phobias, or experiencing stressful life events, may play a major role in the development of agoraphobia.
RISK FACTORS
Agoraphobia usually starts before age 35, but older adults also can develop it. Women are diagnosed with agoraphobia more often than men are.
In addition to having panic disorder or other phobias, agoraphobia risk factors include:
Having a tendency to be nervous or anxious
Experiencing stressful life events, such as abuse, the death of a parent or being attacked
Having a blood relative with agoraphobia
COMPLICATIONS
Agoraphobia can greatly limit your life's activities. If your agoraphobia is severe, you may not even be able to leave your home. Without treatment, some people become housebound for years. You may not be able to visit with family and friends, go to school or work, run errands, or take part in other normal daily activities. You may become dependent on others for help.
Agoraphobia can also lead to or be associated with:
Depression
Other mental health disorders, including other phobias and other anxiety disorders
Alcohol or drug misuse to try to cope with the fear, guilt, hopelessness, isolation and loneliness
PREPARING FOR YOUR APPOINTMENT
If you have agoraphobia, you may be too afraid or embarrassed to go to your health care provider's office. Consider starting, instead, with a phone call to your provider. Some health care providers, particularly mental health experts who specialize in agoraphobia and anxiety disorders, may be able to offer you options that are less stressful than meeting in an office.
What you can do
To prepare for your appointment, make a list of:
Any symptoms you've been experiencing, and for how long.
Your key personal information, especially any significant stress or life changes that you experienced around the time your symptoms first developed.
Your medical information, including other physical or mental health conditions that you have. Also write down the names and dosages of any medications and supplements you're taking.
Ask a trusted family member or friend to go with you to your appointment, if possible, to help you remember information.
Prepare questions to ask your health care provider so that you can make the most of your appointment. For agoraphobia, some basic questions include:
What do you believe is causing my symptoms?
Are there any other possible causes?
How will you determine my diagnosis?
Should I be tested for any underlying medical problems?
Is my condition likely temporary or long term (chronic)?
What type of treatment do you recommend?
I have other health problems. How best can I manage these together with agoraphobia?
What is the risk of side effects from the medication you're recommending?
Are there options other than taking medications?
How soon do you expect my symptoms to improve?
With treatment, will I eventually be comfortable in the situations that currently scare me?
Does agoraphobia increase my risk of other mental health problems?
Should I see a mental health specialist?
Are there any printed materials that I can have? What websites do you recommend?
Don't hesitate to ask questions during your appointment.
What to expect from your doctor
Being ready to answer your health care provider's questions may leave time to go over any points you want to talk about in-depth. Be prepared to answer the following questions from your provider:
Have you recently had a spell or an attack when all of a sudden you felt frightened, anxious or very uneasy?
Have you recently been feeling nervous, anxious or on edge?
During these attacks of fear and anxiety, have you ever felt like you couldn't breathe or like you were having a heart attack?
What other symptoms do you have?
When did you first notice these symptoms?
When are your symptoms most likely to occur?
Does anything seem to make your symptoms better or worse?
Do you avoid any situations or places because you fear they'll trigger your symptoms?
What do you think is causing your symptoms?
How are your symptoms affecting your life and the people closest to you?
Have you been diagnosed with any medical conditions?
Have you been treated for other psychiatric symptoms or mental illness in the past? If yes, what treatment was most helpful?
Have you ever thought about harming yourself or others?
Do you drink alcohol or use illegal drugs? How often?
TESTS AND DIAGNOSIS
Agoraphobia is diagnosed based on signs and symptoms, as well as an in-depth interview with your health care provider. You may also have a physical exam to rule out other conditions that could be causing your symptoms.
To be diagnosed with agoraphobia, you must meet criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.
Diagnostic criteria for agoraphobia include severe fear or anxiety about two or more of the following situations:
Using public transportation, such as a bus or plane
Being in an open space, such as a parking lot, bridge or large mall
Being in an enclosed space, such as a movie theater, meeting room or small store
Waiting in a line or being in a crowd
Being out of your home alone
These situations cause anxiety because you fear you won't be able to escape or find help if you develop panic-like symptoms or other disabling or embarrassing symptoms.
In addition, diagnostic criteria for agoraphobia include:
Fear or anxiety that almost always results from exposure to a situation
Avoidance of the situation, needing a companion to go with you or endurance of this situation with extreme distress
Fear or anxiety that's out of proportion to the actual danger posed by the situation
Significant distress or problems with social situations, work or other areas in your life caused by the fear, anxiety or avoidance
Persistent phobia and avoidance, usually lasting six months or longer
TREATMENTS AND DRUGS
Agoraphobia treatment usually includes both psychotherapy and medication. It may take some time, but treatment can help you get better.
Psychotherapy
Also known as talk therapy or psychological counseling, psychotherapy involves working with a therapist to reduce your anxiety symptoms. Cognitive behavioral therapy is one of the most effective forms of psychotherapy for anxiety disorders, including agoraphobia.
Generally a short-term treatment, cognitive behavioral therapy focuses on teaching you specific skills to gradually return to the activities you've avoided because of anxiety. Through this process, your symptoms improve as you build upon your initial success.
You can learn:
That your fears are unlikely to come true
That your anxiety gradually decreases if you remain in public and you can manage those symptoms until they do
What factors may trigger a panic attack or panic-like symptoms and what makes them worse
How to cope with these symptoms
How to change unwanted or unhealthy behaviors through desensitization, also called exposure therapy, to safely face the places and situations that cause fear and anxiety
If you have trouble leaving your home, you may wonder how you could possibly go to a therapist's office. Therapists who treat agoraphobia will be well aware of this problem. They may offer to see you first in your home, or they may meet you in what you consider a safe place (safe zones). They may also offer some sessions over the phone, through email, or using computer programs or other media.
Look for a therapist who can help you find alternatives to in-office appointments, at least in the early part of your treatment. You may also want to take a trusted relative or friend to your appointment who can offer comfort and help, if needed.
Medications
Antidepressant and anti-anxiety medications are often used to treat agoraphobia and panic symptoms that frequently accompany agoraphobia. You may have to try several different medications before you find one that works best for you.
Your doctor is likely to prescribe one or both of the following:
Antidepressants. Certain antidepressants called selective serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil, Pexeva) and fluoxetine (Prozac), are used for the treatment of panic disorder with agoraphobia. Other types of antidepressants, such as tricyclic antidepressants or monoamine oxidase inhibitors, may effectively treat agoraphobia, although they're associated with more side effects than SSRIs.
Anti-anxiety medication. Also called benzodiazepines, anti-anxiety medications are sedatives that, in limited circumstances, your doctor may prescribe to relieve anxiety symptoms. Drugs in this category that are used for the treatment of panic disorder with agoraphobia include alprazolam (Niravam, Xanax) and clonazepam (Klonopin). Benzodiazepines are generally used only for relieving acute anxiety on a short-term basis. Because they can be habit-forming, these medications aren't a good choice if you've had problems with alcohol or drug abuse.
Both starting and ending a course of antidepressants can cause side effects that seem like a panic attack. For this reason, your health care provider likely will gradually increase your dose during treatment, and slowly decrease your dose when he or she feels you're ready to stop taking medication.
LIFESTYLE AND HOME REMEDIES
There's no sure way to prevent agoraphobia. However, anxiety tends to increase the more you avoid situations that you fear. If you start to have mild fears about going places that are safe, try to practice going to those places before your fear becomes overwhelming. If this is too hard to do on your own, ask a family member or friend to go with you, or seek professional help.
If you experience anxiety going places or have panic attacks, get treatment as soon as possible. Get help early to keep symptoms from getting worse. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
ALTERNATIVE MEDICINE
Certain dietary and herbal supplements claim to have calming and anti-anxiety benefits. Before you take any of these for agoraphobia, talk with your health care provider. Although these supplements are available without a prescription, they still pose possible health risks in some people.
For example, the herbal supplement called kava appeared to be a promising treatment for anxiety, but reports of serious liver damage — even with short-term use — caused several European countries and Canada to pull it off the market. The Food and Drug Administration has issued warnings but not banned sales in the United States. Avoid using kava until more rigorous safety studies are done, especially if you have liver problems or take medications that affect your liver.
COPING AND SUPPORT
Living with agoraphobia can make life difficult. Professional treatment can help you overcome this disorder or manage it effectively so you don't become a prisoner to your fears.
You can also take these steps to cope and care for yourself when you have agoraphobia:
Stick to your treatment plan. Take medications as directed. Keep therapy appointments. Consistency can make a big difference, especially when it comes to taking your medication.
Try not to avoid feared situations. It's hard to go to places or be in situations that make you uncomfortable or that bring on symptoms of anxiety. But practicing going to more and more places can make them less frightening and anxiety provoking. Family, friends and your therapist can help you work on this.
Learn calming skills. Working with your health care professional, you can learn how to calm and soothe yourself. You can practice these skills on your own, especially at the first hint of anxiety.
Practice relaxation techniques. Meditation, yoga and imagery are simple relaxation techniques that may help — and you can do them in the comfort of your own home. Practice these techniques when you aren't anxious or worried, and then put them into action during stressful situations.
Avoid alcohol and illegal drugs. These substances can worsen your panic or anxiety symptoms.
Take care of yourself. Get enough sleep, be physically active every day, and eat a healthy diet, including lots of vegetables and fruits.
AIRPLANE EAR
AIRPLANE EAR
Airplane Ear
Airplane ear is the stress exerted on your eardrum and other middle ear tissues when the air pressure in your middle ear and the air pressure in the environment are out of balance. You may experience airplane ear at the beginning of a flight when the airplane is climbing or at the end of a flight when the airplane is descending. These fast changes in altitude cause air pressure changes and can trigger airplane ear.
Airplane ear is also called ear barotrauma, barotitis media or aerotitis media.
Usually self-care steps — such as yawning, swallowing or chewing gum — can prevent or correct the differences in air pressure and improve airplane ear symptoms. However, a severe case of airplane ear may need to be treated by a doctor.
SYMPTOMS
Airplane ear can occur in one or both ears. Airplane ear signs and symptoms may include:
Moderate discomfort or pain in your ear
Feeling of fullness or stuffiness in your ear
Muffled hearing or slight to moderate hearing loss
If airplane ear is severe or lasts more than a few hours, you may experience:
Severe pain
Pressure in your ear similar to being underwater
Moderate to severe hearing loss
Ringing in your ear (tinnitus)
Spinning sensation (vertigo)
Vomiting resulting from vertigo
Bleeding from your ear
When to see a doctor
Usually you can do things on your own to treat airplane ear. If discomfort, fullness or muffled hearing lasts more than a few hours or if you experience any severe signs or symptoms, call your doctor.
CAUSES
Airplane ear occurs when an imbalance in the air pressure in the middle ear and air pressure in the environment prevents your eardrum (tympanic membrane) from vibrating as it should. Air pressure regulation is the work of a narrow passage called the eustachian tube. One end is connected to the middle ear. The other end has a tiny opening where the back of the nasal cavity and the top of the throat meet (nasopharynx).
When an airplane climbs or descends, the air pressure in the environment changes rapidly, and your eustachian tube often doesn't react quickly enough. Swallowing or yawning activates muscles that open the eustachian tube and allow the middle ear to replenish its air supply, often eliminating the symptoms of airplane ear.
Ear barotrauma also may be caused by:
Scuba diving
Hyperbaric oxygen chambers
Explosions nearby
You may also experience a minor case of barotrauma while riding an elevator in a tall building or driving in the mountains.
RISK FACTORS
Any condition that blocks the eustachian tube or limits its function can increase the risk of airplane ear. Common risk factors include:
A small eustachian tube, especially in infants and toddlers
The common cold
Sinus infection
Hay fever (allergic rhinitis)
Middle ear infection (otitis media)
Sleeping on an airplane during ascent and descent
Frequent or severe airplane ear may damage the tissues of the inner ear or eustachian tube, which increases your chances of experiencing the problem again.
COMPLICATIONS
Airplane ear usually isn't serious and responds to self-care. Long-term complications may occur when the condition is serious or prolonged or if there's damage to middle or inner ear structures.
Rare complications may include:
Permanent hearing loss
Ongoing (chronic) tinnitus
PREPARING FOR YOUR APPOINTMENT
If you experience severe pain or symptoms associated with airplane ear that don't resolve with self-care techniques, you'll likely see your family doctor or a general practitioner first. You may, however, be referred to an ear, nose and throat specialist (ENT). It's useful to prepare for your appointment.
What you can do
Write down any symptoms you're experiencing, including any that may seem unrelated to your ear problems.
Make a list of all medications, vitamins or supplements you're taking.
Write down questions to ask your doctor.
Preparing a list of questions will help you make the most of your time with your doctor. If you're experiencing signs or symptoms of airplane ear, you might want to ask the following questions:
Are these signs and symptoms likely related to my recent airplane travel?
What is the best treatment?
Am I likely to have any long-term complications?
How will we monitor for possible complications?
How can I prevent this from happening again?
Should I consider canceling travel plans?
Are there brochures or other printed material I can take with me? What websites do you recommend?
Don't hesitate to ask your doctor any other questions you have.
What to expect from your doctor
Your doctor will ask you a number of questions, including:
When did your symptoms begin?
How severe are your symptoms?
Do you have allergies?
Have you had a cold, sinus infection or ear infection recently?
Have you had airplane ear before?
Were your past experiences with airplane ear prolonged or severe?
What you can do in the meantime
To treat pain, you may take a nonsteroidal anti-inflammatory drug, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others), or an analgesic pain reliever, such as acetaminophen (Tylenol, others).
TESTS AND DIAGNOSIS
Your doctor will likely be able to make a diagnosis based on questions he or she asks and an examination of your ear with a lighted instrument (otoscope). Signs of airplane ear might include a slight outward or inward bulging of your eardrum. If your condition is more severe, your doctor may see a tear in the eardrum or a pooling of blood or other fluids behind your eardrum.
If you're experiencing a spinning sensation (vertigo), there may be damage to structures of your inner ear. Your doctor may suggest a hearing test (audiometry) to determine how well you detect sounds and whether the source of hearing problems is in the inner ear.
TREATMENTS AND DRUGS
For most people, airplane ear usually heals with time. When the symptoms persist, you may need treatments to equalize pressure and relieve symptoms.
Medications
Your doctor may prescribe medications or direct you to take over-the-counter medications to control conditions that may prevent the eustachian tubes from functioning well. These drugs may include:
Decongestant nasal sprays
Oral decongestants
Oral antihistamines
To ease discomfort, you may want to take a nonsteroidal anti-inflammatory drug, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others), or an analgesic pain reliever, such as acetaminophen (Tylenol, others).
Self-care therapies
With your drug treatment, your doctor will instruct you to use a self-care method called the Valsalva maneuver. To do this, you pinch your nostrils shut, close your mouth and gently force air into the back of your nose, as if you were blowing your nose. Once the medications have improved the function of the eustachian tubes, use of the Valsalva maneuver may force the tubes open.
Surgery
Surgical treatment of airplane ear is rarely necessary. However, your doctor may make an incision in your eardrum (myringotomy) to equalize air pressure and drain fluids.
Severe injuries, such as a ruptured eardrum or ruptured membranes of the inner ear, usually will heal on their own. However, in rare cases, surgery may be needed to repair them.
LIFESTYLE AND HOME REMEDIES
Follow these tips to avoid airplane ear:
Yawn and swallow during ascent and descent. Yawning and swallowing activate the muscles that open your eustachian tubes. You can suck on candy or chew gum to help you swallow.
Use the Valsalva maneuver during ascent and descent. Gently blow, as if blowing your nose, while pinching your nostrils and keeping your mouth closed. Repeat several times, especially during descent, to equalize the pressure between your ears and the airplane cabin.
Don't sleep during takeoffs and landings. If you're awake during ascents and descents, you can do the necessary self-care techniques when you feel pressure on your ears.
Reconsider travel plans. If possible, don't fly when you have a cold, sinus infection, nasal congestion or ear infection. If you've recently had ear surgery, talk to your doctor about when it's safe to travel.
Use an over-the-counter decongestant nasal spray. If you have nasal congestion, use a nasal decongestant about 30 minutes to an hour before takeoff and landing. Avoid overuse, however, because nasal decongestants taken over several days can increase congestion.
Use oral decongestant pills cautiously. Oral decongestants may be helpful if taken 30 minutes to an hour before an airplane flight. However, if you have heart disease, a heart rhythm disorder or high blood pressure or if you've experienced possible medication interactions, avoid taking an oral decongestant unless your doctor approves. If you're a man older than age 50, you may experience serious side effects after taking decongestants containing pseudoephedrine (Actifed, Sudafed), such as urinary retention, especially if you have an enlarged prostate. If you're pregnant, talk to your doctor before taking oral decongestants.
Take allergy medication. If you have allergies, take your medication about an hour before your flight.
Use filtered earplugs. These earplugs slowly equalize the pressure against your eardrum during ascents and descents. You can purchase these at drugstores, airport gift shops or your local hearing clinic.
If you're prone to severe airplane ear and must fly often, your doctor may surgically place tubes in your eardrums to aid fluid drainage, ventilate your middle ear, and equalize the pressure between your outer ear and middle ear.
Helping children prevent airplane ear
These additional tips can help young children avoid airplane ear:
Encourage swallowing. Give a baby or toddler a beverage during ascents and descents to encourage frequent swallowing. A pacifier also may help. Have the child sit up while drinking. Children older than age 4 can try chewing gum, drinking through a straw or blowing bubbles through a straw.
Consider eardrops. Talk to your child's doctor about prescribing your child eardrops that contain a pain reliever and numbing agent for the flight.
Avoid decongestants. Decongestants aren't recommended for young children.
ALBINISM
ALBINISM
Albinism
Albinism includes a group of inherited disorders that are characterized by little or no production of the pigment melanin. The type and amount of melanin your body produces determines the color of your skin, hair and eyes. Most people with albinism are sensitive to sun exposure and are at increased risk of developing skin cancer.
Although there's no cure for albinism, people with the disorder can take steps to protect their skin and maximize their vision. Some people with albinism may feel socially isolated or experience discrimination.
SYMPTOMS
Signs of albinism are usually, but not always, apparent in a person's skin, hair and eye color. However, all people with the disorder experience vision problems.
Skin
Although the most recognizable form of albinism results in white hair and pinkish skin, skin coloring (pigmentation) can range from white to brown, and may be nearly the same as that of parents or siblings without albinism.
For some people with albinism, skin pigmentation never changes. For others, melanin production may begin or increase during childhood and the teen years, resulting in slight changes in pigmentation. With exposure to the sun, some people may develop:
Freckles
Moles, with or without pigment — moles without pigment are generally pink-colored
Large freckle-like spots (lentigines)
The ability to tan
Hair
Hair color can range from very white to brown. People of African or Asian descent who have albinism may have hair color that's yellow, reddish or brown. Hair color may also darken by early adulthood.
Eye color
Eye color can range from very light blue to brown and may change with age.
The lack of pigment in the colored part of the eyes (irises) makes them somewhat translucent. This means that the irises can't completely block light from entering the eye. Because of this, very light-colored eyes may appear red in some lighting. This occurs because you're seeing light reflected off the back of the eye and passing back out through the iris again — similar to the red-eye that occurs in a flash photo.
Vision
Signs and symptoms of albinism related to eye function include:
Rapid, involuntary back-and-forth movement of the eyes (nystagmus)
Inability of both eyes to stay directed at the same point or to move in unison (strabismus)
Extreme nearsightedness or farsightedness
Sensitivity to light (photophobia)
Abnormal curvature of the front surface of your eye or the lens inside your eye (astigmatism), which causes blurred vision
When to see a doctor
If your child lacks pigment in his or her hair or skin at birth that affects the eyelashes and eyebrows — as is often the case in infants with albinism — your doctor will likely order an eye exam and closely follow any changes in your child's pigmentation.
For some infants, the first sign of albinism is poor visual tracking. This may be followed at 3 to 4 months of age by rapid back-and-forth shifting (nystagmus) in the eyes. If you observe these signs in your baby, talk to your doctor.
Contact your doctor if your child with albinism experiences frequent nosebleeds, easy bruising or chronic infections. These signs and symptoms may indicate the presence of Hermansky-Pudlak or Chediak-Higashi syndromes, which are rare but serious genetic disorders.
CAUSES
Albinism is caused by a mutation in one of several genes. Each of these genes provides instructions for making one of several proteins involved in the production of melanin. Melanin is produced by cells called melanocytes, which are found in your skin and eyes. A mutation may result in no melanin at all or a significant decline in the amount of melanin.
In some types of albinism, a person must inherit two copies of a mutated gene — one from each parent — in order to have albinism (recessive inheritance).
Impact on eye development
Regardless of which gene mutation is present, vision impairment is a key feature of all types of albinism. These impairments are caused by irregular development of the optic nerve pathways from the eye to the brain and from abnormal development of the retina.
Types of albinism
Types of albinism, based mainly on which mutated gene caused the disorder, include:
Oculocutaneous albinism. Oculocutaneous (ok-u-low-ku-TAY-nee-us) albinism is caused by a mutation in one of four genes. People with oculocutaneous albinism (OCA) type 1 have milky white skin, white hair and blue eyes at birth. Some people with OCA type 1 never experience an increase in pigmentation, but others begin to produce melanin during early childhood. Their hair may become a golden blond, brown or red, and their irises may change color and lose some translucence.
OCA type 2 is most common in sub-Saharan Africans, African-Americans and Native Americans. The hair may be yellow, auburn, ginger or red, the eyes can be blue-gray or tan, and the skin is white at birth. With sun exposure, the skin may, over time, develop freckles, moles or lentigines.
People with OCA type 3, mainly found in black South Africans, usually have reddish-brown skin, ginger or reddish hair, and hazel or brown eyes. OCA type 4 looks similar to type 2 and is most often found in people of East Asian descent.
X-linked ocular albinism. The cause of X-linked ocular albinism, which occurs almost exclusively in males, is a gene mutation on the X chromosome. People who have ocular albinism have vision problems, but their skin, hair and eye color are generally in the normal range or slightly lighter than that of others in the family.
Hermansky-Pudlak syndrome. Hermansky-Pudlak syndrome is a rare albinism disorder caused by a mutation in one of at least eight different genes. The disorder is much more common in Puerto Rico. People with this disorder have signs and symptoms similar to people with oculocutaneous albinism, but they may also develop lung and bowel diseases, or a bleeding disorder.
Chediak-Higashi syndrome. Chediak-Higashi syndrome is a rare form of albinism associated with a mutation in the LYST gene. With signs and symptoms similar to oculocutaneous albinism, the hair is usually brown or blond with a silvery sheen, and the skin is usually creamy white to grayish. People with this syndrome have a defect in white blood cells that increases their risk of infections.
COMPLICATIONS
Complications of albinism include skin disorders as well as social and emotional challenges.
Skin disorders
One of the most serious complications associated with albinism is the risk of sunburn and skin cancer.
Social and emotional factors
The reactions of other people to those with albinism can often have a negative impact on people with the condition.
Children with albinism may experience name-calling, teasing or questions regarding their appearance, eyewear or visual aid devices.
Many people with albinism find the word "albino" hurtful because they're being labeled simply on the basis of looks rather than being thought of as individuals.
People with albinism usually look very different from members of their own families or ethnic groups, so they may feel like outsiders or be treated like outsiders.
All of these factors may contribute to social isolation, poor self-esteem and stress.
TESTS AND DIAGNOSIS
A complete diagnostic work-up for albinism includes a:
Physical exam
Description of changes in pigmentation
Thorough exam of the eyes
Comparison of your child's pigmentation to that of other family members
A medical doctor specializing in vision and eye disorders (ophthalmologist) should conduct your child's eye exam. The exam will include an assessment of potential nystagmus, strabismus and photophobia. The doctor will also use a device to visually inspect the retina and determine if there are signs of abnormal development. A simple test can measure the brain waves produced when light or a reversing pattern is flashed into each eye. This can indicate the presence of misrouted optical nerves.
If your child has only one eye impairment, such as nystagmus, another condition may be the cause. Disorders other than albinism can affect skin pigmentation, but these don't cause all of the visual problems associated with albinism.
TREATMENTS AND DRUGS
Because albinism is a genetic disorder, treatment is limited. But getting proper eye care and monitoring skin for signs of abnormalities are especially important to your child's health.
Your child will most likely need to wear prescription lenses, and he or she should receive annual eye exams by an ophthalmologist. Although surgery is rarely part of treatment for albinism, your ophthalmologist may recommend surgery on optical muscles to minimize nystagmus. Surgery to correct strabismus may make the condition less noticeable, but it won't improve vision.
Your doctor should conduct an annual assessment of your child's skin to screen for skin cancer or lesions that can lead to cancer. Adults with albinism need annual eye and skin exams throughout their lives.
People with Hermansky-Pudlak and Chediak-Higashi syndromes usually require regular specialized care to prevent complications.
LIFESTYLE AND HOME REMEDIES
If a family member has albinism, a genetic counselor can help you understand your chances of having a future child with albinism. He or she can also explain the available tests and help you figure out the pros and cons of testing for your family member.
COPING AND SUPPORT
Coping with vision impairment
Many people with albinism develop coping skills to adjust to vision impairments. Tilting the head to one side may minimize the effect of nystagmus and improve vision. Holding a book very close can make it easier to read without causing any harm to the eyes.
Coping with educational challenges
Despite visual handicaps and abnormal optic nerve pathways, children with albinism are developmentally normal. If your child has albinism, begin early to work with teachers and school administrators to facilitate measures to help your child adapt. These may include sitting in the front of the class, using large-print books or a tablet computer for learning, avoiding bright light in the learning setting, or allowing more time for taking tests.
If necessary, start with educating the school professionals about what albinism is and how it affects your child. Also ask about services the school can provide to assess your child's needs.
Adjustments to the classroom environment that may help your child include:
A seat near the front of the classroom
A tablet computer that can be synced to an interactive whiteboard (SMART board) at the front of the room, allowing the child to sit farther back in the classroom
Handouts of the content written on boards or overhead screens
High-contrast printed documents, such as black type on white paper rather than colored print or paper
Large-print textbooks
Other options, such as showing the child how to enlarge font size on a computer screen
Coping with teasing and social isolation
Help your child develop skills to deal with other people's reactions to albinism:
Encourage your child to talk to you about experiences and feelings.
Practice responses to teasing or embarrassing questions.
Find a peer support group or online community through agencies such as the National Organization for Albinism and Hypopigmentation (NOAH). You can reach NOAH at 800-473-2310.
Seek the services of a mental health professional, who can help you and your child develop healthy communication and coping skills.
ALCOHOLIC HEPATITIS
ALCOHOLIC HEPATITIS
Alcoholic hepatitis
Alcoholic hepatitis describes liver inflammation caused by drinking alcohol.
Though alcoholic hepatitis is most likely to occur in people who drink heavily over many years, the relationship between drinking and alcoholic hepatitis is complex. Not all heavy drinkers develop alcoholic hepatitis, and the disease can occur in people who drink only moderately.
If you're diagnosed with alcoholic hepatitis, you must stop drinking alcohol. People who continue to drink alcohol face a high risk of serious liver damage and death.
SYMPTOMS
Yellowing of the skin and whites of the eyes (jaundice) and increasing girth (due to fluid accumulation) are the most common signs of alcoholic hepatitis that lead people to seek medical care.
People may also complain of:
Loss of appetite
Nausea and vomiting
Abdominal pain and tenderness
Weight loss
Just about everyone who has alcoholic hepatitis is malnourished. Drinking large amounts of alcohol suppresses the appetite, and heavy drinkers get most of their calories in the form of alcohol.
Signs and symptoms of severe alcoholic hepatitis include:
Retaining large amounts of fluid in your abdominal cavity (ascites)
Confusion and behavior changes due to brain damage from buildup of toxins (encephalopathy)
Kidney and liver failure
When to see a doctor
Alcoholic hepatitis is a serious disease. As many as 35 percent of heavy drinkers develop alcoholic hepatitis. And more than a third of them die within six months after signs and symptoms begin to appear.
See your doctor if you have any signs or symptoms of alcoholic hepatitis or other signs and symptoms that worry you. If you ever feel as though you can't control your drinking or feel that you'd like help in cutting back on your drinking, see your doctor.
CAUSES
Alcoholic hepatitis occurs when the liver is damaged by the alcohol you drink. Just how alcohol damages the liver -— and why it does so only in a minority of heavy drinkers — isn't clear. What is known is that the process of breaking down ethanol — the alcohol in beer, wine and liquor — produces highly toxic chemicals, such as acetaldehyde. These chemicals trigger inflammation that destroys liver cells. Over time, web-like scars and small knots of tissue replace healthy liver tissue, interfering with the liver's ability to function. This irreversible scarring, called cirrhosis, is the final stage of alcoholic liver disease.
Risk increases with time, amount consumed
Heavy alcohol use can lead to liver disease, and the risk increases with the length of time and amount of alcohol you drink. But because many people who drink heavily or binge drink never develop alcoholic hepatitis or cirrhosis, it's likely that factors other than alcohol play a role. These include:
Other types of hepatitis. Long-term alcohol abuse worsens the liver damage caused by other types of hepatitis, especially hepatitis C. If you have hepatitis C and also drink — even moderately — you're more likely to develop cirrhosis than if you don't drink.
Malnutrition. Many people who drink heavily are malnourished, either because they eat poorly or because alcohol and its toxic byproducts prevent the body from properly absorbing and breaking down nutrients, especially protein, certain vitamins and fats. In both cases, the lack of nutrients contributes to liver cell damage.
Obesity.
Genetic factors. Having mutations in certain genes that affect alcohol metabolism may increase your risk of alcoholic liver disease as well as of alcohol-associated cancers and other complications of heavy drinking. The exact genetic associations have not yet been identified.
RISK FACTORS
Major risk factors for alcoholic hepatitis comprise:
Alcohol use. The amount of alcohol consumed is the most important risk factor for alcoholic liver disease. One study found that the risk of cirrhosis of the liver increased with daily ingestion of more than 2 to 2.8 ounces (60 to 80 grams) of alcohol over 10 years for men and 0.7 ounces (20 grams) for women. Yet still, only about 35 percent of heavy long-term drinkers develop alcoholic hepatitis.
Your sex. Women have a higher risk of developing alcoholic hepatitis than men do. This disparity may result from differences in the way alcohol is processed by women.
Genetic factors. A number of genetic mutations have been identified that affect the way alcohol is broken down in the body. Having one or more of these mutations may increase the risk of alcoholic hepatitis.
Other factors which may increase your risk include:
Type of beverage (beer or spirits are riskier than wine)
Binge drinking
Obesity — alcohol and obesity may have a synergistic effect on the liver; that is, their combined effect is worse than the effect of either of them alone
African-American or Hispanic
COMPLICATIONS
Complications of alcoholic hepatitis include:
Increased blood pressure in the portal vein. Blood from your intestine, spleen and pancreas enters your liver through a large blood vessel called the portal vein. If scar tissue slows normal circulation through the liver, this blood backs up, leading to increased pressure within the vein (portal hypertension).
Enlarged veins (varices). When circulation through the portal vein is blocked, blood may back up into other blood vessels in the stomach and esophagus. These blood vessels are thin walled, and because they're filled with more blood than they're meant to carry, they're likely to bleed. Massive bleeding in the upper stomach or esophagus from these blood vessels is a life-threatening emergency that requires immediate medical care.
Fluid retention. Alcoholic hepatitis can cause large amounts of fluid to accumulate in your abdominal cavity (ascites). The fluid may become infected and require treatment with antibiotics. Although not life-threatening in itself, ascites is usually a sign of advanced alcoholic hepatitis or cirrhosis.
Jaundice. This occurs when your liver isn't able to remove bilirubin — the residue of old red blood cells — from your blood. Bilirubin builds up and is deposited in your skin and the whites of your eyes, causing a yellow color.
Hepatic encephalopathy. A liver damaged by alcoholic hepatitis has trouble removing toxins from your body — normally one of the liver's key tasks. The buildup of toxins can damage your brain, leading to changes in your mental state, behavior and personality (hepatic encephalopathy). Signs and symptoms of hepatic encephalopathy include forgetfulness, confusion and mood changes, and in the most severe cases, coma.
Scarred liver (cirrhosis). Over time, the liver inflammation that occurs in alcoholic hepatitis can cause irreversible scarring of the liver (cirrhosis). Cirrhosis frequently leads to liver failure, which occurs when the damaged liver is no longer able to adequately function.
Kidney failure.
PREPARING FOR YOUR APPOINTMENT
Start by seeing your family doctor or a general practitioner. If your doctor thinks you have a liver problem, such as alcoholic hepatitis, you'll likely be referred to a digestive disease specialist (gastroenterologist).
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. 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. Let your doctor know how much alcohol you regularly consume. It's a good idea to track your alcohol consumption for a few days by writing it down, because people tend to underestimate the amount they've consumed.
Make a list of all medications, as well as any vitamins or supplements, that you're taking.
Take a family member or friend along to help you remember everything that was said.
Write down questions to ask your doctor.
Questions to ask your doctor
For alcoholic hepatitis, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
Are there any other possible causes for my symptoms?
What kinds of tests do I need? How should I prepare for them?
Is my condition temporary or chronic?
What treatments are available? Which one do you recommend?
Are there any alternatives to the primary approach that you're suggesting?
What resources are available to help me stop drinking? Which ones will my insurance pay for?
I have other health conditions. How can I best manage them together?
Are there any dietary restrictions that I need to follow?
Should I see a specialist? What will that cost, and will my insurance cover it?
Are there any brochures or other printed material that I can take with me? 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 that your doctor is likely to 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?
How often do you drink alcohol, and how many drinks do you usually consume?
Have you ever had hepatitis or yellowing of the skin before?
Do you use any other recreational drugs?
Are your family members or friends concerned about your drinking?
Do you get angry or anxious when the subject of your drinking is discussed?
Do you feel guilty about drinking?
Do you drink in the morning — do you need an eye-opener?
What you can do in the meantime
Stop drinking alcohol if you think it may be causing your health problems. If you believe you're dependent on alcohol, your doctor can recommend treatment options. However, if you need help to stop drinking while you're waiting to see your doctor, Alcoholics Anonymous or counseling may be helpful.
TESTS AND DIAGNOSIS
Identifying alcoholic liver disease depends on two main things:
Evidence of excessive alcohol consumption
Evidence of liver disease
Alcohol consumption
Your doctor will want to know about your history of alcohol consumption. It is important to be honest in describing your drinking habits. Your doctor may ask to interview family members about your drinking. Many people will have signs of chronic alcoholism, such as skin lesions known as spider nevi.
Liver disease
Your doctor will likely order the following tests to look for liver disease:
Liver function tests (including international normalized ratio, total bilirubin, and albumin)
Complete blood cell count
An ultrasound, CT or MRI scan of the liver
Blood tests to exclude other causes of liver disease
TREATMENTS AND DRUGS
Stop drinking alcohol
If you've been diagnosed with alcoholic hepatitis, you must stop drinking alcohol. It's the only way of possibly reversing liver damage or, in more advanced cases, preventing the disease from becoming worse. Many people who stop drinking have dramatic improvement in symptoms in just a few months.
If you continue to drink alcohol, you're likely to experience serious complications.
If you are dependent on alcohol and want to stop drinking, your doctor can recommend a therapy that's tailored for your needs. This might include medications, counseling, Alcoholics Anonymous, an outpatient treatment program or a residential inpatient stay.
Treatment for malnutrition
Your doctor may recommend a special diet to reverse nutritional deficiencies that often occur in people with alcoholic hepatitis. You may be referred to a dietitian who can help you assess your current diet and suggest changes to increase the vitamins and nutrients you are lacking.
If you have trouble eating enough to get the vitamins and nutrients your body needs, your doctor may recommend tube feeding. This may involve passing a tube down your throat and into your stomach. A special nutrient-rich liquid diet is then passed through the tube.
Medications to reduce liver inflammation
Your doctor may recommend corticosteroids drugs if you have severe alcoholic hepatitis. These drugs have shown some short-term benefit in increasing survival. Steroids have significant side effects and are not recommended if you have failing kidneys, gastrointestinal bleeding or an infection. About 40 percent of people do not respond to corticosteroids. Your doctor may also recommend pentoxifylline, especially if corticosteroids don't work for you. Some studies of pentoxifylline have shown some benefit, others have not. You might also ask about clinical trials of other therapies.
Liver transplant
For many people with severe alcoholic hepatitis, liver transplant is the only hope to avoid death. Survival rates for liver transplant for alcoholic hepatitis are similar to those for other forms of hepatitis, greater than 70 percent five-year survival.
However, most medical centers are reluctant to perform liver transplants on people with alcoholic liver disease because of the fear they will resume drinking after surgery. For most people with alcoholic hepatitis, the disease is considered a contraindication for liver transplantation in most transplant centers in the U.S.
For transplant to be an option, you would need to find a program that will consider you. You would have to meet the requirements of the program, including abstaining from alcohol for six months prior to transplant and agreeing not to resume drinking afterward.
LIFESTYLE AND HOME REMEDIES
You may reduce your risk of alcoholic hepatitis if you:
Drink alcohol in moderation, if at all. If you choose to drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. The only certain way to prevent alcoholic hepatitis is to avoid all alcohol. If you've ever been diagnosed with alcoholic hepatitis, don't drink alcohol.
Check the label before mixing medications with alcohol. Check the label of over-the-counter medications for warnings about drinking alcohol. Ask your doctor if it's safe to drink alcohol when taking your prescription medications. Don't drink alcohol when taking medications that warn of complications when combined with alcohol. This is especially true for over-the-counter pain relievers such as acetaminophen (Tylenol, others).
Protect yourself from hepatitis C. Hepatitis C is a highly infectious liver disease caused by a virus. Untreated, it can lead to cirrhosis. If you have hepatitis C and drink alcohol, you're far more likely to develop cirrhosis than is someone who doesn't drink. Because there's no vaccine to prevent hepatitis C, the only way to protect yourself is to avoid exposure to the virus.
Contaminated drug paraphernalia is responsible for the majority of new cases of hepatitis C. Don't share needles or other drug paraphernalia. Hepatitis C can sometimes be transmitted sexually. If you aren't absolutely certain of the health status of a sexual partner, use a new condom every time you have sex. See your doctor if you have or have had hepatitis C or think you may have been exposed to the virus.
ALTERNATIVE MEDICINE
No alternative medicine treatments have been found to cure alcoholic hepatitis. Some herbs and supplements are touted as treatments for liver diseases. Herbs and supplements can't replace your doctor's treatments or abstaining from alcohol. If you'd like to try supplements, talk to your doctor about the risks and benefits first.
Milk thistle
The leaves and seeds of the milk thistle plant are thought to control inflammation in the liver. Milk thistle supplements are a popular alternative treatment among people with liver disease. But studies haven't found a benefit for people with alcoholic liver disease who take milk thistle supplements.
Milk thistle is generally safe, but can cause diarrhea and nausea. Talk to your doctor about milk thistle if you're considering taking this supplement. Because milk thistle can interfere with prescription medications, ask your doctor whether it's safe for you
SAMe
SAMe is a supplement that's thought to reduce liver inflammation and help the liver repair itself. Your body naturally makes SAMe. Some evidence suggests people with liver disease have a deficiency of SAMe. In theory, taking a SAMe supplement might restore levels of the substance in the liver. But there is insufficient evidence to recommend use of SAMe for alcohol-related liver disease.
SAMe is generally safe when taken as a supplement. Side effects may include gas, nausea, vomiting and diarrhea. Because SAMe can interfere with prescription medications, ask your doctor about whether SAMe is safe for you to take.
ALLERGIES
ALLERGIES
Allergies
Allergies occur when your immune system reacts to a foreign substance — such as pollen, bee venom or pet dander — that doesn't cause a reaction in most people.
Your immune system produces substances known as antibodies. Some antibodies protect you from unwanted invaders that could make you sick or cause infection.
When you have allergies, your immune system makes antibodies that identify a particular allergen as harmful, even though it isn't. When you come into contact with the allergen, your immune system's reaction can inflame your skin, sinuses, airways or digestive system.
The severity of allergies varies from person to person and can range from minor irritation to anaphylaxis — a potentially life-threatening emergency. While most allergies can't be cured, a number of treatments can help relieve your allergy symptoms.
SYMPTOMS
Allergy symptoms depend on the substance involved and can involve the airways, sinuses and nasal passages, skin, and digestive system. Allergic reactions can range from mild to severe. In some severe cases, allergies can trigger a life-threatening reaction known as anaphylaxis.
Hay fever, also called allergic rhinitis, may cause:
Sneezing
Itching of the nose, eyes or roof of the mouth
Runny, stuffy nose
Watery, red or swollen eyes (conjunctivitis)
A food allergy may cause:
Tingling mouth
Swelling of the lips, tongue, face or throat
Hives
Anaphylaxis
An insect sting allergy may cause:
A large area of swelling (edema) at the sting site
Itching or hives all over your body
Cough, chest tightness, wheezing or shortness of breath
Anaphylaxis
A drug allergy may cause:
Hives
Itchy skin
Rash
Facial swelling
Wheezing
Anaphylaxis
Atopic dermatitis, an allergic skin condition also called eczema, may cause skin to:
Itch
Redden
Flake or peel
Anaphylaxis
Some types of allergies, including allergies to foods and insect stings, have the potential to trigger a severe reaction known as anaphylaxis. A life-threatening medical emergency, this reaction can cause you to go into shock. Signs and symptoms of anaphylaxis include:
Loss of consciousness
A drop in blood pressure
Severe shortness of breath
Skin rash
Lightheadedness
A rapid, weak pulse
Nausea and vomiting
When to see a doctor
You might see a doctor if you have symptoms you think may be caused by an allergy, especially if you notice something that seems to trigger your allergies. If you have symptoms after starting a new medication, call the doctor who prescribed it right away.
For a severe allergic reaction (anaphylaxis), call 911 or your local emergency number or seek emergency medical help. If you carry an epinephrine auto-injector (such as EpiPen, Auvi-Q, others), give yourself a shot right away.
Even if symptoms improve after an epinephrine injection, a visit to the emergency department is still necessary to make sure symptoms don't return when the effects of the injection wear off.
If you've had a severe allergy attack or any signs and symptoms of anaphylaxis in the past, make an appointment to see your doctor. Evaluation, diagnosis and long-term management of anaphylaxis are complicated, so you'll probably need to see a doctor who specializes in allergies and immunology.
CAUSES
An allergy starts when your immune system mistakes a normally harmless substance for a dangerous invader. The immune system then produces antibodies that remain on the alert for that particular allergen. When you're exposed to the allergen again, these antibodies can release a number of immune system chemicals, such as histamine, that cause allergy symptoms.
Common allergy triggers include:
Airborne allergens, such as pollen, animal dander, dust mites and mold
Certain foods, particularly peanuts, tree nuts, wheat, soy, fish, shellfish, eggs and milk
Insect stings, such as bee stings or wasp stings
Medications, particularly penicillin or penicillin-based antibiotics
Latex or other substances you touch, which can cause allergic skin reactions
RISK FACTORS
You may be at increased risk of developing an allergy if you:
Have a family history of asthma or allergies. You're at increased risk of allergies if you have family members with asthma or allergies such as hay fever, hives or eczema.
Are a child. Children are more likely to develop an allergy than are adults. Children sometimes outgrow allergic conditions as they get older. However, it's not uncommon for allergies to go away and then come back some time later.
Have asthma or an allergic condition. Having asthma increases your risk of developing an allergy. Also, having one type of allergic condition makes you more likely to be allergic to something else.
COMPLICATIONS
Having an allergy increases your risk of certain other medical problems, including:
Anaphylaxis. If you have severe allergies, you're at increased risk of this serious allergy-induced reaction. Anaphylaxis is most commonly associated with food allergy, penicillin allergy and allergy to insect venom.
Asthma. If you have an allergy, you're more likely to have asthma — an immune system reaction that affects the airways and breathing. In many cases, asthma is triggered by exposure to an allergen in the environment (allergy-induced asthma).
Atopic dermatitis (eczema), sinusitis, and infections of the ears or lungs. Your risk of getting these conditions is higher if you have hay fever, a pet allergy or a mold allergy.
Fungal complications of your sinuses or your lungs. You're at increased risk of getting these conditions, known as allergic fungal sinusitis and allergic bronchopulmonary aspergillosis, if you're allergic to mold.
PREPARING FOR YOUR APPOINTMENT
If you're experiencing symptoms that may be related to an allergy, see your family doctor or general practitioner. Here's some information to help you prepare for your appointment.
What you can do
Write down your symptoms, including any that may seem unrelated to allergies.
Write down your family's history of allergy and asthma, including specific types of allergies, if you know them.
List medications, vitamins and supplements you take.
Ask if you should stop any medications before your appointment. For example, antihistamines can affect the results of an allergy skin test.
Some basic questions to ask your doctor include:
What is the most likely cause of my signs and symptoms?
Are there other possible causes?
Will I need allergy tests?
Should I see an allergy specialist?
What is the best treatment?
I have these other health conditions. How can I best manage them together?
What changes can I make at home to reduce my symptoms?
Do I need to follow restrictions?
What symptoms should prompt me to call your office?
What emergency symptoms should my friends and family be aware of?
Is there a generic alternative to the medicine you're prescribing?
Are there brochures or other printed material I can take? What websites do you recommend?
Don't hesitate to ask other questions.
What to expect from your doctor
Your doctor is likely to ask you questions, including:
What are your symptoms?
When did your symptoms begin?
Have you recently had a cold or other respiratory infection?
Are your symptoms worse at certain times of the day?
Does anything seem to improve or worsen your symptoms?
Are your symptoms worse in certain areas of your house or at work?
Do you have pets, and do they go into bedrooms?
Is there dampness or water damage in your home or workplace?
Do you have a family history of allergies or asthma?
Do you smoke, or are you exposed to secondhand smoke or other pollutants?
What treatments have you tried so far? Have they helped?
Do you have other health problems?
What medications, including herbal remedies, do you take?
TESTS AND DIAGNOSIS
To evaluate whether you have an allergy, your doctor may:
Ask detailed questions about signs and symptoms
Perform a physical exam
Have you keep a detailed diary of symptoms and possible triggers
If you have a food allergy, your doctor may:
Ask you to keep a detailed diary of the foods you eat
Have you eliminate a food from your diet (elimination diet) — and then have you eat the food in question again to see if it causes a reaction
Your doctor may also recommend one or both of the following tests:
Skin test. Your skin is pricked and exposed to small amounts of the proteins found in potential allergens. If you're allergic, you'll likely develop a raised bump (hive) at the test location on your skin. Allergy specialists usually are best equipped to perform and interpret allergy skin tests.
Blood test. A blood test that's sometimes called the radioallergosorbent test (RAST) can measure your immune system's response to a specific allergen by measuring the amount of allergy-causing antibodies in your bloodstream, known as immunoglobulin E (IgE) antibodies. A blood sample is sent to a medical laboratory, where it can be tested for evidence of sensitivity to possible allergens.
If your doctor suspects your problems are caused by something other than an allergy, you may need other tests to identify — or rule out — other medical problems.
TREATMENTS AND DRUGS
Allergy treatments include:
Allergen avoidance. Your doctor will help you take steps to identify and avoid your allergy triggers. This is generally the most important step in preventing allergic reactions and reducing symptoms.
Medications to reduce symptoms. Depending on your allergy, allergy medications can help reduce your immune system reaction and ease symptoms. Medications can include over-the-counter or prescription medications in the form of oral medications, nasal sprays or eyedrops.
Immunotherapy. For severe allergies or allergies not completely relieved by other treatment, your doctor may recommend allergen immunotherapy. This treatment involves a series of injections of purified allergen extracts, usually given over a period of a few years.
Another form of immunotherapy is a tablet that's placed under the tongue (sublingual) until it dissolves. Sublingual drugs are used to treat some pollen allergies.
Emergency epinephrine. If you have a severe allergy, your doctor may give you an emergency epinephrine shot to carry with you at all times. Given for severe allergic reactions, an epinephrine shot (EpiPen, Auvi-Q, others) can reduce symptoms until you get emergency treatment.
LIFESTYLE AND HOME REMEDIES
Preventing allergic reactions depends on the type of allergy you have. General measures include the following:
Avoid known triggers. Even if you're treating your allergy symptoms, try to avoid triggers. If, for instance, you're allergic to pollen, stay inside with windows and doors closed during periods when pollen is high. If you're allergic to dust mites, dust and vacuum and wash bedding often.
Keep a diary. When trying to identify what causes or worsens your allergic symptoms, track your activities and what you eat, when symptoms occur and what seems to help. This may help you and your doctor identify triggers.
Wear a medical alert bracelet. If you've ever had a severe allergic reaction, a medical alert bracelet (or necklace) lets others know that you have a serious allergy in case you have a reaction and you're unable to communicate.
ALS (Lou GEHRIG's DISEASE)
ALS (Lou GEHRIG's DISEASE)
Amyotrophic lateral sclerosis or ALS, is a nervous system (neurological) disease that causes muscle weakness and impacts physical function.
ALS is often called Lou Gehrig's disease, after the famous baseball player who was diagnosed with it. ALS is a type of motor neuron disease that causes nerve cells to gradually break down and die. In the United States, ALS is sometimes called motor neuron disease.
In most cases, doctors don't know why ALS occurs. A small number of cases are inherited.
ALS often begins with muscle twitching and weakness in an arm or leg, or sometimes with slurring of speech. Eventually, ALS can affect your ability to control the muscles needed to move, speak, eat and breathe. ALS can't be cured and eventually leads to death.
SYMPTOMS
Early signs and symptoms of ALS include:
Difficulty walking, tripping or difficulty doing your normal daily activities
Weakness in your leg, feet or ankles
Hand weakness or clumsiness
Slurring of speech or trouble swallowing
Muscle cramps and twitching in your arms, shoulders and tongue
Difficulty holding your head up or keeping a good posture
The disease frequently begins in your hands, feet or limbs, and then spreads to other parts of your body. As the disease advances, your muscles become progressively weaker. This weakness eventually affects chewing, swallowing, speaking and breathing.
However, ALS doesn't usually affect your bowel or bladder control, your senses, or your thinking ability. It's possible to remain actively involved with your family and friends.
CAUSES
In ALS, the nerve cells that control the movement of your muscles gradually die, so your muscles progressively weaken and begin to waste away.
ALS is inherited in 5 to 10 percent of cases. The other cases appear to occur randomly.
Researchers are studying several possible causes of ALS, including:
Gene mutation. Various genetic mutations can lead to inherited ALS, which appears nearly identical to the noninherited form.
Chemical imbalance. People with ALS generally have higher than normal levels of glutamate, a chemical messenger in the brain, around the nerve cells in their spinal fluid. Too much glutamate is known to be toxic to some nerve cells.
Disorganized immune response. Sometimes a person's immune system begins attacking some of his or her body's own normal cells, which may lead to the death of nerve cells.
Protein mishandling. Mishandled proteins within the nerve cells may lead to a gradual accumulation of abnormal forms of these proteins in the cells, eventually causing the nerve cells to die.
RISK FACTORS
Established risk factors for ALS include:
Heredity. Five to 10 percent of the people with ALS inherited it (familial ALS). In most people with familial ALS, their children have a 50-50 chance of developing the disease.
Age. ALS most commonly occurs in people between the ages of 40 and 60.
Sex. Before the age of 65, slightly more men than women develop ALS. This sex difference disappears after age 70.
It may be that in some people ALS, is triggered by certain environmental factors.
Also, some studies examining the entire human genome (genome-wide association studies) found numerous genetic variations that people with familial ALS and some people with noninherited ALS had in common. These genetic variations might make people more susceptible to ALS.
Environmental factors under study that may modify a person's individual risk of ALS include:
Smoking. Smoking cigarettes appears to increase a person's risk of ALS to almost twice that of a nonsmoker. The more years spent smoking, the greater the risk. However, quitting smoking can eventually lower the increased risk.
Lead exposure. Some evidence suggests that exposure to lead in the workplace may be associated with the development of ALS.
Military service. Recent studies indicate that people who have served in the military are at higher risk of ALS. Exactly what about military service may trigger the development of ALS is uncertain, but it may include exposure to certain metals or chemicals, traumatic injuries, viral infections and intense exertion.
COMPLICATIONS
As the disease progresses, people with ALS experience complications, which may include:
Breathing problems
Over time, ALS paralyzes the muscles needed to breathe. Some devices to assist your breathing are worn only at night and are similar to devices used by people with sleep apnea. For example, you may be given noninvasive positive pressure ventilation to assist with your breathing at night.
In the latter stages of ALS, some people choose to have a tracheostomy — a surgically created hole at the front of the neck leading to the windpipe (trachea) — to enable the full-time use of a respirator that inflates and deflates their lungs.
The most common cause of death for people with ALS is respiratory failure. On average, death occurs within three to five years after symptoms begin.
Speaking problems
Most people with ALS will develop trouble speaking over time. This usually starts as some mild slurring of words, often intermittently, but progresses over time to be more severe. With time, speech becomes more difficult for others to understand, and people with ALS often rely on other communication technologies to communicate.
Eating problems
When the muscles that control swallowing are affected, people with ALS can develop malnutrition and dehydration. They are also at higher risk of getting food, liquids or saliva into the lungs, which can cause pneumonia. A feeding tube can reduce these risks.
Dementia
Some people with ALS experience problems with memory and making decisions, and some are eventually diagnosed with a form of dementia called frontotemporal dementia.
PREPARING FOR YOUR APPOINTMENT
If you're having some of the early signs and symptoms of a neuromuscular disease such as ALS, you might first consult your family doctor, who will listen to your description of symptoms and do an initial physical examination. Then your doctor will probably refer you to a doctor trained in nervous system conditions (neurologist) for further evaluation.
What you can do
Once you're under the care of a neurologist, it may still take time to establish the diagnosis.
If you've been referred to certain medical centers, your evaluation may involve an integrated team of neurologists, and other doctors and health care professionals trained in different aspects of motor neuron disease.
Doctors will give you a comprehensive evaluation to diagnose your condition. However, this process can be stressful and frustrating unless your medical team keeps you informed. These strategies may give you a greater sense of control.
Keep a symptom diary. Before you see a neurologist, start using a calendar or notebook to jot down the time and circumstances each time you notice problems with walking, hand coordination, speech, swallowing or involuntary muscle movements. Your observations may reveal a pattern that aids diagnosis.
Find a neurologist and care team. Generally, an integrated care team led by your neurologist is most appropriate for your ALS care. Your team should communicate and be familiar with your individual needs.
An integrated team may prolong survival and improve your quality of care.
What to expect from your doctor
Your family doctor will carefully review your family's medical history and your signs and symptoms. Your neurologist and your family doctor may conduct a physical and neurological examination, which may include testing:
Reflexes
Muscle strength
Muscle tone
Senses of touch and sight
Coordination
Balance
TESTS AND DIAGNOSIS
Amyotrophic lateral sclerosis (ALS) is difficult to diagnose early because it may appear similar to several other neurological diseases. Tests to rule out other conditions may include:
Electromyogram (EMG). During an EMG, your doctor inserts a needle electrode through your skin into various muscles. The test evaluates the electrical activity of your muscles when they contract and when they're at rest.
Abnormalities in muscles seen in an electromyogram can help doctors diagnose ALS, or determine if you have a muscle or nerve condition that may be causing your symptoms. It can also help guide your exercise therapy.
Nerve conduction study. This study measures your nerves' ability to send impulses to muscles in different areas of your body. This test can determine if you have nerve damage or certain muscle diseases.
Magnetic resonance imaging (MRI). Using radio waves and a powerful magnetic field, an MRI can produce detailed images of your brain and spinal cord. An MRI can evaluate if you have spinal cord tumors, herniated disks in your neck or other conditions that may be causing your symptoms.
Blood and urine tests. Analyzing samples of your blood and urine in the laboratory may help your doctor eliminate other possible causes of your signs and symptoms.
Spinal tap (lumbar puncture). Sometimes a specialist may remove a sample of your spinal fluid for analysis. In this procedure, a specialist inserts a small needle between two vertebrae in your lower back and removes a small amount of cerebrospinal fluid for testing in the laboratory.
Muscle biopsy. If your doctor believes you may have a muscle disease rather than ALS, you may undergo a muscle biopsy. In this procedure, while you're under local anesthesia a small portion of your muscle is removed and sent to a lab for analysis.
TREATMENTS AND DRUGS
Because there's no reversing the course of amyotrophic lateral sclerosis, treatments focus on slowing the progression of symptoms, preventing unnecessary complications and making you more comfortable and independent.
Because ALS involves complex physical, mental and social issues, you may find it helpful to have an integrated team of doctors trained in many areas and other health care professionals provide your care. Having an integrated team of doctors and other health care professionals manage your ALS care may prolong your survival and improve your quality of life.
Your team will help you select the right treatments for you. You always retain the right to choose or not choose any of the treatments suggested.
Medications
The drug riluzole (Rilutek) is the only medication approved by the Food and Drug Administration for ALS. The drug appears to slow the disease's progression in some people, perhaps by reducing levels of a chemical messenger in the brain (glutamate) that's often present in higher levels in people with ALS.
Riluzole may cause side effects such as dizziness, gastrointestinal conditions and liver function changes.
Your doctor may also prescribe medications to provide relief from other symptoms, including:
Muscle cramps and spasms
Spasticity
Constipation
Fatigue
Excessive salivation
Excessive phlegm
Pain
Depression
Sleep problems
Uncontrolled outbursts of laughing or crying
Therapy
Breathing care. Over time, you'll have more difficulty breathing as your muscles become weaker. Doctors may test your breathing regularly and provide you with devices to assist your breathing at night.
In some cases, you may choose to breathe through mechanical ventilation. Doctors insert a tube in a surgically created hole at the front of your neck leading to your windpipe (tracheostomy), and the tube is connected to a respirator.
Physical therapy. A physical therapist can address pain, walking, mobility, bracing and equipment needs that help maintain your independence. Some measures include low-impact exercises to maintain your cardiovascular fitness, muscle strength and range of motion for as long as possible.
A physical therapist can also help you become accustomed to a brace, walker or wheelchair and may be able to suggest devices such as ramps that make it easier for you to get around.
Regular exercise can also help improve your sense of well-being. Appropriate stretching can help prevent pain and help your muscles function at their best.
Occupational therapy. An occupational therapist can help you compensate for hand and arm weakness in a manner that helps you to keep your independence for as long as possible. Adaptive equipment can help you to continue to perform daily activities such as dressing, grooming, eating and bathing.
An occupational therapist can also help you understand how to modify your home to allow accessibility if you become less able to walk safely.
Occupational therapists also have a good understanding of how assistive technology and computers can be used, even if your hands are weak.
Speech therapy. Because ALS affects the muscles you use to speak, communication becomes an issue as the disease progresses. A speech therapist can teach you adaptive techniques to make your speech more clearly understood. Speech therapists can also help you explore other methods of communication, such as an alphabet board or simple pen and paper.
Later in disease progression, a speech therapist can recommend devices such as tablet computers with text-to-speech applications or computer-based equipment with synthesized speech that may help you communicate. Ask your therapist about the possibility of borrowing or renting these devices.
Nutritional support. Your team will work with you and your family members to ensure you're eating foods that are easier to swallow and meet your nutritional needs. You may eventually need a feeding tube.
Psychological and social support. Your team may include a social worker to help with financial issues, insurance, and getting equipment and paying for devices you may need. Psychologists, social workers and others may provide emotional support for you and your family.
COPING AND SUPPORT
Learning you have ALS can be devastating. The following tips may help you and your family cope:
Take time to grieve. The news that you have a fatal condition that will reduce your mobility and independence can be difficult to absorb. If you are newly diagnosed, you and your family will likely experience a period of mourning and grief.
Be hopeful. Your team will help you focus on your ability and healthy living. Some people with amyotrophic lateral sclerosis live much longer than the three to five years usually associated with this condition. Some live 10 years or more. Maintaining an optimistic outlook can help improve quality of life for people with ALS.
Think beyond the physical changes. Many people with amyotrophic lateral sclerosis lead rich, rewarding lives despite physical limitations. Try to think of ALS as only one part of your life, not your entire identity.
Join a support group. You may find comfort in sharing your concerns in a support group with others who have ALS. Your family members and friends helping with your care also may benefit from a support group of others who care for people with amyotrophic lateral sclerosis. Find support groups in your area by talking to your doctor or by contacting the ALS Association.
Make decisions now about your future medical care. Planning for the future allows you to be in control of decisions about your life and your care.
With the help of your doctor, hospice nurse or social worker, you can decide whether you want certain life-extending procedures.
You can also determine where you want to spend your final days. You may consider hospice care options. Planning for the future can help you and your loved ones put to rest some common anxieties.
AMENORRHEA
AMENORRHEA
Amenorrhea
Amenorrhea (uh-men-o-REE-uh) is the absence of menstruation — one or more missed menstrual periods. Women who have missed at least three menstrual periods in a row have amenorrhea, as do girls who haven't begun menstruation by age 15.
The most common cause of amenorrhea is pregnancy. Other causes of amenorrhea include problems with the reproductive organs or with the glands that help regulate hormone levels. Treatment of the underlying condition often resolves amenorrhea.
SYMPTOMS
The main sign of amenorrhea is the absence of menstrual periods. Depending on the cause of amenorrhea, you might experience other signs or symptoms along with the absence of periods, such as:
Milky nipple discharge
Hair loss
Headache
Vision changes
Excess facial hair
Pelvic pain
Acne
When to see a doctor
Consult your doctor if you've missed at least three menstrual periods in a row, or if you've never had a menstrual period and you're age 15 or older.
CAUSES
Amenorrhea can occur for a variety of reasons. Some are normal during the course of a woman's life, while others may be a side effect of medication or a sign of a medical problem.
Natural amenorrhea
During the normal course of your life, you may experience amenorrhea for natural reasons, such as:
Pregnancy
Breast-feeding
Menopause
Contraceptives
Some women who take birth control pills may not have periods. Even after stopping oral contraceptives, it may take some time before regular ovulation and menstruation return. Contraceptives that are injected or implanted also may cause amenorrhea, as can some types of intrauterine devices.
Medications
Certain medications can cause menstrual periods to stop, including some types of:
Antipsychotics
Cancer chemotherapy
Antidepressants
Blood pressure drugs
Allergy medications
Lifestyle factors
Sometimes lifestyle factors contribute to amenorrhea, for instance:
Low body weight. Excessively low body weight — about 10 percent under normal weight — interrupts many hormonal functions in your body, potentially halting ovulation. Women who have an eating disorder, such as anorexia or bulimia, often stop having periods because of these abnormal hormonal changes.
Excessive exercise. Women who participate in activities that require rigorous training, such as ballet, may find their menstrual cycles interrupted. Several factors combine to contribute to the loss of periods in athletes, including low body fat, stress and high energy expenditure.
Stress. Mental stress can temporarily alter the functioning of your hypothalamus — an area of your brain that controls the hormones that regulate your menstrual cycle. Ovulation and menstruation may stop as a result. Regular menstrual periods usually resume after your stress decreases.
Hormonal imbalance
Many types of medical problems can cause hormonal imbalance, including:
Polycystic ovary syndrome (PCOS). PCOS causes relatively high and sustained levels of hormones, rather than the fluctuating levels seen in the normal menstrual cycle.
Thyroid malfunction. An overactive thyroid gland (hyperthyroidism) or underactive thyroid gland (hypothyroidism) can cause menstrual irregularities, including amenorrhea.
Pituitary tumor. A noncancerous (benign) tumor in your pituitary gland can interfere with the hormonal regulation of menstruation.
Premature menopause. Menopause usually begins around age 50. But, for some women, the ovarian supply of eggs diminishes before age 40, and menstruation stops.
Structural problems
Problems with the sexual organs themselves also can cause amenorrhea. Examples include:
Uterine scarring. Asherman's syndrome, a condition in which scar tissue builds up in the lining of the uterus, can sometimes occur after a dilation and curettage (D&C), cesarean section or treatment for uterine fibroids. Uterine scarring prevents the normal buildup and shedding of the uterine lining.
Lack of reproductive organs. Sometimes problems arise during fetal development that lead to a girl being born without some major part of her reproductive system, such as her uterus, cervix or vagina. Because her reproductive system didn't develop normally, she can't have menstrual cycles.
Structural abnormality of the vagina. An obstruction of the vagina may prevent visible menstrual bleeding. A membrane or wall may be present in the vagina that blocks the outflow of blood from the uterus and cervix.
RISK FACTORS
Factors that may increase your risk of amenorrhea may include:
Family history. If other women in your family have experienced amenorrhea, you may have inherited a predisposition for the problem.
Eating disorders. If you have an eating disorder, such as anorexia or bulimia, you are at higher risk of developing amenorrhea.
Athletic training. Rigorous athletic training can increase your risk of amenorrhea.
COMPLICATIONS
Complications of amenorrhea may include:
Infertility. If you don't ovulate and have menstrual periods, you can't become pregnant.
Osteoporosis. If your amenorrhea is caused by low estrogen levels, you may also be at risk of osteoporosis — a weakening of your bones.
PREPARING FOR YOUR APPOINTMENT
Your first appointment will likely be with your primary care physician or gynecologist.
Here's some information to help you prepare for your appointment and know what to expect from your doctor.
What you can do
To get ready for your appointment:
Write down details about your symptoms, including when they started and the date and duration of your last period, if you know when your last period was.
Make note of key medical information, including other conditions for which you're being treated and the names and dosages of any medications, vitamins or supplements you regularly take.
Review your family history, checking to see whether your mother or any sisters have also had menstrual problems.
Write down questions to ask your doctor, listing the most important ones first in case time runs short.
For amenorrhea, some basic questions to ask your doctor include:
What might be causing me to miss my periods?
Do I need any tests? How should I prepare for those tests?
What treatments are available? Which do you recommend for me?
Do you have any informational brochures on this topic? What websites do you recommend?
What to expect from your doctor
Your doctor will likely ask you a number of questions, such as:
When was your last period?
Are you sexually active?
Could you be pregnant?
Do you use birth control?
Are you under any stress?
Have you experienced unexplained weight gain or weight loss?
How often and how intensely do you exercise?
Do you have any other medical conditions?
TESTS AND DIAGNOSIS
During your appointment, your doctor will perform a pelvic exam to check for any problems with your reproductive organs. If you've never had a period, your doctor may examine your breasts and genitals to see if you're experiencing the normal changes of puberty.
Amenorrhea can be a sign of a complex set of hormonal problems. Finding the underlying cause can take time and may require more than one kind of testing.
Lab tests
A variety of blood tests may be necessary, including:
Pregnancy test. This will probably be the first test your doctor suggests, to rule out or confirm a possible pregnancy.
Thyroid function test. Measuring the amount of thyroid-stimulating hormone (TSH) in your blood can determine if your thyroid is working properly.
Ovary function test. Measuring the amount of follicle-stimulating hormone (FSH) in your blood can determine if your ovaries are working properly.
Prolactin test. Low levels of the hormone prolactin may be a sign of a pituitary gland tumor.
Male hormone test. If you're experiencing increased facial hair and a lowered voice, your doctor may want to check the level of male hormones in your blood.
Hormone challenge test
For this test, you take a hormonal medication for seven to 10 days to trigger menstrual bleeding. Results from this test can tell your doctor whether your periods have stopped due to a lack of estrogen.
Imaging tests
Depending on your signs and symptoms — and the result of any blood tests you've had — your doctor might recommend one or more imaging tests, including:
Ultrasound. This test uses sound waves to produce images of internal organs. If you have never had a period, your doctor may suggest an ultrasound test to check for any abnormalities in your reproductive organs.
Computerized tomography (CT). CT scans combine many X-ray images taken from different directions to create cross-sectional views of internal structures. A CT scan can indicate whether your uterus, ovaries and kidneys look normal.
Magnetic resonance imaging (MRI). MRI uses radio waves with a strong magnetic field to produce exceptionally detailed images of soft tissues within the body. Your doctor may order an MRI to check for a pituitary tumor.
Scope tests
If other testing reveals no specific cause, your doctor may recommend a hysteroscopy — a test in which a thin, lighted camera is passed through your vagina and cervix to look at the inside of your uterus.
TREATMENTS AND DRUGS
Treatment depends on the underlying cause of your amenorrhea. In some cases, contraceptive pills or other hormone therapies can restart your menstrual cycles. Amenorrhea caused by thyroid or pituitary disorders may be treated with medications. If a tumor or structural blockage is causing the problem, surgery may be necessary.
LIFESTYLE AND HOME REMEDIES
Some lifestyle factors — such as too much exercise or too little food — can cause amenorrhea, so strive for balance in work, recreation and rest. Assess areas of stress and conflict in your life. If you can't decrease stress on your own, ask for help from family, friends or your doctor.
Be aware of changes in your menstrual cycle and check with your doctor if you have concerns. Keep a record of when your periods occur. Note the date your period starts, how long it lasts and any troublesome symptoms you experience.
ACUTE MYELOGENOUS LEUKEMIA (AML)
ACUTE MYELOGENOUS LEUKEMIA (AML)
AML (Acute myelogenous leukemia)
Acute myelogenous leukemia (AML) is a cancer of the blood and bone marrow — the spongy tissue inside bones where blood cells are made.
The word "acute" in acute myelogenous leukemia denotes the disease's rapid progression. It's called myelogenous (my-uh-LOHJ-uh-nus) leukemia because it affects a group of white blood cells called the myeloid cells, which normally develop into the various types of mature blood cells, such as red blood cells, white blood cells and platelets.
Acute myelogenous leukemia is also known as acute myeloid leukemia, acute myeloblastic leukemia, acute granulocytic leukemia and acute nonlymphocytic leukemia.
SYMPTOMS
General signs and symptoms of the early stages of acute myelogenous leukemia may mimic those of the flu or other common diseases. Signs and symptoms may vary based on the type of blood cell affected. Signs and symptoms of acute myelogenous leukemia include:
Fever
Bone pain
Lethargy and fatigue
Shortness of breath
Pale skin
Frequent infections
Easy bruising
Unusual bleeding, such as frequent nosebleeds and bleeding from the gums
When to see a doctor
Make an appointment with a doctor if you develop any signs or symptoms that seem unusual or that worry you.
CAUSES
Acute myelogenous leukemia is caused by damage to the DNA of developing cells in your bone marrow. When this happens, blood cell production goes awry. The bone marrow produces immature cells that develop into leukemic white blood cells called myeloblasts. These abnormal cells are unable to function properly, and they can build up and crowd out healthy cells.
In most cases, it's not clear what causes the DNA mutations that lead to leukemia. Radiation, exposure to certain chemicals and some chemotherapy drugs are known risk factors for acute myelogenous leukemia.
RISK FACTORS
Factors that may increase your risk of acute myelogenous leukemia include:
Increasing age. The risk of acute myelogenous leukemia increases with age. Acute myelogenous leukemia is most common in adults age 65 and older.
Your sex. Men are more likely to develop acute myelogenous leukemia than are women.
Previous cancer treatment. People who've had certain types of chemotherapy and radiation therapy may have a greater risk of developing AML.
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 AML.
Dangerous chemical exposure. Exposure to certain chemicals, such as benzene, is linked to greater risk of AML.
Smoking. AML is linked to cigarette smoke, which contains benzene and other known cancer-causing chemicals.
Other blood disorders. People who've had another blood disorder, such as myelodysplasia, polycythemia vera or thrombocythemia, are at greater risk of developing AML.
Genetic disorders. Certain genetic disorders, such as Down syndrome, are associated with an increased risk of AML.
Many people with AML have no known risk factors, and many people who have risk factors never develop the cancer.
PREPARING FOR YOUR APPOINTMENT
If you have signs and symptoms of acute myelogenous leukemia, you're likely to start by seeing your family doctor or a general practitioner. However, in some cases, you may be referred immediately to a doctor who specializes in blood cell diseases (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 know 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.
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 myelogenous leukemia, some basic questions to ask include:
What is likely causing my symptoms or condition?
What are other 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? What will that cost, and will my insurance cover it?
Should I seek a second opinion? What will that cost, and will my insurance cover it?
Is there a generic alternative to the medicine you're prescribing?
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 your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may allow time later to cover other points you want to address. 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?
What you can do in the meantime
Avoid activities that worsen your signs and symptoms. For instance, try to take it easy if you're feeling fatigued.
TESTS AND DIAGNOSIS
If you have signs or symptoms of acute myelogenous leukemia, your doctor may recommend you undergo diagnostic tests, including:
Blood tests. Most people with acute myelogenous leukemia have too many white blood cells, not enough red blood cells and not enough platelets. The presence of blast cells — immature cells normally found in bone marrow but not circulating in the blood — is another indicator of acute myelogenous leukemia.
Bone marrow test. A blood test can suggest leukemia, but it usually takes a bone marrow test to confirm the diagnosis. During a bone marrow biopsy, a needle is used to remove a sample of your bone marrow. Usually, the sample is taken from your hipbone (posterior iliac crest). The sample is sent to a laboratory for testing.
Lumbar puncture (spinal tap). In some cases, it may be necessary to remove some of the fluid around your spinal cord to check for leukemia cells. Your doctor can collect this fluid by inserting a small needle into the spinal canal in your lower back.
If your doctor suspects leukemia, you may be referred to a doctor who specializes in cancer (oncologist) or a doctor who specializes in blood and blood-forming tissues (hematologist).
Determining your AML subtype
If your doctor determines you have AML, you may need further tests to determine the extent of the cancer and classify it into a more specific AML subtype. Your AML subtype is based on how your cells appear when examined under a microscope. Special laboratory testing may also be used to identify the specific characteristics of your cells.
Your AML subtype helps determine which treatments may be best for you. Doctors are studying how different types of cancer treatment affect people with different AML subtypes.
TREATMENTS AND DRUGS
Treatment of acute myelogenous leukemia depends on several factors, including the subtype of the disease, your age, your overall health and your preferences. In general, treatment falls into two phases:
Remission induction therapy. The purpose of the first phase of treatment is to kill the leukemia cells in your blood and bone marrow. However, remission induction usually doesn't wipe out all of the leukemia cells, so you need further treatment to prevent the disease from returning.
Consolidation therapy. Also called post-remission therapy, maintenance therapy or intensification, this phase of treatment is aimed at destroying the remaining leukemia cells. It's considered crucial to decreasing the risk of relapse.
Therapies used in these phases include:
Chemotherapy. Chemotherapy is the major form of remission induction therapy, though it can also be used for consolidation therapy. Chemotherapy uses chemicals to kill cancer cells in your body. People with AML generally stay in the hospital during chemotherapy treatments because the drugs destroy many normal blood cells in the process of killing leukemia cells. If the first cycle of chemotherapy doesn't cause remission, it can be repeated.
Other drug therapy. Arsenic trioxide (Trisenox) and all-trans retinoic acid (ATRA) are anti-cancer drugs that can be used alone or in combination with chemotherapy for remission induction of a certain subtype of AML called promyelocytic leukemia. These drugs cause leukemia cells with a specific gene mutation to mature and die, or to stop dividing.
Stem cell transplant. Stem cell transplant, also called bone marrow transplant, may be used for consolidation therapy. Stem cell transplant helps re-establish healthy stem cells by replacing unhealthy bone marrow with leukemia-free stem cells that will regenerate healthy bone marrow. Prior to a stem cell transplant, you receive very high doses of chemotherapy or radiation therapy to destroy your leukemia-producing bone marrow. Then you receive infusions of stem cells from a compatible donor (allogeneic transplant). You can also receive your own stem cells (autologous transplant) if you were previously in remission and had your healthy stem cells removed and stored for a future transplant.
Clinical trials. Some people with leukemia choose to enroll in clinical trials to try experimental treatments or new combinations of known therapies.
ALTERNATIVE MEDICINE
No alternative treatments have been found helpful in treating acute myelogenous leukemia. But some complementary and alternative treatments may relieve the signs and symptoms you experience due to cancer or cancer treatment.
Alternative treatments that may help relieve signs and symptoms include:
Acupuncture
Aromatherapy
Massage
Meditation
Relaxation exercises
COPING AND SUPPORT
Acute myelogenous leukemia is an aggressive form of cancer that typically demands quick decision making. That leaves people with a new diagnosis faced with important decisions about a disease they may not yet understand. Here are some tips for coping:
Learn enough to make decisions about your care. The term "leukemia" can be confusing because it refers to a group of cancers that aren't all that similar except for the fact that they affect the bone marrow and blood. You can waste a lot of time researching information that doesn't apply to your kind of leukemia. To avoid that, 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 for 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 family and friends. It can be tough to talk about your diagnosis, and you'll likely get a range of reactions when you share the news. But talking about your diagnosis can be helpful. So can the outpouring of practical help that often results.
Take care of yourself. It's easy to get caught up in the tests, treatments and procedures of therapy. But it's important to take care of yourself, not just the cancer. Try to make time for yoga, gardening, cooking or other favorite diversions.
AMNESIA
AMNESIA
Amnesia
Amnesia refers to the loss of memories, such as facts, information and experiences. Though having no sense of who you are is a common plot device in movies and television, real-life amnesia generally doesn't cause a loss of self-identity.
Instead, people with amnesia — also called amnestic syndrome — are usually lucid and know who they are, but may have trouble learning new information and forming new memories.
Amnesia can be caused by damage to areas of the brain that are vital for memory processing. Unlike a temporary episode of memory loss (transient global amnesia), amnesia can be permanent.
There's no specific treatment for amnesia, but techniques for enhancing memory and psychological support can help people with amnesia and their families cope.
SYMPTOMS
The two main features of amnesia are:
Impaired ability to learn new information following the onset of amnesia (anterograde amnesia)
Impaired ability to recall past events and previously familiar information (retrograde amnesia)
Most people with amnesia have problems with short-term memory — they can't retain new information. Recent memories are most likely to be lost, while more remote or deeply ingrained memories may be spared. Someone may recall experiences from childhood or know the names of past presidents, but not be able to name the current president or remember what month it is or what was for breakfast.
Isolated memory loss doesn't affect a person's intelligence, general knowledge, awareness, attention span, judgment, personality or identity. People with amnesia usually can understand written and spoken words and can learn skills such as bike riding or piano playing. They may understand they have a memory disorder.
Amnesia isn't the same as dementia. Dementia often includes memory loss, but it also involves other significant cognitive problems that lead to a decline in the ability to carry out daily activities.
A pattern of forgetfulness is also a common symptom of mild cognitive impairment (MCI), but the memory and other cognitive problems in MCI aren't as severe as those experienced in dementia.
Additional signs and symptoms
Depending on the cause of the amnesia, other signs and symptoms may include:
False recollections (confabulation), either completely invented or made up of genuine memories misplaced in time
Confusion or disorientation
When to see a doctor
Anyone who experiences unexplained memory loss, head injury, confusion or disorientation requires immediate medical attention.
A person with amnesia may not be able to identify his or her location or have the presence of mind to seek medical care. If someone you know has symptoms of amnesia, help the person get medical attention.
CAUSES
Normal memory function involves many parts of the brain, and any disease or injury that affects the brain can interfere with the intricacies of memory.
Amnesia can result from damage to brain structures that form the limbic system, which controls your emotions and memories. These structures include the thalamus, which lies deep within the center of your brain, and the hippocampal formations, which are situated within the temporal lobes of your brain.
Amnesia caused by brain injury or damage is known as neurological amnesia. Possible causes of neurological amnesia include:
Stroke
Brain inflammation (encephalitis) as a result of infection with a virus such as herpes simplex virus, as an autoimmune reaction to cancer somewhere else in the body (paraneoplastic limbic encephalitis), or as an autoimmune reaction in the absence of cancer
Lack of adequate oxygen in the brain, for example, from heart attack, respiratory distress or carbon monoxide poisoning
Long-term alcohol abuse leading to thiamin (vitamin B-1) deficiency (Wernicke-Korsakoff syndrome)
Tumors in areas of the brain that control memory
Degenerative brain diseases, such as Alzheimer's disease and other forms of dementia
Seizures
Certain medications, such as benzodiazepines
Head injuries that cause a concussion, whether from a car accident or sports, can lead to confusion and problems remembering new information. This is especially common in the early stages of recovery. But head injuries usually don't cause severe amnesia.
Another rare type of amnesia, called dissociative (psychogenic) amnesia, stems from emotional shock or trauma, such as being the victim of a violent crime. In this disorder, a person may lose personal memories and autobiographical information, but usually only briefly.
RISK FACTORS
The chance of developing amnesia might increase if you've experienced:
Brain surgery, head injury or trauma
Stroke
Alcohol abuse
Seizures
COMPLICATIONS
Amnesia varies in severity and scope, but even mild amnesia takes a toll on daily activities and quality of life. The syndrome can cause problems at work, at school and in social settings.
It may not be possible to recover lost memories. Some people with severe memory problems need to live in a supervised situation or extended-care facility.
PREPARING FOR YOUR APPOINTMENT
You're likely to start by seeing your family doctor or a general practitioner. However, you may then be referred to a doctor who specializes in disorders of the brain and nervous system (neurologist).
It's a good idea to arrive at your appointment well-prepared. Here's some information to help you get ready for your appointment and to know what to expect from your doctor.
What you can do
Write down any unusual symptoms as you experience them, 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 you can recall. Ask family members or friends to help you, to ensure your list is complete.
Make a list of all medications, vitamins or supplements you're taking.
Ask a family member or friend to come with you. Even in the best circumstances, it can be difficult to remember all of the information provided to you during an appointment. Someone with you can help you remember everything that was said.
Bring a notepad and pen or pencil to jot down the points you want to be sure to remember later.
Write down questions to ask your doctor.
Preparing a list of questions can help you make the most of your time with your doctor, as well as ensure that you cover everything you want to ask. For amnesia, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
Are there other possible causes for my symptoms?
What kinds of tests do I need? Do these tests require any special preparation?
Will my memory ever come back?
What treatments are available, and which do you recommend?
I have other health conditions. How can I best manage them together?
Do I need to restrict any activities?
Are there any brochures or other printed material that I can take home? 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 at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, including:
When did you first notice your memory loss?
Did you experience any other symptoms at that time?
Were you involved in any trauma? For example, a car accident, violent collision in sports or an assault?
Did an illness or another event seem to trigger the memory loss?
Does anything help improve your memory?
What, if anything, appears to worsen your memory loss?
Are the memory problems intermittent or constant?
Has the memory loss stayed the same or is it getting worse?
Did the memory loss come on suddenly or gradually?
TESTS AND DIAGNOSIS
To diagnose amnesia, a doctor will do a comprehensive evaluation to rule out other possible causes of memory loss, such as Alzheimer's disease, other forms of dementia, depression or brain tumor.
Medical history
The evaluation starts with a detailed medical history. Because the person with memory loss may not be able to provide thorough information, a family member, friend or another caregiver generally takes part in the interview as well.
The doctor will ask many questions to understand the memory loss. Issues that might be addressed include:
Type of memory loss — recent or long term
When the memory problems started and how they progressed
Triggering factors, such as head injury, stroke or surgery
Family history, especially of neurological disease
Drug and alcohol use
Other signs and symptoms, such as confusion, language problems, personality changes or impaired ability to care for self
History of seizures, headaches, depression or cancer
Physical exam
The physical examination may include a neurological exam to check reflexes, sensory function, balance, and other physiological aspects of the brain and nervous system.
Cognitive tests
The doctor will test the person's thinking, judgment, and recent and long-term memory. He or she will check the person's knowledge of general information — such as the name of the current president — as well as personal information and past events.
The memory evaluation can help determine the extent of memory loss and provide insights about what kind of help the person may need.
Diagnostic tests
Imaging tests — including MRI and CT scan — may be ordered to look for damage or abnormalities in the brain. Blood tests can check for infection, nutritional deficiencies or other issues. An electroencephalogram may be ordered to look for the presence of seizure activity.
TREATMENTS AND DRUGS
Treatment for amnesia focuses on techniques and strategies to help make up for the memory problem.
Occupational therapy
A person with amnesia may work with an occupational therapist to learn new information to replace what was lost, or to use intact memories as a basis for taking in new information.
Memory training may also include a variety of strategies for organizing information so that it's easier to remember and for improving understanding of extended conversation.
Technological assistance
Many people with amnesia find it helpful to use smart technology, such as a smartphone or a hand-held tablet device. With some training and practice, even people with severe amnesia can use these electronic organizers to help with day-to-day tasks. For example, smartphones can be programmed to remind them about important events or to take medications.
Low-tech memory aids include notebooks, wall calendars, pill minders, and photographs of people and places.
Medications or supplements
No medications are currently available for treating most types of amnesia.
Amnesia caused by Wernicke-Korsakoff syndrome involves a lack of thiamin. Treatment includes replacing this vitamin and providing proper nutrition. Although treatment, which also needs to include alcohol abstinence, can help prevent further damage, most people won't recover all of their lost memory.
Researchers are investigating several neurotransmitters involved in memory formation, which may one day lead to new treatments for memory disorders. But the complexity of the brain processes involved makes it unlikely that a single medication will be able to resolve memory problems.
LIFESTYLE AND HOME REMEDIES
Because damage to the brain can be a root cause of amnesia, it's important to take steps to minimize your chance of a brain injury. For example:
Avoid excessive alcohol use.
Wear a helmet when bicycling and a seat belt when driving.
Treat any infection quickly so that it doesn't have a chance to spread to the brain.
Seek immediate medical treatment if you have any symptoms that suggest a stroke or brain aneurysm, such as a severe headache or one-sided numbness or paralysis.
COPING AND SUPPORT
Living with amnesia can be frustrating for those with memory loss, and for their family and friends, too. People with more-severe forms of amnesia may require direct assistance from family, friends or professional caregivers.
It can be helpful to talk with others who understand what you're going through, and who may be able to provide advice or tips on living with amnesia. Ask your doctor if he or she knows of a support group in your area for people with amnesia and their loved ones.
If an underlying cause for the amnesia is identified, there are national organizations that can provide additional information or support for the individual and their families. Examples include:
The Alzheimer's Association (800-272-3900)
The Brain Injury Association of America (800-444-6443)
AMNIOTIC FLUID EMBOLISM
AMNIOTIC FLUID EMBOLISM
Amniotic Fluid Embolism
An amniotic fluid embolism is a rare but serious condition that occurs when amniotic fluid — the fluid that surrounds a baby in the uterus during pregnancy — or fetal material, such as hair, enters the maternal bloodstream.
An amniotic fluid embolism is most likely to occur during childbirth or immediately afterward.
An amniotic fluid embolism is difficult to diagnose. If your doctor suspects you might have an amniotic fluid embolism, you'll need immediate treatment to prevent potentially life-threatening complications.
SYMPTOMS
An amniotic fluid embolism develops suddenly and rapidly.
Signs and symptoms of an amniotic fluid embolism might include:
Sudden shortness of breath
Excess fluid in the lungs (pulmonary edema)
Sudden low blood pressure
Sudden circulatory failure (cardiovascular collapse)
Life-threatening problems with blood clotting (disseminated intravascular coagulopathy)
Altered mental status, such as anxiety
Nausea or vomiting
Chills
Rapid heart rate or disturbances in the rhythm of the heart rate
Fetal distress, such as a slow heart rate
Seizures
Coma
CAUSES
Why an amniotic fluid embolism occurs isn't well understood.
An amniotic fluid embolism occurs when amniotic fluid or fetal material enters the maternal bloodstream, possibly by passing through tears in the fetal membranes. It's likely that amniotic fluid contains components that cause an inflammatory reaction and activate clotting in the mother's lungs and blood vessels.
However, amniotic fluid embolisms are rare — and it's likely that some amniotic fluid commonly enters the maternal bloodstream during delivery without causing problems. It's not clear why in some cases this leads to an amniotic fluid embolism.
Further research on what causes amniotic fluid embolisms is needed.
RISK FACTORS
Amniotic fluid embolisms are rare, which makes it difficult to identify risk factors. It's estimated that there are between 1 and 12 cases of amniotic fluid embolism for every 100,000 deliveries.
Research suggests that several factors might be linked to an increased risk of an amniotic fluid embolism, however, including:
Advanced maternal age. If you're 35 or older at the time of your child's birth, you might be at increased risk of an amniotic fluid embolism.
Placenta problems. If there are abnormalities in your placenta — the structure that develops in your uterus during pregnancy — you might be at increased risk of an amniotic fluid embolism. Abnormalities might include the placenta partially or totally covering the cervix (placenta previa) or the placenta peeling away from the inner wall of the uterus before delivery (placental abruption). These conditions can disrupt the physical barriers between you and your baby.
Preeclampsia. If you have preeclampsia — high blood pressure and excess protein in the urine after 20 weeks of pregnancy — you might be at increased risk of developing an amniotic fluid embolism.
Medically induced labor. Limited research suggests that certain labor induction methods are associated with an increased risk of amniotic fluid embolism. Research on this link, however, is conflicting.
Operative delivery. Having a C-section, a forceps delivery or a vacuum extraction might increase your risk of an amniotic fluid embolism. These procedures can disrupt the physical barriers between you and your baby. It's not clear, however, whether operative deliveries are true risk factors for amniotic fluid embolisms or are used after the condition develops to ensure a rapid delivery.
Genetics. Some experts believe that genetics might play a role in determining a woman's risk of amniotic fluid embolism.
COMPLICATIONS
An amniotic fluid embolism can cause serious complications for you and your baby.
If you have an amniotic fluid embolism, you're at increased risk of:
Brain injury. Low blood oxygen can cause permanent, severe neurological damage or brain death.
Lengthy hospital stay. Women who survive an amniotic fluid embolism often require treatment in the intensive care unit and — depending on the extent of their complications — might spend weeks or months in the hospital.
It's estimated that amniotic fluid embolisms cause up to 10 percent of maternal deaths in developed countries. Death can occur within an hour of the start of symptoms.
If you have an amniotic embolism, your unborn baby is at increased risk of a brain injury due to a lack of oxygen. The condition can also be fatal for babies.
PREPARING FOR YOUR APPOINTMENT
An amniotic fluid embolism is a medical emergency, leaving you no time to prepare. If you're concerned about your risk of having an amniotic fluid embolism, talk with your doctor. Keep in mind, however, that amniotic fluid embolisms are rare, unpredictable and seemingly unpreventable.
TESTS AND DIAGNOSIS
There are no lab tests to diagnose an amniotic fluid embolism. A diagnosis is typically made after other conditions have been ruled out. In some cases, a diagnosis is only made after maternal death.
TREATMENTS AND DRUGS
An amniotic fluid embolism requires rapid treatment to address low blood oxygen and low blood pressure.
Emergency treatments might include:
Catheter placement. Your health care team will place a thin, hollow tube into one of your arteries (arterial catheter) to monitor your blood pressure. You'll also have another tube placed into a vein in your chest (central venous catheter), which can be used to give fluids, medications or transfusions, as well as draw blood.
Oxygen. You might need to have a breathing tube inserted into your airway to help you breathe.
Medications. Your doctor might give you medications to improve and support your heart function. Other medications might be used to decrease the pressure caused by fluid going into your heart and lungs.
Transfusions. If you have uncontrollable bleeding, you'll need transfusions of blood, blood products and replacement fluids.
If you have an amniotic fluid embolism before delivering your baby, your doctor will treat you with an eye toward safely delivering your baby as soon as possible. An emergency C-section might be needed.
COPING AND SUPPORT
Experiencing a life-threatening pregnancy condition can be frightening and stressful for you and your family. You and your baby might experience serious complications and require lengthy hospital stays.
During this challenging time, lean on loved ones for support. Consider joining a survivors' network. Also, work with your health care provider to determine how you can safely manage your recovery and your role as the mother of a newborn.
AMYLOIDOSIS
AMYLOIDOSIS
Amyloidosis
Amyloidosis (am-uh-loi-DO-sis) is a rare disease that occurs when a substance called amyloid builds up in your organs. Amyloid is an abnormal protein that is usually produced in your bone marrow and can be deposited in any tissue or organ.
Amyloidosis can affect different organs in different people, and there are different types of amyloid. Amyloidosis frequently affects the heart, kidneys, liver, spleen, nervous system and digestive tract. Severe amyloidosis can lead to life-threatening organ failure.
There's no cure for amyloidosis. But treatments can help you manage your symptoms and limit the production of amyloid protein.
SYMPTOMS
You may not experience signs and symptoms of amyloidosis until the condition is advanced. When signs and symptoms are evident, they depend on which of your organs are affected.
Signs and symptoms of amyloidosis may include:
Swelling of your ankles and legs
Severe fatigue and weakness
Shortness of breath
Numbness, tingling or pain in your hands or feet, especially pain in your wrist (carpal tunnel syndrome)
Diarrhea, possibly with blood, or constipation
Feeling full quickly when eating, and significant weight loss
An enlarged tongue
Skin changes, such as thickening or easy bruising, and purplish patches around the eyes
An irregular heartbeat
Difficulty swallowing
When to see a doctor
See your doctor if you persistently experience any of the signs or symptoms associated with amyloidosis.
CAUSES
In general, amyloidosis is caused by the buildup of an abnormal protein called amyloid. Amyloid is produced in your bone marrow and can be deposited in any tissue or organ. The specific cause of your condition depends on the type of amyloidosis you have.
There are several types of amyloidosis, including:
Immunoglobulin light chain (AL) amyloidosis, the most common type, can affect your heart, kidneys, skin, nerves and liver. It was previously known as primary amyloidosis. It occurs when your bone marrow produces abnormal antibodies that can't be broken down. The antibodies are deposited in your tissues as amyloid, interfering with normal function.
AA amyloidosis mostly affects your kidneys but occasionally your digestive tract, liver or heart. It was previously known as secondary amyloidosis. It occurs along with chronic infectious or inflammatory diseases, such as rheumatoid arthritis or inflammatory bowel disease.
Hereditary (familial) amyloidosis is an inherited disorder that often affects the liver, nerves, heart and kidneys. One type is caused by a certain amyloid (transthyretin amyloid) that can affect the nervous system or the heart. African-Americans have a greater risk of this type than do Caucasians. It is thought to be a significant cause of heart failure in African-American men.
Dialysis-related amyloidosis develops when proteins in blood are deposited in joints and tendons — causing pain, stiffness and fluid in the joints, as well as carpal tunnel syndrome. This type generally affects people on long-term dialysis.
RISK FACTORS
Anyone can develop amyloidosis. Factors that increase your risk include:
Age. Most people diagnosed with AL amyloidosis, the most common type, are age 50 or older, although earlier onset occurs.
Gender. Nearly 70 percent of people with AL amyloidosis are men.
Other diseases. Having a chronic infectious or inflammatory disease increases your risk of AA amyloidosis.
Family history. Some types of amyloidosis are hereditary.
Kidney dialysis. Dialysis can't always remove large proteins from the blood. If you're on dialysis, abnormal proteins can build up in your blood and eventually be deposited in tissue. This condition is less common with modern dialysis techniques.
COMPLICATIONS
The potential complications of amyloidosis depend on which organs the amyloid deposits affect. Amyloidosis can seriously damage your:
Kidneys. Amyloid can harm the kidneys' filtering system, causing protein to leak from your blood into your urine. The kidneys' ability to remove waste products from your body is lowered, which may eventually lead to kidney failure.
Heart. Amyloid reduces your heart's ability to fill with blood between heartbeats. Less blood is pumped with each beat, and you may experience shortness of breath. If amyloidosis affects your heart's electrical system, your heart rhythm may be disturbed.
Nervous system. You may experience pain, numbness or tingling of the fingers or numbness, lack of feeling or a burning sensation in your toes or the soles of your feet. If amyloid affects the nerves that control your bowel function, you may experience periods of alternating constipation and diarrhea. Sometimes amyloidosis affects nerves that control blood pressure, and you may experience dizziness or near fainting when standing too quickly, as a result of a drop in your blood pressure.
PREPARING FOR YOUR APPOINTMENT
You may be referred to a doctor who specializes in blood disorders (hematologist).
What you can do
Write down your symptoms, including any that may seem unrelated to the reason why you scheduled the appointment.
Make a list of all your medications, vitamins and supplements.
Write down your key medical information, including other conditions.
Write down key personal information, including any recent changes or stressors in your life.
Write down questions to ask your doctor.
Ask a relative or friend to accompany you, to help you remember what the doctor says.
Questions to ask your doctor
What's the most likely cause of my symptoms?
What kinds of tests do I need?
What kind of treatments do I need?
Am I at risk of long-term complications?
What types of side effects can I expect from treatment?
Do I need to follow any dietary or activity restrictions?
I have another health condition. How can I best manage them together?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other 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 provide time to go over points you want to spend more time on. You may be asked:
When did you first begin experiencing symptoms? How severe are they, and are they continuous or occasional?
Does anything seem to make your symptoms better or worse?
How is your appetite? Have you recently lost weight without trying?
Have you experienced any leg swelling?
Have you experienced shortness of breath?
Are you able to work and perform normal daily tasks? Are you often tired?
Have you noticed that you bruise easily?
Has anyone in your family ever been diagnosed with amyloidosis?
TESTS AND DIAGNOSIS
Amyloidosis is often overlooked because the signs and symptoms can mimic those of more-common diseases. Diagnosis as early as possible can help prevent further organ damage. Precise diagnosis is important because treatment varies greatly, depending on your specific condition.
Your doctor is likely to start with a thorough medical history and physical exam. After that, you may have:
Laboratory tests. Your blood and urine may be analyzed for abnormal protein that can indicate amyloidosis. Depending on your signs and symptoms, you may also have thyroid and liver function tests.
Biopsy. A tissue sample may be taken and checked for signs of amyloidosis. The biopsy may be taken from your abdominal fat, bone marrow, or an organ such as your liver or kidney. Tissue analysis can help determine the type of amyloid deposit.
Imaging tests. Images of the organs affected by amyloidosis can help establish the extent of your disease. Echocardiogram may be used to assess the size and functioning of your heart. Other imaging tests can evaluate the extent of amyloidosis in your liver or spleen.
TREATMENTS AND DRUGS
There's no cure for amyloidosis. But treatment can help manage signs and symptoms and limit further production of amyloid protein. Specific treatments depend on the type of amyloidosis.
For AL amyloidosis, treatment options include:
Chemotherapy, to stop the growth of abnormal cells that produce amyloid.
Peripheral blood stem cell transplant, in which your own stem cells are collected from your blood and stored for a short time while you have high-dose chemotherapy. The stem cells are then returned to your body via a vein. This treatment is most appropriate for people whose disease isn't advanced and whose heart isn't greatly affected.
Treatment for other types of amyloidosis
AA amyloidosis. The underlying condition is treated with medication — for example, an anti-inflammatory medication to treat rheumatoid arthritis.
Hereditary amyloidosis. Liver transplantation may be an option because the protein that causes this form of amyloidosis is made in the liver.
Dialysis-related amyloidosis. Options include changing your mode of dialysis or having a kidney transplant.
Medications
To manage ongoing signs and symptoms of amyloidosis, your doctor also may recommend:
Pain medication
Fluid retention medication (diuretic) and a low-salt diet
Blood-thinning medication
Medication to control your heart rate
LIFESTYLE AND HOME REMEDIES
These tips can help you live with amyloidosis:
Pace yourself. If you feel short of breath, take a break. You'll need to avoid strenuous activities, but you may be able to continue normal daily activities, such as going to work. Talk to your doctor about an appropriate level of activity for you.
Follow a balanced diet. Good nutrition is important to provide your body with adequate energy. Follow a low-salt diet if your doctor recommends it.
COPING AND SUPPORT
A diagnosis of amyloidosis can be extremely challenging. Here are some suggestions that may make dealing with amyloidosis easier:
Find someone to talk with. You may feel comfortable discussing your feelings with a friend or family member, or you might prefer meeting with a formal support group.
Set reasonable goals. Having goals helps you feel in control and can give you a sense of purpose. Choose goals you can reach.
AMYOTROPHIC LATERAL SCLEROSIS (ALS)
AMYOTROPHIC LATERAL SCLEROSIS (ALS)
Amyotrophic lateral sclerosis, or ALS, is a nervous system (neurological) disease that causes muscle weakness and impacts physical function.
ALS is often called Lou Gehrig's disease, after the famous baseball player who was diagnosed with it. ALS is a type of motor neuron disease that causes nerve cells to gradually break down and die. In the United States, ALS is sometimes called motor neuron disease.
In most cases, doctors don't know why ALS occurs. A small number of cases are inherited.
ALS often begins with muscle twitching and weakness in an arm or leg, or sometimes with slurring of speech. Eventually, ALS can affect your ability to control the muscles needed to move, speak, eat and breathe. ALS can't be cured and eventually leads to death.
SYMPTOMS
Early signs and symptoms of ALS include:
Difficulty walking, tripping or difficulty doing your normal daily activities
Weakness in your leg, feet or ankles
Hand weakness or clumsiness
Slurring of speech or trouble swallowing
Muscle cramps and twitching in your arms, shoulders and tongue
Difficulty holding your head up or keeping a good posture
The disease frequently begins in your hands, feet or limbs, and then spreads to other parts of your body. As the disease advances, your muscles become progressively weaker. This weakness eventually affects chewing, swallowing, speaking and breathing.
However, ALS doesn't usually affect your bowel or bladder control, your senses, or your thinking ability. It's possible to remain actively involved with your family and friends.
CAUSES
In ALS, the nerve cells that control the movement of your muscles gradually die, so your muscles progressively weaken and begin to waste away.
ALS is inherited in 5 to 10 percent of cases. The other cases appear to occur randomly.
Researchers are studying several possible causes of ALS, including:
Gene mutation. Various genetic mutations can lead to inherited ALS, which appears nearly identical to the noninherited form.
Chemical imbalance. People with ALS generally have higher than normal levels of glutamate, a chemical messenger in the brain, around the nerve cells in their spinal fluid. Too much glutamate is known to be toxic to some nerve cells.
Disorganized immune response. Sometimes a person's immune system begins attacking some of his or her body's own normal cells, which may lead to the death of nerve cells.
Protein mishandling. Mishandled proteins within the nerve cells may lead to a gradual accumulation of abnormal forms of these proteins in the cells, eventually causing the nerve cells to die.
RISK FACTORS
Established risk factors for ALS include:
Heredity. Five to 10 percent of the people with ALS inherited it (familial ALS). In most people with familial ALS, their children have a 50-50 chance of developing the disease.
Age. ALS most commonly occurs in people between the ages of 40 and 60.
Sex. Before the age of 65, slightly more men than women develop ALS. This sex difference disappears after age 70.
It may be that in some people ALS, is triggered by certain environmental factors.
Also, some studies examining the entire human genome (genome-wide association studies) found numerous genetic variations that people with familial ALS and some people with noninherited ALS had in common. These genetic variations might make people more susceptible to ALS.
Environmental factors under study that may modify a person's individual risk of ALS include:
Smoking. Smoking cigarettes appears to increase a person's risk of ALS to almost twice that of a nonsmoker. The more years spent smoking, the greater the risk. However, quitting smoking can eventually lower the increased risk.
Lead exposure. Some evidence suggests that exposure to lead in the workplace may be associated with the development of ALS.
Military service. Recent studies indicate that people who have served in the military are at higher risk of ALS. Exactly what about military service may trigger the development of ALS is uncertain, but it may include exposure to certain metals or chemicals, traumatic injuries, viral infections and intense exertion.
COMPLICATIONS
As the disease progresses, people with ALS experience complications, which may include:
Breathing problems
Over time, ALS paralyzes the muscles needed to breathe. Some devices to assist your breathing are worn only at night and are similar to devices used by people with sleep apnea. For example, you may be given noninvasive positive pressure ventilation to assist with your breathing at night.
In the latter stages of ALS, some people choose to have a tracheostomy — a surgically created hole at the front of the neck leading to the windpipe (trachea) — to enable the full-time use of a respirator that inflates and deflates their lungs.
The most common cause of death for people with ALS is respiratory failure. On average, death occurs within three to five years after symptoms begin.
Speaking problems
Most people with ALS will develop trouble speaking over time. This usually starts as some mild slurring of words, often intermittently, but progresses over time to be more severe. With time, speech becomes more difficult for others to understand, and people with ALS often rely on other communication technologies to communicate.
Eating problems
When the muscles that control swallowing are affected, people with ALS can develop malnutrition and dehydration. They are also at higher risk of getting food, liquids or saliva into the lungs, which can cause pneumonia. A feeding tube can reduce these risks.
Dementia
Some people with ALS experience problems with memory and making decisions, and some are eventually diagnosed with a form of dementia called frontotemporal dementia.
PREPARING FOR YOUR APPOINTMENT
If you're having some of the early signs and symptoms of a neuromuscular disease such as ALS, you might first consult your family doctor, who will listen to your description of symptoms and do an initial physical examination. Then your doctor will probably refer you to a doctor trained in nervous system conditions (neurologist) for further evaluation.
What you can do
Once you're under the care of a neurologist, it may still take time to establish the diagnosis.
If you've been referred to certain medical centers, your evaluation may involve an integrated team of neurologists, and other doctors and health care professionals trained in different aspects of motor neuron disease.
Doctors will give you a comprehensive evaluation to diagnose your condition. However, this process can be stressful and frustrating unless your medical team keeps you informed. These strategies may give you a greater sense of control.
Keep a symptom diary. Before you see a neurologist, start using a calendar or notebook to jot down the time and circumstances each time you notice problems with walking, hand coordination, speech, swallowing or involuntary muscle movements. Your observations may reveal a pattern that aids diagnosis.
Find a neurologist and care team. Generally, an integrated care team led by your neurologist is most appropriate for your ALS care. Your team should communicate and be familiar with your individual needs.
An integrated team may prolong survival and improve your quality of care.
What to expect from your doctor
Your family doctor will carefully review your family's medical history and your signs and symptoms. Your neurologist and your family doctor may conduct a physical and neurological examination, which may include testing:
Reflexes
Muscle strength
Muscle tone
Senses of touch and sight
Coordination
Balance
TESTS AND DIAGNOSIS
Amyotrophic lateral sclerosis (ALS) is difficult to diagnose early because it may appear similar to several other neurological diseases. Tests to rule out other conditions may include:
Electromyogram (EMG). During an EMG, your doctor inserts a needle electrode through your skin into various muscles. The test evaluates the electrical activity of your muscles when they contract and when they're at rest.
Abnormalities in muscles seen in an electromyogram can help doctors diagnose ALS, or determine if you have a muscle or nerve condition that may be causing your symptoms. It can also help guide your exercise therapy.
Nerve conduction study. This study measures your nerves' ability to send impulses to muscles in different areas of your body. This test can determine if you have nerve damage or certain muscle diseases.
Magnetic resonance imaging (MRI). Using radio waves and a powerful magnetic field, an MRI can produce detailed images of your brain and spinal cord. An MRI can evaluate if you have spinal cord tumors, herniated disks in your neck or other conditions that may be causing your symptoms.
Blood and urine tests. Analyzing samples of your blood and urine in the laboratory may help your doctor eliminate other possible causes of your signs and symptoms.
Spinal tap (lumbar puncture). Sometimes a specialist may remove a sample of your spinal fluid for analysis. In this procedure, a specialist inserts a small needle between two vertebrae in your lower back and removes a small amount of cerebrospinal fluid for testing in the laboratory.
Muscle biopsy. If your doctor believes you may have a muscle disease rather than ALS, you may undergo a muscle biopsy. In this procedure, while you're under local anesthesia a small portion of your muscle is removed and sent to a lab for analysis.
TREATMENTS AND DRUGS
Because there's no reversing the course of amyotrophic lateral sclerosis, treatments focus on slowing the progression of symptoms, preventing unnecessary complications and making you more comfortable and independent.
Because ALS involves complex physical, mental and social issues, you may find it helpful to have an integrated team of doctors trained in many areas and other health care professionals provide your care. Having an integrated team of doctors and other health care professionals manage your ALS care may prolong your survival and improve your quality of life.
Your team will help you select the right treatments for you. You always retain the right to choose or not choose any of the treatments suggested.
Medications
The drug riluzole (Rilutek) is the only medication approved by the Food and Drug Administration for ALS. The drug appears to slow the disease's progression in some people, perhaps by reducing levels of a chemical messenger in the brain (glutamate) that's often present in higher levels in people with ALS.
Riluzole may cause side effects such as dizziness, gastrointestinal conditions and liver function changes.
Your doctor may also prescribe medications to provide relief from other symptoms, including:
Muscle cramps and spasms
Spasticity
Constipation
Fatigue
Excessive salivation
Excessive phlegm
Pain
Depression
Sleep problems
Uncontrolled outbursts of laughing or crying
Therapy
Breathing care. Over time, you'll have more difficulty breathing as your muscles become weaker. Doctors may test your breathing regularly and provide you with devices to assist your breathing at night.
In some cases, you may choose to breathe through mechanical ventilation. Doctors insert a tube in a surgically created hole at the front of your neck leading to your windpipe (tracheostomy), and the tube is connected to a respirator.
Physical therapy. A physical therapist can address pain, walking, mobility, bracing and equipment needs that help maintain your independence. Some measures include low-impact exercises to maintain your cardiovascular fitness, muscle strength and range of motion for as long as possible.
A physical therapist can also help you become accustomed to a brace, walker or wheelchair and may be able to suggest devices such as ramps that make it easier for you to get around.
Regular exercise can also help improve your sense of well-being. Appropriate stretching can help prevent pain and help your muscles function at their best.
Occupational therapy. An occupational therapist can help you compensate for hand and arm weakness in a manner that helps you to keep your independence for as long as possible. Adaptive equipment can help you to continue to perform daily activities such as dressing, grooming, eating and bathing.
An occupational therapist can also help you understand how to modify your home to allow accessibility if you become less able to walk safely.
Occupational therapists also have a good understanding of how assistive technology and computers can be used, even if your hands are weak.
Speech therapy. Because ALS affects the muscles you use to speak, communication becomes an issue as the disease progresses. A speech therapist can teach you adaptive techniques to make your speech more clearly understood. Speech therapists can also help you explore other methods of communication, such as an alphabet board or simple pen and paper.
Later in disease progression, a speech therapist can recommend devices such as tablet computers with text-to-speech applications or computer-based equipment with synthesized speech that may help you communicate. Ask your therapist about the possibility of borrowing or renting these devices.
Nutritional support. Your team will work with you and your family members to ensure you're eating foods that are easier to swallow and meet your nutritional needs. You may eventually need a feeding tube.
Psychological and social support. Your team may include a social worker to help with financial issues, insurance, and getting equipment and paying for devices you may need. Psychologists, social workers and others may provide emotional support for you and your family.
COPING AND SUPPORT
Learning you have ALS can be devastating. The following tips may help you and your family cope:
Take time to grieve. The news that you have a fatal condition that will reduce your mobility and independence can be difficult to absorb. If you are newly diagnosed, you and your family will likely experience a period of mourning and grief.
Be hopeful. Your team will help you focus on your ability and healthy living. Some people with amyotrophic lateral sclerosis live much longer than the three to five years usually associated with this condition. Some live 10 years or more. Maintaining an optimistic outlook can help improve quality of life for people with ALS.
Think beyond the physical changes. Many people with amyotrophic lateral sclerosis lead rich, rewarding lives despite physical limitations. Try to think of ALS as only one part of your life, not your entire identity.
Join a support group. You may find comfort in sharing your concerns in a support group with others who have ALS. Your family members and friends helping with your care also may benefit from a support group of others who care for people with amyotrophic lateral sclerosis. Find support groups in your area by talking to your doctor or by contacting the ALS Association.
Make decisions now about your future medical care. Planning for the future allows you to be in control of decisions about your life and your care.
With the help of your doctor, hospice nurse or social worker, you can decide whether you want certain life-extending procedures.
You can also determine where you want to spend your final days. You may consider hospice care options. Planning for the future can help you and your loved ones put to rest some common anxieties.
ANAL CANCER
ANAL CANCER
Anal Cancer
Anal cancer is an uncommon type of cancer that occurs in the anal canal. The anal canal is a short tube at the end of your rectum through which stool leaves your body.
Anal cancer can cause signs and symptoms such as rectal bleeding and anal pain.
Most people with anal cancer are treated with a combination of chemotherapy and radiation. Though combining anal cancer treatments increases the chance of a cure, the combined treatments also increase the risk of side effects.
SYMPTOMS
Anal cancer signs and symptoms include:
Bleeding from the anus or rectum
Pain in the area of the anus
A mass or growth in the anal canal
Anal itching
When to see a doctor
Talk to your doctor about any signs and symptoms that bother you, especially if you have any factors that increase your risk of anal cancer.
CAUSES
Anal cancer forms when a genetic mutation turns normal, healthy cells into abnormal cells. Healthy cells grow and multiply at a set rate, eventually dying at a set time. Abnormal cells grow and multiply out of control, and they don't die. The accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby tissues and can separate from an initial tumor to spread elsewhere in the body (metastasize).
Anal cancer is closely related to a sexually transmitted infection called human papillomavirus (HPV). Evidence of HPV is detected in the majority of anal cancers. HPV is thought to be the most common cause of anal cancers.
RISK FACTORS
Several factors have been found to increase the risk of anal cancer, including:
Older age. Most cases of anal cancer occur in people age 50 and older.
Many sexual partners. Men and women who have many sexual partners over their lifetimes have a greater risk of anal cancer.
Anal sex. Men and women who engage in anal sex have an increased risk of anal cancer.
Smoking. Smoking cigarettes may increase your risk of anal cancer.
Human papillomavirus (HPV). HPV infection increases your risk of several cancers, including anal cancer and cervical cancer. HPV infection is a sexually transmitted infection that can also cause genital warts.
Drugs or conditions that suppress your immune system. People who take drugs to suppress their immune systems (immunosuppressive drugs), including people who have received organ transplants, may have an increased risk of anal cancer. HIV — the virus that causes AIDS — suppresses the immune system and increases the risk of anal cancer.
COMPLICATIONS
Anal cancer rarely spreads (metastasizes) to distant parts of the body. Only a small percentage of tumors are found to have spread, but those that do are especially difficult to treat. Anal cancer that metastasizes most commonly spreads to the liver and the lungs.
PREPARING FOR YOUR APPOINTMENT
Make an appointment with your family doctor or a general practitioner if you have any signs or symptoms that worry you. If your doctor thinks you have anal cancer, you may be referred to a surgeon or a specialist who treats digestive diseases (gastroenterologist). Once a cancer diagnosis is made, you may also be referred to a doctor who specializes in treating cancer (oncologist).
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.
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 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 major stresses or recent life changes.
Make a list of all medications, vitamins or supplements you're taking.
Take 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 anal cancer, some basic questions to ask your doctor include:
What is the stage of my anal cancer?
What other tests do I need?
What are my treatment options?
Is there one treatment that's best for my type and stage of cancer?
What are the potential side effects for each treatment?
Should I seek a second opinion? Can you give me names of specialists you recommend?
Am I eligible for clinical trials?
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?
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may allow time later to cover points you want to address. Your doctor may ask:
When did you 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
Tests and procedures used to diagnose anal cancer include:
Examining your anal canal and rectum for abnormalities. During a digital rectal exam, your doctor inserts a gloved, lubricated finger into your rectum. He or she feels for anything unusual, such as growths.
Visually inspecting your anal canal and rectum. Your doctor may use a short, lighted tube (anoscope) to inspect your anal canal and rectum for anything unusual.
Taking sound wave pictures of your anal canal. In order to create a picture of your anal canal, your doctor inserts a probe, similar to a thick thermometer, into your anal canal and rectum. The probe emits high-energy sound waves, called ultrasound waves, which bounce off tissues and organs in your body to create a picture. Your doctor evaluates the picture to look for anything abnormal.
Removing a sample of tissue for laboratory testing. If your doctor discovers any unusual areas, he or she may take small samples of affected tissue (biopsy) and send the samples to a laboratory for analysis. By looking at the cells under a microscope, doctors can determine if the cells are cancerous.
Staging
Once it's confirmed that you have anal cancer, your doctor works to determine the size of the cancer and whether it has spread — a process called staging. Determining your cancer's stage helps your doctor determine the best approach to treating your cancer. Tests and procedures used in the staging of your cancer may include:
Computerized tomography (CT) scan
Magnetic resonance imaging (MRI)
Positron emission tomography (PET)
Your doctor uses the information from the procedures to assign your cancer a stage. The stages of anal cancer are:
Stage I. Anal cancer is 2 centimeters (about 3/4 inch) or less — about the size of a peanut or smaller.
Stage II. Anal cancer is larger than 2 centimeters (about 3/4 inch), but has not spread beyond the anal canal.
Stage IIIA. Anal cancer is any size and has spread either to lymph nodes near the rectum or to nearby areas, such as the bladder, urethra or vagina.
Stage IIIB. Anal cancer is any size and has spread to nearby areas and lymph nodes, or it has spread to other lymph nodes in the pelvis.
Stage IV. Anal cancer has spread to parts of the body away from the pelvis.
TREATMENTS AND DRUGS
What treatment you receive for anal cancer depends on the stage of your cancer, your overall health and your own preferences.
Combined chemotherapy and radiation
Doctors usually treat anal cancer with a combination of chemotherapy and radiation. Combined, these two treatments enhance each other and improve chances for a cure.
Chemotherapy. Chemotherapy drugs are injected into a vein or taken as pills. The chemicals travel throughout your body, killing rapidly growing cells, such as cancer cells. Unfortunately they also damage healthy cells that grow rapidly, including those in your gastrointestinal tract and in your hair follicles. This causes side effects such as nausea, vomiting and hair loss.
Radiation therapy. Radiation therapy uses high-powered beams, such as X-rays, to kill cancer cells. During radiation therapy, you're positioned on a table and a large machine moves around you, directing radiation beams to specific areas of your body in order to target your cancer. Radiation may damage healthy tissue near where the beams are aimed. Side effects may include skin redness and sores in and around your anus, as well as hardening and shrinking of your anal canal.
You typically undergo radiation therapy for anal cancer for five or six weeks. Chemotherapy is typically administered during the first week and the fifth week. Your doctor tailors your treatment schedule based on characteristics of your cancer and your overall health. Though combining chemotherapy and radiation increases the effectiveness of the two treatments, it also makes side effects more likely. Discuss with your doctor what side effects to expect.
Surgery
Doctors typically use different procedures to remove anal cancer based on the stage of the cancer:
Surgery to remove early-stage anal cancers. Very small anal cancers may be removed through surgery. During this procedure, the surgeon removes the tumor and a small amount of healthy tissue that surrounds it.
Because the tumors are small, early-stage cancers can sometimes be removed without damaging the anal sphincter muscles that surround the anal canal. Anal sphincter muscles control bowel movements, so doctors work to keep the muscles intact. Depending on your cancer, your doctor may also recommend chemotherapy and radiation after surgery.
Surgery for late-stage anal cancers or anal cancers that haven't responded to other treatments. If your cancer hasn't responded to chemotherapy and radiation, or if your cancer is advanced, your doctor may recommend a more extensive operation called abdominoperineal resection, which is sometimes referred to as an AP resection. During this procedure the surgeon removes the anal canal, rectum and a portion of the colon. The surgeon then attaches the remaining portion of your colon to an opening (stoma) in your abdomen through which waste will leave your body and collect in a colostomy bag.
LIFESTYLE AND HOME REMEDIES
There is no sure way to prevent anal cancer. In order to reduce your risk of anal cancer:
Practice safer sex. Abstaining from sex or practicing safe sex may help prevent HPV and HIV, two sexually transmitted viruses that may increase your risk of anal cancer. If you choose to have anal sex, use condoms.
Get vaccinated against HPV. Two vaccines — Gardasil and Cervarix — are given to protect against HPV infection. Both boys and girls can be vaccinated against HPV.
Stop smoking. Smoking increases your risk of anal cancer. Don't start smoking. Stop if you currently smoke.
ALTERNATIVE MEDICINE
Alternative medicine treatments can't cure anal cancer. But some alternative medicine treatments may help you cope with the side effects of cancer treatment. Your doctor can treat many side effects, but sometimes medications aren't enough. Alternative treatments can complement your doctor's treatments and may offer additional comfort.
Options for common side effects include:
Anxiety — massage, meditation, hypnosis, music therapy, exercise or relaxation techniques
Fatigue — gentle exercise or tai chi
Nausea — acupuncture, hypnosis or music therapy
Pain — acupuncture, massage, music therapy or hypnosis
Sleep problems — yoga or relaxation techniques
While these options are generally safe, talk with your doctor first to be sure that alternative medicine options won't interfere with your cancer treatment.
COPING AND SUPPORT
A cancer diagnosis can be overwhelming and frightening. You can help yourself to feel more in control by taking an active role in your health care. To help you cope, try to:
Learn enough about anal cancer to make decisions about your care. Ask your doctor about your anal cancer, including the stage of your cancer, your treatment options and, if you like, your prognosis. As you learn more about anal cancer, you may become more confident in making treatment decisions.
Keep friends and family close. Keeping your close relationships strong will help you deal with your anal cancer. Friends and family can provide the practical support you'll need, such as helping take care of your house if you're in the hospital. And they can serve as emotional support when you feel overwhelmed by cancer.
Find someone to talk with. Find a good listener with whom you can talk about your hopes and fears. This may be a friend or family member. The concern and understanding of a counselor, medical social worker, clergy member or cancer support group also may be helpful.
Ask your doctor about support groups in your area. Or check your phone book, library or a cancer organization, such as the National Cancer Institute or the American Cancer Society.
ANAL FISSURE
ANAL FISSURE
Anal Fissure
An anal fissure is a small tear in the thin, moist tissue (mucosa) that lines the anus. An anal fissure may occur when you pass hard or large stools during a bowel movement. Anal fissures typically cause pain and bleeding with bowel movements. You also may experience spasms in the ring of muscle at the end of your anus (anal sphincter).
Anal fissures are very common in young infants but can affect people of any age. An anal fissure usually heals on its own within four to six weeks. If it doesn't, medical treatment or surgery usually can relieve discomfort.
SYMPTOMS
Signs and symptoms of an anal fissure include:
Pain, sometimes severe, during bowel movements
Pain after bowel movements that can last up to several hours
Bright red blood on the stool or toilet paper after a bowel movement
Itching or irritation around the anus
A visible crack in the skin around the anus
A small lump or skin tag on the skin near the anal fissure
When to see a doctor
See your doctor if you have pain during bowel movements or notice blood on stools or toilet paper after a bowel movement.
CAUSES
Common causes of anal fissure include:
Passing large or hard stools
Constipation and straining during bowel movements
Chronic diarrhea
Inflammation of the anorectal area, caused by Crohn's disease or another inflammatory bowel disease
Childbirth
Less common causes of anal fissures include:
Anal cancer
HIV
Tuberculosis
Syphilis
Herpes
RISK FACTORS
Factors that may increase your risk of developing an anal fissure include:
Infancy. Many infants experience an anal fissure during their first year of life; experts aren't sure why.
Aging. Older adults may develop an anal fissure partly due to slowed circulation, resulting in decreased blood flow to the rectal area.
Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.
Childbirth. Anal fissures are more common in women after they give birth.
Crohn's disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the anal canal more vulnerable to tearing.
COMPLICATIONS
Complications of anal fissure can include:
Failure to heal. An anal fissure that fails to heal within six weeks is considered chronic and may need further treatment.
Recurrence. Once you've experienced an anal fissure, you are prone to having another one.
A tear that extends to surrounding muscles. An anal fissure may extend into the ring of muscle that holds your anus closed (internal anal sphincter), making it more difficult for your anal fissure to heal. An unhealed fissure can trigger a cycle of discomfort that may require medications or surgery to reduce the pain and to repair or remove the fissure
PREPARING FOR YOUR APPOINTMENT
If you have an anal fissure, you may be referred to a doctor who specializes in digestive diseases (gastroenterologist) or a colon and rectal surgeon.
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.
Write down questions to ask your doctor.
Questions to ask your doctor
Some basic questions to ask your doctor include:
What is likely causing my symptoms?
Are there any other possible causes for my symptoms?
Do I need any tests?
Is my condition likely temporary (acute) or chronic?
What treatments do you recommend?
Are there any dietary suggestions I should follow?
Don't hesitate to ask other questions during your appointment.
What to expect from your doctor
Your doctor may ask:
When did you begin experiencing symptoms?
Have your symptoms been continuous or occasional?
How severe are your symptoms?
Where do you feel your symptoms the most?
What, if anything, seems to improve your symptoms?
What, if anything, seems to worsen your symptoms?
Do you have any other medical conditions, such as Crohn's disease?
Do you have problems with constipation?
What you can do in the meantime
While you're waiting to see your doctor, take steps to avoid constipation, such as drinking plenty of water, adding fiber to your diet and exercising regularly. Also, avoid straining during bowel movements. The extra pressure may lengthen the fissure or create a new one.
TESTS AND DIAGNOSIS
Your doctor will likely ask about your medical history and perform a physical exam, including inspection of the anal region. Often the tear is visible. Usually this exam is all that's needed to diagnose an anal fissure.
Your doctor will probably refrain from performing a digital rectal exam, which involves inserting a gloved finger into your anal canal, because it is likely to be too painful. If anal fissure is suspected but can't be identified, your doctor may use a short, lighted tube (anoscope) to inspect your anal canal.
The fissure's location offers clues about its cause. A fissure that occurs on the side of the anal opening, rather than the back or front, is more likely to be a sign of another disorder, such as Crohn's disease. If an underlying condition is suspected, your doctor may recommend further testing:
Flexible sigmoidoscopy. A thin, flexible tube with a tiny video camera is inserted into the bottom portion of your colon. This test may be done if you're younger than 50 and have no risk factors for intestinal diseases or colon cancer.
Colonoscopy. A flexible tube is inserted into your rectum to inspect the entire colon. This test may be done if you are older than age 50 or have risk factors for colon cancer, signs of other conditions, or other symptoms such as abdominal pain or diarrhea.
TREATMENTS AND DRUGS
Anal fissures often heal within a few weeks if you take steps to keep your stool soft, such as increasing your intake of fiber and fluids. Soaking in warm water for 10 to 20 minutes several times a day, especially after bowel movements, can help relax the sphincter and promote healing.
If your symptoms persist, you'll likely need further treatment.
Nonsurgical treatments
Your doctor may recommend:
Externally applied nitrogylcerin, to help increase blood flow to the fissure and promote healing, and to help relax the anal sphincter. Nitroglycerin is generally considered the medical treatment of choice when other conservative measures fail. Side effects may include headache.
Steroid creams, to help relieve discomfort.
Botulin toxin type A (Botox) injection, to paralyze the anal sphincter muscle and relax spasms.
Blood pressure medications, which can help relax the anal sphincter. These medications may be taken by mouth or applied externally and may be used when nitroglycerin in not effective or causes significant side effects.
Surgery
If you have a chronic anal fissure that is resistant to other treatments, or if your symptoms are severe, your doctor may recommend surgery. Surgery usually involves cutting a small portion of the anal sphincter muscle to reduce spasm and pain and promote healing. Surgery has a small risk of causing incontinence.
LIFESTYLE AND HOME REMEDIES
You may be able to prevent an anal fissure by taking measures to prevent constipation. Eat high-fiber foods, drink fluids and exercise regularly to keep from having to strain during bowel movements.
ANAL ITCH
ANAL ITCH
Anal Itch
Anal itching is a common condition. The itch, situated in your anus or on the skin just around your anus, is often intense and may be accompanied by a strong urge to scratch. You may find anal itching to be embarrassing and uncomfortable.
Also called pruritus ani (proo-RIE-tus A-nie), anal itching has many causes, such as skin problems, excessive washing or hemorrhoids.
If anal itching is persistent, talk with your doctor. With proper treatment and self-care measures, most people get complete relief from anal itching.
SYMPTOMS
Anal itching may also be associated with burning and soreness. The itching and irritation may be temporary or more persistent, depending on the cause.
When to see a doctor
Most anal itching doesn't require medical care. However, see your doctor if:
Anal itching is severe or lasts longer than one to two months
There's bleeding from the rectum
You can't figure out what's causing a persistent itch
Persistent anal itching may be related to a skin condition or other health problem that requires medical treatment.
CAUSES
Possible causes of anal itching include:
Skin irritation. Friction and moisture can irritate the sensitive skin in the anal area. This irritation sometimes causes anal itching. Scents, dyes and softening agents in products such as soap and toilet paper may also trigger irritation and anal itching. Overuse of these products often aggravates the problem.
Digestive problems. Repeated bouts of diarrhea can cause anal irritation and itching. Accidental leakage of feces (fecal soiling or incontinence) is often a contributing factor.
Hemorrhoids. Hemorrhoids are engorged veins located just under the membrane that lines the lowest part of your rectum and anus. They often occur as a result of straining during a bowel movement. Anal itching can be a symptom of hemorrhoids.
Infections. Sexually transmitted infections may also involve the anus and can cause anal itching. In children, the parasite that causes pinworms can cause persistent anal itching. Adults in the same household can also be infected. Other parasites may cause similar itching. Yeast infections, which usually affect women, can also cause itching in the anal area.
Skin disease. Sometimes, anal itching is the result of a specific skin disease, such as psoriasis or contact dermatitis.
Anal tumors. Rarely, benign or cancerous tumors in or around the anus may be a cause of anal itching.
PREPARING FOR YOUR APPOINTMENT
Often, you won't need to see a doctor about anal itching. If the itching is persistent, bring it up with your primary care doctor. Depending on the cause of your anal itching, your primary care doctor may refer you to a skin specialist (dermatologist) or a doctor who specializes in treating rectal and anal problems (proctologist).
Here's some information to help you prepare for your initial appointment.
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 you're taking.
Write down questions to ask your doctor.
Preparing a list of questions for your doctor will help you make the most of your time together. For anal itching, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
What kinds of tests do I need?
Is this problem temporary?
What treatments are available? Which do you recommend?
Should I see a specialist?
Are there any brochures or other printed material that I can take home? What websites do you recommend?
What to expect from your doctor
Your doctor is likely to ask you a number of questions, including:
When did you begin experiencing symptoms?
Have your symptoms been continuous or do they come and go?
How severe are your symptoms?
Have you had recent changes in bowel habits, such as diarrhea or loose bowel movements?
What type of soap or other cleansers do you use on your body?
Does anything seem to improve your symptoms?
What, if anything, worsens your symptoms?
What you can do in the meantime
Cleanse the area gently immediately after bowel movements and dry thoroughly. Wear cotton underwear and loose clothing. Try not to scratch.
TESTS AND DIAGNOSIS
Your doctor may be able to diagnose the cause of your itching simply by asking you questions about your symptoms.
If the cause of your itching isn't obvious, your doctor may refer you to a skin specialist (dermatologist) or a doctor who specializes in treating rectal and anal problems (proctologist) for further evaluation. A rectal exam may be all that's required for you to get an answer — and a solution — to a very uncomfortable problem.
Other tests, such as proctoscopy or colonoscopy to view more of the digestive tract, are sometimes needed to identify an underlying cause of anal itching. However, the precise cause of the itching may never be identified.
TREATMENTS AND DRUGS
Treatment of anal itching depends on the cause of the problem. It may include self-care measures, changes to your diet, treatment of infections or, rarely, surgery to correct an underlying problem.
Medications
Medications that might help include:
Over-the-counter cream or ointment containing hydrocortisone (Cortaid, Preparation H Anti-Itch Cream). Apply sparingly to the affected area to reduce inflammation and itching.
A protective ointment that contains zinc oxide (Desitin, Balmex). Applied to the affected area, this also may help.
Antihistimine. If your symptoms are worse at night, your doctor may prescribe an antihistamine to reduce itching until topical treatments take effect.
Anti-parasite treatment. Several medications are available for treating pinworm infections. A single dose may cure the infection, but often a second dose is given one to two weeks later.
With proper treatment, most people experience relief from anal itching in less than a week. Anal itching that continues for more than one to two months needs to be evaluated by your doctor.
LIFESTYLE AND HOME REMEDIES
Prevention of anal itching mainly involves washing properly and avoiding irritants. If you already have anal itching, try these self-care measures:
Cleanse gently. Wash the area immediately after bowel movements. Don't scrub and avoid using soap. Instead, use a wet washcloth, wet unscented toilet paper or a small squeeze bottle of water to cleanse the area.
Dry thoroughly. After cleansing, pat the area dry with toilet paper or a towel or use a hair dryer. Cornstarch powder can help keep the area dry.
Don't scratch. Scratching further irritates your skin and leads to persistent inflammation. If you can't tolerate the itching, apply a cold compress to the area or take a lukewarm bath to find some immediate relief.
Wear cotton underwear and loose clothing. This helps keep the area dry. Avoid wearing pantyhose and other tightfitting garments because these can trap moisture.
Avoid irritants. Avoid bubble baths and genital deodorants. Cut back or avoid beverages, such as coffee or cola, and foods that you know might cause diarrhea. Avoid overuse of laxatives.
Maintain regular, firm bowel movements. If soft stools or frequent bowel movements are a problem, gradually adding fiber to your diet may help. Fiber supplements, such a Metamucil or Citrucel, also may help.
ANAPHYLAXIS
ANAPHYLAXIS
Anaphylaxis
Anaphylaxis is a severe, potentially life-threatening allergic reaction. It can occur within seconds or minutes of exposure to something you're allergic to, such as a peanut or the venom from a bee sting.
The flood of chemicals released by your immune system during anaphylaxis can cause you to go into shock; your blood pressure drops suddenly and your airways narrow, blocking normal breathing. Signs and symptoms of anaphylaxis include a rapid, weak pulse, a skin rash, and nausea and vomiting. Common triggers of anaphylaxis include certain foods, some medications, insect venom and latex.
Anaphylaxis requires an immediate trip to the emergency department and an injection of epinephrine. If anaphylaxis isn't treated right away, it can lead to unconsciousness or even death.
SYMPTOMS
Anaphylaxis symptoms usually occur within minutes of exposure to an allergen. Sometimes, however, anaphylaxis can occur a half-hour or longer after exposure. Anaphylaxis symptoms include:
Skin reactions, including hives along with itching, and flushed or pale skin (almost always present with anaphylaxis)
A feeling of warmth
The sensation of a lump in your throat
Constriction of the airways and a swollen tongue or throat, which can cause wheezing and trouble breathing
A weak and rapid pulse
Nausea, vomiting or diarrhea
Dizziness or fainting
When to see a doctor
Seek emergency medical help if you, your child or someone else you're with has a severe allergic reaction.
If the person having the attack carries an epinephrine autoinjector (such as an EpiPen or EpiPen Jr), give him or her a shot right away. Even if symptoms improve after an emergency epinephrine injection, a visit to the emergency department is still necessary to make sure symptoms don't return.
Make an appointment to see your doctor if you or your child has had a severe allergy attack or any signs and symptoms of anaphylaxis in the past.
The diagnosis and long-term management of anaphylaxis are complicated, so you'll probably need to see a doctor who specializes in allergies and immunology.
CAUSES
Your immune system produces antibodies that defend against foreign substances. This is good when a foreign substance is harmful (such as certain bacteria or viruses). But some people's immune systems overreact to substances that shouldn't cause an allergic reaction. When this occurs, the immune system sets off a chemical chain reaction, leading to allergy symptoms. Normally, allergy symptoms aren't life-threatening. But some people have a severe allergic reaction that can lead to anaphylaxis. Even if you or your child has had only a mild anaphylactic reaction in the past, there's still a risk of more severe anaphylaxis.
A number of allergens can trigger anaphylaxis, depending on what you're allergic to.
Common anaphylaxis triggers include:
Certain medications, especially penicillin
Foods, such as peanuts, tree nuts (walnuts, pecans, almonds, cashews), wheat (in children), fish, shellfish, milk and eggs
Insect stings from bees, yellow jackets, wasps, hornets and fire ants
Less common causes of anaphylaxis include:
Latex
Medications used in anesthesia
Exercise
Anaphylaxis symptoms are sometimes caused by aspirin and other drugs — such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve, Midol Extended Relief) — and the intravenous (IV) contrast used in some X-ray imaging tests. Although similar to allergy-induced anaphylaxis, this type of reaction isn't triggered by allergy antibodies.
Anaphylaxis triggered by exercise is not common and varies from person to person. In some people, aerobic activity, such as jogging, triggers anaphylaxis. In others, less intense physical activity, such as walking, can trigger a reaction. Eating certain foods before exercise or exercising when the weather is hot, cold or humid also has been linked to anaphylaxis in some people. Talk with your doctor about any precautions you should take when exercising.
If you don't know what triggers your allergy attack, your doctor may do tests to try to identify the offending allergen. In some cases, the cause of anaphylaxis is never identified. This is known as idiopathic anaphylaxis.
RISK FACTORS
There aren't many known risk factors for anaphylaxis, but some things that may increase your risk include:
A personal history of anaphylaxis. If you've experienced anaphylaxis once, your risk of having this serious reaction increases. Future reactions may be more severe than the first reaction.
Allergies or asthma. People who have either condition are at increased risk of having anaphylaxis.
A family history. If you have family members who've experienced exercise-induced anaphylaxis, your risk of developing this type of anaphylaxis is higher than it is for someone without a family history.
COMPLICATIONS
An anaphylactic reaction can be life-threatening when a severe attack occurs; it can stop breathing or stop your heartbeat. In this case, you'll need cardiopulmonary resuscitation (CPR) and other emergency treatment right away.
TESTS AND DIAGNOSIS
Your doctor will ask you questions about your allergies or any previous allergic reactions you've had. This evaluation will include questions about:
Whether any particular foods seem to cause a reaction
Any medications you take, and if certain medications seem linked to your symptoms
Whether you've had allergy symptoms when your skin has been exposed to latex
Whether stings from any particular type of insect seem to cause your symptoms
To help confirm the diagnosis:
You may be tested for allergies with skin tests or blood tests
You may also be asked to keep a detailed list of what you eat or to stop eating certain foods for a time
Your doctor will want to rule out other conditions as a possible cause of your symptoms, including:
Seizure disorders
A condition other than allergies that causes flushing or other skin symptoms
Mastocytosis, an immune system disorder
Psychological issues, such as panic attacks
Heart or lung problems
TREATMENTS AND DRUGS
During an anaphylactic attack, an emergency medical team may perform cardiopulmonary resuscitation (CPR) if you stop breathing or your heart stops beating. You may be given medications including:
Epinephrine (adrenaline) to reduce your body's allergic response
Oxygen, to help compensate for restricted breathing
Intravenous (IV) antihistamines and cortisone to reduce inflammation of your air passages and improve breathing
A beta-agonist (such as albuterol) to relieve breathing symptoms
What to do in an emergency
If you're with someone who is having an allergic reaction and shows signs of shock caused by anaphylaxis, act fast. Signs and symptoms of shock caused by anaphylaxis include pale, cool and clammy skin, weak and rapid pulse, trouble breathing, confusion, and loss of consciousness. Even if you're not sure symptoms are caused by anaphylaxis, take the following steps immediately:
Call 911 or emergency medical help.
Get the person in a comfortable position and elevate his or her legs.
Check the person's pulse and breathing and, if necessary, administer CPR or other first-aid measures.
Give medications to treat an allergy attack, such as an epinephrine autoinjector or antihistamines, if the person has them.
Using an autoinjector
Many people at risk of anaphylaxis carry an autoinjector. This device is a combined syringe and concealed needle that injects a single dose of medication when pressed against your thigh. Always be sure to replace epinephrine before its expiration date, or it may not work properly.
Be sure you know how to use the autoinjector. Also, make sure the people closest to you know how to administer the drug — if they're with you during an anaphylactic emergency, one of them could save your life. Medical personnel called in to respond to a severe anaphylactic reaction also may give you an epinephrine injection or another medication to treat your symptoms.
Long-term treatment
If your anaphylactic reaction is triggered by insect stings, you may be able to get a series of allergy shots (immunotherapy) to reduce your body's allergic response and prevent a severe reaction in the future.
Unfortunately, in most other cases there's no way to treat the underlying immune system condition that can lead to anaphylaxis. But you can take steps to prevent a future attack — and be prepared in the event one does occur.
Avoid your known allergy triggers as much as you can.
You may need to carry self-administered epinephrine. During an anaphylactic attack, you can give yourself the drug using an autoinjector (EpiPen, EpiPen Jr or Twinject).
Your doctor may recommend taking prednisone or antihistamines.
LIFESTYLE AND HOME REMEDIES
The best way to prevent anaphylaxis is to avoid substances that you know cause this severe reaction. Follow these steps:
Wear a medical alert necklace or bracelet to indicate if you have an allergy to specific drugs or other substances.
Alert your doctor to your drug allergies before having any medical treatment. If you receive allergy shots, always wait at least 30 minutes before leaving the clinic so that you can receive immediate treatment if you have a severe reaction after the allergy shot.
Keep a properly stocked emergency kit with prescribed medications available at all times. Your doctor can advise you on the appropriate contents. This may include an epinephrine autoinjector. Make sure your autoinjector has not expired; these medications generally last 18 months.
If you're allergic to stinging insects, exercise caution when they're nearby. Wear long-sleeved shirts and pants and don't wear sandals or walk barefoot in the grass. Avoid bright colors and don't wear perfumes or colognes. Stay calm if you are near a stinging insect. Move away slowly and avoid slapping at the insect.
If you have specific food allergies, carefully read the labels of all the foods you buy and eat. Manufacturing processes can change, so it's important to periodically recheck the labels of foods you commonly eat. When eating out, ask about ingredients in the food, and ask about food preparation because even small amounts of the food that you're allergic to can cause a serious reaction.
COPING AND SUPPORT
Having a potentially life-threatening reaction is frightening, whether it happens to you, others close to you or your child. Developing an anaphylaxis emergency action plan may help put your mind at ease. Work with your own or your child's doctor to develop this written step-by-step plan of what to do in the event of a reaction. That way, you'll know exactly what you need to do if anaphylaxis occurs, and you'll have a written plan that you can share with teachers, baby sitters and other caregivers so that they'll know what they need to do, too.
If your child has experienced anaphylaxis, talk to his or her school nurse and teachers to find out what plans they have in place for dealing with an emergency. Make sure school officials have a current autoinjector in case your child needs treatment.
ANEMIA
ANEMIA
Vitamin deficiency anemia is a lack of healthy red blood cells caused by lower than normal amounts of certain vitamins. Vitamins linked to vitamin deficiency anemia include folate, vitamin B-12 and vitamin C.
Vitamin deficiency anemia can occur if you don't eat enough folate, vitamin B-12 or vitamin C. Or vitamin deficiency anemia can occur if your body has trouble absorbing or processing these vitamins.
Not all anemias are caused by a vitamin deficiency. Other causes include iron deficiency and certain blood diseases. That's why it's important to have your doctor diagnose and treat your anemia. Vitamin deficiency anemia can usually be corrected with vitamin supplements and changes to your diet.
SYMPTOMS
Signs and symptoms of vitamin deficiency anemia include:
Fatigue
Shortness of breath
Dizziness
Pale or yellowish skin
Irregular heartbeats
Weight loss
Numbness or tingling in your hands and feet
Muscle weakness
Personality changes
Unsteady movements
Mental confusion or forgetfulness
Vitamin deficiencies usually develop slowly over several months to years. Vitamin deficiency symptoms may be subtle at first, but they increase as the deficiency worsens.
CAUSES
Vitamin deficiency anemia occurs when your body doesn't have enough of the vitamins needed to produce adequate numbers of healthy red blood cells. Red blood cells carry oxygen from your lungs throughout your body. If your diet is lacking in certain vitamins, vitamin deficiency anemia can develop. Or vitamin deficiency anemia may develop because your body can't properly absorb the nutrients from the foods you eat.
Causes of vitamin deficiency anemias, also known as megaloblastic anemias, include:
Folate deficiency anemia. Folate, also known as vitamin B-9, is a nutrient found mainly in fruits and leafy green vegetables. A diet consistently lacking in these foods can lead to a deficiency.
An inability to absorb folate from food can also lead to a deficiency. Most nutrients from food are absorbed in your small intestine. People with diseases of the small intestine, such celiac disease, or those who have had a large part of the small intestine surgically removed or bypassed may have difficulty absorbing folate or its synthetic form, folic acid. Alcohol decreases absorption of folate, so drinking alcohol to excess may lead to a deficiency. Certain prescription drugs, such as some anti-seizure medications, can interfere with absorption of this nutrient.
Pregnant women and women who are breast-feeding have an increased demand for folate, as do people undergoing hemodialysis for kidney disease. Failure to meet this increased demand can result in a deficiency.
Vitamin B-12 deficiency anemia (pernicious anemia). Vitamin B-12 deficiency can result from a diet lacking in vitamin B-12, which is found mainly in meat, eggs and milk. Vitamin B-12 deficiency anemia can also occur if your small intestine can't absorb vitamin B-12. This may be due to surgery to your stomach or small intestine (such as gastric bypass surgery), abnormal bacterial growth in your small intestine, or an intestinal disease, such as Crohn's disease or celiac disease, that interferes with absorption of the vitamin. Vitamin B-12 deficiency can also be caused by a tapeworm ingested from contaminated fish because the tapeworm saps nutrients from your body. However, a vitamin B-12 deficiency is most often due to a lack of a substance called intrinsic factor.
Intrinsic factor is a protein secreted by the stomach that joins vitamin B-12 in the stomach and escorts it through the small intestine to be absorbed by your bloodstream. Without intrinsic factor, vitamin B-12 can't be absorbed and leaves your body as waste. Lack of intrinsic factor may be due to an autoimmune reaction in which your immune system mistakenly attacks the stomach cells that produce it. Vitamin B-12 deficiency anemia caused by a lack of intrinsic factor is called pernicious anemia.
Vitamin C deficiency anemia. Vitamin C deficiency can develop if you don't get enough vitamin C from the foods you eat. Vitamin C deficiency is also possible if something impairs your ability to absorb vitamin C from food. For instance, smoking impairs your body's ability to absorb vitamin C.
RISK FACTORS
Risk factors for vitamin deficiency anemia vary by type of vitamin deficiency.
Folate deficiency anemia
Your risk of folate deficiency anemia may be increased if:
You're pregnant, and you aren't taking a multivitamin containing folic acid.
You have intestinal problems that interfere with absorption of folate.
You abuse alcohol because alcohol interferes with the absorption of folate.
You take certain prescription medications, such as some anti-seizure drugs, that can block absorption of folate.
You're undergoing hemodialysis for kidney failure. Ask your doctor whether you need supplemental folic acid to prevent a deficiency.
You're undergoing cancer treatment. Some drugs used to treat cancer can interfere with the metabolism of folate.
You don't eat many fruits and vegetables. If your diet is greatly lacking in fresh fruits and vegetables, or you consistently overcook your food, you may be at risk of folate deficiency anemia.
Vitamin B-12 deficiency anemia (pernicious anemia)
Your risk of vitamin B-12 deficiency anemia may be increased if:
You don't eat meat and dairy products, foods that contain a lot of vitamin B-12. Vegetarians who don't eat dairy products and vegans, who don't eat any foods from animals, may fall into this category.
You have an intestinal disease or abnormal bacterial growth in your stomach or have had surgery to your intestines or stomach that interferes with the absorption of vitamin B-12.
You lack intrinsic factor. Most people with a vitamin B-12 deficiency anemia lack intrinsic factor — a protein secreted by the stomach that is necessary for absorption of vitamin B-12. Lack of intrinsic factor may be due to an autoimmune reaction, or it may be inherited.
You take certain medications. Antacids and some drugs used to treat type 2 diabetes may interfere with B-12 absorption.
You have another autoimmune disorder. People with endocrine-related autoimmune disorders, such as diabetes or thyroid disease, may have an increased risk of developing a specific type of vitamin B-12 deficiency anemia called pernicious anemia.
Vitamin C deficiency anemia
Your risk of vitamin C deficiency anemia may be increased if:
You're malnourished and you're not getting the nutrients and vitamins you need.
You smoke. Smoking can lead to vitamin C deficiency because it decreases the absorption of this vitamin.
You abuse alcohol. People who drink heavily don't absorb vitamin C as effectively, putting them at risk of vitamin C deficiency anemia.
You have a chronic illness. Certain chronic illnesses, such as cancer or chronic kidney disease, increase your risk of vitamin D deficiency anemia by affecting the absorption of vitamin C.
COMPLICATIONS
Being deficient in vitamins increases your risk of many health problems:
Pregnancy complications. Pregnant women with folate deficiency may be more likely to experience complications, such as premature birth. A developing fetus that doesn't get enough folate from its mother can develop birth defects of the brain and spinal cord. If you're thinking of becoming pregnant, ask your doctor whether you should consider taking folic acid supplements so that your body's stores of folate will be enough to support your baby.
Nervous system disorders. While vitamin B-12 is important for the production of red blood cells, it's also important for a healthy nervous system. Untreated, vitamin B-12 deficiency can lead to neurological problems, such as persistent tingling in your hands and feet or problems with balance. It can lead to mental confusion and forgetfulness because vitamin B-12 is necessary for healthy brain function. Without treatment for vitamin B-12 deficiency, neurological complications can become permanent. Vitamin B-12 deficiency can cause these and other health problems before it leads to anemia.
Scurvy. Vitamin C deficiency can lead to scurvy. Signs and symptoms of this rare disease include bleeding under the skin and around the gums.
PREPARING FOR YOUR APPOINTMENT
If you suspect that you have a vitamin deficiency anemia, you're likely to start by seeing your family doctor or a general practitioner. However, in some cases, you may be referred to a doctor who specializes in treating blood disorders (hematologist).
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.
Write down key personal information, including any major stresses or recent life changes.
Make a list of all medications as well as any vitamins or supplements you're taking.
Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. For vitamin deficiency anemia, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
Could anything else be causing my symptoms?
Is my condition likely temporary or long lasting?
What treatment do you recommend?
Are there any alternatives to the approach that you're suggesting?
I have another health condition. How can I best manage these conditions together?
Are there any foods I need to add to my diet?
Are there any brochures or other material that I can take 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 anytime that 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 reserve time to go over points you want to spend more time on. Your doctor may ask:
When did you begin experiencing symptoms?
How severe are your symptoms?
Does anything seem to improve your symptoms?
What, if anything, appears to worsen your symptoms?
Are you a vegetarian?
How many servings of fruits and vegetables do you usually eat in a day?
Do you drink alcohol? If so, how often, and how many drinks do you usually have?
Are you a smoker?
TESTS AND DIAGNOSIS
Doctors diagnose vitamin deficiency anemias through blood tests that check:
The number and appearance of red blood cells. People with anemia have fewer red blood cells than normal. In vitamin deficiency anemias related to a lack of vitamin B-12 and folate, the red blood cells appear large and underdeveloped. In advanced deficiencies, the numbers of white blood cells and platelets also might be decreased and look abnormal under a microscope.
The amount of folate, vitamin B-12 and vitamin C in your blood. Folate and vitamin B-12 levels are measured at the same time because these deficiencies can cause similar signs and symptoms.
Additional tests for B-12 deficiency
If blood tests reveal a vitamin deficiency, your doctor may perform other tests to determine the type and cause, such as:
Antibodies test. Your doctor may draw a sample of your blood to check for antibodies to intrinsic factor. Their presence indicates pernicious anemia.
Methylmalonic acid test. You may undergo a blood test to measure the presence of a substance called methylmalonic acid. The level of this substance is higher in people with vitamin B-12 deficiency.
Schilling test. In this test, you first ingest a tiny amount of radioactive vitamin B-12. Then your blood is checked to see if your body absorbed the vitamin B-12. After that, you ingest a combination of radioactive vitamin B-12 and intrinsic factor. If the radioactive B-12 is absorbed only when taken with intrinsic factor, it confirms that you lack your own intrinsic factor.
TREATMENTS AND DRUGS
Treatment for vitamin deficiency anemia includes supplements and changes in diet.
Folate deficiency anemia. Treatment involves eating a healthy diet and taking folic acid supplements as prescribed by your doctor. In most cases, folic acid supplements are taken orally. Once your body's level of folate increases to normal, you may be able to stop taking the supplements. But if the cause of your folate deficiency can't be corrected, you may need to take folic acid supplements indefinitely.
Vitamin B-12 deficiency anemia (pernicious anemia). For milder cases of vitamin B-12 deficiency, treatment may involve changes to your diet and vitamin B-12 supplements in pill form or as a nasal spray. Your doctor may suggest vitamin B-12 injections, particularly if your vitamin B-12 deficiency is severe. At first, you may receive the shots as often as every other day. Eventually, you'll need injections just once a month, which may continue for life, depending on your situation.
Vitamin C deficiency anemia. Treatment for anemia related to vitamin C deficiency is with vitamin C tablets. Additionally, you increase your intake of foods and beverages that contain vitamin C.
LIFESTYLE AND HOME REMEDIES
Choose a healthy diet
You can prevent some forms of vitamin deficiency anemias by choosing a healthy diet that includes a variety of foods.
Foods rich in folate include:
Dark green leafy vegetables
Nuts
Enriched grain products, such as bread, cereal, pasta and rice
Fruits and fruit juices
Foods rich in vitamin B-12 include:
Eggs
Fortified foods, such as breakfast cereals
Milk, cheese and yogurt
Red and white meats and shellfish
Foods rich in vitamin C include:
Broccoli
Citrus fruits and juices
Strawberries
Sweet peppers
Tomatoes
Most adults need these daily dietary amounts of the following vitamins:
Vitamin B-12, 2.4 micrograms (mcg)
Folate or folic acid, 400 mcg
Vitamin C, 75 to 90 milligrams
Pregnant and breast-feeding women may require more of each vitamin.
Consider a multivitamin
If you're concerned about getting enough vitamins from the food you eat, ask your doctor whether a multivitamin may be right for you. Most people get enough vitamins from the foods they eat. But if your diet is restricted, you may wish to take a multivitamin.
Don't smoke
Smoking interferes with the absorption of nutrients, such as vitamin C, so it can raise your risk of a vitamin deficiency. If you smoke, quit. If you don't smoke, don't start. If you've tried to quit on your own and haven't been successful, talk with your doctor about strategies to help you quit.
Drink alcohol in moderation, if at all
Alcohol can contribute to vitamin deficiency anemia. If you choose to drink alcohol, do so in moderation. For healthy adults, moderate drinking is generally considered to be:
Two drinks a day for men age 65 and younger
One drink a day for men older than age 65
One drink a day for women of any age
A drink is 12 ounces (355 milliliters) of beer, 5 ounces (148 milliliters) of wine or 1.5 ounces (44 milliliters) of 80-proof distilled spirits.
ANEURYSM
ANEURYSM
Aneurysm
An aneurysm is an abnormal bulge or ballooning in your blood vessels.
You may have one of several types of aneurysms, including:
Aortic aneurysm. An aortic aneurysm forms in your aorta, a major blood vessel about the size of a garden hose. Your aorta carries blood from your heart to your vital organs. You may not know you have an aneurysm because they usually don't cause symptoms, even when they are large. However, an aneurysm can burst (rupture) or split (dissect), causing internal bleeding and often leading to death.
Abdominal aortic aneurysms form along the aorta in the section that passes through your abdomen. Thoracic aortic aneurysms form along the aorta in the section that passes through your chest area. Thoracoabdominal aortic aneurysms form along the section of the aorta between your chest area and abdomen.
Brain aneurysm. A brain aneurysm occurs in a blood vessel supplying your brain, usually at branching points of arteries. The weakened area forms a small sac or balloon that fills with blood. Brain aneurysms can rupture and cause bleeding into your brain, resulting in a subarachnoid hemorrhage.
Some small brain aneurysms, especially those located on the arteries in the front part of your brain, have a low risk of rupture. Doctors will assess the size, location and appearance of the aneurysm to clarify the risk of rupture. Medical and family history also can help clarify the risk. Doctors will then compare that risk to the risk of treatment and decide whether to manage or treat the aneurysm.
Peripheral aneurysm. A peripheral aneurysm forms in other blood vessels in your body, including arteries in your legs, groin or neck.
ANGELMAN SYNDROME
ANGELMAN SYNDROME
Angelman syndrome
Angelman syndrome is a genetic disorder that causes developmental disabilities and neurological problems, such as difficulty speaking, balancing and walking, and, in some cases, seizures. Frequent smiles and outbursts of laughter are common for people with Angelman syndrome, and many have happy, excitable personalities.
Angelman syndrome usually isn't detected until parents begin to notice developmental delays when a baby is about 6 to 12 months old. Seizures often begin when a child is between 2 and 3 years old.
People with Angelman syndrome tend to live a normal life span. But they may become less excitable and develop sleep problems that may improve with age. Treatment focuses on managing medical and developmental issues.
SYMPTOMS
Characteristic Angelman syndrome signs and symptoms include:
Developmental delays, such as lack of crawling or babbling at 6 to 12 months, and intellectual disability
Lack of or minimal speech
Inability to walk, move or balance well (ataxia)
Frequent smiling and laughter
Happy, excitable personality
People who have Angelman syndrome may also have other signs and symptoms, including:
Seizures, usually beginning between 2 and 3 years of age
Stiff or jerky movements
Small head size, with flatness in the back of the head (microbrachycephaly)
Tongue thrusting
Light pigmentation in hair, skin and eyes (hypopigmentation)
Unusual behaviors, such as hand flapping and arms uplifted while walking
When to see a doctor
Most babies with Angelman syndrome don't show signs or symptoms of the disorder when they're born. The first signs of Angelman syndrome are usually developmental delays, such as lack of crawling or babbling, between 6 and 12 months.
If your child seems to have developmental delays or if your child has other signs or symptoms of Angelman syndrome, make an appointment with your child's doctor.
CAUSES
Angelman syndrome is a genetic disorder, most often caused by problems with a gene located on chromosome 15 called the ubiquitin protein ligase E3A (UBE3A) gene.
A missing or defective gene
You receive your genes, which occur in pairs, from your parents — one copy from your mother (maternal copy) and the other from your father (paternal copy). Your cells typically use information from both copies, but in a small number of genes, only one copy is active.
Normally, only the maternal copy of the UBE3A gene is active in the brain. Most cases of Angelman syndrome occur when part of the maternal copy is missing or damaged. In a few cases, Angelman syndrome is caused when two paternal copies of the gene are inherited, instead of one from each parent.
RISK FACTORS
Angelman syndrome is rare. In most cases, researchers don't know what causes the genetic changes that result in Angelman syndrome. Most people with Angelman syndrome don't have a family history of the disease.
In a small percentage of cases, however, Angelman syndrome may be inherited from a parent, so a family history of the disease may increase a baby's risk of developing Angelman syndrome.
COMPLICATIONS
Complications associated with Angelman syndrome include:
Feeding difficulties. An inability to coordinate sucking and swallowing may cause feeding problems during the infant's early months. Your pediatrician may recommend a high-calorie formula to help your baby gain weight.
Hyperactivity. Moving quickly from one activity to another, short attention span, and keeping hands or a toy in their mouths may characterize children with Angelman syndrome. Hyperactivity often decreases with age, and medication usually isn't necessary.
Sleep disorders. People with Angelman syndrome often have abnormal sleep-wake patterns and need less sleep than normal. In some cases, sleep difficulties may improve with age. Medication and behavior therapy may help control sleep disorders.
Curving of the spine (scoliosis). Some people with Angelman syndrome develop an abnormal side-to-side spinal curvature over time.
Obesity. Older children with Angelman syndrome tend to have large appetites, which may lead to obesity.
PREPARING FOR YOUR APPOINTMENT
Call your doctor if your baby or child isn't reaching expected developmental milestones or has other signs or symptoms common to Angelman syndrome. Your doctor may then refer you to a doctor who specializes in conditions that affect the brain and nervous system (neurologist).
Here's some information to help you get ready for your appointment.
What you can do
Write down signs or symptoms you've noticed in your child, and for how long.
Bring baby books and other records of your child's development to the appointment. Photographs and video recordings can be helpful.
List your child's key medical information, including other conditions for which your child is being treated, and the names of medications, vitamins or supplements that he or she takes.
Ask a family member or friend to join you for your child's appointment. If your child's doctor mentions the possibility of a developmental disorder, you may have great difficulty focusing on anything the doctor says next. Take someone along who can offer emotional support and can help you remember the information.
Write down questions to ask your doctor.
Questions to ask your child's doctor include:
What is likely causing my child's signs and symptoms?
Are there other possible causes for these signs and symptoms?
What tests does my child need?
Should my child see a specialist?
Questions to ask a specialist include:
Does my child have Angelman syndrome?
What are the possible complications of this condition?
What therapies are available?
What treatment do you recommend?
What is the long-term outlook for my child?
Should my child or I be tested for the genetic mutations associated with this condition?
What other specialists should my child see?
How can I find other families who are coping with Angelman syndrome?
Don't hesitate to ask other questions, as well.
What to expect from your doctor
A doctor who sees your child for possible Angelman syndrome is likely to ask you a number of questions, such as:
What are your child's signs and symptoms and when did you notice them?
Does your child have feeding problems?
Is your child reaching the expected, age-related physical milestones?
Have you noticed problems with balance, coordination or movement?
Does your child laugh, smile or express excitement more often than his or her peers?
Does your child express excitement with unusual physical behaviors, such as hand flapping?
Does your child communicate verbally?
How well does your child sleep?
Has your child had seizures? If so, how often?
Have any of your child's first-degree relatives — such as a parent or sibling — been diagnosed with Angelman syndrome?
TESTS AND DIAGNOSIS
Your child's doctor may suspect Angelman syndrome if your child has developmental delays and other signs and symptoms of the disorder, such as problems with movement and balance, small head size, flatness in the back of the head, and frequent laughter.
Confirming a diagnosis of Angelman syndrome requires taking a blood sample from your child for genetic studies. A combination of genetic tests can reveal the chromosome defects related to Angelman syndrome. These tests may look at:
Parental DNA pattern. This test, known as a DNA methylation test, screens for three of the four known genetic mechanisms that cause Angelman syndrome.
Missing chromosomes. Either a fluorescence in situ hybridization (FISH) test or a comparative genomic hybridization test (CGH) can show if portions of chromosomes are missing.
Gene mutation. Rarely, Angelman syndrome may occur when a person's maternal copy of the UBE3A gene is active, but mutated. If results from a DNA methylation test are normal, your child's doctor may order a UBE3A gene sequencing test to look for a maternal mutation.
TREATMENTS AND DRUGS
There's no cure for Angelman syndrome. Research is focusing on targeting specific genes for treatment. For now, treatment focuses on managing the medical and developmental issues.
A team of health care professionals will likely work with you to manage your child's condition. Depending on your child's signs and symptoms, treatment for Angelman syndrome may involve:
Anti-seizure medication to control seizures
Physical therapy to help with walking and movement problems
Communication therapy, which may include sign language and picture communication
Behavior therapy to help overcome hyperactivity and a short attention span and to aid in development
LIFESTYLE AND HOME REMEDIES
In rare cases, Angelman syndrome may be passed from affected parent to child through defective genes. If you're concerned about a family history of Angelman syndrome, or if you already have a child with Angelman syndrome, consider talking to your doctor or a genetic counselor for help planning future pregnancies.
COPING AND SUPPORT
Finding out that your child has Angelman syndrome can be overwhelming. You may not know what to expect, and you may worry about your ability to care for a child with medical concerns and developmental disabilities. There are resources that can help.
Work with a team
Find a team of doctors and therapists you trust to help you with important decisions about your child's care and treatment. These professionals can also help identify and evaluate appropriate resources in your area.
Consider a support group
Connecting with other families facing similar challenges may help you feel less alone. Ask your child's doctor for information about support groups and other helpful organizations in your area.
ANGINA PECTORIS
ANGINA PECTORIS
Angina Pectoris
Angina is a term used for chest pain caused by reduced blood flow to the heart muscle. Angina (an-JIE-nuh or AN-juh-nuh) is a symptom of coronary artery disease. Angina is typically described as squeezing, pressure, heaviness, tightness or pain in your chest.
Angina, also called angina pectoris, can be a recurring problem or a sudden, acute health concern.
Angina is relatively common but can be hard to distinguish from other types of chest pain, such as the pain or discomfort of indigestion. If you have unexplained chest pain, seek medical attention right away.
SYMPTOMS
Symptoms associated with angina include:
Chest pain or discomfort
Pain in your arms, neck, jaw, shoulder or back accompanying chest pain
Nausea
Fatigue
Shortness of breath
Sweating
Dizziness
The chest pain and discomfort common with angina may be described as pressure, squeezing, fullness or pain in the center of your chest. Some people with angina symptoms describe angina as feeling like a vise is squeezing their chest or feeling like a heavy weight has been placed on their chest. For others, it may feel like indigestion.
The severity, duration and type of angina can vary. It's important to recognize if you have new or changing chest discomfort. New or different symptoms may signal a more dangerous form of angina (unstable angina) or a heart attack.
Stable angina is the most common form of angina, and it typically occurs with exertion and goes away with rest. If chest discomfort is a new symptom for you, it's important to see your doctor to find out what's causing your chest pain and to get proper treatment. If your stable angina gets worse or changes, seek medical attention immediately.
Characteristics of stable angina
Develops when your heart works harder, such as when you exercise or climb stairs
Can usually be predicted and the pain is usually similar to previous types of chest pain you've had
Lasts a short time, perhaps five minutes or less
Disappears sooner if you rest or use your angina medication
Characteristics of unstable angina (a medical emergency)
Occurs even at rest
Is a change in your usual pattern of angina
Is unexpected
Is usually more severe and lasts longer than stable angina, maybe as long as 30 minutes
May not disappear with rest or use of angina medication
Might signal a heart attack
Angina in women
A woman's angina symptoms can be different from the classic angina symptoms. For example, women often experience symptoms such as nausea, shortness of breath, abdominal pain or extreme fatigue, with or without chest pain. Or a woman may feel discomfort in her neck, jaw or back or stabbing pain instead of the more typical chest pressure. These differences may lead to delays in seeking treatment.
When to see a doctor
If your chest pain lasts longer than a few minutes and doesn't go away when you rest or take your angina medications, it may be a sign you're having a heart attack. Call 911 or emergency medical help. Arrange for transportation. Only drive yourself to the hospital as a last resort.
CAUSES
Angina is caused by reduced blood flow to your heart muscle. Your blood carries oxygen, which your heart muscle needs to survive. When your heart muscle isn't getting enough oxygen, it causes a condition called ischemia.
The most common cause of reduced blood flow to your heart muscle is coronary artery disease (CAD). Your heart (coronary) arteries can become narrowed by deposits called plaques. This is called atherosclerosis.
This reduced blood flow is a supply problem — your heart is not getting enough oxygen-rich blood. You may wonder why you don't always have angina if your heart arteries are narrowed due to fatty buildup. This is because during times of low oxygen demand — when you're resting, for example — your heart muscle may be able to get by on the reduced amount of blood flow without triggering angina symptoms. But when you increase the demand for oxygen, such as when you exercise, this can cause angina.
Stable angina. Stable angina is usually triggered by physical exertion. When you climb stairs, exercise or walk, your heart demands more blood, but it's harder for the muscle to get enough blood when your arteries are narrowed. Besides physical activity, other factors, such as emotional stress, cold temperatures, heavy meals and smoking, also can narrow arteries and trigger angina.
Unstable angina. If fat-containing deposits (plaques) in a blood vessel rupture and a blood clot forms, it can quickly block or reduce flow through a narrowed artery, suddenly and severely decreasing blood flow to your heart muscle. Unstable angina can also be caused by blood clots that block or partially block your heart's blood vessels.
Unstable angina worsens and is not relieved by rest or your usual medications. If the blood flow doesn't improve, heart muscle deprived of oxygen dies — a heart attack. Unstable angina is dangerous and requires emergency treatment.
Variant angina. Variant angina, also called Prinzmetal's angina, is caused by a spasm in a coronary artery in which the artery temporarily narrows. This narrowing reduces blood flow to your heart, causing chest pain. Variant angina can occur even when you're at rest, and is often severe. It can be relieved with medications.
RISK FACTORS
The following risk factors increase your risk of coronary artery disease and angina:
Tobacco use. Chewing tobacco, smoking and long-term exposure to secondhand smoke damage the interior walls of arteries — including arteries to your heart — allowing deposits of cholesterol to collect and block blood flow.
Diabetes. Diabetes is the inability of your body to produce enough insulin or respond to insulin properly. Insulin, a hormone secreted by your pancreas, allows your body to use glucose, which is a form of sugar from foods. Diabetes increases the risk of coronary artery disease, which leads to angina and heart attacks by speeding up atherosclerosis.
High blood pressure. Blood pressure is determined by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. Over time, high blood pressure damages arteries.
High blood cholesterol or triglyceride levels. Cholesterol is a major part of the deposits that can narrow arteries throughout your body, including those that supply your heart. A high level of the wrong kind of cholesterol, known as low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol), increases your risk of angina and heart attacks. A high level of triglycerides, a type of blood fat related to your diet, also is undesirable.
History of heart disease. If you have coronary artery disease or if you've had a heart attack, you're at a greater risk of developing angina.
Older age. Men older than 45 and women older than 55 have a greater risk than do younger adults.
Lack of exercise. An inactive lifestyle contributes to high cholesterol, high blood pressure, type 2 diabetes and obesity. However, it is important to talk with your doctor before starting an exercise program.
Obesity. Obesity raises the risk of angina and heart disease because it's associated with high blood cholesterol levels, high blood pressure and diabetes. Also, your heart has to work harder to supply blood to the excess tissue.
Stress. Stress can increase your risk of angina and heart attacks. Too much stress, as well as anger, can also raise your blood pressure. Surges of hormones produced during stress can narrow your arteries and worsen angina.
COMPLICATIONS
The chest pain that can occur with angina can make some normal activities, such as walking, uncomfortable. However, the most dangerous complication to be concerned about with angina is a heart attack.
Common signs and symptoms of a heart attack include:
Pressure, fullness or a squeezing pain in the center of your chest that lasts for more than a few minutes
Pain extending beyond your chest to your shoulder, arm, back, or even to your teeth and jaw
Increasing episodes of chest pain
Prolonged pain in the upper abdomen
Shortness of breath
Sweating
Impending sense of doom
Fainting
Nausea and vomiting
PREPARING FOR YOUR APPOINTMENT
If you're having sudden chest pain (unstable angina), call 911 or your local emergency number right away.
If you think you may have recurring angina because your symptoms are brief and only occur during exercise, or you're worried about your angina risk because of a strong family history, make an appointment with your family doctor. If angina is found early, your treatment may be easier and more effective.
Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be 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. For a blood test to check indicators of heart disease, for example, you may need to fast for a period of time beforehand.
Write down any symptoms you're experiencing, including any that may seem unrelated to angina.
Write down key personal information, including any family history of angina, chest pain, heart disease, stroke, high blood pressure or diabetes and any major stresses or recent life changes.
Make a list of all medications, vitamins or supplements you're taking.
Take a family member or friend along, if possible. Sometimes it can be difficult to remember all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
Be prepared to discuss your diet and exercise habits. If you don't already follow a diet or exercise routine, be ready to talk to your doctor about any challenges you might face in getting started.
Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions 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 angina, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
Are there any other possible causes?
What kinds of tests will I need? How do I need to prepare for these tests?
What treatments are available, and what do you recommend?
What foods should I eat or avoid?
What's an appropriate level of physical activity?
I have other health conditions. How can I best manage these conditions together?
How often do I need to follow up with you about my angina?
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 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?
Is it pain? Discomfort? Tightness? Pressure? Sharp? Stabbing?
Where is the pain located? Is it in a specific area or more generalized?
Does the pain spread to your neck and arms? How and when did the pain start? Did something specific seem to trigger the pain? Does it start gradually and build up or start suddenly?
How long does it last?
What makes it worse? Activity? Breathing? Body movement?
What makes it feel better? Rest? Deep breaths? Sitting up?
Do you have other symptoms with the pain, such as nausea or dizziness?
Do you have trouble swallowing?
Do you often have heartburn? (Heartburn can mimic the feeling of angina.)
What you can do in the meantime
It's never too early to make healthy lifestyle changes, such as quitting smoking, eating healthy foods and becoming more physically active. These are primary lines of defense against angina and its complications, including heart attack and stroke.
TESTS AND DIAGNOSIS
To diagnose angina, your doctor will start by doing a physical exam and asking about your symptoms. You'll also be asked about any risk factors, including whether you have a family history of heart disease.
There are several tests your doctor may order to help confirm whether you have angina:
Electrocardiogram (ECG or EKG). An electrocardiogram traces the electrical signals that cause your heart to beat as they travel through your heart. Your doctor can look for patterns among these heartbeats to see if the blood flow through your heart has been slowed, interrupted or if you're having a heart attack.
Stress test. Sometimes angina is easier to diagnose when your heart is working harder. During a stress test, you exercise by walking on a treadmill or pedaling a stationary bicycle. While exercising, your blood pressure is monitored and your ECG readings are watched. If you're unable to exercise, you may be given drugs that cause your heart to work harder to simulate exercising.
Echocardiogram. An echocardiogram uses sound waves to produce images of the heart. Your doctor can use these images to identify whether there are areas of your heart muscle that have been damaged by poor blood flow — a cause of angina. An echocardiogram is sometimes given during a stress test.
Nuclear stress test. A nuclear stress test helps measure blood flow to your heart muscle at rest and during stress. It is similar to a routine stress test, but during a nuclear stress test, a radioactive substance is injected into your bloodstream. This substance mixes with your blood and travels to your heart. A special scanner — which detects the radioactive material in your heart — creates images of your heart muscle. Inadequate blood flow to any part of your heart will show up as a light spot on the images.
Chest X-ray. This test takes images of your heart and lungs. This is to look for other conditions that might explain your symptoms and to see if you have an enlarged heart.
Blood tests. Certain heart enzymes slowly leak out into your blood if your heart has been damaged by a heart attack. Samples of your blood can be tested for the presence of these enzymes.
Coronary angiography. Coronary angiography uses X-ray imaging to examine the inside of your heart's blood vessels. It's part of a general group of procedures known as cardiac catheterization. During coronary angiography, a type of dye that's visible by X-ray machine is injected into the blood vessels of your heart. The X-ray machine rapidly takes a series of images (angiograms), offering a detailed look at your blood vessels.
Cardiac computerized tomography (CT) scan. In a cardiac CT scan, you lie on a table inside a doughnut-shaped machine. An X-ray tube inside the machine rotates around your body and collects images of your heart and chest, which can show if any of your heart's arteries are narrowed or if your heart is enlarged.
TREATMENTS AND DRUGS
There are many options for angina treatment, including lifestyle changes, medications, angioplasty and stenting, or coronary bypass surgery. The goals of treatment are to reduce the frequency and severity of your symptoms and to lower your risk of heart attack and death.
However, if you have unstable angina or angina pain that's different from what you usually have, such as occurring when you're at rest, you need immediate treatment in a hospital.
Lifestyle changes
If your angina is mild, lifestyle changes may be all you need to do. Even if your angina is severe, making lifestyle changes can still help. These changes include the following:
If you smoke, stop smoking. Avoid exposure to secondhand smoke.
If you're overweight, talk to your doctor about weight-loss options.
If you have diabetes, make sure that it is well-controlled and that you're following an optimal diet and exercise plan.
Because angina is often brought on by exertion, it's helpful to pace yourself and take rest breaks.
Avoid large meals.
Avoiding stress is easier said than done, but try to find ways to relax. Talk with your doctor about stress-reduction techniques.
Eat a healthy diet with lots of whole grains, many fruits and vegetables, and limited amounts of saturated fat.
Talk to your doctor about starting a safe exercise plan.
Medications
If lifestyle changes alone don't help your angina, you may need to take medications. These may include:
Nitrates. Nitrates are often used to treat angina. Nitrates relax and widen your blood vessels, allowing more blood to flow to your heart muscle. You might take a nitrate when you have angina-related chest discomfort, before doing something that normally triggers angina (such as physical exertion), or on a long-term preventive basis. The most common form of nitrate used to treat angina is with nitroglycerin tablets put under your tongue.
Aspirin. Aspirin reduces the ability of your blood to clot, making it easier for blood to flow through narrowed heart arteries. Preventing blood clots can also reduce your risk of a heart attack. But don't start taking a daily aspirin without talking to your doctor first.
Clot-preventing drugs. Certain medications, such as clopidogrel (Plavix), prasugrel (Effient) and ticagrelor (Brilinta), can help prevent blood clots from forming by making your blood platelets less likely to stick together.
Beta blockers. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. As a result, the heart beats more slowly and with less force, thereby reducing blood pressure. Beta blockers also help blood vessels relax and open up to improve blood flow, thus reducing or preventing angina.
Statins. Statins are drugs used to lower blood cholesterol. They work by blocking a substance your body needs to make cholesterol. They may also help your body reabsorb cholesterol that has accumulated in plaques in your artery walls, helping prevent further blockage in your blood vessels. Statins also have many other beneficial effects on your heart arteries.
Calcium channel blockers. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial walls. This increases blood flow in your heart, reducing or preventing angina.
Ranolazine (Ranexa). Ranexa can be used alone or with other angina medications, such as calcium channel blockers, beta blockers or nitroglycerin. Unlike some other angina medications, Ranexa can be used if you're taking oral erectile dysfunction medications.
Medical procedures and surgery
Lifestyle changes and medications are frequently used to treat stable angina. But procedures, such as angioplasty, stenting and coronary artery bypass surgery, also are used to treat angina.
Angioplasty and stenting. During an angioplasty — also called a percutaneous coronary intervention (PCI) — a tiny balloon is inserted into your narrowed artery. The balloon is inflated to widen the artery, and then a small wire mesh coil (stent) is usually inserted to keep the artery open. This procedure improves blood flow in your heart, reducing or eliminating angina. Angioplasty and stenting is a good treatment option if you have unstable angina or if lifestyle changes and medications don't effectively treat your chronic, stable angina.
Coronary artery bypass surgery. During coronary artery bypass surgery, a vein or artery from somewhere else in your body is used to bypass a blocked or narrowed heart artery. Bypass surgery increases blood flow to your heart and reduces or eliminates angina. It's a treatment option for both unstable angina and stable angina that has not responded to other treatments.
LIFESTYLE AND HOME REMEDIES
You can help prevent angina by making the same lifestyle changes that might improve your symptoms if you already have angina. These include:
Quitting smoking
Monitoring and controlling other health conditions, such as high blood pressure, high cholesterol and diabetes
Eating a healthy diet
Increasing your physical activity after you get your doctor's OK
Maintaining a healthy weight
Reducing your stress level
ANHIDROSIS
ANHIDROSIS
Anhidrosis is the inability to sweat normally. When you don't sweat (perspire), your body can't cool itself, which can lead to overheating and sometimes to heatstroke — a potentially fatal condition.
Anhidrosis — sometimes called hypohidrosis — can be difficult to diagnose. Mild anhidrosis often goes unrecognized. Dozens of factors can cause the condition, including skin trauma and certain diseases and medications. You can inherit anhidrosis or develop it later in life.
Treatment of anhidrosis involves addressing the underlying cause, if one can be found.
SYMPTOMS
Signs and symptoms of anhidrosis include:
Little or no perspiration
Dizziness
Muscle cramps or weakness
Flushing
Feeling hot
A lack of perspiration can occur:
Over most of your body (generalized)
In a single area
In scattered patches
Areas that can sweat may try to produce more perspiration, so it's possible to sweat profusely on one part of your body and very little or not at all on another. Anhidrosis that affects a large portion of your body prevents proper cooling, so vigorous exercise, hard physical work and hot weather can cause heat cramps, heat exhaustion or even heatstroke.
Anhidrosis can develop on its own or as one of several signs and symptoms of another condition, such as diabetes or skin injury.
When to see a doctor
If you barely sweat, even when it's hot or you're working or exercising strenuously, talk to your doctor. Talk to your doctor if you notice you're sweating less than usual. Because anhidrosis increases your risk of heatstroke, seek medical care if you develop signs or symptoms of a heat-related illness, such as:
Weakness
Nausea
Dizziness
Rapid heartbeat
Goose bumps on the skin, despite warm temperatures
CAUSES
Anhidrosis occurs when your sweat glands don't function properly, either as a result of a condition you're born with (congenital condition) or one that affects your nerves or skin. Dehydration also can cause anhidrosis. Sometimes the cause of anhidrosis can't be found.
Causes of anhidrosis include:
Conditions you're born with, such as certain congenital displasias that affect the development of sweat glands
Inherited conditions that affect your metabolic system, such as Fabry's disease
Connective tissue diseases, such as Sjogren's syndrome, which causes dry eyes and mouth
Skin damage, such as from burns or radiation therapy, or diseases that clog your pores (poral occlusion), such as psoriasis
Conditions that cause nerve damage (neuropathy), such as diabetes, alcoholism and Guillain-Barre syndrome
Certain drugs, such as morphine and botulinum toxin type A, and those used to treat psychosis.
RISK FACTORS
Certain factors make anhidrosis more likely, including:
Age. People age 65 and older, infants, and children are more prone to heat stress, which can contribute to anhidrosis.
Certain health problems. Any medical condition that damages your autonomic nerves, such as diabetes, makes sweat gland problems more likely.
Skin disorders. Many diseases that irritate or inflame the skin also affect the sweat glands. They include psoriasis; exfoliative dermatitis, which is marked by severe skin scaling; heat rash; scleroderma, which causes hard, tight skin; and ichthyosis — extremely dry, scaly skin.
Genetic abnormalities. Mutations in certain genes can lead to disorders that affect the sweat glands.
COMPLICATIONS
Heat-related illnesses are the most serious complications of anhidrosis. Children are especially vulnerable because their core temperatures rise faster than adults', and their bodies release heat less efficiently.
Heat-related problems include:
Heat cramps. These muscle spasms, which can tighten muscles in your legs, arms, abdomen and back, are generally more painful and prolonged than are typical nighttime leg cramps.
Heat exhaustion. Signs and symptoms such as weakness, nausea and a rapid heartbeat usually begin after strenuous exercise. Monitor someone with heat exhaustion because symptoms can quickly become worse.
Heatstroke. This life-threatening condition occurs when your body temperature reaches 104 F (40 C) or higher. If not treated immediately, heatstroke can cause hallucinations, loss of consciousness, coma and even death.
PREPARING FOR YOUR APPOINTMENT
You're likely to start by seeing your family doctor or a general practitioner. You may then be referred to a doctor who specializes in skin disorders (dermatologist).
Here's information to help you get ready for your appointment.
What you can do
Be aware of pre-appointment restrictions. When you make the appointment, ask if you need to do anything to prepare, such as modifying your diet.
Write down your symptoms, including ones that seem unrelated to your reason for scheduling an appointment.
Write down key personal information, including major stresses or recent life changes.
List all medications, vitamins and supplements you take.
Ask a family member or friend to come with you to help you remember information you're given.
Write down questions to ask your doctor.
Preparing a list of questions can help you make the most of your time with your doctor. For anhidrosis, some basic questions to ask your doctor include:
Why don't certain parts of my body sweat?
What tests do I need?
What caused this condition?
Will I always have this condition?
What treatments are available, and which do you recommend?
How can I best manage this condition with my other health conditions?
Should I restrict activities?
Do you have any brochures or other printed material for me? What websites do you recommend?
Don't hesitate to ask other questions, as well.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, including:
When did you notice you weren't sweating?
What parts of your body don't perspire?
Are you aware of others in your family with similar symptoms?
Do you have other symptoms?
Does anything seem to improve your symptoms?
What, if anything, appears to worsen your symptoms?
Did symptoms begin when you changed a medication or were diagnosed with another illness?
TESTS AND DIAGNOSIS
Your doctor is likely to suspect anhidrosis based on your signs and symptoms, your medical history, and a physical exam. But you may need certain tests to confirm the diagnosis. These include:
Sweat test. During this test, known as thermoregulatory sweat test, you're coated with a powder that changes color when and where you sweat. You then enter a chamber that causes your body temperature to increase to a level that makes most people perspire. Digital photos document the results, and the whole body surface can be tested at once.
Skin biopsy. In some cases, your doctor might request a biopsy of the area suspected of anhidrosis. For this test, skin cells and sometimes sweat glands are removed for examination under a microscope.
TREATMENTS AND DRUGS
Anhidrosis that affects a small part of your body usually isn't a problem and doesn't need treatment. But large areas of decreased perspiration can be life-threatening. Treatments may depend on the condition that's causing the anhidrosis.
Treating heat-related problems
Overheating needs prompt treatment to prevent symptoms from becoming worse.
Heat cramps
To relieve cramping:
Rest and cool down
Drink cool fruit juice or a sports drink that contains electrolytes
Get medical care if cramps become worse or don't go away in about an hour
Wait at least several hours before returning to strenuous activity
Heat exhaustion
Act quickly when someone develops signs and symptoms of heat exhaustion, such as nausea, dizziness and a rapid heartbeat:
Move the person into a shady or air-conditioned space, and elevate his or her legs slightly.
Loosen the person's clothing, and remove any heavy pieces of clothing.
Have the person drink a cool beverage that doesn't have caffeine or alcohol.
Spray or sponge the person with cool water.
If symptoms don't improve quickly, call 911 or emergency medical help.
Heatstroke
Heatstroke requires immediate medical care, so call 911 or emergency medical help. This condition can be fatal if left untreated. Until help arrives:
Move the person into a shady or air-conditioned space.
Spray or sponge the person with cool water. Or wrap him or her in wet towels or sheets. Use a fan or newspaper to increase air circulation.
Have the person drink a cool beverage that doesn't have caffeine or alcohol if he or she is able.
LIFESTYLE AND HOME REMEDIES
Anhidrosis often can't be prevented, but serious heat-related illnesses can. To stay safe:
Wear loose, light clothing when it's warm.
Stay indoors on hot days.
Monitor your activity level closely so you don't overdo.
Learn the signs of heat-related illness and how to treat them.
ANKYLOSING SPONDYLITIS
ANKYLOSING SPONDYLITIS
Ankylosing Spondylitis
Ankylosing spondylitis is an inflammatory disease that can cause some of the vertebrae in your spine to fuse together. This fusing makes the spine less flexible and can result in a hunched-forward posture. If ribs are affected, it may be difficult to breathe deeply.
Ankylosing spondylitis affects men more often than women. Signs and symptoms of ankylosing spondylitis typically begin in early adulthood. Inflammation also can occur in other parts of your body — most commonly, your eyes.
There is no cure for ankylosing spondylitis, but treatments can decrease your pain and lessen your symptoms.
SYMPTOMS
Early signs and symptoms of ankylosing spondylitis may include pain and stiffness in your lower back and hips, especially in the morning and after periods of inactivity. Over time, symptoms may worsen, improve or stop completely at irregular intervals.
The areas most commonly affected are:
The joint between the base of your spine and your pelvis
The vertebrae in your lower back
The places where your tendons and ligaments attach to bones, mainly in your spine, but sometimes along the back of your heel
The cartilage between your breastbone and ribs
Your hip and shoulder joints
When to see a doctor
Seek medical attention if you have low back or buttock pain that came on slowly, is worse in the morning or awakens you from your sleep in the second half of the night — particularly if this pain improves with exercise and worsens with rest. See an eye specialist (ophthalmologist) immediately if you develop a painful red eye, severe light sensitivity or blurred vision.
CAUSES
Ankylosing spondylitis has no known specific cause, though genetic factors seem to be involved. In particular, people who have a gene called HLA-B27 are at significantly increased risk of developing ankylosing spondylitis.
RISK FACTORS
Your sex. Men are more likely to develop ankylosing spondylitis than are women.
Your age. Onset generally occurs in late adolescence or early adulthood.
Your heredity. Most people who have ankylosing spondylitis have the HLA-B27 gene. But many people who have this gene never develop ankylosing spondylitis.
COMPLICATIONS
In severe cases of ankylosing spondylitis, new bone forms as part of the body's attempt to heal. This new bone gradually bridges the gap between vertebrae and eventually fuses sections of vertebrae together. Those parts of your spine become stiff and inflexible. Fusion can also stiffen your rib cage, restricting your lung capacity and function.
Other complications may include:
Eye inflammation (uveitis). One of the most common complications of ankylosing spondylitis, uveitis can cause rapid-onset eye pain, sensitivity to light and blurred vision. See your doctor right away if you develop these symptoms.
Compression fractures. Some people experience a thinning of their bones during the early stages of ankylosing spondylitis. Weakened vertebrae may crumble, increasing the severity of your stooped posture. Vertebral fractures sometimes can damage the spinal cord and the nerves that pass through the spine.
Heart problems. Ankylosing spondylitis can cause problems with your aorta, the largest artery in your body. The inflamed aorta can enlarge to the point that it distorts the shape of the aortic valve in the heart, which impairs its function.
PREPARING FOR YOUR APPOINTMENT
You might first bring your symptoms to the attention of your family doctor. He or she may refer you to a doctor who specializes in inflammatory disorders (rheumatologist).
What you can do
Before your appointment, you may want to write a list of answers to the following questions:
When did you begin experiencing symptoms?
Where exactly does the pain occur?
Are your symptoms worse in the morning or after long periods of inactivity?
What medications and supplements do you take on a regular basis?
What to expect from your doctor
Your doctor might ask some of the following questions:
How severe are your symptoms?
Have your symptoms been continuous or occasional?
What, if anything, seems to worsen or improve your symptoms?
Have you taken medications to relieve the pain? What helped most?
TESTS AND DIAGNOSIS
During the physical exam, your doctor may ask you to bend your back in different directions. He or she may also measure your chest circumference — once with your lungs empty and once with them full of air — to compare the difference.
Your doctor may also try to reproduce your pain by pressing on specific portions of your pelvis or by moving your legs into a particular position. He or she might also ask you to try to stand upright, with your heels and the back of your head against a wall.
Imaging tests
X-rays allow your doctor to check for changes in your joints and bones, though the visible signs of ankylosing spondylitis may not be evident early in the disease.
Magnetic resonance imaging (MRI) uses radio waves and a strong magnetic field to provide more-detailed images of bones and soft tissues. MRI scans can reveal evidence of ankylosing spondylitis earlier in the disease process, but are much more expensive.
Lab tests
There are no specific lab tests to identify ankylosing spondylitis. Certain blood tests can check for markers of inflammation, but inflammation can be caused by many different health problems. Your blood can be tested for the HLA-B27 gene, but most people who have that gene don't have ankylosing spondylitis.
TREATMENTS AND DRUGS
The goal of treatment is to relieve your pain and stiffness, and prevent or delay complications and spinal deformity. Ankylosing spondylitis treatment is most successful before the disease causes irreversible damage to your joints.
Medications
Nonsteroidal anti-inflammatory drugs (NSAIDs) — such as naproxen (Naprosyn) and indomethacin (Indocin) — are the medications doctors most commonly use to treat ankylosing spondylitis. They can relieve your inflammation, pain and stiffness. However, these medications also can cause gastrointestinal bleeding.
If NSAIDs aren't helpful, your doctor may suggest tumor necrosis factor (TNF) blockers. TNF is a cell protein that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers target this protein to help reduce pain, stiffness, and tender or swollen joints. They are administered by injecting the medication under the skin or through an intravenous line.
Examples of TNF blockers include:
Adalimumab (Humira)
Etanercept (Enbrel)
Golimumab (Simponi)
Infliximab (Remicade)
TNF blockers can reactivate latent tuberculosis and may cause certain neurological problems.
Therapy
Physical therapy can provide a number of benefits, from pain relief to improved physical strength and flexibility. Your doctor may recommend that you meet with a physical therapist to provide you with specific exercises designed for your needs.
Range-of-motion and stretching exercises can help maintain flexibility in your joints and preserve good posture. Proper sleep and walking positions and abdominal and back exercises can help maintain your upright posture.
Surgery
Most people with ankylosing spondylitis don't need surgery. However, your doctor may recommend surgery if you have severe pain or joint damage, or if your hip joint is so damaged that it needs to be replaced.
LIFESTYLE AND HOME REMEDIES
If you smoke, quit. Smoking is generally bad for your health, but it creates additional problems for people with ankylosing spondylitis. Depending on the severity of your condition, ankylosing spondylitis can affect the mobility of your rib cage. Damaging your lungs by smoking can further compromise your ability to breathe.
COPING AND SUPPORT
The course of your condition may change over time, and you may experience relapses and remissions throughout your life. But most people are able to live productive lives despite a diagnosis of ankylosing spondylitis.
You may want to join an online or in-person support group of people with this condition, to share experiences and support.
ANORGASMIA
ANORGASMIA
Anorgasmia
Anorgasmia is the medical term for regular difficulty reaching orgasm after ample sexual stimulation, causing you personal distress. Anorgasmia is a common occurrence, affecting a significant number of women.
Orgasms vary in intensity, and women vary in the frequency of their orgasms and the amount of stimulation necessary to trigger an orgasm. In fact, most women don't consistently have orgasms with vaginal penetration alone. Plus, orgasms often change with age, medical issues or medications you're taking.
If you're happy with the climax of your sexual activities, there's no need for concern. However, if you're bothered by lack of orgasm or the intensity of your orgasms, talk to your doctor about anorgasmia. Lifestyle changes and sex therapy may help.
SYMPTOMS
An orgasm is a feeling of intense physical pleasure and release of tension, accompanied by involuntary, rhythmic contractions of your pelvic floor muscles. But it doesn't always look — or sound — like it does in the movies. The way an orgasm feels varies from woman to woman, and in an individual woman, it may even differ from orgasm to orgasm.
By definition, the major symptoms of anorgasmia are inability to experience orgasm or long delays in reaching orgasm. But there are different types of anorgasmia:
Lifelong anorgasmia. This means you've never experienced an orgasm.
Acquired anorgasmia. This means you used to have orgasms, but now experience difficulty reaching climax.
Situational anorgasmia. This means you are able to orgasm only during certain circumstances, such as during oral sex or with a certain partner. Most women can't reach orgasm through vaginal penetration alone.
Generalized anorgasmia. This means you aren't able to orgasm in any situation or with any partner.
When to see a doctor
Talk to your doctor if you have questions about orgasm or concerns about your ability to reach orgasm. You may find that your sexual experiences are normal. Or your doctor may recommend strategies to reduce your anxiety and increase your satisfaction.
CAUSES
Despite what you see in the media, orgasm is no simple, sure thing. This pleasurable peak is actually a complex reaction to many physical, emotional and psychological factors. If you're experiencing trouble in any of these areas, it can affect your ability to orgasm.
Physical causes
A wide range of illnesses, physical changes and medications can interfere with orgasm:
Medical diseases. Any illness can affect this part of the human sexual response cycle, including diabetes and neurological diseases, such as multiple sclerosis.
Gynecologic issues. Orgasm may be affected by gynecologic surgeries, such as hysterectomy or cancer surgeries. In addition, lack of orgasm often goes hand in hand with other sexual concerns, such as uncomfortable or painful intercourse.
Medications. Many prescription and over-the-counter medications can interfere with orgasm, including blood pressure medications, antihistamines and antidepressants — particularly selective serotonin reuptake inhibitors (SSRIs).
Alcohol and smoking. Too much alcohol can cramp your ability to climax; the same is true of smoking, which can limit blood flow.
The aging process. As you age, normal changes in your anatomy, hormones, neurological system and circulatory system can affect your sexuality. A tapering of estrogen levels during the transition to menopause can decrease blood flow to the vagina and clitoris, which can delay or stop orgasm entirely.
Psychological causes
Many psychological factors play a role in your ability to orgasm, including:
Mental health problems, such as anxiety or depression
Poor body image
Stress and financial pressures
Cultural and religious beliefs
Fear of pregnancy or sexually transmitted infections
Embarrassment
Guilt about enjoying sexual experiences
Past sexual or emotional abuse
Relationship issues
Many couples who have problems outside of the bedroom also experience problems in the bedroom.Overarching issues may include:
Lack of connection with your partner
Unresolved conflicts or fights
Poor communication of sexual needs and preferences
Infidelity or breach of trust
Intimate partner violence
PREPARING FOR YOUR APPOINTMENT
If you rarely or never experience orgasm from sexual activity and it distresses you, make an appointment with your doctor. Your regular doctor may diagnose and treat the problem or refer you to a specialist who can.
You may feel embarrassed to talk about sex with your doctor, but this topic is perfectly appropriate. Your doctor knows that a satisfying sex life is very important to a woman's well-being at every age and stage of life. You may have a treatable, underlying condition, or you may benefit from lifestyle changes, therapy or a combination of treatments.
Here's some information to help you prepare for your appointment, and what to expect from your doctor.
Information to write down in advance
Your symptoms. It will help your doctor to know whether you've ever had an orgasm, and if so, under what circumstances.
Your sexual history. Your doctor likely will ask about your relationships and experiences since you first became sexually active. He or she may also ask about any history of sexual trauma or abuse.
Your medical history. Write down any medical conditions with which you've been diagnosed, including mental health conditions. Also note the names and strengths of all medications you're currently taking or have recently taken, including prescription and over-the-counter drugs, vitamins and supplements.
Questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.
Basic questions to ask your doctor
The list below suggests questions to raise with your doctor about anorgasmia. Don't hesitate to ask more questions during your appointment if you don't understand something.
What may be causing my difficulty to orgasm?
Do I need any medical tests?
What treatment approach do you recommend?
If you're prescribing medication, are there any possible side effects?
How much improvement can I reasonably expect with treatment?
Are there any lifestyle changes or self-care steps that may help me?
Do you recommend therapy?
Should my partner be involved in treatment?
Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
What to expect from your doctor
Your doctor may ask a number of very personal questions and may want to include your partner in the interview. To help your doctor determine the cause of your problem and the best course of treatment, be ready to answer questions such as:
When did you first become sexually active?
For how long have you had difficulty reaching orgasm?
If you've had orgasms in the past, what were the circumstances?
Do you become sexually aroused during sexual interactions with your partner?
Do you experience any pain with vaginal penetration?
How much are you bothered by your lack of orgasm?
How satisfied are you with your current relationship?
Are you using any form of birth control? If yes, what form?
What medications are you taking, including prescription and over-the-counter drugs as well as vitamins and supplements?
Do you use alcohol or recreational drugs? How much?
Have you ever had surgery that involved your reproductive system?
Have you been diagnosed with any other medical conditions, including mental health conditions?
What were your family's beliefs about sexuality?
Have you ever been the victim of sexual violence?
What you can do in the meantime
While you wait for your appointment, be open with your partner about the situation. Continue sexual activity, and also explore other ways of being intimate. Shifting the focus from orgasm to pleasure may be a helpful strategy in treating anorgasmia.
TESTS AND DIAGNOSIS
A medical evaluation for anorgasmia usually consists of:
A thorough medical history. Your doctor may ask about your sexual history, surgical history and current relationship. Don't let embarrassment stop you from giving candid answers. These questions provide clues to the cause of your problem.
A physical exam. Your doctor will probably conduct a general physical exam to look for physical causes of anorgasmia, such as an underlying medical condition. Your doctor may also examine your genital area to see if there's some obvious physical or anatomical reason for lack of orgasm.
TREATMENTS AND DRUGS
Anorgasmia can be difficult to treat. Your treatment plan will depend on the underlying cause of your symptoms, but your doctor may recommend a combination of lifestyle changes, therapy and medication.
Lifestyle changes and therapy
For most women, a key part of treatment includes addressing relationship issues and everyday stressors. Understanding your body and trying different types of sexual stimulation also can help.
Understand your body better. Understanding your own anatomy and how you like to be touched can lead to better sexual satisfaction. If you need a refresher course on your genital anatomy, ask your doctor for a diagram or get out a mirror and look. Then take some time to explore your own body. Self-stimulation or using a vibrator can help you discover what type of touch feels best to you, and then you can share that information with your partner. If you're uncomfortable with self-exploration, try exploring your body with your partner.
Increase sexual stimulation. Women who've never had an orgasm may not be getting enough effective sexual stimulation. Most women need direct or indirect stimulation of the clitoris in order to orgasm, but not all women realize this.
Switching sexual positions can produce more clitoral stimulation during vaginal penetration; some positions also allow for you or your partner to gently touch your clitoris during sex. Using a vibrator during sex also can help trigger an orgasm. Mental imagery or fantasizing during sex also may help.
For some women, a device called a clitoral vacuum may improve blood flow and increase stimulation. This device is battery operated and hand-held, with a cup that fits over the clitoris.
Seek couples counseling. Conflicts and disagreements in your relationship can affect your ability to orgasm. A counselor can help you work through disagreements and tensions and get your sex life back on track.
Cognitive behavioral therapy. This type of therapy attempts to change the negative thoughts you may have about sex. You may be given directed masturbation exercises to do at home to learn how to achieve orgasm on your own.
Try sex therapy. Sex therapists are therapists who specialize in treating sexual concerns. You may be embarrassed or nervous about seeing a sex therapist, but sex therapists can be very helpful in treating anorgasmia. Therapy often includes sex education, help with communication skills, and behavioral exercises that you and your partner try at home.
For example, you and your partner may be asked to practice "sensate focus" exercises, a specific set of body-touching exercises that teach you how to touch and pleasure your partner without focusing on orgasm. Or you and your partner may learn how to combine a situation in which you reach orgasm — such as clitoral stimulation — with a situation in which you desire to reach orgasm, such as vaginal penetration. By using these techniques and others, you may learn to view orgasm as one pleasurable part of sexual intimacy, not the whole goal of every sexual encounter.
Medical treatments
Hormone therapies aren't a guaranteed fix for anorgasmia. But they can help. So can treating underlying medical conditions.
Treating underlying conditions. If a medical condition is hindering your ability to orgasm, treating the underlying cause may resolve your problem. Changing or modifying medications known to inhibit orgasm also may eliminate your symptoms.
Estrogen therapy for postmenopausal women. Systemic estrogen therapy — by pill, patch or gel — can have a positive effect on brain function and mood factors that affect sexual response. Local estrogen therapy — in the form of a vaginal cream or a slow-releasing suppository or ring that you place in your vagina — can increase blood flow to the vagina and help improve sexual arousal. In some cases, your doctor may prescribe a combination of estrogen and progesterone.
Testosterone therapy. Testosterone plays an important role in female sexual function, though in much lower amounts. As a result, testosterone may help increase sexual arousal. However, replacing testosterone in women is controversial and it's not approved by the Food and Drug Administration for sexual dysfunction in women.
Additionally, it can cause negative side effects, including acne, excess body hair (hirsutism) and male-pattern baldness. Testosterone seems most effective for women with low testosterone levels as a result of surgical removal of the ovaries (oophorectomy). If you choose to use this therapy, your doctor will closely monitor your symptoms to make sure you're not experiencing negative side effects.
ALTERNATIVE MEDICINE
Natural products, such as those made with L-arginine, are marketed as helpful for improving a woman's sex life. But these supplements haven't been well-studied for this use, and they're not regulated by the Food and Drug Administration.
Talk with your doctor before trying any natural therapies. These products can cause side effects and may interact with other medications. Your doctor can help determine if they are safe for you.
COPING AND SUPPORT
If you're experiencing difficulty reaching orgasm, it can be frustrating for you and your partner. Plus, concentrating on climax can make the problem worse.
Most couples aren't experiencing the headboard-banging, earth-shaking sex that appears on TV and in the movies. So try to reframe your expectations. Focus on mutual pleasure, instead of orgasm. You may find that a sustained pleasure plateau is just as satisfying as orgasm.
ANTERIOR PROLAPSE
ANTERIOR PROLAPSE
Anterior prolapse
Anterior prolapse, also known as a cystocele (SIS-toe-seel), occurs when the supportive tissue between a woman's bladder and vaginal wall weakens and stretches, allowing the bladder to bulge into the vagina. Anterior prolapse is also called a prolapsed bladder.
Straining the muscles that support your pelvic organs may lead to anterior prolapse. Such straining occurs during vaginal childbirth or with chronic constipation, violent coughing or heavy lifting. Anterior prolapse also tends to cause problems after menopause, when estrogen levels decrease.
For a mild or moderate anterior prolapse, nonsurgical treatment is often effective. In more severe cases, surgery may be necessary to keep the vagina and other pelvic organs in their proper positions.
SYMPTOMS
In mild cases of anterior prolapse, you may not notice any signs or symptoms. When signs and symptoms occur, they may include:
A feeling of fullness or pressure in your pelvis and vagina
Increased discomfort when you strain, cough, bear down or lift
A feeling that you haven't completely emptied your bladder after urinating
Repeated bladder infections
Pain or urinary leakage during sexual intercourse
In severe cases, a bulge of tissue that protrudes through your vaginal opening and may feel like sitting on an egg
Signs and symptoms often are especially noticeable after standing for long periods of time and may go away when you lie down.
When to see a doctor
A severely prolapsed bladder can be uncomfortable. It can make emptying your bladder difficult and may lead to bladder infections. Make an appointment with your doctor if you have any signs or symptoms that bother you.
CAUSES
Your pelvic floor consists of muscles, ligaments and connective tissues that support your bladder and other pelvic organs. The connections between your pelvic floor muscles and ligaments can weaken over time, as a result of trauma from childbirth or chronic straining of pelvic floor muscles. When this happens, your bladder can slip down lower than normal and bulge into your vagina (anterior prolapse).
Possible causes of anterior prolapse include:
Pregnancy and vaginal childbirth
Being overweight or obese
Repeated heavy lifting
Straining with bowel movements
A chronic cough or bronchitis
RISK FACTORS
These factors may increase your risk of anterior prolapse:
Childbirth. Women who have vaginally delivered one or more children have a higher risk of anterior prolapse.
Aging. Your risk of anterior prolapse increases as you age. This is especially true after menopause, when your body's production of estrogen — which helps keep the pelvic floor strong — decreases.
Hysterectomy. Having your uterus removed may contribute to weakness in your pelvic floor support.
Genetics. Some women are born with weaker connective tissues, making them more susceptible to anterior prolapse.
Obesity. Women who are overweight or obese are at higher risk of anterior prolapse.
PREPARING FOR YOUR APPOINTMENT
Make an appointment with your family doctor or gynecologist if you have signs or symptoms of anterior prolapse that bother you or interfere with your normal activities.
Here's some information to help you prepare for your appointment and know what to expect from your doctor.
What you can do
Write down any symptoms you've had, and for how long.
Make note of key medical information, including other conditions for which you're being treated and the names of medications, vitamins or supplements you regularly take.
Bring a friend or relative along, if possible. Having someone else there may help you remember important information or provide details on something that you missed during the appointment.
Write down questions to ask your doctor, listing the most important ones first in case time runs short.
For anterior prolapse, some basic questions to ask your doctor include:
What is the most likely cause of my symptoms?
Are there any other possible causes?
Do I need any tests to confirm the diagnosis?
What treatment approach do you recommend?
If the first treatment doesn't work, what will you recommend next?
Am I at risk of complications from this condition?
What's the likelihood that the anterior prolapse will recur after treatment?
Should I follow any activity restrictions?
What can I do at home to ease my symptoms?
Should I see a specialist?
Besides the questions you prepare in advance, don't hesitate to ask other questions during your appointment if you need clarification.
What to expect from your doctor
During your appointment, your doctor may ask a number of questions, such as:
When did you first notice your symptoms?
Do you have urine leakage (urinary incontinence)?
Do you have frequent bladder infections?
Do you have pain or leak urine during intercourse?
Do you have a chronic or severe cough?
Do you experience constipation and straining during bowel movements?
What, if anything, seems to improve your symptoms?
What, if anything, seems to worsen your symptoms?
Does your mother or a sister have any pelvic floor problems?
Have you delivered a baby vaginally? How many times?
Do you wish to have children in the future?
What else concerns you?
TESTS AND DIAGNOSIS
Diagnosis of anterior prolapse may involve:
A pelvic exam. You may be examined while lying down and while standing up. During the exam, your doctor looks for a tissue bulge into your vagina that indicates pelvic organ prolapse. You'll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you'll be asked to contract them, as if you're trying to stop the stream of urine.
Filling out a questionnaire. You may fill out a form that helps your doctor assess the degree of your prolapse and how much it affects your quality of life. Information gathered also helps guide treatment decisions.
Bladder and urine tests. If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection, if it seems that you're retaining more urine in your bladder than is normal after urinating.
TREATMENTS AND DRUGS
Treatment depends on how severe your anterior prolapse is and whether you have any related conditions, such as a uterus that slips into the vaginal canal (uterine prolapse).
Mild cases — those with few or no obvious symptoms — typically don't require treatment. You could opt for a wait-and-see approach, with occasional visits to your doctor to see if your prolapse is worsening, along with self-care measures, such as exercises that strengthen your pelvic floor muscles.
If self-care measures aren't effective, anterior prolapse treatment might involve:
A supportive device (pessary). A vaginal pessary is a plastic or rubber ring inserted into your vagina to support the bladder. Your doctor or other care provider fits you for the device and shows you how to clean and reinsert it on your own. Many women use pessaries as a temporary alternative to surgery, and some use them when surgery is too risky.
Estrogen therapy. Your doctor may recommend using estrogen — usually a vaginal cream, pill or ring — especially if you've already experienced menopause. This is because estrogen, which helps keep pelvic muscles strong, decreases after menopause.
When surgery is necessary
If you have noticeable, uncomfortable symptoms, anterior prolapse may require surgery.
How it's done. Often, the surgery is performed vaginally and involves lifting the prolapsed bladder back into place, removing extra tissue, and tightening the muscles and ligaments of the pelvic floor. Your doctor may use a special type of tissue graft to reinforce vaginal tissues and increase support if your vaginal tissues seem very thin.
If you have a prolapsed uterus. For anterior prolapse associated with a prolapsed uterus, your doctor may recommend removing the uterus (hysterectomy) in addition to repairing the damaged pelvic floor muscles, ligaments and other tissues.
If you're thinking about becoming pregnant, your doctor may recommend that you delay surgery until after you're done having children. Using a pessary may help relieve your symptoms in the meantime. The benefits of surgery can last for many years, but there's some risk of recurrence — which may mean another surgery at some point.
Dealing with incontinence
If your anterior prolapse is accompanied by stress incontinence — involuntary loss of urine during strenuous activity — your doctor may recommend one of a number of procedures to support the urethra (urethral suspension) and ease your incontinence symptoms.
LIFESTYLE AND HOME REMEDIES
To reduce your risk of developing anterior prolapse, try these self-care measures:
Perform Kegel exercises on a regular basis. These exercises can strengthen your pelvic floor muscles, and this is especially important after you have a baby.
Treat and prevent constipation. High-fiber foods can help.
Avoid heavy lifting, and lift correctly. When lifting, use your legs instead of your waist or back.
Control coughing. Get treatment for a chronic cough or bronchitis, and don't smoke.
Avoid weight gain. Talk to your doctor to determine your ideal weight and get advice on weight-loss strategies, if you need them.
ANTIPHOSPHOLIPID SYNDROME
ANTIPHOSPHOLIPID SYNDROME
Antiphospholipid syndrome
Antiphospholipid syndrome occurs when your immune system mistakenly attacks some of the normal proteins in your blood. Antiphospholipid syndrome can cause blood clots to form within your arteries or veins. It can also cause pregnancy complications, such as miscarriage and stillbirth.
Antiphospholipid syndrome may cause blood clots to form in your leg veins, a condition known as deep vein thrombosis (DVT). Antiphospholipid syndrome may also cause blood clots to form in organs such as your kidneys or lungs. Damage depends on the extent and location of the clot. For instance, a clot in your brain can cause stroke.
There's no cure for antiphospholipid syndrome, but medications can be effective in reducing your risk of blood clots.
SYMPTOMS
Signs and symptoms of antiphospholipid syndrome may include:
Blood clots in your legs (deep vein thrombosis, or DVT) that may travel to your lungs (pulmonary embolism)
Repeated miscarriages or stillbirths and other complications of pregnancy, such as premature delivery and high blood pressure during pregnancy (preeclampsia)
Stroke
Blood clots in the arteries of your arms or legs (peripheral arterial thrombosis)
Other less common signs and symptoms include:
Neurological symptoms. Chronic headaches, including migraines, dementia and seizures are possible when a blood clot blocks blood flow to parts of your brain.
Rash. Some people develop a red rash with a lacy, net-like pattern (livedo reticularis).
Cardiovascular disease. Heart valves can be damaged in people with antiphospholipid syndrome.
Bleeding. Some people experience a decrease in platelets, blood cells necessary for normal clotting. If you have this condition (thrombocytopenia), you may have few or no symptoms. However, if your platelet count drops too low, you may have episodes of bleeding, particularly from your nose and gums. You can also bleed into your skin, which will appear as patches of small, red spots (petechiae).
Infrequent signs and symptoms include:
Movement disorder, in which your body and limbs jerk uncontrollably (chorea)
Cognitive problems, such as poor memory
Sudden hearing loss
When to see a doctor
If you already have an autoimmune condition, talk to your doctor about whether you should be tested for antiphospholipid antibodies.
Other reasons to contact your doctor include:
Pain or swelling in your leg or arm. See your doctor especially if an area of your leg or arm is red, swollen or tender. Seek emergency care if vein swelling and pain are severe or are accompanied by chest pain or shortness of breath, which could indicate DVT and an increased chance of a blood clot traveling to your lungs (pulmonary embolism).
Vaginal spotting or bleeding during pregnancy. This may be a sign of miscarriage or other pregnancy problems. However, many women spot or bleed and are able to have a healthy pregnancy. If you've had repeated pregnancy losses or unexplained severe complications of pregnancy, it could be related to antiphospholipid syndrome. Talk to your doctor about whether testing would be right for you.
If you have antiphospholipid syndrome and you're thinking of attempting pregnancy, treatments are available during your pregnancy. But be sure to seek the care of an expert obstetrical provider to discuss your options.
When it's an emergency
Seek emergency care if you have certain other serious signs and symptoms. Look for:
Signs and symptoms of stroke. These include sudden numbness, weakness or paralysis of your face, arm or leg; sudden difficulty speaking or understanding speech; sudden visual disturbances; sudden, severe headache; and dizziness.
Signs and symptoms of pulmonary embolism. These include sudden shortness of breath, chest pain and coughing up blood-streaked sputum.
Signs and symptoms of deep vein thrombosis. These include the development of leg swelling or pain.
Other signs of bleeding. These include unexplained bleeding from your nose or gums; an unusually heavy menstrual cycle; vomit that is bright red or looks like coffee grounds; black, tarry stool or bright red stool; and unexplained abdominal pain.
CAUSES
The role of phospholipids
In antiphospholipid syndrome, your body mistakenly produces antibodies against proteins that bind phospholipids, a type of fat present in your blood that plays a key role in clotting (coagulation). Antibodies are specialized proteins that normally attack body invaders, such as viruses and bacteria. When antibodies attack your phospholipid-binding proteins, your blood may clot abnormally.
Classifications
There are two main classifications of antiphospholipid syndrome:
Primary. If there's no known underlying reason, such as an autoimmune disorder, you have primary antiphospholipid syndrome.
Secondary. If you have systemic lupus erythematosus or another autoimmune disorder, certain infections, or have taken certain medications, your antiphospholipid syndrome is secondary. The cause of your antiphospholipid syndrome is considered to be the underlying condition or medication.
Some factors are associated with developing antiphospholipid antibodies — though not necessarily with developing the syndrome. They include:
Infections. People with certain infections, including syphilis, HIV infection, hepatitis C and Lyme disease, among others, have a higher incidence of having antiphospholipid antibodies.
Medications. The high blood pressure medication hydralazine, the heart rhythm-regulating medication quinidine, the anti-seizure medication phenytoin (Dilantin) and the antibiotic amoxicillin may lead to an increased risk of developing antiphospholipid antibodies.
Genetic predispositions. Although the disorder isn't considered hereditary, research indicates that relatives of people with antiphospholipid syndrome are more likely to have the antibodies.
RISK FACTORS
Risk factors for antiphospholipid syndrome include:
Having an autoimmune condition, such as systemic lupus erythematosus or Sjogren's syndrome.
Having certain infections, such as syphilis, HIV/AIDS, hepatitis C or Lyme disease.
Taking certain medications, such as hydralazine for high blood pressure, the heart rhythm-regulating medication quinidine, the anti-seizure medication phenytoin (Dilantin) and the antibiotic amoxicillin.
Having a family member with antiphospholipid syndrome.
Risk factors for developing symptoms
It's possible to have the antibodies associated with antiphospholipid syndrome without ever developing signs or symptoms. However, if you have these antibodies, your risk of developing blood clots increases particularly if you:
Become pregnant
Remain immobile for a period of time (such as when you're on bed rest or sitting during a long airline flight)
Have surgery
Smoke cigarettes
Take oral contraceptives
Have high cholesterol and triglycerides levels
COMPLICATIONS
Depending on which organ is affected by a blood clot and how severe the obstruction of blood flow to that organ is, untreated antiphospholipid syndrome can lead to permanent damage or death. Complications may include:
Kidney failure. This can result from decreased blood flow to your kidneys.
Stroke. Decreased blood flow to a part of your brain can cause a stroke, which can result in permanent neurological damage, such as partial paralysis and loss of speech (aphasia).
Cardiovascular problems. If a clot forms in your leg (deep vein thrombosis), the clot can damage the valves in the veins in your affected leg, which normally serve to keep the blood flowing upward to your heart. This may result in a condition called chronic venous insufficiency, which causes chronic swelling and discoloration in your lower legs, because of the impaired blood flow upward to your heart. Another possible complication is heart damage.
Lung problems. Complications related to your lungs may include high blood pressure in your lungs (pulmonary hypertension) and pulmonary embolism.
Pregnancy complications. These may include miscarriages, stillbirths, premature delivery and high blood pressure during pregnancy (preeclampsia).
PREPARING FOR YOUR APPOINTMENT
In most cases, it's the complications of antiphospholipid syndrome — such as deep vein thrombosis, stroke or pregnancy loss — that will prompt you to seek medical care. Depending on your complication, you'll likely see a specialist. For deep vein thrombosis, for instance, you may meet with a specialist in vascular disease, obstetrics or hematology. You're more likely to see a specialist if testing done for unexplained clotting or pregnancy loss shows antiphospholipid antibodies.
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, including 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.
Write down any signs or symptoms you've had, including any that may seem unrelated to your main health problem.
Write down key personal information, including any major recent events or changes in your life.
Make a list of your key medical information, including other conditions or infections with which you've been diagnosed. Be sure to mention if any close relatives have had antiphospholipid syndrome. Also write down the names of any medications, vitamins or supplements you're taking.
Consider taking a family member or friend along. Sometimes it can be difficult to remember all of 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 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 antiphospholipid syndrome, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
What kinds of tests do I need?
What treatment do you recommend?
Will I need to take medications long term?
What are the possible side effects of the medications you're prescribing?
How will you determine whether my treatment is working?
Does this condition increase my risk of any other medical problems?
Does this condition increase my risk of health problems during pregnancy? Are treatment options available to reduce that risk?
Are there any brochures or other printed material that I can take 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 additional 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 points you want to talk about in-depth. Your doctor may ask:
Do you have a history of stroke or blood clots?
Do you have a history of pregnancy complications, such as high blood pressure, miscarriage or stillbirth?
Do you have lupus or another autoimmune disorder?
Have you ever been tested for sexually transmitted infections or chronic viral diseases, such as hepatitis?
Have you experienced frequent headaches?
Have you noticed a red, net-like rash on your wrists or knees?
Do you smoke?
Do any of your close relatives have antiphospholipid syndrome?
TESTS AND DIAGNOSIS
If you have one or more episodes of thrombosis or pregnancy loss that are not explained by known health conditions, your doctor can schedule blood tests to check for abnormal clotting and for the presence of antibodies to phospholipid-binding proteins.
Blood tests for antiphospholipid syndrome look for at least one of the following three antibodies in your blood:
Lupus anticoagulant
Anti-cardiolipin
Beta-2 glycoprotein I
To confirm a diagnosis of antiphospholipid syndrome, the antibodies must appear in your blood at least twice, in tests conducted at least 12 weeks apart.
TREATMENTS AND DRUGS
Doctors generally use medications that reduce your blood's tendency to clot to treat antiphospholipid syndrome. This doesn't cure the disease but does help to prevent its most serious complications.
Standard initial treatment
If you have thrombosis, standard initial treatment involves a combination of anticoagulant (blood-thinning) medications.
Heparin. Typically, you'll first be given an injection of the blood thinner heparin, combined with another blood thinner in pill form, likely warfarin (Coumadin).
Warfarin. After several days of combined heparin and warfarin, your doctor may discontinue the heparin and continue the warfarin, possibly for the rest of your life.
Aspirin. In some cases, your doctor may recommend adding low-dose aspirin to your treatment plan.
When you're taking anticoagulant medication, your doctor will monitor your dosage with blood tests to be sure your blood is capable of clotting enough to stop the bleeding of a cut or the bleeding under the skin from a bruise.
Treatment during pregnancy
Anticoagulation therapy is more complex during pregnancy. The therapy is expensive, requires regular injections and carries some significant risks of side effects.
Heparin. Some forms of heparin — enoxaparin (Lovenox) and dalteparin (Fragmin) — are known as low-molecular-weight heparin, which you can inject yourself under your skin (subcutaneously). Heparin is considered safe to take during pregnancy.
Aspirin. If you're pregnant, your doctor may recommend taking one tablet of aspirin daily in addition to the heparin, to increase your chances of a successful pregnancy.
Rarely, warfarin can cause birth defects, so it isn't recommended for use during pregnancy. In rare cases, a doctor may prescribe warfarin during pregnancy if the benefits of using it outweigh the risks.
Although anticoagulation therapy during pregnancy may be complicated, the good news is that it usually prevents antiphospholipid syndrome-related miscarriage.
Throughout your pregnancy, your doctor will monitor your dosage of blood-thinning medication with blood tests. These tests ensure that your blood is capable of clotting enough to stop the bleeding of a cut or the bleeding under the skin from a bruise.
Experimental treatments
Several new treatments are being considered for antiphospholipid syndrome, including:
Statins. These medications are normally used to lower cholesterol, but they may lessen the risk of blood clots and cardiovascular disease in antiphospholipid syndrome.
New blood thinners (anticoagulants). A number of oral blood thinners — dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis) — have recently been approved to treat other conditions. It's not clear yet if these drugs are appropriate for treating antiphospholipid syndrome. However, none of these medications is recommended for use during pregnancy or breast-feeding.
Rituximab (Rituxan). This drug has been used successfully to treat conditions affecting the function of the immune system. But there isn't enough evidence of benefit to recommend rituximab as a treatment for antiphospholipid syndrome.
LIFESTYLE AND HOME REMEDIES
Depending on your treatment plan for antiphospholipid syndrome, there are additional steps you can take to protect your health.
If you take anticoagulants
If your antiphospholipid syndrome requires that you take anticoagulant medication, take extra precautions to keep from injuring yourself and to avoid bleeding. Follow these suggestions:
Avoid contact sports or other activities that could cause bruising or injury or cause you to fall.
Use a softer toothbrush and waxed floss.
Shave with an electric razor.
Take extra care when using knives, scissors and other sharp tools.
Certain foods and medications may affect how well your anticoagulants work. Ask your doctor for guidance about:
Safe dietary choices. Vitamin K can lessen the effectiveness of warfarin. It's important to be consistent in how much vitamin K you get daily. The average daily value of vitamin K for adult men is 120 micrograms (mcg). For adult women, it's 90 mcg. While eating small amounts of foods that are rich in vitamin K may not be harmful, avoid eating large amounts of kale, spinach, lettuce, broccoli, Brussels sprouts, parsley, collard greens, mustard greens and soybeans.
On the other hand, cranberry juice and alcohol may dangerously increase warfarin's blood-thinning effect. Ask your doctor if you need to limit or avoid these drinks.
Safe medications and dietary supplements. Certain medications, vitamins and herbal products may interact dangerously with warfarin. These may include over-the-counter pain relievers, cold medicines, stomach remedies or multivitamins, as well as garlic, ginkgo and green tea products.
If you don't take anticoagulants
If you have antiphospholipid antibodies but do not take anticoagulant medication, take these precautions:
Tell your doctor that you have antiphospholipid antibodies.
Ask your health care provider to take measures to help prevent deep vein thrombosis if you can't move due to surgery or other medical reasons.
Don't smoke.
Take steps, such as lowering your cholesterol level, to help prevent a heart attack or stroke.
ANTISOCIAL PERSONALITY DISORDER
ANTISOCIAL PERSONALITY DISORDER
Antisocial Personality Disorder
Antisocial personality disorder is a type of chronic mental condition in which a person's ways of thinking, perceiving situations and relating to others are dysfunctional — and destructive. People with antisocial personality disorder typically have no regard for right and wrong and often disregard the rights, wishes and feelings of others.
Those with antisocial personality disorder tend to antagonize, manipulate or treat others either harshly or with callous indifference. They may often violate the law, landing in frequent trouble, yet they show no guilt or remorse. They may lie, behave violently or impulsively, and have problems with drug and alcohol use. These characteristics typically make people with antisocial personality disorder unable to fulfill responsibilities related to family, work or school.
SYMPTOMS
Antisocial personality disorder signs and symptoms may include:
Disregard for right and wrong
Persistent lying or deceit to exploit others
Using charm or wit to manipulate others for personal gain or for sheer personal pleasure
Intense egocentrism, sense of superiority and exhibitionism
Recurring difficulties with the law
Repeatedly violating the rights of others by the use of intimidation, dishonesty and misrepresentation
Child abuse or neglect
Hostility, significant irritability, agitation, impulsiveness, aggression or violence
Lack of empathy for others and lack of remorse about harming others
Unnecessary risk-taking or dangerous behaviors
Poor or abusive relationships
Irresponsible work behavior
Failure to learn from the negative consequences of behavior
Antisocial personality disorder symptoms may begin in childhood and are fully evident for most people during their 20s and 30s. In children, cruelty to animals, bullying behavior, impulsivity or explosions of anger, social isolation, and poor school performance may be, in some cases, early signs of the disorder.
Although considered a lifelong disorder, some symptoms — particularly destructive and criminal behavior and the use of alcohol or drugs — may decrease over time, but it's not clear whether this decrease is a result of aging or an increased awareness of the consequences of antisocial behavior.
CAUSES
Personality is the combination of thoughts, emotions and behaviors that makes everyone unique. It's the way people view, understand and relate to the outside world, as well as how they see themselves. Personality forms during childhood, shaped through an interaction of these factors:
Genetics. These inherited tendencies are aspects of a person's personality passed on by parents, such as shyness or having a positive outlook. This is sometimes called temperament.
Environment. This means the surroundings a person grows up in, events that occurred, and relationships with family members and others. It includes such life situations as the type of parenting a person experienced, whether loving or abusive.
Personality disorders are thought to be caused by a combination of these genetic and environmental influences. Some people may have genes that make them vulnerable to developing antisocial personality disorder — and life situations may trigger its development.
There may be a link between an early lack of empathy — understanding the perspectives and problems of others, including other children — and later onset of antisocial personality disorder. Identifying these personality problems early may help improve long-term outcomes.
RISK FACTORS
Although the precise cause of antisocial personality disorder isn't known, certain factors seem to increase the risk of developing or triggering it, including:
Diagnosis of childhood conduct disorder
Family history of antisocial personality disorder or other personality disorders or mental illness
Being subjected to verbal, physical or sexual abuse during childhood
Unstable or chaotic family life during childhood
Loss of parents through traumatic divorce during childhood
History of substance abuse in parents or other family members
Men are at greater risk of having antisocial personality disorder than women are.
COMPLICATIONS
Complications, consequences and problems of antisocial personality disorder include:
Aggressiveness leading to verbal or physical violence
Gang participation
Reckless behavior
Risky sexual behavior
Child abuse
Alcohol or substance abuse
Gambling problems
Being in jail or prison
Homicidal or suicidal behaviors
Relationship difficulties
Occasional periods of depression or anxiety
School and work problems
Strained relationships with health care providers
Low social and economic status, and homelessness
Premature death, usually as a result of violence
TESTS AND DIAGNOSIS
When doctors believe someone has antisocial personality disorder, they typically run a series of medical and psychological tests and exams to help determine a diagnosis. These evaluations generally include:
Physical exam. This is done to help rule out other problems that could be causing symptoms and to check for any related complications.
Lab tests. These may include, for example, a complete blood count (CBC), a thyroid function check, and screening for alcohol and drugs to determine if there are other causes for symptoms.
Psychological evaluation. A doctor or mental health provider explores thoughts, feelings, relationships, behavior patterns and family history, which may include psychological tests about personality. He or she asks about symptoms, including when they started, how severe they are, how they affect daily life and whether similar episodes have occurred in the past. The doctor also asks about thoughts of suicide, self-injury or harming others.
A person with antisocial personality disorder is unlikely to provide an accurate account of his or her signs and symptoms. Family and friends may be able to provide helpful information.
Pinpointing the type of personality disorder
It's sometimes difficult to determine if symptoms point to antisocial personality disorder or another personality disorder because some symptoms overlap more than one disorder. A key factor in diagnosis is how the affected person relates to others. Someone with antisocial personality disorder is likely to have an accurate — sometimes superior — understanding of others' thinking with little awareness or regard for their feelings. This leads the person to act out and make other people miserable — with no feeling of remorse.
Diagnostic criteria
To be diagnosed with antisocial personality disorder, a person must meet the symptom criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual, published by the American Psychiatric Association, is used by mental health providers to diagnose mental illnesses and by insurance companies to reimburse for treatment.
Symptom criteria required for a diagnosis of antisocial personality disorder include:
Being at least 18 years old
Having had symptoms of conduct disorder before age 15, which may include such acts as stealing, vandalism, violence, cruelty to animals and bullying
Repeatedly breaking the law
Repeatedly conning or lying to others
Being irritable and aggressive, repeatedly engaging in physical fights or assaults
Feeling no remorse — or justifying behavior — after harming others
Having no regard for the safety of self or others
Acting impulsively and not planning ahead
Being irresponsible and repeatedly failing to honor work or financial obligations
TREATMENTS AND DRUGS
Antisocial personality disorder is very difficult to treat. People with this disorder may not even want treatment or think they need it. But people with antisocial personality disorder need treatment and close follow-up over the long term.
People with antisocial personality disorder may also need treatment for other conditions, such as depression, anxiety or substance use disorders. Medical and mental health providers with experience treating antisocial personality disorder and commonly associated conditions are most likely to be helpful.
The best treatment or combination of treatments depends on each person's particular situation and severity of symptoms.
Psychotherapy
Psychotherapy, also called talk therapy, is sometimes used to treat antisocial personality disorder. Psychotherapy is not always effective, especially if symptoms are severe and the person can't admit that he or she contributes to problems.
Psychotherapy may be provided in individual sessions, in group therapy, or in sessions that include family or even friends.
Medications
There are no medications specifically approved by the Food and Drug Administration to treat antisocial personality disorder. However, several types of psychiatric medications may help with certain conditions sometimes associated with antisocial personality disorder or with symptoms such as aggression. These medications may include antipsychotic, antidepressant or mood-stabilizing medications. They must be prescribed cautiously because some have the potential for misuse.
Skills for family members
If you have a loved one with antisocial personality disorder, it's critical that you also get help for yourself. Mental health professionals with experience managing this condition can teach you skills to learn how to set boundaries and help protect yourself from the aggression, violence and anger common to antisocial personality disorder. They can also recommend strategies for coping.
Ask the people on your loved one's treatment team for a referral. They may also be able to recommend support groups for families and friends affected by antisocial personality disorder.
LIFESTYLE AND HOME REMEDIES
There's no sure way to prevent antisocial personality disorder from developing in those at risk. Trying to identify those most at risk, such as children living with neglect or abuse, and offering early intervention may help. Getting appropriate treatment early, and sticking with it for the long term, may prevent symptoms from worsening.
Because antisocial behavior is thought to have its roots in childhood, parents, teachers and pediatricians may be able to spot early warning signs. While diagnosis of antisocial personality disorder generally isn't done before age 18, children at risk may have symptoms of conduct disorder, especially behavior that involves violence or aggression toward others, such as:
Bullying
Conflict with peers, family members and authority figures
Stealing
Cruelty to people and animals
Fire starting and vandalism
Use of weapons
Sexual assault
Repeated lying
Problem behaviors in school and poor academic performance
Gang involvement
Running away from home
Early, effective and appropriate discipline, lessons in behavioral skills, family therapy, and psychotherapy may help reduce the chance that at-risk children go on to become adults with antisocial personality disorder.
AORTIC VALVE STENOSIS
AORTIC VALVE STENOSIS
Aortic valve stenosis — or aortic stenosis — occurs when the heart's aortic valve narrows. This narrowing prevents the valve from opening fully, which obstructs blood flow from your heart into your aorta and onward to the rest of your body.
When the aortic valve is obstructed, your heart needs to work harder to pump blood to your body. Eventually, this extra work limits the amount of blood it can pump and may weaken your heart muscle.
If you have severe aortic valve stenosis, you'll usually need surgery to replace the valve. Left untreated, aortic valve stenosis can lead to serious heart problems.
SYMPTOMS
Aortic valve stenosis ranges from mild to severe. Aortic valve stenosis signs and symptoms generally develop when narrowing of the valve is severe and can include:
Chest pain (angina) or tightness
Feeling faint or fainting with exertion
Shortness of breath, especially with exertion
Fatigue, especially during times of increased activity
Heart palpitations — sensations of a rapid, fluttering heartbeat
Heart murmur
The heart-weakening effects of aortic valve stenosis may lead to heart failure. Heart failure signs and symptoms include fatigue, shortness of breath, and swollen ankles and feet.
Aortic valve stenosis often doesn't produce warning signs or symptoms right away, making it difficult to detect at first. You also may not recognize that you're experiencing symptoms. The condition is often discovered during a routine physical when your doctor hears an abnormal heart sound (heart murmur). This murmur may occur long before other signs and symptoms develop.
Depending on the amount of narrowing, an infant or child with aortic valve stenosis may have no symptoms, may tire easily or may have chest pain with vigorous physical activity.
When to see a doctor
Aortic valve stenosis usually affects adults but can occur in children. Infants and children with the condition may experience symptoms similar to those of adults. If you or your child experiences such signs or symptoms, see a doctor — especially if you or your child has a known heart problem.
CAUSES
Aortic valve stenosis is narrowing of the aortic valve. Many things can narrow this passageway between your heart and aorta. Causes of aortic valve stenosis include:
Congenital heart defect. The aortic valve consists of three tightly fitting, triangular-shaped flaps of tissue called leaflets. Some children are born with an aortic valve that has only one (unicuspid), two (bicuspid) or four (quadricuspid) leaflets — not three. This deformity may not cause any problems until adulthood, at which time the valve may begin to narrow or leak and may need to be repaired or replaced.
Having a congenitally abnormal aortic valve requires regular evaluation by a doctor to watch for signs of valve problems. In most cases, doctors don't know why a heart valve fails to develop properly, so it isn't something you could have prevented.
Calcium buildup on the valve. With age, heart valves may accumulate deposits of calcium (aortic valve calcification). Calcium is a mineral found in your blood. As blood repeatedly flows over the aortic valve, deposits of calcium can accumulate on the valve's leaflets. These deposits may never cause any problems. These calcium deposits aren't linked to taking calcium tablets or drinking calcium-fortified drinks.
However, in some people — particularly those with a congenitally abnormal aortic valve, such as a bicuspid aortic valve — calcium deposits result in stiffening of the leaflets of the valve. This stiffening narrows the aortic valve and can occur at a younger age. However, aortic valve stenosis that is related to increasing age and the buildup of calcium deposits on the aortic valve is most common in men older than 65 and women older than 75.
Rheumatic fever. A complication of strep throat infection, rheumatic fever may result in scar tissue forming on the aortic valve. Scar tissue alone can narrow the aortic valve and lead to aortic valve stenosis. Scar tissue can also create a rough surface on which calcium deposits can collect, contributing to aortic valve stenosis later in life.
Rheumatic fever may damage more than one heart valve, and in more than one way. A damaged heart valve may not open fully or close fully — or both. While rheumatic fever is rare in the United States, some older adults had rheumatic fever as children.
How your heart works
Your heart, the center of your circulatory system, consists of four chambers. The two upper chambers (atria) receive blood. The two lower chambers (ventricles) pump blood.
Blood returning to your heart enters the right upper chamber (right atrium). From there, blood empties into the right ventricle underneath. The right ventricle pumps blood into your lungs, where blood is oxygenated.
Blood from your lungs then returns to your heart but this time to the left side — to the left upper chamber (left atrium). Blood then flows into the left ventricle — your heart's main pump. With each heartbeat, the left ventricle forces blood through the aortic valve into the aorta, your body's largest artery.
Blood flows through your heart's chambers, aided by four heart valves. These valves open and close to let blood flow in only one direction through your heart:
Tricuspid valve
Pulmonary valve
Mitral valve
Aortic valve
The aortic valve — your heart's gateway to the aorta — consists of three tightly fitting, triangular-shaped flaps of tissue called leaflets. These leaflets connect to the aorta via a ring called the annulus.
Heart valves open like a one-way gate. The leaflets of the aortic valve are forced open as the left ventricle contracts and blood flows into the aorta. When all of the left ventricular blood has gone through the valve and the left ventricle has relaxed, the leaflets swing closed to prevent the blood that has just passed into the aorta from flowing back into the left ventricle.
A defective heart valve is one that fails to either open or close fully. When a valve doesn't close tightly, blood can leak backward. This backward flow through a valve is called regurgitation. When a valve narrows, the condition is called stenosis.
RISK FACTORS
Aortic valve stenosis isn't considered preventable, and presently it's not known why some people develop this condition. Some risk factors include:
A deformed aortic valve. Some people are born with an already narrowed aortic valve or develop aortic valve stenosis later in life because they were born with a bicuspid aortic valve — one with two flaps (leaflets) instead of three. People may also develop aortic valve stenosis if they were born with one leaflet (unicuspid aortic valve) or four leaflets (quadricuspid aortic valve), but these are much more rare conditions.
A bicuspid aortic valve is a major risk factor for aortic valve stenosis. A bicuspid aortic valve can run in families, so knowing your family history is important. If you have a first-degree relative — a parent, sibling or child — with a bicuspid aortic valve, it is reasonable to check to see if you have this abnormality.
Age. Aortic valve stenosis may be related to increasing age and the buildup of calcium deposits on heart valves.
Previous rheumatic fever. Rheumatic fever can cause the flaps (leaflets) of your aortic valve to stiffen and fuse, eventually resulting in aortic valve stenosis.
Chronic kidney disease. Aortic valve stenosis is associated with chronic kidney disease.
Risk factors for aortic valve stenosis and atherosclerotic heart disease are similar — such as high blood pressure, high cholesterol, type 2 diabetes and smoking — which may indicate a link between the two.
COMPLICATIONS
Aortic valve stenosis — of any cause — can be a serious condition. If the aortic valve is narrowed, the left ventricle has to work harder to pump a sufficient amount of blood into the aorta and onward to the rest of your body.
In response, the left ventricle may thicken and enlarge. At first, these adaptations help the left ventricle pump blood with more force. But eventually it's harder for the heart to maintain the blood flow to the body through the narrowed valve. Then you will start to experience symptoms. Eventually, the extra work of the heart can weaken the left ventricle — and your heart overall.
Left unchecked, aortic valve stenosis can lead to life-threatening heart problems, including:
Chest pain (angina)
Fainting (syncope)
Heart failure
Irregular heart rhythms (arrhythmias)
Cardiac arrest
PREPARING FOR YOUR APPOINTMENT
You're likely to start by first seeing your family doctor. After your initial appointment, your doctor may refer you to a doctor trained in diagnosing and treating heart conditions (cardiologist).
Here's some information to help you prepare for your appointment, and what to expect from your doctor.
What you can do
Write down any symptoms you're experiencing and for how long.
Make a list of your key medical information, including other recent health problems you've had and the names of any prescription and over-the-counter medications you're taking.
Find a family member or friend who can come with you to the appointment, if possible. Someone who accompanies you can help remember what the doctor says.
Write down the questions you want to be sure to ask your doctor.
Questions to ask your doctor at your initial appointment include:
What is likely causing my signs or symptoms?
Are there any other possible causes for these signs or symptoms?
What tests do I need?
Should I see a specialist?
Should I follow any restrictions in the time leading up to my appointment with a cardiologist?
Questions to ask if you are referred to a cardiologist include:
What is my diagnosis?
What treatment approach do you recommend?
If you're recommending medications, what are the possible side effects?
If you're recommending surgery, what procedure is most likely to be successful in my case? Why?
If you're recommending surgery, what will my recovery be like?
If you don't think I need immediate treatment, how will you determine the right time to treat my condition?
How frequently will you see me for follow-up visits?
What is my risk of long-term complications from this condition?
What restrictions do I need to follow?
Will physical activity, including sexual activity, increase my risk of complications?
What diet and lifestyle changes should I make?
I have these other health problems. How can I best manage them together?
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
A doctor who sees you for possible aortic valve stenosis may ask:
What are your symptoms?
When did you first begin experiencing symptoms?
Have your symptoms gotten worse over time?
Do your symptoms include rapid, fluttering or pounding heartbeats?
Do your symptoms include dizziness?
Have you ever fainted?
Have you ever coughed up blood?
Does exercise or physical exertion make your symptoms worse?
Are you aware of any history of heart problems in your family?
Have you ever knowingly had rheumatic fever?
Are you being treated or have you recently been treated for any other health conditions?
Do you or did you smoke? How much?
Do you use alcohol or caffeine? How much?
Are you planning to become pregnant in the future?
What you can do in the meantime
While you wait for your appointment, check with your family members to find out if any close relatives have been diagnosed with cardiac disease. The symptoms of aortic valve stenosis are similar to a number of other heart conditions, including some that tend to run in families. Knowing as much as possible about your family's health history will help your doctor determine the next steps for your diagnosis and treatment.
If exercise makes your symptoms worse, avoid exerting yourself physically until you've been seen by your doctor.
TESTS AND DIAGNOSIS
To diagnose your condition, your doctor will review your medical history and symptoms and conduct a physical examination. As part of a routine physical exam, your doctor uses a stethoscope to listen to your heart. He or she is listening for, among other things, an abnormal heart sound (heart murmur).
If your doctor discovers a heart murmur, he or she will discuss it with you. Many heart conditions, including aortic valve stenosis, can produce a heart murmur. In the case of aortic valve stenosis, the heart murmur results from turbulent blood flow through the narrowed valve.
Diagnostic tests
If your doctor suspects that you or your child may have a deformed or narrowed aortic valve, you may need to undergo several tests to confirm the diagnosis and gauge the severity of the problem. You may be referred to a doctor trained in heart conditions (cardiologist) for tests such as:
Echocardiogram. This test uses sound waves to produce an image of your heart. This is the primary test your doctor may use to diagnose your condition if he or she suspects you have a heart valve condition. In an echocardiogram, sound waves are directed at your heart from a wandlike device (transducer) 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 helps your doctor closely examine the heart and heart valves to check for any problems or abnormalities. This test helps your doctor to diagnose aortic valve stenosis, evaluate the severity of your condition and determine the most appropriate treatment for your condition. An echocardiogram will also be used to monitor your condition over time.
In some cases, your doctor may insert a tube with a transducer attached to it and guide it down your throat into your esophagus (transesophageal echocardiogram) while you are sedated. This type of echocardiogram may offer more detailed images of your heart.
Electrocardiogram (ECG). In this test, patches with wires (electrodes) are attached to your skin to measure the electrical impulses given off by your heart. Impulses are recorded as waves displayed on a monitor or printed on paper. An ECG can provide clues about whether the left ventricle is thickened or enlarged, a problem which can occur with aortic valve stenosis.
Chest X-ray. An X-ray image of your chest allows your doctor to check the size and shape of your heart to determine whether the left ventricle is enlarged — a possible indicator of aortic valve stenosis.
A chest X-ray can also reveal calcium deposits on the aortic valve. In addition, a chest X-ray helps your doctor check the condition of your lungs. Aortic valve stenosis may lead to blood and fluid backing up in your lungs, which causes congestion that may be visible on an X-ray.
Cardiac catheterization. Your doctor may order this procedure if noninvasive tests haven't provided enough information to firmly diagnose the type or severity of your heart condition. In this procedure, your doctor threads a thin tube (catheter) through an artery in your arm or groin and guides it to an artery in your heart.
Doctors may inject a dye through the catheter, which helps your arteries become visible on an X-ray (coronary angiogram). This test helps show any blockages in arteries to your heart that can coexist with aortic valve stenosis that may need surgical treatment along with aortic valve stenosis.
Exercise tests. In exercise tests, you exercise to increase your heart rate and make your heart work harder. If you have severe aortic valve stenosis but aren't experiencing symptoms, your doctor may order exercise tests to evaluate how your heart responds to exertion (exercise) and to measure your tolerance for activity.
Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed images of your heart and heart valves. Doctors may use this test to measure the size of your aorta and look at your aortic valve more closely. Sometimes doctors may inject a dye into your blood vessels to show the blood flow (CT angiography).
Magnetic resonance imaging (MRI). An MRI uses powerful magnets and radio waves to create detailed images of your heart and heart valves. Doctors may inject a dye into your blood vessels to highlight the heart and blood vessels in images (magnetic resonance angiography). Doctors may use this test to measure the size of your aorta.
These tests and others help your doctor determine how narrow or tight your aortic valve may be and how well your heart is pumping. Once aortic valve stenosis is discovered, your doctor will either recommend treatment or suggest careful monitoring.
TREATMENTS AND DRUGS
Medications sometimes can ease symptoms of aortic valve stenosis. However, the only way to eliminate aortic valve stenosis is surgery to repair or replace the valve and open up the passageway.
Surgery isn't always needed right away. If tests reveal that you have mild to moderate aortic valve stenosis and you have no symptoms, your doctor will schedule checkups to carefully monitor the valve so that surgery can be done at the appropriate time. In follow-up appointments, your doctor will review your medical history and conduct a physical examination. Your doctor may also discuss symptoms and what to expect as your condition progresses.
Your doctor may order an echocardiogram to view your aortic valve and monitor your condition every three to five years if you have mild aortic valve stenosis, and every year if you have moderate aortic valve stenosis.
If you have severe aortic valve stenosis, your doctor may schedule checkups every three to six months. Your doctor may order an echocardiogram every six to 12 months to view your heart valve and monitor your condition. In some cases, your doctor may order additional tests.
In general, surgery is necessary when narrowing becomes severe and symptoms develop. In some cases, your doctor may recommend surgery if you have severe aortic valve stenosis even if you aren't experiencing symptoms. If you have moderate or severe aortic valve stenosis and other conditions that require heart surgery, your doctor may recommend surgery to treat your conditions.
Medications
No medications can reverse aortic valve stenosis. However, your doctor may prescribe certain medications to help your symptoms, such as ones to reduce fluid accumulation, to slow your heart rate or to control heart rhythm disturbances associated with aortic valve stenosis. Lowering blood pressure may prevent or slow the development of aortic stenosis. Ask your doctor if you need to lower your blood pressure with medications.
Procedures
You may need valve repair or replacement to treat aortic valve stenosis. Although less invasive approaches are possible in some cases, surgery is the primary treatment for this condition.
Therapies to repair or replace the aortic valve include:
Balloon valvuloplasty. Occasionally, balloon valvuloplasty is an option. Balloon valvuloplasty uses a soft, thin tube (catheter) tipped with a balloon.
A doctor guides the catheter through a blood vessel in your groin to your heart and into your narrowed aortic valve. Once in position, a balloon at the tip of the catheter is inflated. The balloon pushes open the aortic valve and stretches the valve opening, improving blood flow. The balloon is then deflated, and the catheter with the balloon is guided back out of your body.
Balloon valvuloplasty may relieve aortic valve stenosis and its symptoms, especially in infants and children. However, in adults, the valve tends to narrow again even after initial success. For these reasons, doctors rarely use balloon valvuloplasty today to treat aortic valve stenosis in adults, except in people who are too sick to undergo surgery or are waiting for a transcatheter aortic valve replacement.
Aortic valve replacement. This is the primary surgical treatment for severe aortic valve stenosis. Your surgeon removes the narrowed aortic valve and replaces it with a mechanical valve or a tissue valve. This procedure is generally performed during open-heart surgery.
Mechanical valves, made from metal, are durable, but they carry the risk of blood clots forming on or near the valve. If you receive a mechanical valve, you'll need to take an anticoagulant medication, such as warfarin (Coumadin), for life to prevent blood clots.
Tissue valves — which may come from a pig, cow or human deceased donor — often eventually narrow over the years and need to be replaced. Another type of tissue valve replacement that uses your own pulmonary valve (autograft) is sometimes possible but less likely in an older person. Your doctor can discuss the risks and benefits of each type of heart valve with you. Aortic valve replacement can relieve aortic valve stenosis and its symptoms.
Transcatheter aortic valve replacement (TAVR). Aortic valve replacement, the most common treatment for aortic valve stenosis, has traditionally been performed with open-heart surgery.
A less invasive approach — transcatheter aortic valve replacement — involves replacing the aortic valve with a prosthetic valve via the femoral artery in your leg (transfemoral) or the left ventricular apex of your heart (transapical).
In TAVR, doctors insert a catheter with a balloon at the tip in an artery in your leg or in a small incision in your chest and guide it to your heart and into your aortic valve. A balloon at the tip of the catheter, which has a folded valve around it, is then inflated. This pushes open the aortic valve and stretches the valve opening and expands the folded valve into the aortic valve. Doctors then deflate the balloon and guide the catheter with the balloon back out of your body. Alternatively, a self-expanding valve may be inserted into the aortic valve, and a balloon then isn't used.
In some cases, a valve can be inserted via a catheter into a tissue replacement valve that needs to be replaced (valve-in-valve procedure).
TAVR is usually reserved for individuals with severe aortic valve stenosis who are at increased risk of complications from aortic valve surgery. This procedure can relieve severe aortic valve stenosis and its symptoms in those who are at increased risk of complications from aortic valve surgery. TAVR has a higher risk of stroke and vascular complications than aortic valve replacement surgery. The technique is relatively new and is evolving quickly, and there are newer valves and indications occurring frequently. TAVR is sometimes referred to as transcatheter aortic valve implantation (TAVI).
Surgical valvuloplasty. In rare cases, surgical repair may be a more effective option than balloon valvuloplasty, such as in infants born with an aortic valve in which the leaflets of the valve are fused together. Using traditional surgical tools, a cardiac surgeon operates on the valve and separates these leaflets to reduce stenosis and improve blood flow.
Aortic valve stenosis can be treated effectively with surgery. However, you'll need regular follow-up appointments with your doctor to check for any changes in your condition. You may still be at risk of irregular heart rhythms even after you've been treated for aortic valve stenosis. You may need to take medications to lower that risk. If your heart has become weakened from aortic valve stenosis, you may need medications to treat heart failure.
If you've had aortic valve replacement surgery, you need to take antibiotics before certain dental or medical procedures due to the risk of infection in your heart tissue (endocarditis).
LIFESTYLE AND HOME REMEDIES
Some possible ways to prevent aortic valve stenosis include:
Taking steps to prevent rheumatic fever. You can do this by making sure you see your doctor when you have a sore throat. Untreated strep throat can develop into rheumatic fever. Fortunately, strep throat can usually be easily treated with antibiotics. Rheumatic fever is more common in children and young adults.
Addressing risk factors for coronary artery disease. These include high blood pressure, obesity and high cholesterol levels. These factors may be linked to aortic valve stenosis, so it's a good idea to keep your weight, blood pressure and cholesterol levels under control if you have aortic valve stenosis.
Taking care of your teeth and gums. There may be a link between infected gums (gingivitis) and infected heart tissue (endocarditis). Inflammation of heart tissue caused by infection can narrow arteries and aggravate aortic valve stenosis.
Once you know that you have aortic valve stenosis, your doctor may recommend that you limit strenuous activity to avoid overworking your heart.
If you're a woman of childbearing age with aortic valve stenosis, discuss pregnancy and family planning with your doctor before you become pregnant. Your heart works harder during pregnancy. How a heart with aortic valve stenosis tolerates this extra work depends on the degree of stenosis and how well your heart pumps. Should you become pregnant, you'll need evaluation by your cardiologist and obstetrician throughout your pregnancy, labor and delivery, and after delivery.
APHASIA
APHASIA
Aphasia is a condition that robs you of the ability to communicate. It can affect your ability to speak, write and understand language, both verbal and written.
Aphasia typically occurs suddenly after a stroke or a head injury. But it can also come on gradually from a slow-growing brain tumor or a disease that causes progressive, permanent damage (degenerative). Where and how bad the brain damage is and what caused it determine the degree of disability.
Once the cause has been addressed, the main treatment for aphasia is speech and language therapy. The person with aphasia relearns and practices language skills and learns to use other ways to communicate. Family members often participate in the process, helping the person communicate.
SYMPTOMS
Aphasia is a sign of some other condition, such as a stroke or a brain tumor.
A person with aphasia may:
Speak in short or incomplete sentences
Speak in sentences that don't make sense
Substitute one word for another or one sound for another
Speak unrecognizable words
Not understand other people's conversation
Write sentences that don't make sense
The severity and scope of the problems depend on the extent of damage and the area of the brain affected.
Types of aphasia
Your doctor may refer to aphasia as nonfluent, fluent or global:
Nonfluent aphasia. Damage to the language network near the left frontal area of the brain usually results in Broca aphasia, which is also called nonfluent aphasia. People with this disorder struggle to get words out, speak in very short sentences and omit words. A person might say "Want food" or "Walk park today." A listener can usually understand the meaning.
People with Broca aphasia may understand what other people say better than they can speak. They're often aware of their difficulty communicating and may get frustrated. People with Broca aphasia may also have right-sided paralysis or weakness.
Fluent aphasia. People with this form of aphasia may speak easily and fluently in long, complex sentences that don't make sense or include unrecognizable, incorrect or unnecessary words. They usually don't understand spoken language well and often don't realize that others can't understand them. Also known as Wernicke aphasia, this type of aphasia is the result of damage to the language network in the middle left side of the brain.
Global aphasia. Global aphasia results from extensive damage to the brain's language networks. People with global aphasia have severe disabilities with expression and comprehension.
When to see a doctor
Because aphasia is often a sign of a serious problem, such as a stroke, seek emergency medical care if you suddenly develop:
Difficulty speaking
Trouble understanding speech
Difficulty with word recall
Problems with reading or writing
CAUSES
The most common cause of aphasia is brain damage resulting from a stroke — the blockage or rupture of a blood vessel in the brain. Loss of blood to the brain leads to brain cell death or damage in areas that control language.
Brain damage caused by a severe head injury, a tumor, an infection or a degenerative process also can cause aphasia. In these cases, the aphasia usually occurs with other types of cognitive problems, such as memory problems or confusion.
Primary progressive aphasia is the term used for language difficulty that develops gradually. This is due to the gradual degeneration of brain cells located in the language networks. Sometimes this type of aphasia will progress to a more generalized dementia.
Sometimes temporary episodes of aphasia can occur. These can be due to migraines, seizures or a transient ischemic attack (TIA). A TIA occurs when blood flow is temporarily blocked to an area of the brain. People who've had a TIA are at an increased risk of having a stroke in the near future.
COMPLICATIONS
Aphasia can create numerous quality-of-life problems because communication is so much a part of your life. Communication difficulty may affect your:
Job
Relationships
Day-to-day function
Language barriers may lead to embarrassment, depression and relationship problems.
PREPARING FOR YOUR APPOINTMENT
If your aphasia is due to a stroke or head injury, you'll probably first see an emergency room physician. You'll then see a doctor who specializes in disorders of the nervous system (neurologist), and you may eventually be referred to a speech-language pathologist for rehabilitation.
Because this condition generally arises as an emergency, you won't have time to prepare. If possible, bring the medications or supplements you take with you to the hospital so that your doctor is aware of them.
When you have follow-up appointments, you'll likely need a companion to drive you to your doctor's office. In addition, this person may be able to help you communicate with your doctor.
Some questions a loved one or friend may want to ask your doctor include:
What's the most likely cause of these speech difficulties?
Are tests needed?
Is aphasia temporary or long lasting?
What treatments are available for aphasia, and which do you recommend?
Are there services available, such as speech-language therapy or home health assistance?
Are there ways to help my loved one understand others or communicate more effectively?
What to expect from your doctor
Your doctor will likely have questions, too. A loved one or friend can help your doctor get the information needed. Your doctor may ask:
When did the symptoms start?
Do you understand what others are saying?
Do others understand what you're saying?
Has the aphasia been continuous, or does it come and go?
Have you noticed changes in your speech — such as the way you move your jaw, tongue and lips to make speech sounds — or the sound of your voice?
Have you noticed changes in your ability to understand what you read or your ability to spell and write sentences?
TESTS AND DIAGNOSIS
Your doctor will likely give you a physical and a neurological exam, test your strength, feeling and reflexes, and listen to your heart and the vessels in your neck. He or she will likely request an imaging test, usually an MRI, to quickly identify what's causing the aphasia.
You'll also likely undergo tests and informal observations to assess your language skills, such as the ability to:
Name common objects
Engage in a conversation
Understand and use words correctly
Answer questions about something read or heard
Repeat words and sentences
Follow instructions
Answer yes-no questions and respond to open-ended questions about common subjects
Read and write
TREATMENTS AND DRUGS
If the brain damage is mild, a person may recover language skills without treatment. However, most people undergo speech and language therapy to rehabilitate their language skills and supplement their communication experiences. Researchers are currently investigating the use of medications, alone or in combination with speech therapy, to help people with aphasia.
Speech and language rehabilitation
Recovery of language skills is usually a relatively slow process. Although most people make significant progress, few people regain full pre-injury communication levels.
For aphasia, speech and language therapy tries to improve the person's ability to communicate by restoring as much language as possible, teaching how to compensate for lost language skills and finding other methods of communicating.
Therapy:
Starts early. Some studies have found that therapy is most effective when it begins soon after the brain injury.
Often works in groups. In a group setting, people with aphasia can try out their communication skills in a safe environment. Participants can practice initiating conversations, speaking in turn, clarifying misunderstandings and fixing conversations that have completely broken down.
May include use of computers. Using computer-assisted therapy can be especially helpful for relearning verbs and word sounds (phonemes).
Medications
Certain drugs are currently being studied for the treatment of aphasia. These include drugs that may improve blood flow to the brain, enhance the brain's recovery ability or help replace depleted chemicals in the brain (neurotransmitters). Several medications, such as memantine (Namenda) and piracetam, have shown promise in small studies. But more research is needed before these treatments can be recommended.
COPING AND SUPPORT
People with aphasia
If you have aphasia, the following tips may help you communicate with others:
Carry a card explaining that you have aphasia and what aphasia is.
Carry identification and information on how to contact significant others.
Carry a pencil and a small pad of paper with you at all times.
Use drawings, diagrams or photos as shortcuts.
Use gestures or point to objects.
Family and friends
Family members and friends can use the following tips when communicating with a person with aphasia:
Simplify your sentences and slow your pace.
Keep conversations one-on-one initially.
Allow the person time to talk.
Don't finish sentences or correct errors.
Reduce distracting noise in the environment.
Keep paper and pencils or pens available.
Write a key word or a short sentence to help explain something.
Help the person with aphasia create a book of words, pictures and photos to assist with conversations.
Use drawings or gestures when you aren't understood.
Involve the person with aphasia in conversations as much as possible.
Check for comprehension or summarize what you've discussed.
Support groups
Local chapters of such organizations as the National Aphasia Association, the American Stroke Association, the American Heart Association and some medical centers may offer support groups for people with aphasia and others affected by the disorder. These groups provide people with a sense of community, a place to air frustrations and learn coping strategies. Ask your doctor or speech-language pathologist if he or she knows of any local support groups.
PRIMARY PROGRESSIVE APHASIA
PRIMARY PROGRESSIVE APHASIA
Primary progressive aphasia (uh-FAY-zhuh) is a rare nervous system (neurological) syndrome that impairs language capabilities. People with primary progressive aphasia may have trouble expressing their thoughts and comprehending or finding words.
Symptoms of primary progressive aphasia begin gradually, sometimes before age 65, and tend to worsen over time. People with primary progressive aphasia can become mute and may eventually lose the ability to understand written or spoken language.
People with primary progressive aphasia may continue caring for themselves and participating in daily life activities for several years after the disorder's onset, as the condition progresses slowly.
Primary progressive aphasia is a type of frontotemporal degeneration, a cluster of related disorders that originate in the frontal or temporal lobes of the brain.
SYMPTOMS
Primary progressive aphasia symptoms may vary by individual, depending on which portion of the brain's language center is involved.
Primary progressive aphasia has three types, which cause different symptoms.
Semantic variant primary progressive aphasia
In this condition, you may experience symptoms such as:
Difficulty comprehending spoken or written language, particularly single words
Difficulty comprehending word meanings
Difficulty naming objects
Lopogenic variant primary progressive aphasia
In this condition, you may experience symptoms such as:
Difficulty retrieving correct words in speech
Frequent pauses in your speech while searching for words
Slow speech
Difficulty repeating phrases or sentences
Nonfluent-agrammatic variant primary progressive aphasia
In this condition, you may experience symptoms such as:
Difficulty speaking
Hesitant, halting speech
Making errors in speech sounds
Difficulty understanding sentences
Using grammar incorrectly
Symptoms may vary depending on the speaking situation and the type of primary progressive aphasia. For example, a person may need to pause frequently to find words during a conversation requiring a high level of precision but then have no pauses when exchanging small talk. Reading and writing also are usually affected.
CAUSES
Primary progressive aphasia is caused by a shrinking (atrophy) of the frontal and temporal lobes in the brain, primarily on the left side of the brain. Primary progressive aphasia affects the language center in your brain. Scar tissue and abnormal proteins also may be present, and brain activity is often reduced.
RISK FACTORS
Risk factors for primary progressive aphasia include:
Having learning disabilities. People with learning disabilities, particularly dyslexia, may be at higher risk of primary progressive aphasia, perhaps because both conditions involve using and understanding language.
Having certain gene mutations. Rare gene mutations have been linked to the disorder. If several other members of your family have had primary progressive aphasia, you may be more likely to develop it.
COMPLICATIONS
People with primary progressive aphasia may become mute and may eventually lose the ability to understand written and spoken language.
As the disease progresses, other mental skills, such as memory, may become impaired. Some people may develop other neurological conditions over time. If these complications occur, the affected person eventually will need help with day-to-day care.
People with primary progressive aphasia may also develop behavioral or social problems, such as being anxious or irritable. Other problems may include blunted emotions, poor judgment or inappropriate social behavior.
PREPARING FOR YOUR APPOINTMENT
You may initially talk to your family doctor about your difficulties in using and understanding language. He or she may refer you to a doctor trained in brain and nervous system conditions (neurologist) or a speech-language pathologist for further evaluation or treatment.
What you can do
Write down all your symptoms, including when each one started and whether any activity or task seems to make them worse.
Make a list of all your medications, including vitamins and supplements.
Take a family member or friend along to help with communication issues.
Write down questions to ask your doctor, including what types of tests you might need and what treatments might be helpful.
What to expect from your doctor
What happens during your appointment may vary depending on the type of doctor you see. Your doctor may:
Ask detailed questions about your symptoms
Use written or verbal tests to determine the severity of your communication problems
Test your short-term memory
Order additional medical tests to rule out other causes of aphasia
Talk to someone who knows you well to get more information about your communication problems and any recent changes in your behavior
TESTS AND DIAGNOSIS
To diagnose primary progressive aphasia, your doctor will review your symptoms and order several tests. Because there is no specific test to diagnose primary progressive aphasia, your doctor will need to order tests to diagnose your condition and rule out other possible causes of your symptoms.
Neurological examination
Doctors may conduct a neurological examination as well as a speech-language evaluation and a neuropsychological evaluation. Tests will be conducted to measure your speech, language comprehension and skills, recognition and naming of objects, recall, and other factors.
Blood tests
Doctors may order blood tests to check for infections, measure medication levels or test for other medical conditions. You may also have genetic tests to determine if you have genetic mutations associated with primary progressive aphasia or other neurological conditions.
Brain scans
Magnetic resonance imaging (MRI) scans can help diagnose primary progressive aphasia, detect shrinking of certain areas of the brain and show which area of the brain may be affected. MRI scans can also detect strokes, tumors or other conditions that may affect brain function.
Single-photon emission computerized tomography or PET scans can show blood flow or glucose metabolism abnormalities in areas of your brain.
TREATMENTS AND DRUGS
Primary progressive aphasia can't be cured. However, doctors and other health care professionals can help you manage your condition.
Medications
There are no drugs that specifically treat primary progressive aphasia.
Researchers continue to study potential medications to treat primary progressive aphasia. Experimental therapies may be available in upcoming years.
Speech and language therapy
Working with a speech-language pathologist, focusing primarily on efforts to compensate for eroding language skills, can be helpful. Although speech and language therapy hasn't been proved to prevent or slow progression of the condition, it can help you manage your condition.
COPING AND SUPPORT
Losing the ability to communicate is distressing and incredibly frustrating. Friends and family members can make communication easier by:
Paying close attention to the affected person
Giving feedback about the need for clarification
Providing more time for communication
Confirming information
Keeping statements relatively brief
Supplementing speech with gestures
Family members eventually may need to consider long-term care options for the person with primary progressive aphasia. Family members may also need to plan the person's finances and help make legal decisions to prepare for more-serious stages of the condition.
Support groups may be available for you and the person with primary progressive aphasia or related conditions. Ask your social worker or other members of your treatment team about community resources or support groups.
APLASTIC ANEMIA
APLASTIC ANEMIA
Aplastic anemia is a condition that occurs when your body stops producing enough new blood cells. Aplastic anemia leaves you feeling fatigued and with a higher risk of infections and uncontrolled bleeding.
A rare and serious condition, aplastic anemia can develop at any age. Aplastic anemia may occur suddenly, or it can occur slowly and get worse over a long period of time. Treatment for aplastic anemia may include medications, blood transfusions or a stem cell transplant.
SYMPTOMS
Aplastic anemia symptoms may include:
Fatigue
Shortness of breath with exertion
Rapid or irregular heart rate
Pale skin
Frequent or prolonged infections
Unexplained or easy bruising
Nosebleeds and bleeding gums
Prolonged bleeding from cuts
Skin rash
Dizziness
Headache
Aplastic anemia can progress slowly over weeks or months, or it may come on suddenly. The illness may be brief, or it may become chronic. Aplastic anemia can be very severe and even fatal.
CAUSES
Aplastic anemia develops when damage occurs to your bone marrow, slowing or shutting down the production of new blood cells. Bone marrow is a red, spongy material inside your bones that produces stem cells, which give rise to other cells. Stem cells in the bone marrow produce blood cells — red cells, white cells and platelets. In aplastic anemia, the bone marrow is described in medical terms as aplastic or hypoplastic — meaning that it's empty (aplastic) or contains very few blood cells (hypoplastic).
Factors that can temporarily or permanently injure bone marrow and affect blood cell production include:
Radiation and chemotherapy treatments. While these cancer-fighting therapies kill cancer cells, they can also damage healthy cells, including stem cells in bone marrow. Aplastic anemia can be a temporary side effect of these treatments.
Exposure to toxic chemicals. Exposure to toxic chemicals, such as some used in pesticides and insecticides, may cause aplastic anemia. Exposure to benzene — an ingredient in gasoline — also has been linked to aplastic anemia. This type of anemia may get better on its own if you avoid repeated exposure to the chemicals that caused your initial illness.
Use of certain drugs. Some medications, such as those used to treat rheumatoid arthritis and some antibiotics, can cause aplastic anemia.
Autoimmune disorders. An autoimmune disorder, in which your immune system begins attacking healthy cells, may involve stem cells in your bone marrow.
A viral infection. Viral infections that affect bone marrow may play a role in the development of aplastic anemia in some people. Viruses that have been linked to the development of aplastic anemia include hepatitis, Epstein-Barr, cytomegalovirus, parvovirus B19 and HIV.
Pregnancy. Aplastic anemia that occurs in pregnancy may be related to an autoimmune problem — your immune system may attack your bone marrow during pregnancy.
Unknown factors. In many cases, doctors aren't able to identify the cause of aplastic anemia. This is called idiopathic aplastic anemia.
Confusion with myelodysplastic syndrome
Aplastic anemia can be mistaken for a condition called myelodysplastic syndrome. In this group of disorders, the bone marrow produces new blood cells, but they're deformed and underdeveloped. The bone marrow in myelodysplastic syndrome is sometimes called hyperplastic — meaning that it's packed with blood cells. But some people with myelodysplastic syndrome have empty marrow that's difficult to distinguish from aplastic anemia.
Connections with other rare disorders
Some people with aplastic anemia also have a rare disorder known as paroxysmal nocturnal hemoglobinuria. This disorder causes red blood cells to break down too soon. Paroxysmal nocturnal hemoglobinuria can lead to aplastic anemia, or aplastic anemia can evolve into paroxysmal nocturnal hemoglobinuria.
Fanconi's anemia is a rare, inherited disease that leads to aplastic anemia. Children born with it tend to be smaller than average and have birth defects, such as underdeveloped limbs. The disease is diagnosed with the help of blood tests.
RISK FACTORS
Aplastic anemia is rare. Factors that may increase your risk include:
Treatment with high-dose radiation or chemotherapy for cancer
Exposure to toxic chemicals
The use of some prescription drugs — such as chloramphenicol, which is used to treat bacterial infections, and gold compounds used to treat rheumatoid arthritis
Certain blood diseases, autoimmune disorders and serious infections
Pregnancy, rarely
PREPARING FOR YOUR APPOINTMENT
If you have signs or symptoms of aplastic anemia, start by making an appointment with your family doctor or a general practitioner. If your doctor suspects aplastic anemia, you'll likely be referred to a doctor who specializes in treating blood disorders (hematologist). If aplastic anemia comes on suddenly, you may begin treatment in the emergency room.
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.
Write down key personal information, including any recent life changes, such as a new job, particularly one that exposes you to chemicals.
Make a list of all medications, as well as any vitamins or supplements, that you're taking.
Ask a family member or a friend to stay with you while you talk to your doctor. You may be tired or overwhelmed by all the information. A friend or a family member can take notes for you, or bring up questions you may forget to ask.
Write down questions you want to ask your doctor.
Preparing a list of questions ahead of time can help you make the most of your time together. For aplastic anemia, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
Are there other possible causes for my symptoms?
What's my prognosis?
What treatments are available, and which do you recommend?
Are there any alternatives to the primary approach that you're suggesting?
I have another health condition. How can I best manage them together?
Are there any brochures or other printed material that I can take 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, such as:
Have you had any infections?
Have you had any unexpected bleeding?
Have you felt more tired than usual?
When did you begin experiencing symptoms?
Is there anything new in your life, such as a new job or a new medication?
Does anything seem to improve your symptoms?
Does anything appear to worsen your symptoms?
TESTS AND DIAGNOSIS
To diagnose aplastic anemia, your doctor may recommend:
Blood tests. Normally, red blood cell, white blood cell and platelet levels stay within a certain range. Your doctor may suspect aplastic anemia when all three of these blood cell levels are very low.
Bone marrow biopsy. To confirm a diagnosis, you'll need to undergo a bone marrow biopsy. In this procedure, a doctor uses a needle to remove a small sample of bone marrow from a large bone in your body, such as your hipbone. The bone marrow sample is examined under a microscope to rule out other blood-related diseases. In aplastic anemia, bone marrow contains fewer blood cells than normal.
Once you've received a diagnosis of aplastic anemia, you may need additional tests to determine an underlying cause.
TREATMENTS AND DRUGS
Treatments for aplastic anemia may include observation for mild cases, blood transfusions and medications for more-serious cases, and in severe cases, bone marrow transplantation. Severe aplastic anemia, in which your blood cell counts are extremely low, is life-threatening and requires immediate hospitalization for treatment.
Blood transfusions
Treatment for aplastic anemia usually involves blood transfusions to control bleeding and relieve anemia symptoms. Blood transfusions aren't a cure for aplastic anemia. But they do relieve signs and symptoms by providing blood cells that your bone marrow isn't producing. A transfusion may include:
Red blood cells. Transfusions of red blood cells raise red blood cell counts. This helps relieve anemia and fatigue.
Platelets. Transfusions of platelets help prevent excessive bleeding.
While there's generally no limit to the number of blood cell transfusions you can have, complications can sometimes arise with multiple transfusions. Transfused red blood cells contain iron that can accumulate in your body and can damage vital organs if an iron overload isn't treated. Medications can help your body get rid of excess iron. Another possible complication is that over time, your body may develop antibodies to transfused blood cells, making them less effective at relieving symptoms. However, the use of immunosuppressant medication makes this complication less likely.
Stem cell transplant
A stem cell transplant to rebuild the bone marrow with stem cells from a donor may offer the only successful treatment option for people with severe aplastic anemia. A stem cell transplant, which is also called a bone marrow transplant, is generally the treatment of choice for people who are younger and have a matching donor — most often a sibling.
If a donor is found, your diseased bone marrow is first depleted with radiation or chemotherapy. Healthy stem cells from the donor are filtered from the blood. The healthy stem cells are injected intravenously into your bloodstream, where they migrate to the bone marrow cavities and begin generating new blood cells. The procedure requires a lengthy hospital stay. After the transplant, you'll receive drugs to help prevent rejection of the donated stem cells.
A stem cell transplant carries risks. There's a chance that your body may reject the transplant, leading to life-threatening complications. In addition, not everyone is a candidate for transplantation or can find a suitable donor.
Immunosuppressants
For people who can't undergo a bone marrow transplant or for those whose aplastic anemia may be due to an autoimmune disorder, treatment may involve drugs that alter or suppress the immune system (immunosuppressants).
Drugs such as cyclosporine (Gengraf, Neoral, Sandimmune) and anti-thymocyte globulin (Thymoglobulin) are examples. These drugs suppress the activity of immune cells that are damaging your bone marrow. This helps your bone marrow recover and generate new blood cells. Cyclosporine and anti-thymocyte globulin are often used in combination.
Corticosteroids, such as methylprednisolone (Medrol, Solu-Medrol), are often given at the same time as these drugs.
Immune-suppressing drugs can be very effective at treating aplastic anemia. The downside is that these drugs further weaken your immune system. It's also possible that after you stop taking these drugs, aplastic anemia may return.
Bone marrow stimulants
Certain drugs — including colony-stimulating factors, such as sargramostim (Leukine), filgrastim (Neupogen) and pegfilgrastim (Neulasta), and epoetin alfa (Epogen, Procrit) — may help stimulate the bone marrow to produce new blood cells. Growth factors are often used in combination with immune-suppressing drugs.
Antibiotics, antivirals
Having aplastic anemia weakens your immune system. You have fewer white blood cells in circulation to fight off germs. This leaves you susceptible to infections.
At the first sign of infection, such as a fever, see your doctor. You don't want the infection to get worse, because it could prove life-threatening. If you have severe aplastic anemia, your doctor may give you antibiotics or antiviral medications to help prevent infections.
Other treatments
Aplastic anemia caused by radiation and chemotherapy treatments for cancer usually improves once you complete those treatments. The same is true for most other drugs that induce aplastic anemia.
Pregnant women with aplastic anemia are treated with blood transfusions. For many women, pregnancy-related aplastic anemia improves once the pregnancy ends. If that doesn't happen, treatment is still necessary.
LIFESTYLE AND HOME REMEDIES
There's generally no prevention for most cases of aplastic anemia. However, avoiding exposure to insecticides, herbicides, organic solvents, paint removers and other toxic chemicals may lower your risk of the disease.
COPING AND SUPPORT
Tips to help you and your family better cope with your illness include:
Research your disease. The more you know, the better prepared you'll be to make treatment decisions.
Ask questions. Be sure to ask your doctor about anything related to your disease or treatment that you don't understand. It may help you to record or write down what your doctor tells you.
Be vocal. Don't be afraid to express any concerns you have to your doctor or any other health care professional treating you.
Seek support. Ask family and friends for emotional support. Ask them to consider becoming blood donors or bone marrow donors. Consider joining an aplastic anemia support group. It may be helpful to talk to others coping with the disease. Ask your doctor if he or she knows of any local support groups, or contact the Aplastic Anemia & MDS International Foundation. It offers a peer support network and can be reached at 800-747-2820.
Take care of yourself. Proper nutrition and sleep are important to optimize blood production.
CENTRAL SLEEP APNEA
CENTRAL SLEEP APNEA
Central sleep apnea is a disorder in which your breathing repeatedly stops and starts during sleep.
Central sleep apnea occurs because your brain doesn't send proper signals to the muscles that control your breathing. This condition is different from obstructive sleep apnea, in which you can't breathe normally because of upper airway obstruction.
Central sleep apnea is less common than obstructive sleep apnea.
Central sleep apnea may occur as a result of other conditions, such as heart failure and stroke. Sleeping at a high altitude also may cause central sleep apnea.
Treatments for central sleep apnea may involve treating existing conditions, using a device to assist breathing or using supplemental oxygen.
SYMPTOMS
Common signs and symptoms of central sleep apnea include:
Observed episodes of stopped breathing or abnormal breathing patterns during sleep
Abrupt awakenings accompanied by shortness of breath
Shortness of breath that's relieved by sitting up
Difficulty staying asleep (insomnia)
Excessive daytime sleepiness (hypersomnia)
Difficulty concentrating
Mood changes
Morning headaches
Snoring
Although snoring indicates some degree of increased obstruction to airflow, snoring also may be heard in the presence of central sleep apnea. However, snoring may not be as prominent with central sleep apnea as it is with obstructive sleep apnea.
When to see a doctor
Consult a medical professional if you experience, or if your partner observes, any signs or symptoms of central sleep apnea, particularly the following:
Shortness of breath that awakens you from sleep
Intermittent pauses in your breathing during sleep
Difficulty staying asleep
Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving
Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness (hypersomnia) may be due to other disorders, such as narcolepsy or obstructive sleep apnea.
CAUSES
Central sleep apnea occurs when your brain fails to transmit signals to your breathing muscles.
Central sleep apnea can be caused by a number of conditions that affect the ability of your brainstem — which links your brain to your spinal cord and controls many functions such as heart rate and breathing — to control your breathing. The cause varies with the type of central sleep apnea you have. Types include:
Cheyne-Stokes breathing. This type of central sleep apnea is most commonly associated with congestive heart failure or stroke. This condition is characterized by a gradual increase and then decrease in breathing effort and airflow. During the weakest breathing effort, a total lack of airflow (central sleep apnea) can occur.
Drug-induced apnea. Taking certain medications such as opioids — including morphine sulfate (Ms Contin, Avinza, others), oxycodone (Oxycodone HCL, Oxycontin, others) or codeine sulfate — may cause your breathing to become irregular, to increase and decrease in a regular pattern, or to temporarily stop completely.
High-altitude periodic breathing. A Cheyne-Stokes breathing pattern may occur if you're exposed to a very high altitude. The change in oxygen at this altitude is the reason for the alternating rapid breathing (hyperventilation) and under breathing.
Complex sleep apnea. Some people with obstructive sleep apnea develop central sleep apnea while using continuous positive airway pressure (CPAP) for their sleep apnea treatment. This condition is known as complex sleep apnea because it's a combination of obstructive and central sleep apneas.
Medical condition-induced central sleep apnea. Several medical conditions may give rise to central sleep apnea of the non-Cheyne-Stokes variety.
Idiopathic (primary) central sleep apnea. The cause of this uncommon type of central sleep apnea isn't known. It results in repeated pauses in breathing effort and airflow.
RISK FACTORS
Certain factors put you at increased risk of central sleep apnea:
Sex. Males are more likely to develop central sleep apnea than are females.
Age. Central sleep apnea is more common among older adults, especially adults older than age 65, possibly because they may have other medical conditions or sleep patterns that are more likely to cause central sleep apnea.
Heart disorders. People with atrial fibrillation or congestive heart failure are at greater risk of central sleep apnea. Sleep disordered breathing, such as Cheyne-Stokes breathing and obstructive sleep apnea, may be present in up to 50 percent of people with congestive heart failure.
Stroke or brain tumor. These brain conditions can impair the brain's ability to regulate breathing.
High altitude. Sleeping at an altitude higher than you're accustomed to may increase your risk of sleep apnea. High-altitude sleep apnea is no longer a problem when you return to a lower altitude.
Opioid use. Opioid medications may increase the risk of central sleep apnea.
CPAP. Some people with obstructive sleep apnea develop central sleep apnea while using continuous positive airway pressure (CPAP). This condition is known as complex sleep apnea because it is a combination of obstructive and central sleep apneas.
For some people, complex sleep apnea goes away with continued use of a CPAP device. Other people may be treated with a different kind of positive airway pressure therapy.
COMPLICATIONS
Central sleep apnea is a serious medical condition. Some complications include:
Fatigue. The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with central sleep apnea often experience severe fatigue, daytime drowsiness and irritability.
You may have difficulty concentrating and find yourself falling asleep at work, while watching television or even when driving.
Cardiovascular problems. In addition, sudden drops in blood oxygen levels that occur during central sleep apnea may adversely affect heart health.
If there's underlying heart disease, these repeated multiple episodes of low blood oxygen (hypoxia or hypoxemia) worsen prognosis and increase the risk of abnormal heart rhythms.
PREPARING FOR YOUR APPOINTMENT
You're likely to start by seeing your family doctor or a general practitioner. However, you may then be referred to a sleep specialist.
Because appointments can be brief and there's often a lot to talk about, 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
Bring results of prior sleep studies or other tests with you, or ask that they be given to your sleep specialist.
Ask someone, such as a spouse or partner, who has seen you sleeping to come with you to your appointment. He or she will likely be able to provide your doctor with additional information.
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.
Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions 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 central sleep apnea, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
Are there other possible causes for my symptoms?
What kinds of tests do I need? Do these tests require any special preparation?
Is this condition temporary or long lasting?
What treatments are available, and which do you recommend?
How will treating or not treating my central sleep apnea affect my health now and in the future?
I have other health conditions. How can I best manage them together?
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 begin experiencing symptoms?
Have your symptoms been continuous or occasional?
Can you describe your typical sleep schedule?
How long do you sleep, and do you sleep soundly?
Does anything unusual occur while you're sleeping?
Do you know if you snore?
How do you feel when you wake up?
Do you fall asleep easily during the day?
Has anyone ever told you that you stop breathing while you're sleeping?
How many times do you wake up at night?
Are you short of breath when you wake up at night?
Does anything seem to improve your symptoms?
Is there anything that seems to worsen your symptoms?
Do you have any other medical conditions?
What medications, if any, are you currently taking?
TESTS AND DIAGNOSIS
Your doctor may make an evaluation based on your signs and symptoms or may refer you to a sleep specialist in a sleep disorder center.
A sleep specialist can help you decide on your need for further evaluation. Such an evaluation often involves overnight monitoring of your breathing and other body functions during a sleep study called polysomnography.
During polysomnography, you're connected to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep. You may have a full-night or split-night sleep study.
In a split-night sleep study, you'll be monitored during the first half of the night. If you're diagnosed with obstructive sleep apnea, staff may wake you and give you continuous positive airway pressure for the second half of the night.
Polysomnography can help your doctor diagnose central sleep apnea. It also can help your doctor rule out other sleep disorders, such as periodic limb movements of sleep or narcolepsy, which can cause excessive daytime sleepiness but require different treatment.
Doctors trained in nervous system diseases (neurologists), heart diseases (cardiologists) and others may be involved in evaluating your condition. Doctors may order imaging of your head or heart.
TREATMENTS AND DRUGS
Treatments for central sleep apnea may include:
Addressing associated medical problems. Possible causes of central sleep apnea include other disorders, and treating those conditions may help your central sleep apnea. For example, therapy for heart failure may improve central sleep apnea.
Reduction of opioid medications. If opioid medications are causing your central sleep apnea, your doctor may gradually reduce your dose of those medications.
Continuous positive airway pressure (CPAP). This method, also used to treat obstructive sleep apnea, involves wearing a mask over your nose while you sleep. CPAP is usually the first treatment given for central sleep apnea.
The mask is attached to a small pump that supplies a continuous amount of pressurized air to hold open your upper airway. CPAP may prevent the airway closure that can trigger central sleep apnea.
As with obstructive sleep apnea, it's important that you use the device only as directed. If your mask is uncomfortable or the pressure feels too strong, talk with your doctor. Several types of masks are available. Doctors can also adjust the air pressure.
Adaptive servo-ventilation (ASV). If CPAP hasn't effectively treated your condition, you may be given ASV.
Like CPAP, ASV also delivers pressurized air. However, unlike CPAP, ASV adjusts the amount of pressure during inspiration on a breath-by-breath basis to smooth out the breathing pattern. The device may also automatically deliver a breath if you haven't taken a breath within a certain number of seconds.
Bilevel positive airway pressure (BPAP). Like ASV, BPAP delivers pressure when you breathe in and a different amount of pressure when you breathe out. Unlike ASV, the amount of pressure during inspiration is fixed rather than variable.
BPAP can also be configured to deliver a breath if you haven't taken a breath within a certain number of seconds.
Supplemental oxygen. Using supplemental oxygen while you sleep may help if you have central sleep apnea. Various devices are available to deliver oxygen to your lungs.
Medications. Certain medications, such as acetazolamide (Diamox) or theophylline (Theo-24, Theochron, others), have been used to stimulate breathing in people with central sleep apnea.
Doctors may prescribe medications to help your breathing as you sleep if you can't take positive airway pressure. Also, some doctors prescribe medications to prevent central sleep apnea in high altitude.
OBSTRUCTIVE SLEEP APNEA
OBSTRUCTIVE SLEEP APNEA
Obstructive sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts during sleep.
Several types of sleep apnea exist, but the most common type is obstructive sleep apnea, which occurs when your throat muscles intermittently relax and block your airway during sleep. The most noticeable sign of obstructive sleep apnea is snoring.
Anyone can develop obstructive sleep apnea, although it most commonly affects middle-aged and older adults and people who are overweight.
Obstructive sleep apnea treatment may involve using a device to keep your airway open or using a mouthpiece to thrust your jaw forward during sleep. Some people undergo a procedure to change the structure of their nose, mouth or throat.
SYMPTOMS
Signs and symptoms of obstructive sleep apnea include:
Excessive daytime sleepiness
Loud snoring
Observed episodes of breathing cessation during sleep
Abrupt awakenings accompanied by shortness of breath
Awakening with a dry mouth or sore throat
Awakening with chest pain
Morning headache
Difficulty concentrating during the day
Experiencing mood changes, such as depression or irritability
Difficulty staying asleep (insomnia)
Having high blood pressure
When to see a doctor
Consult a medical professional if you experience, or if your partner observes, the following:
Snoring loud enough to disturb your sleep or that of others
Shortness of breath that awakens you from sleep
Intermittent pauses in your breathing during sleep
Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving a vehicle
Many people don't think of snoring as a sign of something potentially serious, and not everyone who snores has obstructive sleep apnea. However, be sure to talk to your doctor if you experience loud snoring, especially snoring that's punctuated by periods of silence.
With obstructive sleep apnea, snoring usually is loudest when you sleep on your back, and it quiets when you turn on your side.
Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness may be due to other disorders, such as narcolepsy.
CAUSES
Obstructive sleep apnea occurs when the muscles in the back of your throat relax too much to allow normal breathing. These muscles support structures including the soft palate, the uvula — a triangular piece of tissue hanging from the soft palate, the tonsils and the tongue.
When the muscles relax, your airway narrows or closes as you breathe in and breathing may be inadequate for 10 to 20 seconds. This may lower the level of oxygen in your blood. Your brain senses this impaired breathing and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it.
You can awaken with a transient shortness of breath that corrects itself quickly, within one or two deep breaths. You may make a snorting, choking or gasping sound.
This pattern can repeat itself five to 30 times or more each hour, all night long. These disruptions impair your ability to reach the desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours.
People with obstructive sleep apnea may not be aware that their sleep was interrupted. In fact, many people with this type of sleep apnea think they slept well all night.
RISK FACTORS
Anyone can develop obstructive sleep apnea. However, certain factors put you at increased risk, including:
Being overweight. Around half of people with obstructive sleep apnea are overweight. Fat deposits around the upper airway may obstruct breathing. Also, people with obstructive sleep apnea tend to have a larger waist.
However, not everyone with obstructive sleep apnea is overweight and vice versa. Thin people can develop the disorder, too.
Having a large neck. The size of your neck may indicate whether you have an increased risk.
A thick neck may narrow the airway and may be an indication of excess weight. A neck circumference greater than 17 inches for men and 16 inches for women is associated with an increased risk of obstructive sleep apnea.
Having high blood pressure (hypertension). Obstructive sleep apnea is relatively common in people with hypertension.
Having a narrowed airway. You may inherit a naturally narrow throat. Or your tonsils or adenoids may become enlarged, which can block your airway.
Having chronic nasal congestion. Obstructive sleep apnea occurs twice as often in those who have consistent nasal congestion at night, regardless of the cause. This may be due to narrowed airways.
Having diabetes. Obstructive sleep apnea may be more common in people with diabetes.
Being male. In general, men are twice as likely to have obstructive sleep apnea.
Being black. Among people under age 35, obstructive sleep apnea is more common in blacks.
Being a certain age. Obstructive sleep apnea usually occurs in adults who are ages 18 to 60, but it can occur at any age.
Having a family history of sleep apnea. If you have family members with obstructive sleep apnea, you may be at increased risk.
Smoking. People who smoke are more likely to have obstructive sleep apnea.
Using alcohol. Alcohol may worsen obstructive sleep apnea.
COMPLICATIONS
Obstructive sleep apnea is considered a serious medical condition. Complications may include:
Cardiovascular problems. Sudden drops in blood oxygen levels that occur during obstructive sleep apnea increase blood pressure and strain the cardiovascular system.
Many people with obstructive sleep apnea develop high blood pressure (hypertension), which can increase the risk of heart disease.
The more severe the obstructive sleep apnea, the greater the risk of coronary artery disease, heart attack, heart failure and stroke. In a study, men with obstructive sleep apnea appeared to be at risk of heart failure, but women with obstructive sleep apnea didn't appear to have a higher risk of heart failure.
People with obstructive sleep apnea are much more likely to develop abnormal heart rhythms (arrhythmias).
If there's underlying heart disease, these repeated multiple episodes of low blood oxygen (hypoxia or hypoxemia) could lead to sudden death from a cardiac event.
Daytime fatigue. The repeated awakenings associated with obstructive sleep apnea make normal, restorative sleep impossible. People with obstructive sleep apnea often experience severe daytime drowsiness, fatigue and irritability. They may have difficulty concentrating and find themselves falling asleep at work, while watching TV or even when driving.
Children and young people with obstructive sleep apnea may do poorly in school and commonly have attention or behavior problems.
Treatment of obstructive sleep apnea can improve these symptoms, restoring alertness and improving quality of life.
Complications with medications and surgery. Obstructive sleep apnea also is a concern with certain medications and general anesthesia. These medications, such as sedatives, narcotic analgesics and general anesthesia, relax your upper airway and may worsen your obstructive sleep apnea.
If you have obstructive sleep apnea, you may experience worse breathing problems after major surgery, especially after being sedated and lying on your back.
People with obstructive sleep apnea may be more prone to complications after surgery.
Before you have surgery, tell your doctor if you have obstructive sleep apnea or symptoms related to obstructive sleep apnea. If you have obstructive sleep apnea symptoms, your doctor may test you for obstructive sleep apnea prior to surgery.
Eye problems. Some research has found a connection between obstructive sleep apnea and certain eye conditions, such as glaucoma. Eye complications can usually be treated.
Sleep-deprived partners. Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. It's not uncommon for a partner to choose to sleep in another room. Many bed partners of people who snore are sleep deprived as well.
People with obstructive sleep apnea may also complain of memory problems, morning headaches, mood swings or feelings of depression, and a need to urinate frequently at night (nocturia).
PREPARING FOR YOUR APPOINTMENT
If you suspect that you have obstructive sleep apnea, you'll likely first see your family doctor or a primary care doctor. Your doctor may refer you to a sleep specialist.
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 requests. When you make your appointment, ask if there's anything you need to do in advance, such as keeping a sleep diary. In a sleep diary, you record your sleep patterns — bedtime, number of hours slept, nighttime awakenings and awake time — as well as your daily routine, naps and how you feel during the day. You may be asked to record a sleep diary for one to two weeks.
Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for your appointment.
Write down key personal information, including new or ongoing health problems, major stresses or recent life changes.
Bring a list of all medications, vitamins or supplements that you're taking. Include anything you've taken to help you sleep.
Take your bed partner along, if possible. Your doctor may want to talk to your partner to learn more about how much and how well you're sleeping.
Write down questions to ask your doctor. Preparing a list of questions can help you make the most of your time with your doctor.
For obstructive sleep apnea, some basic questions to ask your doctor include:
What is likely causing my symptoms?
Other than the most likely cause, what are other possible causes for my symptoms?
Is my condition likely temporary or chronic?
What kinds of tests do I need?
Should I go to a sleep clinic?
What is the best course of action?
What are the alternatives to the primary approach that you're suggesting?
Are there any restrictions that I need to follow?
I have other health conditions. How can I best manage them together?
Don't hesitate to ask other questions that occur to you.
What to expect from your doctor
A key part of the evaluation of obstructive sleep apnea is a detailed history, meaning your doctor will ask you many questions. These may include:
When did you begin experiencing symptoms?
Have your symptoms been continuous or occasional?
Do you snore? If so, does your snoring disrupt anyone else's sleep?
How often do you snore? Do you snore in all sleep positions or just when sleeping on your back?
Do you ever snore, snort, gasp or choke yourself awake?
Has anyone ever seen you stop breathing during sleep?
How refreshed do you feel when you wake up?
Do you experience headache or dry mouth upon awakening?
Are you tired during the day?
Do you doze off or have trouble staying awake while sitting quietly or driving?
Do you nap during the day?
Do you use tobacco or drink alcohol?
Do you worry about falling asleep or staying asleep?
Do you have any family members with sleep problems?
What medications do you take?
What you can do in the meantime
Try to sleep on your side. Most forms of obstructive sleep apnea are milder when you sleep on your side.
Avoid drinking alcohol close to bedtime. Alcohol worsens obstructive sleep apnea.
If you're drowsy, avoid driving. If you have obstructive sleep apnea you may be abnormally sleepy, which can put you at higher risk of motor vehicle accidents. To be safe, schedule rest breaks. At times, a close friend or family member might tell you that you appear sleepier than you feel. If this is true, try to avoid driving.
TESTS AND DIAGNOSIS
To diagnose your condition, your doctor may make an evaluation based on your signs and symptoms, an examination, and tests. Your doctor may refer you to a sleep specialist in a sleep center for further evaluation.
You'll have a physical examination, and your doctor will examine the back of your throat, mouth and nose for extra tissue or abnormalities. Your doctor may measure your neck and waist circumference and check your blood pressure.
A sleep specialist may conduct additional evaluations to diagnose your condition, determine the severity of your condition and plan your treatment. The evaluation may involve overnight monitoring of your breathing and other body functions as you sleep. Tests to detect obstructive sleep apnea include:
Polysomnography. During this sleep study, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep. You may have a full-night study, in which you're monitored all night, or a split-night sleep study.
In a split-night sleep study, you'll be monitored during the first half of the night. If you're diagnosed with obstructive sleep apnea, staff may wake you and give you continuous positive airway pressure for the second half of the night.
This test can help your doctor diagnose obstructive sleep apnea and adjust positive airway pressure therapy, if appropriate. This sleep study can also help rule out other sleep disorders, such as periodic limb movements of sleep or narcolepsy, which also can cause excessive daytime sleepiness, but require different treatment.
Oximetry. This test monitors and records your blood oxygen level while you're asleep and can be used a screening test for obstructive sleep apnea. If you have obstructive sleep apnea, the results of this test will often show drops in your blood oxygen level during apneas and subsequent rises with awakenings.
If the study reveals temporary drops in oxygen compatible with obstructive sleep apnea, a polysomnogram may follow to formally diagnose obstructive sleep apnea and determine appropriate therapy.
Portable monitoring. Under certain circumstances, your doctor may provide you with an at-home version of polysomnography to diagnose obstructive sleep apnea. This test usually involves measurement of airflow, breathing patterns and blood oxygen levels.
Your doctor also may refer you to an ear, nose and throat doctor to rule out any anatomic blockage in your nose or throat.
TREATMENTS AND DRUGS
Lifestyle changes
For milder cases of obstructive sleep apnea, your doctor may recommend lifestyle changes:
Lose weight if you're overweight.
Exercise regularly.
Drink alcohol moderately, if at all, and don't drink several hours before bedtime.
Quit smoking.
Use a nasal decongestant.
Don't sleep on your back.
If these measures don't improve your sleep or if your apnea is moderate to severe, then your doctor may recommend other treatments. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary.
Therapies
Positive airway pressure. If you have obstructive sleep apnea, you may benefit from positive airway pressure. In this treatment, a machine delivers air pressure through a piece that fits into the nose or is placed over the nose and mouth while you sleep.
Positive airway pressure reduces the number of respiratory events that occur as you sleep, reduces daytime sleepiness and improves your quality of life.
The most common type is called continuous positive airway pressure, or CPAP (SEE-pap). With this treatment, the pressure of the air breathed is continuous, constant and somewhat greater than that of the surrounding air, which is just enough to keep your upper airway passages open. This air pressure prevents obstructive sleep apnea and snoring.
Although CPAP is the most consistently successful and most commonly used method of treating obstructive sleep apnea, some people find the mask cumbersome, uncomfortable or loud. However, newer machines are smaller and less noisy than older machines.
Also, with some practice, most people learn to adjust the mask to obtain a comfortable and secure fit. You may need to try different types to find a suitable mask. Several options are available, such as nasal masks, nasal pillows or face masks.
If you're having particular difficulties tolerating pressure, some machines have special adaptive pressure functions to improve comfort. You also may benefit from using a humidifier along with your CPAP system.
CPAP may be given at a continuous (fixed) pressure or varied (autotitrating) pressure. In fixed CPAP, the pressure stays constant. In autotitrating CPAP, the levels of pressure are adjusted if the device senses increased airway resistance.
Bilevel positive airway pressure (BPAP), another type of positive airway pressure, delivers a preset amount of pressure when you breathe in and a different amount of pressure when you breathe out.
CPAP is more commonly used because it's been well studied for obstructive sleep apnea and has been shown to effectively treat obstructive sleep apnea. However, for people who have difficulty tolerating fixed CPAP, BPAP or autotitrating CPAP may be worth a try.
Don't stop using your positive airway pressure machine if you have problems. Check with your doctor to see what adjustments you can make to improve its comfort. In addition, contact your doctor if you still snore despite treatment, if you begin snoring again or if your weight changes.
Mouthpiece (oral device). Though positive airway pressure is often an effective treatment, oral appliances are an alternative for some people with mild or moderate obstructive sleep apnea. These devices may reduce your sleepiness and improve your quality of life.
These devices are designed to keep your throat open. Some devices keep your airway open by bringing your jaw forward, which can sometimes relieve snoring and obstructive sleep apnea. Other devices hold your tongue in a different position.
If you and your doctor decide to explore this option, you'll need to see a dentist experienced in dental sleep medicine appliances for the fitting and follow-up therapy.
A number of devices are available. Close follow-up is needed to ensure successful treatment.
Medications. If you continue to experience daytime sleepiness after treatment for your obstructive sleep apnea, your doctor may prescribe medications to reduce sleepiness.
Surgery or other procedures
The goal of surgery for obstructive sleep apnea is to prevent blockage of the upper airway during sleep. Surgery is usually considered only if other therapies haven't been effective or haven't been appropriate options for you. Surgical options may include:
Surgical removal of tissue. Uvulopalatopharyngoplasty (UPPP) is a procedure in which your doctor removes tissue from the back of your mouth and top of your throat. Your tonsils and adenoids are commonly removed as well.
UPPP usually is performed in a hospital and requires a general anesthetic.
Doctors sometimes remove tissue from the back of the throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) to treat snoring. These procedures don't treat obstructive sleep apnea, but they may reduce snoring.
Jaw surgery. In this procedure, called maxillomandibular advancement, the upper and lower parts of your jaw are moved forward from the rest of your facial bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely.
This procedure often requires an oral surgeon and possibly an orthodontist. Complications could include numbness of the mouth, bleeding, infection, removal of hardware or temporomandibular joint problems.
Surgical opening in the neck. You may need this form of surgery if other treatments have failed and you have severe, life-threatening obstructive sleep apnea.
In this procedure, called a tracheostomy, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. Air passes in and out of your lungs, bypassing the blocked air passage in your throat.
Implants. The Pillar procedure is a minimally invasive treatment that involves placement of three tiny polyester rods in the soft palate. These inserts stiffen and support the tissue of the soft palate and reduce upper airway collapse and snoring. This treatment is recommended only for people with mild obstructive sleep apnea.
Other types of surgery may help reduce snoring and sleep apnea by clearing or enlarging air passages, including:
Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated nasal septum)
Surgery to remove enlarged tonsils or adenoids
LIFESTYLE AND HOME REMEDIES
In many cases, self-care may be the most appropriate way for you to deal with obstructive sleep apnea. Try these tips:
Lose weight. If you're overweight or obese, even a slight loss of excess weight may help relieve constriction of your airway. Losing weight can also improve your health and quality of life, and may reduce your sleepiness during the day.
Exercise. Exercising, such as aerobic exercise and strength training, can help improve your condition. Aim to exercise about 150 minutes per week, and generally try to exercise four or more days per week.
Avoid alcohol and medications such as tranquilizers and sleeping pills. Alcohol can worsen obstructive sleep apnea and sleepiness and may lead to you gaining weight. Certain medications also can worsen your sleep.
Sleep on your side or abdomen rather than on your back. Sleeping on your back can cause your tongue and soft palate to rest against the back of your throat and block your airway. To prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top.
Keep your nasal passages open while you sleep. If you have congestion, use a saline nasal spray to help keep your nasal passages open. Talk to your doctor about using nasal decongestants or antihistamines, because some medications may only be recommended for short-term use.
ABDOMINAL AORTIC ANEURYSM
ABDOMINAL AORTIC ANEURYSM
Abdominal Aortic Aneurysm
An abdominal aortic aneurysm is an enlarged area in the lower part of the aorta, the major blood vessel that supplies blood to the body. The aorta, about the thickness of a garden hose, runs from your heart through the center of your chest and abdomen. Because the aorta is the body's main supplier of blood, a ruptured abdominal aortic aneurysm can cause life-threatening bleeding.
Depending on the size and rate at which your abdominal aortic aneurysm is growing, treatment may vary from watchful waiting to emergency surgery. Once an abdominal aortic aneurysm is found, doctors will closely monitor it so that surgery can be planned if it's necessary. Emergency surgery for a ruptured abdominal aortic aneurysm can be risky.
SYMPTOMS
Abdominal aortic aneurysms often grow slowly and usually without symptoms, making them difficult to detect. Some aneurysms will never rupture. Many start small and stay small, although many expand over time. Others expand quickly. Predicting how fast an abdominal aortic aneurysm may enlarge is difficult.
As an abdominal aortic aneurysm enlarges, some people may notice:
A pulsating feeling near the navel
Deep, constant pain in your abdomen or on the side of your abdomen
Back pain
When to see a doctor
You should see your doctor if you have any of the symptoms listed above.
Anyone age 60 and older who has risk factors for developing an abdominal aortic aneurysm, such as smoking or a family history of abdominal aortic aneurysm, should consider regular screening for the condition. Because being male and smoking significantly increase the risk of abdominal aortic aneurysm, men ages 65 to 75 who have ever smoked cigarettes should have a one-time screening for abdominal aortic aneurysm using abdominal ultrasound.
If you have a family history of abdominal aortic aneurysm, your doctor may recommend an ultrasound exam to screen for the condition.
There are no specific screening recommendations for women. Ask your doctor if you need to have an ultrasound screening based on your risk factors.
CAUSES
Most aortic aneurysms occur in the part of your aorta that's in your abdomen. Although the exact cause of abdominal aortic aneurysms is unknown, a number of factors may play a role, including:
Tobacco use. Cigarette smoking and other forms of tobacco use appear to increase your risk of aortic aneurysms. In addition to the damaging effects that smoking causes directly to the arteries, smoking contributes to the buildup of fatty plaques in your arteries (atherosclerosis) and high blood pressure. Smoking can also cause your aneurysm to grow faster by further damaging your aorta.
Hardening of the arteries (atherosclerosis). Atherosclerosis occurs when fat and other substances build up on the lining of a blood vessel, increasing your risk of an aneurysm.
Infection in the aorta (vasculitis). In rare cases, abdominal aortic aneurysm may be caused by an infection or inflammation that weakens a section of the aortic wall.
Aneurysms can develop anywhere along the aorta, but when they occur in the upper part of the aorta, they are called thoracic aortic aneurysms. More commonly, aneurysms form in the lower part of your aorta and are called abdominal aortic aneurysms. These aneurysms may also be referred to as AAA or triple A.
RISK FACTORS
Abdominal aortic aneurysm risk factors include:
Age. Abdominal aortic aneurysms occur most often in people age 65 and older.
Tobacco use. Tobacco use is a strong risk factor for the development of an abdominal aortic aneurysm. The longer you've smoked or chewed tobacco, the greater your risk.
Atherosclerosis. Atherosclerosis, the buildup of fat and other substances that can damage the lining of a blood vessel, increases your risk of an aneurysm.
Being male. Men develop abdominal aortic aneurysms much more often than women do.
Family history. People who have a family history of abdominal aortic aneurysm are at increased risk of having the condition. People who have a family history of aneurysms tend to develop aneurysms at a younger age and are at higher risk of rupture.
COMPLICATIONS
Tears in the wall of the aorta (dissection) are the main complications of abdominal aortic aneurysm. A ruptured aortic aneurysm can lead to life-threatening internal bleeding. In general, the larger the aneurysm, the greater the risk of rupture.
Signs and symptoms that your aortic aneurysm has burst include:
Sudden, intense and persistent abdominal or back pain
Pain that radiates to your back or legs
Sweatiness
Clamminess
Dizziness
Nausea
Vomiting
Low blood pressure
Fast pulse
Loss of consciousness
Shortness of breath
Another complication of aortic aneurysms is the risk of blood clots. Small blood clots can develop in the area of the aortic aneurysm. If a blood clot breaks loose from the inside wall of an aneurysm and blocks a blood vessel elsewhere in your body, it can cause pain or block the blood flow to the legs, toes, kidneys or abdominal organs.
PREPARING FOR YOUR APPOINTMENT
If you think you may have an abdominal aortic aneurysm, or are worried about your aneurysm risk because of a strong family history, make an appointment with your family doctor. If an aneurysm is found early, your treatment may be easier and more effective.
Since many abdominal aortic aneurysms are found during a routine physical exam, or while your doctor is looking for another condition, there are no special preparations necessary. If you're being screened for an aortic aneurysm, your doctor will likely ask if anyone in your family has ever had an aortic aneurysm, so have that information ready.
Because appointments can be brief and there's often a lot of ground to cover, it's a good idea to be 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. For an ultrasound or echocardiogram, for example, you may need to fast for a period of time beforehand.
Write down any symptoms you're experiencing, including any that may seem unrelated to an abdominal aortic aneurysm.
Write down key personal information, including a family history of heart disease or aneurysms.
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 remember all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
Be prepared to discuss your diet, exercise habits and tobacco use. If you don't already follow a healthy diet or exercise routine, talk to your doctor about any challenges you might face in getting started. Be sure to tell your doctor if you're a current or former smoker.
Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions 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 an abdominal aortic aneurysm, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
What kinds of tests will I need?
What treatments are available, and which do you think would be the best treatment for me?
What's an appropriate level of physical activity?
How often do I need to be screened for this aneurysm?
Should I tell other family members to be screened for an aneurysm?
I have other health conditions. How can I best manage these conditions together?
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 visiting for more information?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask additional questions during your appointment at any time that 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 reserve time to go over any points you want to spend more time on. Your doctor may ask:
When did you first notice your symptoms?
Do your symptoms come and go, or do you always feel them?
How severe are your symptoms?
Do you have a family history of aneurysms?
Have you ever smoked?
Does anything seem to improve your symptoms?
What, if anything, appears to worsen your symptoms?
What you can do in the meantime
It's never too early to make healthy lifestyle changes, such as quitting smoking, eating healthy foods and becoming more physically active. These are primary lines of defense to keep your blood vessels healthy and prevent an abdominal aortic aneurysm from developing or worsening.
If you're diagnosed with an abdominal aortic aneurysm, you should ask about the size of your aneurysm, whether your doctor has noticed any changes, and how frequently you should visit your doctor for follow-up appointments.
TESTS AND DIAGNOSIS
Abdominal aortic aneurysms are often found during an examination for another reason. For example, during a routine exam, your doctor may feel a pulsating bulge in your abdomen, though it's unlikely your doctor will be able to hear signs of an aneurysm through a stethoscope. Aortic aneurysms are often found during routine medical tests, such as a chest X-ray or ultrasound of the heart or abdomen, sometimes ordered for a different reason.
If your doctor suspects that you have an aortic aneurysm, specialized tests can confirm it. These tests might include:
Abdominal ultrasound. This exam can help diagnose an abdominal aortic aneurysm. During this painless exam, you lie on your back on an examination table and a small amount of warm gel is applied to your abdomen. The gel helps eliminate the formation of air pockets between your body and the instrument the technician uses to see your aorta, called a transducer. The technician presses the transducer against your skin over your abdomen, moving from one area to another. The transducer sends images to a computer screen that the technician monitors to check for a potential aneurysm.
Computerized tomography (CT) scan. This painless test can provide your doctor with clear images of your aorta. During a CT scan, you lie on a table inside a doughnut-shaped machine called a gantry. Detectors inside the gantry measure the radiation that has passed through your body and converts it into electrical signals. A computer gathers these signals and assigns them a color ranging from black to white, depending on signal intensity. The computer then assembles the images and displays them on a computer monitor.
Magnetic resonance imaging (MRI). MRI is another painless imaging test. Most MRI machines contain a large magnet shaped like a doughnut or tunnel. You lie on a movable table that slides into the tunnel. The magnetic field aligns atomic particles in some of your cells. When radio waves are broadcast toward these aligned particles, they produce signals that vary according to the type of tissue they are. Your doctor can use the images produced by the signals to see if you have an aneurysm.
Regular screening for people at risk of abdominal aortic aneurysms
The U.S. Preventive Services Task Force recommends that men ages 65 to 75 who have ever smoked should have a one-time screening for abdominal aortic aneurysm using abdominal ultrasound. People older than age 60 with a family history of abdominal aortic aneurysm or other risk factors should talk with their doctors about whether to have a screening ultrasound.
TREATMENTS AND DRUGS
Here are the general guidelines for treating abdominal aortic aneurysms.
Small aneurysm
If you have a small abdominal aortic aneurysm — about 1.6 inches, or 4 centimeters (cm), in diameter or smaller — and you have no symptoms, your doctor may suggest a watch-and-wait (observation) approach, rather than surgery. In general, surgery isn't needed for small aneurysms because the risk of surgery likely outweighs the risk of rupture.
If you choose this approach, your doctor will monitor your aneurysm with periodic ultrasounds, usually every six to 12 months and encourage you to report immediately if you start having abdominal tenderness or back pain — potential signs of a dissection.
Medium aneurysm
A medium aneurysm measures between 1.6 and 2.1 inches (4 and 5.3 cm). It's less clear how the risks of surgery versus waiting stack up in the case of a medium-size abdominal aortic aneurysm. You'll need to discuss the benefits and risks of waiting versus surgery and make a decision with your doctor. If you choose watchful waiting, you'll need to have an ultrasound every six to 12 months to monitor your aneurysm.
Large, fast-growing or leaking aneurysm
If you have an aneurysm that is large (larger than 2.2 inches, or 5.6 cm) or growing rapidly (grows more than 0.5 cm in six months), you'll probably need surgery. In addition, a leaking, tender or painful aneurysm requires treatment. There are two types of surgery for abdominal aortic aneurysms.
Open-abdominal surgery to repair an abdominal aortic aneurysm involves removing the damaged section of the aorta and replacing it with a synthetic tube (graft), which is sewn into place, through an open-abdominal approach. With this type of surgery, it will likely take you a month or more to fully recover.
Endovascular surgery is a less invasive procedure sometimes used to repair an aneurysm. Doctors attach a synthetic graft to the end of a thin tube (catheter) that's inserted through an artery in your leg and threaded up into your aorta. The graft — a woven tube covered by a metal mesh support — is placed at the site of the aneurysm and fastened in place with small hooks or pins. The graft reinforces the weakened section of the aorta to prevent rupture of the aneurysm.
Recovery time for people who have endovascular surgery is shorter than for people who have open-abdominal surgery. However, follow-up appointments are more frequent because endovascular grafts can leak. Follow-up ultrasounds are generally done every six months for the first year, and then once a year after that. Long-term survival rates are similar for both endovascular surgery and open surgery.
The options for treatment of your aneurysm will depend on a variety of factors, including location of the aneurysm, your age, kidney function and other conditions that may increase your risk of surgery or endovascular repair.
LIFESTYLE AND HOME REMEDIES
The best approach to prevent an aortic aneurysm is to keep your blood vessels as healthy as possible. That means taking these steps:
Quit smoking or chewing tobacco.
Keep your blood pressure under control.
Get regular exercise.
Reduce cholesterol and fat in your diet.
If you have some risk factors for aortic aneurysm, talk to your doctor. If you are at risk, your doctor may recommend additional measures, including medications to lower your blood pressure and relieve stress on weakened arteries.
APPENDICITIS
APPENDICITIS
Appendicitis
Appendicitis is an inflammation of the appendix, a finger-shaped pouch that projects from your colon on the lower right side of your abdomen. The appendix doesn't seem to have a specific purpose.
Appendicitis causes pain in your lower right abdomen. However, in most people, pain begins around the navel and then moves. As inflammation worsens, appendicitis pain typically increases and eventually becomes severe.
Although anyone can develop appendicitis, most often it occurs in people between the ages of 10 and 30. Standard treatment is surgical removal of the appendix.
SYMPTOMS
Signs and symptoms of appendicitis may include:
Sudden pain that begins on the right side of the lower abdomen
Sudden pain that begins around your navel and often shifts to your lower right abdomen
Pain that worsens if you cough, walk or make other jarring movements
Nausea and vomiting
Loss of appetite
Low-grade fever that may worsen as the illness progresses
Constipation or diarrhea
Abdominal bloating
The site of your pain may vary, depending on your age and the position of your appendix. When you're pregnant, the pain may seem to come from your upper abdomen because your appendix is higher during pregnancy.
When to see a doctor
Make an appointment with a doctor if you or your child has worrisome signs or symptoms. Severe abdominal pain requires immediate medical attention.
CAUSES
A blockage in the lining of the appendix that results in infection is the likely cause of appendicitis. The bacteria multiply rapidly, causing the appendix to become inflamed, swollen and filled with pus. If not treated promptly, the appendix can rupture.
COMPLICATIONS
Appendicitis can cause serious complications, such as:
A ruptured appendix. A rupture spreads infection throughout your abdomen (peritonitis). Possibly life-threatening, this condition requires immediate surgery to remove the appendix and clean your abdominal cavity.
A pocket of pus that forms in the abdomen. If your appendix bursts, you may develop a pocket of infection (abscess). In most cases, a surgeon drains the abscess by placing a tube through your abdominal wall into the abscess. The tube is left in place for two weeks, and you're given antibiotics to clear the infection.
Once the infection is clear, you'll have surgery to remove the appendix. In some cases, the abscess is drained, and the appendix is removed immediately.
PREPARING FOR YOUR APPOINTMENT
Make an appointment with your family doctor or a general practitioner if you have abdominal pain. If you have appendicitis, you'll likely be hospitalized and referred to a surgeon to remove your appendix.
Questions your doctor may ask you
To help in diagnosing your condition, your doctor is likely to ask you a number of questions, such as:
When did your abdominal pain begin?
Where does it hurt?
Has the pain moved?
How severe is your pain?
What makes your pain more severe?
What helps relieve your pain?
Do you have a fever?
Do you feel nauseated?
What other signs and symptoms do you have?
Questions you can ask your doctor
Do I have appendicitis?
Will I need more tests?
What else could I have besides appendicitis?
Do I need surgery and, if so, how soon?
What are the risks of appendix removal?
How long will I need to stay in the hospital after surgery?
How long will recovery take?
How soon after surgery can I go back to work?
Can you tell whether my appendix has burst?
Don't hesitate to ask other questions.
TESTS AND DIAGNOSIS
To help diagnose appendicitis, your doctor will likely take a history of your signs and symptoms and examine your abdomen.
Tests and procedures used to diagnose appendicitis include:
Physical exam to assess your pain. Your doctor may apply gentle pressure on the painful area. When the pressure is suddenly released, appendicitis pain will often feel worse, signaling that the adjacent peritoneum is inflamed.
Your doctor also may look for abdominal rigidity and a tendency for you to stiffen your abdominal muscles in response to pressure over the inflamed appendix (guarding).
Your doctor may use a lubricated, gloved finger to examine your lower rectum (digital rectal exam). Women of childbearing age may be given a pelvic exam to check for possible gynecological problems that could be causing the pain.
Blood test. This allows your doctor to check for a high white blood cell count, which may indicate an infection.
Urine test. Your doctor may want you to have a urinalysis to make sure that a urinary tract infection or a kidney stone isn't causing your pain.
Imaging tests. Your doctor may also recommend an abdominal X-ray, an abdominal ultrasound or a computerized tomography (CT) scan to help confirm appendicitis or find other causes for your pain.
TREATMENTS AND DRUGS
Appendicitis treatment usually involves surgery to remove the inflamed appendix. Before surgery you may be given a dose of antibiotics to prevent infection.
Surgery to remove the appendix (appendectomy)
Appendectomy can be performed as open surgery using one abdominal incision about 2 to 4 inches (5 to 10 centimeters) long (laparotomy). Or the surgery can be done through a few small abdominal incisions (laparoscopic surgery). During a laparoscopic appendectomy, the surgeon inserts special surgical tools and a video camera into your abdomen to remove your appendix.
In general, laparoscopic surgery allows you to recover faster and heal with less pain and scarring. It may be better for people who are elderly or obese. But laparoscopic surgery isn't appropriate for everyone. If your appendix has ruptured and infection has spread beyond the appendix or you have an abscess, you may need an open appendectomy, which allows your surgeon to clean the abdominal cavity.
Expect to spend one or two days in the hospital after your appendectomy.
Draining an abscess before appendix surgery
If your appendix has burst and an abscess has formed around it, the abscess may be drained by placing a tube through your skin into the abscess. Appendectomy can be performed several weeks later after controlling the infection.
LIFESTYLE AND HOME REMEDIES
Expect a few weeks of recovery from an appendectomy, or longer if your appendix burst. To help your body heal:
Avoid strenuous activity at first. If your appendectomy was done laparoscopically, limit your activity for three to five days. If you had an open appendectomy, limit your activity for 10 to 14 days. Always ask your doctor about limitations on your activity and when you can resume normal activities following surgery.
Support your abdomen when you cough. Place a pillow over your abdomen and apply pressure before you cough, laugh or move to help reduce pain.
Call your doctor if your pain medications aren't helping. Being in pain puts extra stress on your body and slows the healing process. If you're still in pain despite your pain medications, call your doctor.
Get up and move when you're ready. Start slowly and increase your activity as you feel up to it. Start with short walks.
Sleep when tired. As your body heals, you may find you feel sleepier than usual. Take it easy and rest when you need to.
Discuss returning to work or school with your doctor. You can return to work when you feel up to it. Children may be able to return to school less than a week after surgery. They should wait two to four weeks to resume strenuous activity, such as gym classes or sports.
ALTERNATIVE MEDICINE
Your doctor will prescribe medications to help you control your pain after your appendectomy. Some complementary and alternative treatments, when used with your medications, can help control pain. Ask your doctor about safe options, such as:
Distracting activities, such as listening to music and talking with friends, that take your mind off your pain. Distraction can be especially effective with children.
Guided imagery, such as closing your eyes and thinking about a favorite place.
CHILDHOOD APRAXIA OF SPEECH (CAS)
CHILDHOOD APRAXIA OF SPEECH (CAS)
Childhood apraxia of speech (CAS) is an uncommon speech disorder in which a child has difficulty making accurate movements when speaking. It's important to know that CAS is just a label for a speech disorder.
To speak correctly, your child's brain has to learn how to make plans that tell his or her speech muscles how to move the lips, jaw and tongue in ways that result in accurate sounds and words. Your child's brain also plans these movements so that he or she speaks with normal speed and rhythm.
In childhood apraxia of speech, the brain struggles to develop plans for speech movement. As a result, children with CAS don't learn accurate movements for speech with normal ease. In CAS, the speech muscles aren't weak, but they don't perform normally because the brain has difficulty directing or coordinating the movements.
SYMPTOMS
Children with childhood apraxia of speech (CAS) may have many speech symptoms or characteristics that vary depending on their age and the severity of their speech problems.
CAS can be associated with delayed onset of first words, a limited number of spoken words, or the ability to form only a few consonant or vowel sounds. These symptoms usually may be noticed between ages 18 months and 2 years, and may indicate suspected CAS.
As children produce more speech, usually between ages 2 and 4, characteristics that likely indicate CAS include vowel and consonant distortions; separation of syllables in or between words; and voicing errors, such as "pie" sounding like "bye."
Many children with CAS have difficulty getting their jaws, lips and tongues to the correct position to make a sound, and they may have difficulty moving smoothly to the next sound. /p>
Children vary in how quickly their speech improves, but with speech therapy many children with CAS develop understandable speech.
Many children with CAS also have language problems, such as difficulty comprehending speech, reduced vocabulary or difficulty with word order.
Some symptoms may primarily be seen in children with CAS and can be helpful to diagnose the problem. However, some symptoms of CAS are also symptoms of other types of speech or language disorders. It's difficult to diagnose CAS if a child has only symptoms that are found in both CAS and in other types of speech or language disorders.
Some characteristics, sometimes called markers, help distinguish CAS from other types of speech disorders. Those particularly associated with CAS include:
Difficulty moving smoothly from one sound, syllable or word to another
Groping movements with the jaw, lips or tongue to make the correct movement for speech sounds
Vowel distortions, such as attempting to use the correct vowel, but saying it incorrectly
Using the wrong stress in a word, such as pronouncing "banana" as "BUH-nan-uh" instead of "buh-NAN-uh"
Using equal emphasis on all syllables, such as saying "BUH-NAN-UH"
Separation of syllables, such as putting a pause or gap between syllables
Inconsistency, such as making different errors when trying to say the same word a second time
Difficulty imitating simple words
Inconsistent voicing errors, such as saying "down" instead of "town," or "zoo" instead of "Sue"
Other characteristics are seen in most children with speech or language problems and aren't helpful in distinguishing CAS. Characteristics seen in both children with CAS and in children with other types of speech or language disorders include:
Reduced amount of babbling or vocal sounds from ages 7 to 12 months old
Speaking first words late (after ages 12 to 18 months old)
Using a limited number of consonants and vowels
Frequently leaving out (omitting) sounds
Difficult to understand speech
Other speech disorders sometimes confused with CAS
Some speech sound disorders often get confused with CAS because some of the characteristics may overlap. These speech sound disorders include articulation disorders, phonologic disorders and dysarthria.
A child who has trouble learning how to make specific sounds, but doesn't have trouble planning or coordinating the movements to speak, may have an articulation or phonologic disorder. In an articulation disorder, a child has difficulty with specific sounds. He or she may leave out the sound or use another sound in its place. In phonologic disorders, a child has certain sound error patterns, such as difficulty producing sounds in the back of his or her mouth.
Articulation and phonologic disorders are more common than CAS.
Articulation or phonologic speech errors may include:
Substituting sounds, such as saying "fum" instead of "thumb," "wabbit" instead of "rabbit" or "tup" instead of "cup"
Leaving out (omitting) final consonants, such as saying "duh" instead of "duck" or "uh" instead of "up"
Stopping the airstream, such as saying "tun" instead of "sun" or "doo" instead of "zoo"
Simplifying sound combinations, such as saying "ting" instead of "string" or "fog" instead of "frog"
Dysarthria is a motor speech disorder that is due to weakness, spasticity or inability to control the speech muscles. Making speech sounds is difficult because the speech muscles can't move as far, as quickly or as strongly as normal. People with dysarthria may also have a hoarse, soft or even strained voice, or slurred or slow speech.
Dysarthria is often easier to identify than CAS. However, when dysarthria is caused by damage to certain areas of the brain that affect coordination, it can be difficult to determine the differences between CAS and dysarthria. In some children, both dysarthria and CAS are present.
CAUSES
Childhood apraxia of speech (CAS) has a number of possible causes, but in many cases a cause can't be determined. Doctors often don't observe a problem in the brain of a child with CAS.
CAS may be the result of brain (neurological) conditions or injury, such as stroke, infections or traumatic brain injury.
CAS also may occur as a symptom of a genetic disorder, syndrome or metabolic condition. For example, CAS occurs more frequently in children with velocardiofacial syndrome and galactosemia.
CAS is sometimes referred to as developmental apraxia. However, children with CAS don't necessarily grow out of CAS as they develop. In many children with delayed or developmental disorders, children follow usual patterns in development of speech and sounds, but they develop more slowly than usual. Children with CAS don't make typical developmental sound errors. They need speech therapy to make maximum progress.
RISK FACTORS
Abnormalities in the FOXP2 gene appear to increase the risk of childhood apraxia of speech (CAS) and other speech and language disorders. The FOXP2 gene may be involved in how certain nerves and pathways in the brain develop. Researchers continue to study how abnormalities in the FOXP2 gene may affect motor coordination and speech and language processing in the brain.
Boys are more likely to have CAS than girls. However, girls tend to have a more severe form of CAS.
COMPLICATIONS
Many children with childhood apraxia of speech (CAS) have other problems that affect their ability to communicate. These problems aren't due to CAS, but they may be seen along with CAS.
Symptoms or problems that are often present along with CAS include:
Delayed language, such as difficulty understanding speech, reduced vocabulary, or difficulty using correct grammar when putting words together in a phrase or sentence
Delays in intellectual and motor development and problems with reading, spelling and writing
Difficulties with gross and fine motor movement skills or coordination
Hypersensitivity, in which the child may not like some textures in clothing or the texture of certain foods, or the child may not like tooth brushing
PREPARING FOR YOUR APPOINTMENT
Your child is likely to start by seeing a doctor trained in the general care and treatment of children (pediatrician) or a doctor trained in treating children with neurological conditions (pediatric neurologist). Your child will then be referred to a specialist in speech and language conditions (speech-language pathologist).
Because appointments have limited time, and because there's often a lot to talk about, it's a good idea to be well prepared for your child's appointment. Here's some information to help you and your child get ready, and what to expect from your child's doctor and speech-language pathologist.
What you can do
Write down any symptoms your child is experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
Bring a list of all medications, vitamins or supplements that your child is taking.
Write down questions to ask your child's doctor and speech-language pathologist.
Bring a copy of a recent progress report and individual education plan from your child's speech-language pathologist if your child has previously been seen by a speech-language pathologist.
Your time with your child's doctor or speech-language pathologist is limited, so preparing a list of questions ahead of time will help you make the most of your time together. For childhood apraxia of speech (CAS), some basic questions to ask the speech-language pathologist include:
Does my child have CAS, or any other speech or language problems?
What is CAS?
How is CAS different from other types of speech disorders?
Is my child's condition going to improve?
What treatments are available, and which do you recommend?
What can I do at home to help my child?
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 child's doctor or speech-language pathologist, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your child's speech-language pathologist
Your child's speech-language pathologist is likely to ask you a number of questions. Being ready to answer them may allow more time to ask questions about your child's diagnosis and recommended treatment. Your child's speech-language pathologist may ask:
When did you first have concerns about your child's speech development?
Did your child babble? For example, did your child produce cooing sounds and then produce syllables, such as "ba-ba-ba" or "da-da-da"? If so, when did that start?
When did your child say his or her first word?
When did your child have five words in his or her vocabulary that he or she would use frequently?
How many words does your child currently have in his or her vocabulary that would be understandable to most people?
In what other ways does your child communicate? For example, does your child point, make gestures, make signs or act things out?
Has anyone in your family had speech or language difficulties?
Has your child had ear infections? About how many ear infections has he or she had?
When was your child's hearing tested? Was any hearing loss detected?
TESTS AND DIAGNOSIS
To evaluate your child's condition, your child's speech-language pathologist will review your child's symptoms and medical history, conduct an examination of the muscles used for speech, and examine how your child produces speech sounds, words and phrases.
Your child's speech-language pathologist will also assess your child's language skills, such as his or her vocabulary, sentence structure and ability to understand speech.
Several tests will help determine if childhood apraxia of speech (CAS) is present and rule out or identify other problems that may be affecting your child's ability to speak. The specific tasks conducted during the evaluation will depend on your child's age, ability to cooperate and the severity of the speech problem.
Diagnosis of CAS isn't based on any single test or observation. It depends on the pattern of problems that are seen.
It's important to identify whether your child shows symptoms of CAS, because CAS is treated differently from other speech disorders. Children with CAS also may have other communication problems.
It can sometimes be difficult to diagnose CAS, especially when a child speaks very little or has difficulty interacting with the speech-language pathologist.
Your child's speech-language pathologist may determine that CAS may be present. However, your child's speech-language pathologist may not be able to definitely diagnose CAS.
Your child's speech-language pathologist often may be able to determine an appropriate treatment approach for your child, even if the diagnosis is initially uncertain.
Tests may include:
Hearing tests. Your doctor may order hearing tests to determine if hearing problems could be contributing to your child's speech problems.
Oral-motor assessment. Your child's speech-language pathologist will examine your child's lips, tongue, jaw and palate for structural problems, such as tongue-tie or a cleft palate, or other problems, such as low muscle tone. Low muscle tone usually isn't associated with CAS, but it may be a sign of other conditions.
Your child's speech-language pathologist will observe how your child moves his or her lips, tongue and jaw in activities such as blowing, smiling, and kissing.
Speech evaluation. Your child's ability to say sounds, words and sentences will be observed during play or other activities.
Your child may be asked to name pictures to see if he or she has difficulty making specific sounds or speaking certain words or syllables.
Your child's speech-language pathologist may evaluate your child's coordination and smoothness of movement in speech during speech tasks. To evaluate your child's coordination of movement in speech, your child may asked to repeat syllables such as "pa-ta-ka" or say words such as "buttercup."
If your child can produce sentences, your child's speech-language pathologist will observe your child's melody and rhythm of speech, such as how he or she stresses syllables and words.
Your child's speech-language pathologist may help your child be more accurate by providing cues, such as saying the word or sound more slowly or providing touch cues to his or her face.
TREATMENTS AND DRUGS
Speech-language pathologists may treat childhood apraxia of speech (CAS) with many therapies.
Speech therapy
Because there isn't evidence to show that medications effectively treat CAS, speech therapy is the primary treatment for CAS.
Your child's speech-language pathologist will usually provide therapy that focuses on practicing syllables, words and phrases. When CAS is relatively severe, your child may need frequent speech therapy, three to five times a week. As your child improves, the frequency of speech therapy may be reduced.
Children with CAS generally benefit from individual therapy. Individual therapy allows your child to have more time to practice speech during each session.
It's important that children with CAS get a significant amount of practice saying words and phrases during each speech therapy session. Learning to say words or phrases takes children with CAS time and practice.
Because children with CAS have difficulties planning movements for speech, speech therapy often focuses your child's attention to the sound and feel of speech movements.
Speech-language pathologists may use different types of cues in speech therapy. For example, your child's speech-language pathologist may ask your child to listen carefully and watch him or her form the target word or phrase with his or her mouth.
Your child's speech-language pathologist also may touch your child's face as he or she makes certain sounds or syllables. For example, your child's speech-language pathologist may use his or her hands to help your child round his or her lips to say "oo."
No single speech therapy approach has been shown to be most effective for treating CAS, but some important general principles of speech therapy for CAS include:
Your child's speech-language therapist will focus on speech drills, such as asking your child to say words or phrases many times during a therapy session.
Your child will be asked to listen to the speech-language pathologist and to watch his or her mouth as he or she says the target word or phrase. By watching the speech-language pathologist's mouth, your child also sees the movements that go along with the sounds.
Your child will most likely practice syllables, words or phrases, rather than isolated sounds, during speech therapy. Children with CAS need practice making the movements from one sound to another.
Because many children with CAS distort vowel sounds, your child's speech-language pathologist may choose words for your child to practice that contain vowels in different types of syllables. For example, your child may be asked to say "hi," "mine" and "bite," or "out," "down" and "house."
If your child has severe CAS, your child's speech-language pathologist may use a small set of practice words at first, and gradually increase the number of words for practice as your child improves.
Speech practice at home
Because speech practice is very important, your child's speech-language pathologist may encourage you to be involved in your child's speech practice at home.
Your child's speech-language pathologist may give you words and phrases to practice with your child at home that he or she has learned in speech therapy. Each home practice session can be short, such as five minutes in length, and you may practice with your child twice a day.
Children also need to practice words and phrases in real-life situations. Create situations where it will be appropriate for your child to say the word or phrase spontaneously. For example, ask your child to say "Hi, Mom" each time mom enters a room. Practicing words or phrases in real-life situations will make it easier for your child to say the practice words automatically.
Alternative communication methods
If your child has a severe speech disorder and can't effectively communicate, alternative communication methods can be very helpful.
Alternative communication methods may include sign language or natural gestures, such as pointing or pretending to eat or drink. For example, your child could use signs to communicate he or she wants a cookie. Sometimes electronic devices, such as electronic tablets, can be helpful in communication.
It's often important to use alternative communication methods early. Using these methods may help your child become less frustrated when trying to communicate. It may also help your child to develop language skills such as vocabulary and the ability to put words together in sentences.
As speech improves, these strategies and devices may no longer be necessary.
Therapies for coexisting problems
Many children with CAS also have delays in their language development, and they may need therapy to address their language difficulties.
Children with CAS who have fine and gross motor movement difficulties in their arms or legs may need physical or occupational therapy.
If a child with CAS has another medical condition, then effective treatment for that condition may be important to improving the child's speech.
Treatments which aren't helpful for CAS
Some treatments aren't helpful in improving the speech of children with CAS. For example, there is no evidence to show that exercises to strengthen speech muscles will help improve speech in children with CAS.
LIFESTYLE AND HOME REMEDIES
Diagnosing and treating childhood apraxia of speech at an early stage may reduce the risk of long-term persistence of the problem.
If your child experiences speech problems, it's a good idea to have a speech-language pathologist evaluate your child as soon as you notice any speech problems.
ALTERNATIVE MEDICINE
Currently, there isn't any evidence that proves that the use of medications, vitamins or other supplements improves symptoms of childhood apraxia of speech (CAS). Children with CAS improve through practicing words and phrases in speech therapy.
More research is needed to study the potential use of vitamins, supplements and other medical treatments to improve speech in children with CAS.
COPING AND SUPPORT
It can be difficult to have a child who has problems communicating. There are a number of support groups available for parents of children with childhood apraxia of speech. Support groups may offer a place for you to find people who understand your situation and who can share similar experiences.
To learn about support groups in your area, see the Apraxia-KIDS website.
ARTERIOSCLEROSIS
ARTERIOSCLEROSIS
Arteriosclerosis occurs when the blood vessels that carry oxygen and nutrients from your heart to the rest of your body (arteries) become thick and stiff — sometimes restricting blood flow to your organs and tissues. Healthy arteries are flexible and elastic, but over time, the walls in your arteries can harden, a condition commonly called hardening of the arteries.
Atherosclerosis is a specific type of arteriosclerosis, but the terms are sometimes used interchangeably. Atherosclerosis refers to the buildup of fats, cholesterol and other substances in and on your artery walls (plaques), which can restrict blood flow.
These plaques can burst, triggering a blood clot. Although atherosclerosis is often considered a heart problem, it can affect arteries anywhere in your body. Atherosclerosis usually is preventable and is treatable.
SYMPTOMS
Atherosclerosis develops gradually. Mild atherosclerosis usually doesn't have any symptoms.
You usually won't have atherosclerosis symptoms until an artery is so narrowed or clogged that it can't supply adequate blood to your organs and tissues. Sometimes a blood clot completely blocks blood flow, or even breaks apart and can trigger a heart attack or stroke.
Symptoms of moderate to severe atherosclerosis depend on which arteries are affected. For example:
If you have atherosclerosis in your heart arteries, you may have symptoms, such as chest pain or pressure (angina).
If you have atherosclerosis in the arteries leading to your brain, you may have signs and symptoms such as sudden numbness or weakness in your arms or legs, difficulty speaking or slurred speech, or drooping muscles in your face. These signal a transient ischemic attack (TIA), which, if left untreated, may progress to a stroke.
If you have atherosclerosis in the arteries in your arms and legs, you may have symptoms of peripheral artery disease, such as leg pain when walking (intermittent claudication).
If you have atherosclerosis in the arteries leading to your kidneys, you develop high blood pressure or kidney failure.
If you have atherosclerosis in the arteries leading to your genitals, you may have difficulties having sex. Sometimes, atherosclerosis can cause erectile dysfunction in men. In women, high blood pressure can reduce blood flow to the vagina, making sex less pleasurable.
When to see a doctor
If you think you have atherosclerosis, talk to your doctor. Also pay attention to early symptoms of inadequate blood flow, such as chest pain (angina), leg pain or numbness. Early diagnosis and treatment can stop atherosclerosis from worsening and prevent a heart attack, stroke or another medical emergency.
CAUSES
Atherosclerosis is a slow, progressive disease that may begin as early as childhood. Although the exact cause is unknown, atherosclerosis may start with damage or injury to the inner layer of an artery. The damage may be caused by:
High blood pressure
High cholesterol, often from getting too much cholesterol or saturated fats in your diet
High triglycerides, a type of fat (lipid) in your blood
Smoking and other sources of tobacco
Diabetes
Inflammation from diseases, such as arthritis, lupus or infections, or inflammation of unknown cause
Once the inner wall of an artery is damaged, blood cells and other substances often clump at the injury site and build up in the inner lining of the artery. Over time, fatty deposits (plaques) made of cholesterol and other cellular products also build up at the injury site and harden, narrowing your arteries. The organs and tissues connected to the blocked arteries then don't receive enough blood to function properly.
Eventually pieces of the fatty deposits may break off and enter your bloodstream. In addition, the smooth lining of a plaque may rupture, spilling cholesterol and other substances into your bloodstream. This may cause a blood clot, which can block the blood flow to a specific part of your body, such as occurs when blocked blood flow to your heart causes a heart attack. A blood clot can also travel to other parts of your body, blocking flow to another organ.
RISK FACTORS
Hardening of the arteries occurs over time. Besides aging, factors that increase the risk of atherosclerosis include:
High blood pressure
High cholesterol
Diabetes
Obesity
Smoking and other tobacco use
A family history of early heart disease
Lack of exercise
COMPLICATIONS
The complications of atherosclerosis depend on which arteries are blocked. For example:
Coronary artery disease. When atherosclerosis narrows the arteries close to your heart, you may develop coronary artery disease, which can cause chest pain (angina), a heart attack or heart failure.
Carotid artery disease. When atherosclerosis narrows the arteries close to your brain, you may develop carotid artery disease, which can cause a transient ischemic attack (TIA) or stroke.
Peripheral artery disease. When atherosclerosis narrows the arteries in your arms or legs, you may develop circulation problems in your arms and legs called peripheral artery disease. This can make you less sensitive to heat and cold, increasing your risk of burns or frostbite. In rare cases, poor circulation in your arms or legs can cause tissue death (gangrene).
Aneurysms. Atherosclerosis can also cause aneurysms, a serious complication that can occur anywhere in your body. An aneurysm is a bulge in the wall of your artery. Most people with aneurysms have no symptoms. Pain and throbbing in the area of an aneurysm may occur and is a medical emergency.
If an aneurysm bursts, you may face life-threatening internal bleeding. Although this is usually a sudden, catastrophic event, a slow leak is possible. If a blood clot within an aneurysm dislodges, it may block an artery at some distant point.
PREPARING FOR YOUR APPOINTMENT
If you think you may have atherosclerosis or are worried about having atherosclerosis because of a strong family history of heart disease, make an appointment with your doctor to have your cholesterol level checked.
Here's some information to help you get ready for your appointment and know what to expect from your doctor.
What you can do
Be aware of any pre-appointment restrictions. When you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your diet. Many blood tests, including cholesterol and triglycerides, require that you fast beforehand.
Write down any symptoms you're experiencing. Atherosclerosis seldom has symptoms, but it is a risk factor for heart disease. Knowing you have symptoms such as chest pains or shortness of breath can help your doctor decide how aggressively to treat your atherosclerosis.
Write down key personal information, including a family history of high cholesterol, heart disease, stroke, high blood pressure or diabetes, and any major stresses or recent life changes.
Make a list of all medications, vitamins or supplements you're taking.
Take a family member or friend along, if possible. Someone who accompanies you may remember something that you missed or forgot.
Be prepared to discuss your diet and exercise habits. If you don't already eat a healthy diet or exercise, you can talk to your doctor about challenges you might face in getting started.
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 atherosclerosis, some basic questions to ask your doctor include:
What tests will I need?
What's the best treatment?
What foods should I eat or avoid?
What's an appropriate level of physical activity?
How often do I need a cholesterol test?
What are the alternatives to the primary approach you're suggesting?
I have other health conditions. How can I best manage them together?
Are there restrictions I need to follow?
Should I see a specialist?
Is there a generic alternative to the medicine you're prescribing?
Are there brochures or other printed material that I can take with me? What websites do you recommend?
Don't hesitate to ask any other questions you have.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, including:
Do you have a family history of high cholesterol, high blood pressure or heart disease?
What are your diet and exercise habits like?
Do you or did you smoke or use tobacco in any form?
Have you had a cholesterol test? If so, when was your last test? What were your cholesterol levels?
Do you have discomfort in your chest or pain in your legs with walking or at rest?
Have you had a stroke or unexplained numbness, tingling or weakness of one side of your body or difficulty speaking?
What you can do in the meantime
It's never too early to make healthy lifestyle changes, such as quitting smoking, eating healthy foods and becoming more physically active. These are primary lines of defense against atherosclerosis and its complications, including heart attack and stroke.
TESTS AND DIAGNOSIS
During a physical exam, your doctor may find signs of narrowed, enlarged or hardened arteries, including:
A weak or absent pulse below the narrowed area of your artery
Decreased blood pressure in an affected limb
Whooshing sounds (bruits) over your arteries, heard using a stethoscope
Signs of a pulsating bulge (aneurysm) in your abdomen or behind your knee
Evidence of poor wound healing in the area where your blood flow is restricted
Depending on the results of the physical exam, your doctor may suggest one or more diagnostic tests, including:
Blood tests. Lab tests can detect increased levels of cholesterol and blood sugar that may increase the risk of atherosclerosis. You'll need to go without eating or drinking anything but water for nine to 12 hours before your blood test. Your doctor should tell you ahead of time if this test will be performed during your visit.
Doppler ultrasound. Your doctor may use a special ultrasound device (Doppler ultrasound) to measure your blood pressure at various points along your arm or leg. These measurements can help your doctor gauge the degree of any blockages, as well as the speed of blood flow in your arteries.
Ankle-brachial index. This test can tell if you have atherosclerosis in the arteries in your legs and feet. Your doctor may compare the blood pressure in your ankle with the blood pressure in your arm. This is known as the ankle-brachial index. An abnormal difference may indicate peripheral vascular disease, which is usually caused by atherosclerosis.
Electrocardiogram (ECG). An electrocardiogram records electrical signals as they travel through your heart. An ECG can often reveal evidence of a previous heart attack. If your signs and symptoms occur most often during exercise, your doctor may ask you to walk on a treadmill or ride a stationary bike during an ECG.
Stress test. A stress test, also called an exercise stress test, is used to gather information about how well your heart works during physical activity. Because exercise makes your heart pump harder and faster than it does during most daily activities, an exercise stress test can reveal problems within your heart that might not be noticeable otherwise. An exercise stress test usually involves walking on a treadmill or riding a stationary bike while your heart rhythm and blood pressure and breathing are monitored. In some types of stress tests, pictures will be taken of your heart, such as during a stress echocardiogram (ultrasound) or nuclear stress test. If you're unable to exercise, you may receive a medication that mimics the effect of exercise on your heart.
Cardiac catheterization and angiogram. 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.
Other imaging tests. Your doctor may use ultrasound, a computerized tomography (CT) scan or magnetic resonance angiography (MRA) to study your arteries. These tests can often show hardening and narrowing of large arteries, as well as aneurysms and calcium deposits in the artery walls.
TREATMENTS AND DRUGS
Lifestyle changes, such as eating a healthy diet and exercising, are often the best treatment for atherosclerosis. Sometimes, medication or surgical procedures may be recommended as well.
Various drugs can slow — or even reverse — the effects of atherosclerosis. Here are some common choices:
Cholesterol medications. Aggressively lowering your low-density lipoprotein (LDL) cholesterol, the "bad" cholesterol, can slow, stop or even reverse the buildup of fatty deposits in your arteries. Boosting your high-density lipoprotein (HDL) cholesterol, the "good" cholesterol, may help, too. Your doctor can choose from a range of cholesterol medications, including drugs known as statins and fibrates. In addition to lowering cholesterol, statins have additional effects that help stabilize the lining of your heart arteries and prevent atherosclerosis.
Anti-platelet medications. Your doctor may prescribe anti-platelet medications, such as aspirin, to reduce the likelihood that platelets will clump in narrowed arteries, form a blood clot and cause further blockage.
Beta blocker medications. These medications are commonly used for coronary artery disease. They lower your heart rate and blood pressure, reducing the demand on your heart and often relieve symptoms of chest pain. Beta blockers reduce the risk of heart attacks and some heart rhythm problems.
Angiotensin-converting enzyme (ACE) inhibitors. These medications may help slow the progression of atherosclerosis by lowering blood pressure and producing other beneficial effects on the heart arteries. ACE inhibitors can also reduce the risk of recurrent heart attacks.
Calcium channel blockers. These medications lower blood pressure and are sometimes used to treat angina.
Water pills (diuretics). High blood pressure is a major risk factor for atherosclerosis. Diuretics lower blood pressure.
Other medications. Your doctor may suggest certain medications to control specific risk factors for atherosclerosis, such as diabetes. Sometimes specific medications to treat symptoms of atherosclerosis, such as leg pain during exercise, are prescribed.
Sometimes more aggressive treatment is needed. If you have severe symptoms or a blockage that threatens muscle or skin tissue survival, you may be a candidate for one of the following surgical procedures:
Angioplasty and stent placement. In this procedure, your doctor inserts a long, thin tube (catheter) into the blocked or narrowed part of your artery. A second catheter with a deflated balloon on its tip is then 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.
Endarterectomy. In some cases, fatty deposits must be surgically removed from the walls of a narrowed artery. When the procedure is done on arteries in the neck (the carotid arteries), it's called a carotid endarterectomy.
Thrombolytic therapy. If you have an artery that's blocked by a blood clot, your doctor may use a clot-dissolving drug to break it apart.
Bypass surgery. Your doctor may create a graft bypass using a vessel from another part of your body or a tube made of synthetic fabric. This allows blood to flow around the blocked or narrowed artery.
LIFESTYLE AND HOME REMEDIES
The same healthy lifestyle changes recommended to treat atherosclerosis also help prevent it. These include:
Quitting smoking
Eating healthy foods
Exercising regularly
Maintaining a healthy weight
Just remember to make changes one step at a time, and keep in mind what lifestyle changes are manageable for you in the long run.
ALTERNATIVE MEDICINE
It's thought that some foods and herbal supplements can help reduce your high cholesterol level and high blood pressure, two major risk factors for developing atherosclerosis. With your doctor's OK, consider these supplements and products:
Alpha-linolenic acid (ALA)
Artichoke
Barley
Beta-sitosterol (found in oral supplements and some margarines, such as Promise Activ)
Blond psyllium (found in seed husk and products such as Metamucil)
Calcium
Cocoa
Cod liver oil
Coenzyme Q10
Garlic
Oat bran (found in oatmeal and whole oats)
Omega-3 fatty acids
Sitostanol (found in oral supplements and some margarines, such as Benecol)
Talk to your doctor before adding any of these supplements to your atherosclerosis treatment. Some supplements can interact with medications, causing harmful side effects.
You can also practice relaxation techniques, such as yoga or deep breathing, to help you relax and reduce your stress level. These practices can temporarily reduce your blood pressure, reducing your risk of developing atherosclerosis.
ARTHRITIS
ARTHRITIS
Arthritis
Arthritis is inflammation of one or more of your joints. The main symptoms of arthritis are joint pain and stiffness, which typically worsen with age. The most common types of arthritis are osteoarthritis and rheumatoid arthritis.
Osteoarthritis causes cartilage — the hard, slippery tissue that covers the ends of bones where they form a joint — to break down. Rheumatoid arthritis is an autoimmune disorder that first targets the lining of joints (synovium).
Uric acid crystals, infections or underlying disease, such as psoriasis or lupus, can cause other types of arthritis.
Treatments vary depending on the type of arthritis. The main goals of arthritis treatments are to reduce symptoms and improve quality of life.
SYMPTOMS
The most common signs and symptoms of arthritis involve the joints. Depending on the type of arthritis you have, your signs and symptoms may include:
Pain
Stiffness
Swelling
Redness
Decreased range of motion
CAUSES
The two main types of arthritis — osteoarthritis and rheumatoid arthritis — damage joints in different ways.
Osteoarthritis
The most common type of arthritis, osteoarthritis involves wear-and-tear damage to your joint's cartilage — the hard, slick coating on the ends of bones. Enough damage can result in bone grinding directly on bone, which causes pain and restricted movement. This wear and tear can occur over many years, or it can be hastened by a joint injury or infection.
Rheumatoid arthritis
In rheumatoid arthritis, the body's immune system attacks the lining of the joint capsule, a tough membrane that encloses all the joint parts. This lining, known as the synovial membrane, becomes inflamed and swollen. The disease process can eventually destroy cartilage and bone within the joint.
RISK FACTORS
Risk factors for arthritis include:
Family history. Some types of arthritis run in families, so you may be more likely to develop arthritis if your parents or siblings have the disorder. Your genes can make you more susceptible to environmental factors that may trigger arthritis.
Age. The risk of many types of arthritis — including osteoarthritis, rheumatoid arthritis and gout — increases with age.
Your sex. Women are more likely than are men to develop rheumatoid arthritis, while most of the people who have gout, another type of arthritis, are men.
Previous joint injury. People who have injured a joint, perhaps while playing a sport, are more likely to eventually develop arthritis in that joint.
Obesity. Carrying excess pounds puts stress on joints, particularly your knees, hips and spine. Obese people have a higher risk of developing arthritis.
COMPLICATIONS
Severe arthritis, particularly if it affects your hands or arms, can make it difficult for you to do daily tasks. Arthritis of weight-bearing joints can keep you from walking comfortably or sitting up straight. In some cases, joints may become twisted and deformed.
PREPARING FOR YOUR APPOINTMENT
While you might first discuss your symptoms with your family doctor, he or she may refer you to a doctor who specializes in the treatment of joint problems (rheumatologist) for further evaluation.
What you can do
Before your appointment, make a list that includes:
Detailed descriptions of your symptoms
Information about medical problems you've had in the past
Information about the medical problems of your parents or siblings
All the medications and dietary supplements you take
Questions you want to ask the doctor
What to expect from your doctor
Your doctor may ask some of the following questions:
When did your symptoms start?
Does activity make the pain better or worse?
What joints are painful?
Do you have a family history of joint pain?
TESTS AND DIAGNOSIS
During the physical exam, your doctor will check your joints for swelling, redness and warmth. He or she will also want to see how well you can move your joints. Depending on the type of arthritis suspected, your doctor may suggest some of the following tests.
Laboratory tests
The analysis of different types of body fluids can help pinpoint the type of arthritis you may have. Fluids commonly analyzed include blood, urine and joint fluid. To obtain a sample of your joint fluid, your doctor will cleanse and numb the area before inserting a needle in your joint space to withdraw some fluid (aspiration).
Imaging
These types of tests can detect problems within your joint that may be causing your symptoms. Examples include:
X-rays. Using low levels of radiation to visualize bone, X-rays can show cartilage loss, bone damage and bone spurs. X-rays may not reveal early arthritic damage, but they are often used to track progression of the disease.
Computerized tomography (CT). CT scanners take X-rays from many different angles and combine the information to create cross-sectional views of internal structures. CTs can visualize both bone and the surrounding soft tissues.
Magnetic resonance imaging (MRI). Combining radio waves with a strong magnetic field, MRI can produce more-detailed cross-sectional images of soft tissues such as cartilage, tendons and ligaments.
Ultrasound. This technology uses high-frequency sound waves to image soft tissues, cartilage and fluid-containing structures such as bursae. Ultrasound also is used to guide needle placement for joint aspirations and injections.
Arthroscopy
In some cases, your doctor may look for damage in your joint by inserting a small, flexible tube — called an arthroscope — through an incision near your joint. The arthroscope transmits images from inside the joint to a video screen.
TREATMENTS AND DRUGS
Arthritis treatment focuses on relieving symptoms and improving joint function. You may need to try several different treatments, or combinations of treatments, before you determine what works best for you.
Medications
The medications used to treat arthritis vary depending on the type of arthritis. Commonly used arthritis medications include:
Analgesics. These types of medications help reduce pain, but have no effect on inflammation. Examples include acetaminophen (Tylenol, others), tramadol (Ultram, others) and narcotics containing oxycodone (Percocet, Oxycontin, others) or hydrocodone (Vicodin, Lortab, others).
Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs reduce both pain and inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Some types of NSAIDs are available only by prescription. Oral NSAIDs can cause stomach irritation, and some may increase your risk of heart attack or stroke. Some NSAIDs are also available as creams or gels, which can be rubbed on joints.
Counterirritants. Some varieties of creams and ointments contain menthol or capsaicin, the ingredient that makes hot peppers spicy. Rubbing these preparations on the skin over your aching joint may interfere with the transmission of pain signals from the joint itself.
Disease-modifying antirheumatic drugs (DMARDs). Often used to treat rheumatoid arthritis, DMARDs slow or stop your immune system from attacking your joints. Examples include methotrexate (Trexall) and hydroxychloroquine (Plaquenil).
Biologics. Typically used in conjunction with DMARDs, biologic response modifiers are genetically engineered drugs that target various protein molecules that are involved in the immune response. Examples include etanercept (Enbrel) and infliximab (Remicade).
Corticosteroids. This class of drug, which includes prednisone and cortisone, reduces inflammation and suppresses the immune system. Corticosteroids can be taken orally or be injected directly into the painful joint.
Therapy
Physical therapy can be helpful for some types of arthritis. Exercises can improve range of motion and strengthen the muscles surrounding joints. In some cases, splints or braces may be warranted.
Surgery
If conservative measures don't help, your doctor may suggest surgery, such as:
Joint replacement. This procedure removes your damaged joint and replaces it with an artificial one. Joints most commonly replaced are hips and knees.
Joint fusion. This procedure is more often used for smaller joints, such as those in the wrist, ankle and fingers. It removes the ends of the two bones in the joint and then locks those ends together until they heal into one rigid unit.
LIFESTYLE AND HOME REMEDIES
Weight loss. If you're obese, losing weight will reduce the stress on your weight-bearing joints. This may increase your mobility and limit future joint injury.
Exercise. Regular exercise can help keep your joints flexible. Swimming and water aerobics may be good choices because the buoyancy of the water reduces stress on weight-bearing joints.
Heat and cold. Heating pads or ice packs may help relieve arthritis pain.
Assistive devices. Using canes, walkers, raised toilet seats and other assistive devices can help protect your joints and improve your ability to perform daily tasks.
ALTERNATIVE MEDICINE
Many people use alternative remedies for arthritis, but there is little reliable evidence to support the use of many of these products. The most promising alternative remedies for arthritis include:
Acupuncture. This therapy uses fine needles inserted at specific points on the skin to reduce many types of pain, including that caused by some types of arthritis.
Glucosamine. Although study results have been mixed, it now appears that glucosamine works no better than placebo. However, glucosamine and the placebo both relieved arthritis pain better than taking nothing, particularly in people who have moderate to severe pain.
Transcutaneous electrical nerve stimulation (TENS). Using a small device that produces mild electrical pulses, TENS therapy stimulates nerves near the aching joint and may interfere with the transmission of pain signals to the brain.
Yoga or tai chi. The slow, stretching movements associated with yoga and tai chi may help improve joint flexibility and range of motion in people with some types of arthritis.
Massage. Light stroking and kneading of muscles may increase blood flow and warm affected joints, temporarily relieving pain. Make sure your massage therapist knows which joints are affected by arthritis.
JUVENILE RHEUMATOID ARTHRITIS
JUVENILE RHEUMATOID ARTHRITIS
Juvenile rheumatoid arthritis, also known as juvenile idiopathic arthritis, is the most common type of arthritis in children under the age of 17. Juvenile rheumatoid arthritis causes persistent joint pain, swelling and stiffness. Some children may experience symptoms for only a few months, while others have symptoms for the rest of their lives.
Some types of juvenile rheumatoid arthritis can cause serious complications, such as growth problems and eye inflammation. Treatment of juvenile rheumatoid arthritis focuses on controlling pain, improving function and preventing joint damage.
SYMPTOMS
The most common signs and symptoms of juvenile rheumatoid arthritis are:
Pain. While your child might not complain of joint pain, you may notice that he or she limps — especially first thing in the morning or after a nap.
Swelling. Joint swelling is common but is often first noticed in larger joints like the knee.
Stiffness. You might notice that your child appears clumsier than usual, particularly in the morning or after naps.
Juvenile rheumatoid arthritis can affect one joint or many. In some cases, juvenile rheumatoid arthritis affects the entire body — causing swollen lymph nodes, rashes and fever.
Like other forms of arthritis, juvenile rheumatoid arthritis is characterized by times when symptoms flare up and times when symptoms disappear.
When to see a doctor
Take your child to the doctor if he or she has joint pain, swelling or stiffness for more than a week — especially if he or she also has a fever.
CAUSES
Juvenile rheumatoid arthritis occurs when the body's immune system attacks its own cells and tissues. It's unknown why this happens, but both heredity and environment seem to play a role. Certain gene mutations may make a person more susceptible to environmental factors — such as viruses — that may trigger the disease.
RISK FACTORS
Some forms of juvenile rheumatoid arthritis are more common in girls.
COMPLICATIONS
Several serious complications can result from juvenile rheumatoid arthritis. But keeping a careful watch on your child's condition and seeking appropriate medical attention can greatly reduce the risk of these complications:
Eye problems. Some forms of juvenile rheumatoid arthritis can cause eye inflammation (uveitis). If this condition is left untreated, it may result in cataracts, glaucoma and even blindness.
Eye inflammation frequently occurs without symptoms, so it's important for children with juvenile rheumatoid arthritis to be examined regularly by an ophthalmologist.
Growth problems. Juvenile rheumatoid arthritis can interfere with your child's growth and bone development. Some medications used to treat juvenile rheumatoid arthritis, mainly corticosteroids, also can inhibit growth.
PREPARING FOR YOUR APPOINTMENT
If your pediatrician or family doctor suspects that your child has juvenile rheumatoid arthritis, he or she may refer you to a doctor who specializes in arthritis (rheumatologist) to confirm the diagnosis and explore treatment.
What you can do
Before the appointment, you might want to write a list that includes:
Detailed descriptions of your child's symptoms
Information about medical problems your child has had in the past
Information about the medical problems that tend to run in your family
All the medications and dietary supplements your child takes
Questions you want to ask the doctor
What to expect from your doctor
Your doctor may ask some of the following questions:
Which joints appear to be affected?
When did the symptoms begin? Do they seem to come and go?
Does anything make the symptoms better or worse?
Is the joint stiffness worse after a period of rest?
TESTS AND DIAGNOSIS
Diagnosis of juvenile rheumatoid arthritis can be difficult because joint pain can be caused by many different types of problems. No single test can confirm a diagnosis, but tests can help rule out some other conditions that produce similar signs and symptoms.
Blood tests
Some of the most common blood tests for suspected cases of juvenile rheumatoid arthritis include:
Erythrocyte sedimentation rate (ESR). Sedimentation rate is the speed at which your red blood cells settle to the bottom of a tube of blood. An elevated rate can indicate inflammation.
Measuring the ESR may be used to rule out other conditions, to help classify the type of juvenile rheumatoid arthritis and to determine the degree of inflammation.
C-reactive protein. This blood test also measures levels of general inflammation in the body but on a different scale than the ESR.
Anti-nuclear antibody. Anti-nuclear antibodies are proteins commonly produced by the immune systems of people with certain autoimmune diseases, including arthritis.
Rheumatoid factor. This antibody is commonly found in the blood of children who have rheumatoid arthritis.
Cyclic citrullinated peptide (CCP). Like the rheumatoid factor, the CCP is another antibody that may be found in the blood of children with rheumatoid arthritis.
In many children with juvenile rheumatoid arthritis, no significant abnormality will be found in these blood tests.
Imaging scans
X-rays or magnetic resonance imaging (MRI) may be taken to exclude other conditions, such as:
Fractures
Tumors
Infection
Congenital defects
Imaging may also be used from time to time after the diagnosis to monitor bone development and to detect joint damage.
TREATMENTS AND DRUGS
Treatment for juvenile rheumatoid arthritis focuses on helping your child maintain a normal level of physical and social activity. To accomplish this, doctors may use a combination of strategies to relieve pain and swelling, maintain full movement and strength, and prevent complications.
Medications
For some children, pain relievers may be the only medication needed. Other children may need help from medications designed to limit the progression of the disease.
Typical medications used for juvenile rheumatoid arthritis include:
Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), reduce pain and swelling. Stronger NSAIDs are available by prescription. Side effects include stomach upset and liver problems.
Disease-modifying antirheumatic drugs (DMARDs). Doctors use these medications when NSAIDs alone fail to relieve symptoms of joint pain and swelling.
They may be taken in combination with NSAIDs and are used to slow the progress of juvenile rheumatoid arthritis. Commonly used DMARDs for children include methotrexate (Trexall) and leflunomide (Arava).
Side effects may include nausea and liver problems.
Biologic agents. Also known as biologic response modifiers, this newer class of drugs includes tumor necrosis factor (TNF) blockers, such as etanercept (Enbrel) and adalimumab (Humira). These medications can help reduce pain, morning stiffness and swollen joints.
But these types of drugs increase the risk of infections. There may also be a mild increase in the chance of getting some cancers, such as lymphoma.
Other biologic agents work to suppress the immune system, including abatacept (Orencia), rituximab (Rituxin), anakinra (Kineret) and tocilizumab (Actemra).
Corticosteroids. Medications such as prednisone may be used to control symptoms until a DMARD takes effect or to prevent complications, such as inflammation of the sac around the heart (pericarditis).
Corticosteroids may be administered by mouth or by injection directly into a joint. But these drugs can interfere with normal growth and increase susceptibility to infection, so they generally should be used for the shortest possible duration.
Therapies
Your doctor may recommend that your child work with a physical therapist to help keep joints flexible and maintain range of motion and muscle tone.
A physical therapist or an occupational therapist may make additional recommendations regarding the best exercise and protective equipment for your child.
A therapist may also recommend that your child make use of joint supports or splints to help protect joints and keep them in a good functional position.
Surgery
In very severe cases of juvenile rheumatoid arthritis, surgery may be needed to improve the position of a joint.
LIFESTYLE AND HOME REMEDIES
Caregivers can help children learn self-care techniques that help limit the effects of juvenile rheumatoid arthritis. Techniques include:
Getting regular exercise. Exercise is important because it promotes both muscle strength and joint flexibility. Swimming is an excellent choice because it places minimal stress on joints.
Applying cold or heat. Stiffness affects many children with juvenile rheumatoid arthritis, particularly in the morning. Although some children respond well to cold packs, most children prefer a hot pack or a hot bath or shower.
Eating well. Some children with arthritis have poor appetites. Others may gain excess weight due to medications or physical inactivity. A healthy diet can help maintain an appropriate body weight.
Adequate calcium in the diet is important because children with juvenile rheumatoid arthritis are at risk of developing weak bones (osteoporosis) due to the disease, the use of corticosteroids, and decreased physical activity and weight bearing.
COPING AND SUPPORT
Family members can play critical roles in helping a child cope with juvenile rheumatoid arthritis. As a parent, you may want to try the following:
Treat your child, as much as possible, like other children in your family.
Allow your child to express anger about having juvenile rheumatoid arthritis. Explain that the disease isn't caused by anything he or she did.
Encourage your child to participate in physical activities, keeping in mind the recommendations of your child's doctor and physical therapist.
Discuss your child's condition and the issues surrounding it with teachers and administrators at his or her school.
ASTHMA
ASTHMA
Asthma is a condition in which your airways narrow and swell and produce extra mucus. This can make breathing difficult and trigger coughing, wheezing and shortness of breath.
For some people, asthma is a minor nuisance. For others, it can be a major problem that interferes with daily activities and may lead to a life-threatening asthma attack.
Asthma can't be cured, but its symptoms can be controlled. Because asthma often changes over time, it's important that you work with your doctor to track your signs and symptoms and adjust treatment as needed.
SYMPTOMS
Asthma symptoms range from minor to severe and vary from person to person. You may have infrequent asthma attacks, have symptoms only at certain times — such as when exercising — or have symptoms all the time.
Asthma signs and symptoms include:
Shortness of breath
Chest tightness or pain
Trouble sleeping caused by shortness of breath, coughing or wheezing
A whistling or wheezing sound when exhaling (wheezing is a common sign of asthma in children)
Coughing or wheezing attacks that are worsened by a respiratory virus, such as a cold or the flu
Signs that your asthma is probably worsening include:
Asthma signs and symptoms that are more frequent and bothersome
Increasing difficulty breathing (measurable with a peak flow meter, a device used to check how well your lungs are working)
The need to use a quick-relief inhaler more often
For some people, asthma symptoms flare up in certain situations:
Exercise-induced asthma, which may be worse when the air is cold and dry
Occupational asthma, triggered by workplace irritants such as chemical fumes, gases or dust
Allergy-induced asthma, triggered by particular allergens, such as pet dander, cockroaches or pollen
When to see a doctor
Seek emergency treatment
Severe asthma attacks can be life-threatening. Work with your doctor ahead of time to determine what to do when your signs and symptoms worsen — and when you need emergency treatment. Signs of an asthma emergency include:
Rapid worsening of shortness of breath or wheezing
No improvement even after using a quick-relief inhaler, such as albuterol
Shortness of breath when you are doing minimal physical activity
Contact your doctor
See your doctor:
If you think you have asthma. If you have frequent coughing or wheezing that lasts more than a few days or any other signs or symptoms of asthma, see your doctor. Treating asthma early may prevent long-term lung damage and help keep the condition from worsening over time.
To monitor your asthma after diagnosis. If you know you have asthma, work with your doctor to keep it under control. Good long-term control helps you feel better on a daily basis and can prevent a life-threatening asthma attack.
If your asthma symptoms get worse. Contact your doctor right away if your medication doesn't seem to ease your symptoms or if you need to use your quick-relief inhaler more often. Don't try to solve the problem by taking more medication without consulting your doctor. Overusing asthma medication can cause side effects and may make your asthma worse.
To review your treatment. Asthma often changes over time. Meet with your doctor on a regular basis to discuss your symptoms and make any needed treatment adjustments.
CAUSES
It isn't clear why some people get asthma and others don't, but it's probably due to a combination of environmental and genetic (inherited) factors.
Asthma triggers
Exposure to various substances that trigger allergies (allergens) and irritants can trigger signs and symptoms of asthma. Asthma triggers are different from person to person and can include:
Airborne allergens, such as pollen, animal dander, mold, cockroaches and dust mites
Respiratory infections, such as the common cold
Physical activity (exercise-induced asthma)
Cold air
Air pollutants and irritants, such as smoke
Certain medications, including beta blockers, aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve)
Strong emotions and stress
Sulfites and preservatives added to some types of foods and beverages, including shrimp, dried fruit, processed potatoes, beer and wine
Gastroesophageal reflux disease (GERD), a condition in which stomach acids back up into your throat
Menstrual cycle in some women
RISK FACTORS
A number of factors are thought to increase your chances of developing asthma. These include:
Having a blood relative (such as a parent or sibling) with asthma
Having another allergic condition, such as atopic dermatitis or allergic rhinitis (hay fever)
Being overweight
Being a smoker
Exposure to secondhand smoke
Having a mother who smoked while pregnant
Exposure to exhaust fumes or other types of pollution
Exposure to occupational triggers, such as chemicals used in farming, hairdressing and manufacturing
Exposure to allergens, exposure to certain germs or parasites, and having some types of bacterial or viral infections also may be risk factors. However, more research is needed to determine what role they may play in developing asthma.
COMPLICATIONS
Asthma complications include:
Symptoms that interfere with sleep, work or recreational activities
Sick days from work or school during asthma flare-ups
Permanent narrowing of the bronchial tubes (airway remodeling) that affects how well you can breathe
Emergency room visits and hospitalizations for severe asthma attacks
Side effects from long-term use of some medications used to stabilize severe asthma
Proper treatment makes a big difference in preventing both short-term and long-term complications caused by asthma.
PREPARING FOR YOUR APPOINTMENT
You're likely to start by seeing your family doctor or a general practitioner. However, when you call to set up an appointment, you may be referred to an allergist or a pulmonologist.
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 for your appointment, as well as what to expect from your doctor.
What you can do
These steps can help you make the most of your appointment:
Write down any symptoms you're having, including any that may seem unrelated to the reason for which you scheduled the appointment.
Note when your symptoms bother you most — for example, if your symptoms tend to get worse at certain times of the day, during certain seasons, or when you're exposed to cold air, pollen or other triggers.
Write down key personal information, including any major stresses or recent life changes.
Make a list of all medications, vitamins and 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 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 asthma, some basic questions to ask your doctor include:
Is asthma the most likely cause of my breathing problems?
Other than the most likely cause, what are other possible causes for my symptoms?
What kinds of tests do I need?
Is my condition likely temporary or chronic?
What's the best treatment?
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 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:
What exactly are your symptoms?
When did you first notice your symptoms?
How severe are your symptoms?
Do you have breathing problems most of the time or only at certain times or in certain situations?
Do you have allergies, such as atopic dermatitis or hay fever?
What, if anything, seems to improve your symptoms?
Do allergies or asthma run in your family?
Do you have any chronic health problems?
TESTS AND DIAGNOSIS
Physical exam
To rule out other possible conditions — such as a respiratory infection or chronic obstructive pulmonary disease (COPD) — your doctor will do a physical exam and ask you questions about your signs and symptoms and about any other health problems.
Tests to measure lung function
You may also be given lung (pulmonary) function tests to determine how much air moves in and out as you breathe. These tests may include:
Spirometry. This test estimates the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath and how fast you can breathe out.
Peak flow. A peak flow meter is a simple device that measures how hard you can breathe out. Lower than usual peak flow readings are a sign your lungs may not be working as well and that your asthma may be getting worse. Your doctor will give you instructions on how to track and deal with low peak flow readings.
Lung function tests often are done before and after taking a bronchodilator (brong-koh-DIE-lay-tur), such as albuterol, to open your airways. If your lung function improves with use of a bronchodilator, it's likely you have asthma.
Additional tests
Other tests to diagnose asthma include:
Methacholine challenge. Methacholine is a known asthma trigger that, when inhaled, will cause mild constriction of your airways. If you react to the methacholine, you likely have asthma. This test may be used even if your initial lung function test is normal.
Nitric oxide test. This test, though not widely available, measures the amount of the gas, nitric oxide, that you have in your breath. When your airways are inflamed — a sign of asthma — you may have higher than normal nitric oxide levels.
Imaging tests. A chest X-ray and high-resolution computerized tomography (CT) scan of your lungs and nose cavities (sinuses) can identify any structural abnormalities or diseases (such as infection) that can cause or aggravate breathing problems.
Allergy testing. This can be performed by skin test or blood test. Allergy tests can identify allergy to pets, dust, mold and pollen. If important allergy triggers are identified, this can lead to a recommendation for allergen immunotherapy.
Sputum eosinophils. This test looks for certain white blood cells (eosinophils) in the mixture of saliva and mucus (sputum) you discharge during coughing. Eosinophils are present when symptoms develop and become visible when stained with a rose-colored dye (eosin).
Provocative testing for exercise and cold-induced asthma. In these tests, your doctor measures your airway obstruction before and after you perform vigorous physical activity or take several breaths of cold air.
How asthma is classified
To classify your asthma severity, your doctor considers your answers to questions about symptoms (such as how often you have asthma attacks and how bad they are), along with the results of your physical exam and diagnostic tests.
Determining your asthma severity helps your doctor choose the best treatment. Asthma severity often changes over time, requiring treatment adjustments.
Asthma is classified into four general categories:
Asthma classification Signs and symptoms
Mild intermittent Mild symptoms up to two days a week and up to two nights a month
Mild persistent Symptoms more than twice a week, but no more than once in a single day
Moderate persistent Symptoms once a day and more than one night a week
Severe persistent Symptoms throughout the day on most days and frequently at night
TREATMENTS AND DRUGS
Prevention and long-term control are key in stopping asthma attacks before they start. Treatment usually involves learning to recognize your triggers, taking steps to avoid them and tracking your breathing to make sure your daily asthma medications are keeping symptoms under control. In case of an asthma flare-up, you may need to use a quick-relief inhaler, such as albuterol.
Medications
The right medications for you depend on a number of things, including your age, your symptoms, your asthma triggers and what seems to work best to keep your asthma under control.
Preventive, long-term control medications reduce the inflammation in your airways that leads to symptoms. Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting breathing. In some cases, allergy medications are necessary.
Long-term asthma control medications, generally taken daily, are the cornerstone of asthma treatment. These medications keep asthma under control on a day-to-day basis and make it less likely you'll have an asthma attack. Types of long-term control medications include:
Inhaled corticosteroids. These anti-inflammatory drugs include fluticasone (Flovent HFA), budesonide (Pulmicort Flexhaler), flunisolide (Aerobid), ciclesonide (Alvesco), beclomethasone (Qvar) and mometasone (Asmanex).
You may need to use these medications for several days to weeks before they reach their maximum benefit. Unlike oral corticosteroids, these corticosteroid medications have a relatively low risk of side effects and are generally safe for long-term use.
Leukotriene modifiers. These oral medications — including montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo) — help relieve asthma symptoms for up to 24 hours. In rare cases, these medications have been linked to psychological reactions, such as agitation, aggression, hallucinations, depression and suicidal thinking. Seek medical advice right away for any unusual reaction.
Long-acting beta agonists. These inhaled medications, which include salmeterol (Serevent) and formoterol (Foradil, Perforomist), open the airways. Some research shows that they may increase the risk of a severe asthma attack, so take them only in combination with an inhaled corticosteroid. And because these drugs can mask asthma deterioration, don't use them for an acute asthma attack.
Combination inhalers. These medications — such as fluticasone-salmeterol (Advair Diskus), budesonide-formoterol (Symbicort) and mometasone-formoterol (Dulera) — contain a long-acting beta agonist along with a corticosteroid. Because these combination inhalers contain long-acting beta agonists, they may increase your risk of having a severe asthma attack.
Theophylline. Theophylline (Theo-24, Elixophyllin, others) is a daily pill that helps keep the airways open (bronchodilator) by relaxing the muscles around the airways. It's not used as often now as in past years.
Quick-relief (rescue) medications are used as needed for rapid, short-term symptom relief during an asthma attack — or before exercise if your doctor recommends it. Types of quick-relief medications include:
Short-acting beta agonists. These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex) and pirbuterol (Maxair). Short-acting beta agonists can be taken using a portable, hand-held inhaler or a nebulizer — a machine that converts asthma medications to a fine mist — so that they can be inhaled through a face mask or a mouthpiece.
Ipratropium (Atrovent). Like other bronchodilators, ipratropium acts quickly to immediately relax your airways, making it easier to breathe. Ipratropium is mostly used for emphysema and chronic bronchitis, but it's sometimes used to treat asthma attacks.
Oral and intravenous corticosteroids. These medications — which include prednisone and methylprednisolone — relieve airway inflammation caused by severe asthma. They can cause serious side effects when used long term, so they're used only on a short-term basis to treat severe asthma symptoms.
If you have an asthma flare-up, a quick-relief inhaler can ease your symptoms right away. But if your long-term control medications are working properly, you shouldn't need to use your quick-relief inhaler very often.
Keep a record of how many puffs you use each week. If you need to use your quick-relief inhaler more often than your doctor recommends, see your doctor. You probably need to adjust your long-term control medication.
Allergy medications may help if your asthma is triggered or worsened by allergies. These include:
Allergy shots (immunotherapy). Over time, allergy shots gradually reduce your immune system reaction to specific allergens. You generally receive shots once a week for a few months, then once a month for a period of three to five years.
Omalizumab (Xolair). This medication, given as an injection every two to four weeks, is specifically for people who have allergies and severe asthma. It acts by altering the immune system.
Allergy medications. These include oral and nasal spray antihistamines and decongestants as well as corticosteroid and cromolyn nasal sprays.
Bronchial thermoplasty
This treatment — which isn't widely available nor right for everyone — is used for severe asthma that doesn't improve with inhaled corticosteroids or other long-term asthma medications.
Generally, over the span of three outpatient visits, bronchial thermoplasty heats the insides of the airways in the lungs with an electrode, reducing the smooth muscle inside the airways. This limits the ability of the airways to tighten, making breathing easier and possibly reducing asthma attacks.
Treat by severity for better control: A stepwise approach
Your treatment should be flexible and based on changes in your symptoms, which should be assessed thoroughly each time you see your doctor. Then your doctor can adjust your treatment accordingly. For example, if your asthma is well controlled, your doctor may prescribe less medicine. If your asthma isn't well controlled or is getting worse, your doctor may increase your medication and recommend more-frequent visits.
Asthma action plan
Work with your doctor to create an asthma action plan that outlines in writing when to take certain medications or when to increase or decrease the dose of your medications based on your symptoms. Also include a list of your triggers and the steps you need to take to avoid them.
Your doctor may also recommend tracking your asthma symptoms or using a peak flow meter on a regular basis to monitor how well your treatment is controlling your asthma.
LIFESTYLE AND HOME REMEDIES
While there's no way to prevent asthma, by working together, you and your doctor can design a step-by-step plan for living with your condition and preventing asthma attacks.
Follow your asthma action plan. With your doctor and health care team, write a detailed plan for taking medications and managing an asthma attack. Then be sure to follow your plan. Asthma is an ongoing condition that needs regular monitoring and treatment. Taking control of your treatment can make you feel more in control of your life in general.
Get vaccinated for influenza and pneumonia. Staying current with vaccinations can prevent flu and pneumonia from triggering asthma flare-ups.
Identify and avoid asthma triggers. A number of outdoor allergens and irritants — ranging from pollen and mold to cold air and air pollution — can trigger asthma attacks. Find out what causes or worsens your asthma, and take steps to avoid those triggers.
Monitor your breathing. You may learn to recognize warning signs of an impending attack, such as slight coughing, wheezing or shortness of breath. But because your lung function may decrease before you notice any signs or symptoms, regularly measure and record your peak airflow with a home peak flow meter.
Identify and treat attacks early. If you act quickly, you're less likely to have a severe attack. You also won't need as much medication to control your symptoms.
When your peak flow measurements decrease and alert you to an oncoming attack, take your medication as instructed and immediately stop any activity that may have triggered the attack. If your symptoms don't improve, get medical help as directed in your action plan.
Take your medication as prescribed. Just because your asthma seems to be improving, don't change anything without first talking to your doctor. It's a good idea to bring your medications with you to each doctor visit, so your doctor can double-check that you're using your medications correctly and taking the right dose.
Pay attention to increasing quick-relief inhaler use. If you find yourself relying on your quick-relief inhaler, such as albuterol, your asthma isn't under control. See your doctor about adjusting your treatment.
ALTERNATIVE MEDICINE
Certain alternative treatments may help with asthma symptoms. However, keep in mind that these treatments are not a replacement for medical treatment — especially if you have severe asthma. Talk to your doctor before taking any herbs or supplements, as some may interact with medications you take.
While some alternative remedies are used for asthma, in most cases more research is needed to see how well they work and to measure the extent of possible side effects. Alternative asthma treatments include:
Breathing techniques. These exercises may reduce the amount of medication you need to keep your asthma symptoms under control. Yoga classes increase fitness and reduce stress, which may help with asthma as well.
Acupuncture. This technique involves placing very thin needles at strategic points on your body. It's safe and generally painless.
Relaxation techniques. Techniques such as meditation, biofeedback, hypnosis and progressive muscle relaxation may help with asthma by reducing tension and stress.
Herbal and natural remedies. A few herbal and natural remedies that may help improve asthma symptoms include caffeine, magnesium and pycnogenol. Blends of different types of herbs are commonly used in traditional Chinese, Indian and Japanese medicine. However, more studies are needed to determine how well herbal remedies and preparations work for asthma.
Omega-3 fatty acids. Found in fish, flaxseed and other foods, these healthy oils may reduce the inflammation that leads to asthma symptoms.
COPING AND SUPPORT
Asthma can be challenging and stressful. You may sometimes become frustrated, angry or depressed because you need to cut back on your usual activities to avoid environmental triggers. You may also feel limited or embarrassed by the symptoms of the disease and by complicated management routines.
But asthma doesn't have to be a limiting condition. The best way to overcome anxiety and a feeling of helplessness is to understand your condition and take control of your treatment. Here are some suggestions that may help:
Pace yourself. Take breaks between tasks and avoid activities that make your symptoms worse.
Make a daily to-do list. This may help you avoid feeling overwhelmed. Reward yourself for accomplishing simple goals.
Talk to others with your condition. Chat rooms and message boards on the Internet or support groups in your area can connect you with people facing similar challenges and let you know you're not alone.
If your child has asthma, be encouraging. Focus attention on the things your child can do, not on the things he or she can't. Involve teachers, school nurses, coaches, friends and relatives in helping your child manage asthma.
ASTHMA ATTACK
ASTHMA ATTACK
During an asthma attack, also called an asthma exacerbation, your airways become swollen and inflamed. The muscles around the airways contract, causing your breathing (bronchial) tubes to narrow.
During an asthma attack, you may cough, wheeze and have trouble breathing. An asthma attack may be minor, with symptoms that get better with prompt home treatment, or it may be more serious. A severe asthma attack that doesn't improve with home treatment can become a life-threatening emergency.
The key to stopping an asthma attack is recognizing and treating an asthma flare-up early. Follow the treatment plan you worked out with your doctor ahead of time. This plan should include what to do when your asthma starts getting worse, and how to deal with an asthma attack in progress.
SYMPTOMS
Asthma attack signs and symptoms include:
Severe shortness of breath, chest tightness or pain, and coughing or wheezing
Low peak expiratory flow (PEF) readings, if you use a peak flow meter
Worsening symptoms despite use of a quick-relief (rescue) inhaler
Signs and symptoms of an asthma attack vary from person to person. Work with your doctor to identify your particular signs and symptoms of worsening asthma — and what to do when they occur.
If your asthma symptoms keep getting worse even after you take medication as your doctor directed, you may need a trip to the emergency room. Your doctor can help you learn to recognize an asthma emergency so that you'll know when to get help.
When to see the doctor
If your asthma flares up, immediately follow the treatment steps you and your doctor worked out ahead of time in your written asthma plan. If your symptoms and peak expiratory flow (PEF) readings improve, home treatment may be all that's needed. If your symptoms don't improve with home treatment, you may need to seek emergency care.
When your asthma symptoms flare up, follow your written asthma plan's instructions for using your quick-acting (rescue) inhaler. If you use a peak flow meter to monitor your asthma, PEF readings ranging from 50 to 79 percent of your personal best are a sign you need to use quick-acting (rescue) medications prescribed by your doctor.
Check asthma control steps with your doctor
Asthma can change over time, so you'll need periodic adjustments to your treatment plan to keep daily symptoms under control. If your asthma isn't well controlled, it increases your risk of future asthma attacks. Lingering lung inflammation means your asthma could flare up at any time.
Go to all scheduled doctor's appointments. If you have regular asthma flare-ups, low peak flow readings or other signs your asthma isn't well controlled, make an appointment to see your doctor.
When to seek emergency medical treatment
Seek medical attention right away if you have signs or symptoms of a serious asthma attack, which include:
Severe breathlessness or wheezing, especially at night or in the early morning
The inability to speak more than short phrases due to shortness of breath
Having to strain your chest muscles to breathe
Low peak flow readings when you use a peak flow meter
CAUSES
An overly sensitive immune system makes your airways (bronchial tubes) become inflamed and swollen when you're exposed to certain triggers. Asthma triggers vary from person to person. Common asthma attack triggers include:
Pollen, pets, mold and dust mites
Upper respiratory infections
Tobacco smoke
Exercise
Inhaling cold, dry air
Gastroesophageal reflux disease (GERD)
For many people, asthma symptoms get worse with a respiratory infection such as a cold. Some people have asthma flare-ups caused by something in their work environment. Sometimes, asthma attacks occur with no apparent cause.
RISK FACTORS
Anyone who has asthma is at risk of an asthma attack. You may be at increased risk of a serious asthma attack if:
You've had a severe asthma attack in the past
You've previously been admitted to the hospital or had to go to the emergency room for asthma
You use more than two quick-relief (rescue) inhalers a month
Your asthma attacks tend to "sneak up" on you before you notice symptoms have worsened
You have other chronic health conditions, such as sinusitis or nasal polyps
COMPLICATIONS
Asthma attacks can be serious.
Asthma attacks can interrupt everyday activities such as sleep, school, work and exercise, causing a significant impact on your quality of life — and can disrupt the lives of those around you.
Serious asthma attacks mean you're likely to need trips to the emergency room, which can be stressful and costly.
A very severe asthma attack can lead to respiratory arrest and death.
PREPARING FOR YOUR APPOINTMENT
Be prepared for your visit to your doctor so that you can get the most out of your appointment. At each visit:
Take your asthma action plan with you when you see your doctor. If you haven't made one yet, work with your doctor to create one. This plan should discuss how to treat an asthma attack.
Include your peak flow meter results and all of your medications.
Be prepared to discuss your symptoms, and how much your asthma has been bothering you. Often, periodic changes in treatment are needed to keep asthma under control and to prevent asthma attacks.
Be prepared to demonstrate using your metered-dose inhaler. Improper use can reduce an inhaler's effectiveness.
Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. Some good questions to ask your doctor include:
Do my medications or treatment plan need to be changed?
What are the signs that I may be about to have an asthma attack?
What can I take to prevent an asthma attack when my symptoms get worse, or when I'm exposed to my triggers?
What steps do I need to take to stop an asthma attack in progress?
When do I need to go to the emergency room or seek other emergency treatment?
I'm having more heartburn. What can I do to prevent this?
Is it time for my flu shot? Am I due for a pneumonia shot?
What else can I do to protect my health during cold and flu season?
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:
Have you noticed anything that makes your asthma worse?
What medications are you taking?
How and when are you taking them?
Can you show me how you use your inhaled medication?
Are you having any problems with your medications?
Do you know when to call me or go to the hospital?
Do you have any questions about your asthma action plan?
Are you having any problems with your asthma action plan?
Is there anything you want to be able to do that you can't because of your asthma?
TESTS AND DIAGNOSIS
For adults and children over 5 years old, lung (pulmonary) function tests are used to check how well the lungs are working. Poor lung function is a sign that your asthma isn't well controlled. In some cases, lung function tests are used in asthma emergencies to help check the severity of an asthma attack or how well treatment is working.
Lung function tests include:
Peak flow. Your doctor may take a peak flow reading when you come in for a scheduled visit or for emergency treatment during an asthma attack. This test measures how quickly you can breathe out. You may also use a peak flow meter at home to monitor your lung function.
The results of this test are known as peak expiratory flow (PEF). A peak flow test is done by blowing into a mouthpiece as hard and as fast as you can with a single breath (expiration).
Spirometry. During spirometry, you take deep breaths and forcefully exhale into a hose connected to a machine called a spirometer. A common spirometry measurement is forced expiratory volume, which measures how much air you can breathe out in one second.
The results of this test are known as forced expiratory volume (FEV). Spirometry can also measure how much air your lungs can hold and the rate at which you can inhale and exhale.
Nitric oxide measurement. A newer diagnostic test, this exam measures the amount of nitric oxide gas you have in your breath. High nitric oxide readings indicate inflammation of the bronchial tubes.
To do this test, you exhale slowly into a mouthpiece attached to an electronic measurement device. This device is attached to a computer with a monitor that displays your test results.
Pulse oximetry. This test is used during a severe asthma attack. It measures the amount of oxygen in your blood. It's measured through your fingernail and only takes seconds.
TREATMENTS AND DRUGS
If you're having an asthma attack, follow the steps in the asthma plan you worked out with your doctor. If your symptoms don't improve, seek immediate medical care.
Home treatment steps to stop an asthma attack generally include taking 2.5 to 5 milligrams of albuterol (ProAir HFA, Ventolin HFA, others) every 20 minutes for an hour. You may also use a different quick-acting medication. Generally, less medication is needed for children and in adults with less severe symptoms.
Your plan for treating an asthma attack at home may include oral corticosteroid medication such as prednisone. Ask your doctor if a plan for home corticosteroid treatment of an asthma attack is right for you.
If you use a peak flow meter to monitor your asthma, peak expiratory flow readings ranging from 50 to 79 percent of your personal best are a sign you need to use albuterol or other quick-acting (rescue) inhaler medication. Routinely checking your peak flow readings is important because your lung function may decrease before you notice any other signs or symptoms of worsening asthma.
Emergency treatment
If you go to the emergency room for an asthma attack in progress, you'll need medications to get your asthma under immediate control. These can include:
Short-acting beta agonists, such as albuterol. These medications are the same medications as those in your quick-acting (rescue) inhaler. You may need to use a machine called a nebulizer, which turns the medication into a mist that can be inhaled deep into your lungs.
Oral corticosteroids. Taken in pill form, these medications help reduce lung inflammation and get your asthma symptoms under control. For more-severe asthma attacks, corticosteroids can be given intravenously.
Ipratropium (Atrovent). Ipratropium is sometimes used as a bronchodilator to treat a severe asthma attack, especially if albuterol is not fully effective.
Intubation, mechanical ventilation and oxygen. If your asthma attack is life-threatening, your doctor may put a breathing tube down your throat into your upper airway. Using a machine that pumps oxygen into your lungs will help you breathe while your doctor gives you medications to get your asthma under control.
After your asthma symptoms get better, your doctor may want you to stay in the emergency room for a few hours or longer to make sure you don't have another asthma attack. When your doctor feels your asthma is sufficiently under control, you'll be able to go home. Your doctor will give you instructions on what to do if you have another asthma attack.
If your asthma symptoms don't improve after emergency treatment, your doctor may admit you to the hospital and give you medications every hour or every few hours. If you're having severe asthma symptoms, you may need to breathe oxygen through a mask. In some cases, a severe, persistent asthma attack requires a stay in the intensive care unit (ICU).
LIFESTYLE AND HOME REMEDIES
The best way to avoid an asthma attack is to make sure your asthma is well controlled in the first place. This means following a written asthma plan to track symptoms and adjust your medication.
While you may not be able to eliminate your risk of an asthma attack, you're less likely to have one if your current treatment keeps your asthma under control. Take your inhaled medications as prescribed in your written asthma plan.
These preventive medications treat the airway inflammation that causes asthma signs and symptoms. Taken on a daily basis, these medications can reduce or eliminate asthma flare-ups — and your need to use a quick-relief inhaler.
See your doctor if you're following your asthma action plan but you still have frequent or bothersome symptoms or low peak flow readings. This is a sign that your asthma isn't well controlled, and you need to work with your doctor to change your treatment.
If your asthma symptoms flare up when you have a cold or the flu, take steps to avoid an asthma attack by watching your lung function and symptoms and adjusting your treatment as needed. Be sure to reduce exposure to your allergy triggers. And when exercising in cold weather, wear a face mask.
ASTIGMATISM
ASTIGMATISM
Astigmatism is a common, mild and generally easily treatable imperfection in the curvature of your eye. The condition can cause blurred vision.
Astigmatism occurs when the front surface of your eye (cornea) or the lens, inside your eye, has a slightly different surface curvature in one direction from the other. Instead of being even and smooth in all directions, the surface may have some areas that are flatter or steeper.
Astigmatism blurs your vision at all distances. Astigmatism is often present at birth and may occur in combination with nearsightedness or farsightedness. Often it's not pronounced enough to require corrective action. When it is, your treatment options include corrective lenses and surgery.
SYMPTOMS
Signs and symptoms of astigmatism may include:
Blurred or distorted vision
Eyestrain
Headaches
When to see a doctor
If your quality of vision detracts from your enjoyment of activities or interferes with your ability to perform everyday tasks, see an eye doctor. An eye doctor can determine whether you have astigmatism and, if so, to what degree. He or she can then advise you of your options to correct your vision.
If you're a healthy adult older than 40, have your eyes examined about every two to four years until age 55.
After age 55, have them checked every one to three years for signs of eye disease or problems and after age 65, every one to two years.
If you have eye problems, such as astigmatism, you may need to have your eyes checked more frequently. If you're at risk of certain eye diseases, such as glaucoma, or you have diabetes, check with your doctor to see how often you need to have your eyes examined.
CAUSES
Your eye has two parts that focus images, the cornea and the lens. In a perfectly shaped eye, each of these focusing elements has a perfectly smooth curvature, like the surface of a smooth ball.
A cornea or lens with such a surface curvature bends (refracts) all incoming light the same way and makes a sharply focused image on the back of your eye (retina).
However, if your cornea or lens isn't evenly and smoothly curved, then it causes light rays to be unevenly focused. This causes a refractive error. Astigmatism is a type of refractive error.
In astigmatism, your cornea or lens is curved more steeply in one direction than in another. You have corneal astigmatism if your cornea has a distorted shape. You have lenticular astigmatism if your lens is distorted.
Either type of astigmatism can cause blurred vision. Blurred vision may occur more in one direction, either horizontally, vertically or diagonally.
Astigmatism may occur in combination with other refractive errors, which include:
Nearsightedness (myopia). This occurs when your cornea is curved too much or your eye is longer than normal. Instead of being focused precisely on your retina, light is focused in front of your retina, resulting in a blurry appearance for distant objects.
Farsightedness (hyperopia). This occurs when your cornea is curved too little or your eye is shorter than normal. The effect is the opposite of nearsightedness. When your eye is in a relaxed state, light is focused behind the back of your eye, making nearby objects blurry.
Astigmatism may be present from birth, or it may develop after an eye injury, disease or surgery. Astigmatism isn't caused or made worse by reading in poor light, sitting too close to the television or squinting.
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 eye doctor (ophthalmologist).
Because appointments can be brief, and because there's often a lot to discuss, 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
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.
Bring a list of all medications, vitamins or supplements that you're taking.
Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions 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 astigmatism, some basic questions to ask your doctor include:
What is likely causing my symptoms?
Other than the most likely cause, what are other possible causes for my symptoms?
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 corneal specialist?
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 at any time that 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 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
To diagnose your condition, your eye doctor (ophthalmologist) may review your symptoms and conduct a comprehensive eye examination.
Your eye examination may include several tests, such as:
Vision tests. Your doctor may ask you to read letters on a chart to test your vision in a visual acuity test.
Test to measure the curvature of your cornea. By measuring light reflected from the surface of your cornea, a device called a keratometer measures the amount of curvature to your cornea's surface and can confirm the presence of astigmatism. This test is called keratometry.
The curvature of your cornea is an important piece of information for contact lens fitting. The curvature tends to be irregular in astigmatism.
To measure variations in corneal surface curvature, doctors may use a process called computerized corneal mapping. Computerized corneal mapping uses a keratoscope fitted with a video camera (videokeratoscope) to create a map of your cornea's surface.
Test to measure light focus. To measure how your eyes focus light, your eye doctor may place different lenses in front of your eyes using a device called a phoropter.
Your doctor may also use a device called a retinoscope, which directs a beam of light into your eye, to determine how your eye focuses light.
These procedures can assess the degree of your refractive error and help calculate prescriptions for contact lenses and glasses.
TREATMENTS AND DRUGS
The goal of treating astigmatism is to address the uneven curvature that's causing your blurred vision and improve your vision.
Treatments include corrective lenses and refractive surgery.
Corrective lenses
Wearing corrective lenses treats astigmatism by counteracting the uneven curvature of your cornea.
Types of corrective lenses include:
Eyeglasses. Eyeglasses can be made with special lenses that help compensate for the uneven shape of your eye. In addition to correcting astigmatism, eyeglasses can also correct for other refractive errors, such as nearsightedness or farsightedness.
Contact lenses. Like eyeglasses, contact lenses can correct astigmatism. A wide variety of contact lenses are available, including hard, soft, extended wear, disposable, rigid, gas permeable and bifocal contact lenses. Ask your eye doctor about the pros and cons of each and which contact lenses might be best for you.
Contact lenses are also used in a procedure called orthokeratology. In orthokeratology, you wear rigid contact lenses for several hours a day until the curvature of your eye improves. Then, you wear the lenses less frequently to maintain the new shape. If you discontinue this treatment, your eyes return to their former shape.
Wearing contact lenses for extended periods of time increases the risk of infection in the eye.
Refractive surgery
This astigmatism-treatment method corrects the problem by reshaping the surface of your eye. Before surgery, doctors will evaluate you and determine if you're a candidate for refractive surgery. Refractive-surgery methods include:
LASIK surgery. Laser-assisted in-situ keratomileusis (LASIK) is a procedure in which a doctor uses an instrument called a keratome to make a thin, circular hinged cut into your cornea. Alternatively, this same cut can be made with a special cutting laser.
The surgeon lifts the flap and then uses an excimer laser to sculpt the shape of the cornea under the flap. An excimer laser differs from other lasers in that it doesn't produce heat.
Photorefractive keratectomy (PRK). In PRK, your surgeon removes the outer protective layer of the cornea before using an excimer laser to change the curvature of the cornea.
LASEK surgery. In laser-assisted subepithelial keratomileusis (LASEK) a much thinner layer of cornea is folded back, which makes your eye less vulnerable to damage should an injury occur. LASEK may be a better option if you have a thin cornea or if you're at high risk of an eye injury at work or from playing sports.
ATAXIA
ATAXIA
Ataxia describes a lack of muscle control during voluntary movements, such as walking or picking up objects. A sign of an underlying condition, ataxia can affect movement, speech, eye movement and swallowing.
Persistent ataxia usually results from damage to your cerebellum — the part of your brain that controls muscle coordination. Many conditions can cause ataxia, including alcohol abuse, stroke, tumor, cerebral palsy and multiple sclerosis. An inherited defective gene also can cause ataxia.
Treatment for ataxia depends on the cause. Adaptive devices, such as walkers or canes, might help you maintain your independence. Physical therapy, occupational therapy and speech therapy also might help.
SYMPTOMS
Ataxia can develop over time or come on suddenly. Ataxia, a sign of a number of neurological disorders, may cause:
Poor coordination
Unsteady walk and a tendency to stumble
Difficulty with fine motor tasks, such as eating, writing or buttoning a shirt
Change in speech
Involuntary back-and-forth eye movements (nystagmus)
Difficulty swallowing
When to see a doctor
If you aren't aware of having a condition that causes ataxia, such as multiple sclerosis, see your doctor if you:
Lose balance
Lose muscle coordination in a hand, arm or leg
Have difficulty walking
Slur your speech
Have difficulty swallowing
CAUSES
Damage, degeneration or loss of nerve cells in the part of your brain that controls muscle coordination (cerebellum), results in ataxia. Your cerebellum comprises two pingpong-ball-sized portions of folded tissue situated at the base of your brain near your brainstem. The right side of your cerebellum controls coordination on the right side of your body; the left side of your cerebellum controls coordination on the left.
Diseases that damage the spinal cord and peripheral nerves that connect your cerebellum to your muscles also may cause ataxia. Ataxia causes include:
Head trauma. Damage to your brain or spinal cord from a blow to your head, such as might occur in a car accident, can cause sudden-onset ataxia, also known as acute cerebellar ataxia.
Stroke. When the blood supply to a part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients, brain cells die.
Transient ischemic attack (TIA). Caused by a temporary decrease in blood supply to part of your brain, most TIAs last only a few minutes. Loss of coordination and other signs and symptoms of a TIA are temporary.
Cerebral palsy. This is a general term for a group of disorders caused by damage to a child's brain during early development — before, during or shortly after birth — that affects the child's ability to coordinate body movements.
Multiple sclerosis (MS). MS is a chronic, potentially debilitating disease that affects your central nervous system.
Chickenpox. Ataxia can be an uncommon complication of chickenpox and other viral infections. It may appear in the healing stages of the infection and last for days or weeks. Normally, the ataxia resolves over time.
Paraneoplastic syndromes. These are rare, degenerative disorders triggered by your immune system's response to a cancerous tumor (neoplasm), most commonly from lung, ovarian, breast or lymphatic cancer. Ataxia may appear months or years before the cancer is diagnosed.
Tumor. A growth on the brain, cancerous (malignant) or noncancerous (benign), can damage the cerebellum.
Toxic reaction. Ataxia is a potential side effect of certain medications, especially barbiturates, such as phenobarbital, and sedatives, such as benzodiazepines. Alcohol and drug intoxication; heavy metal poisoning, such as from lead or mercury; and solvent poisoning, such as from paint thinner, also can cause ataxia.
Vitamin E or vitamin B-12 deficiency. Not getting enough vitamin E or vitamin B-12, because of the inability to absorb enough of the vitamin or other reasons, can lead to ataxia.
For some adults who develop sporadic ataxia, no specific cause can be found. This is known as sporadic degenerative ataxia, which can take a number of forms, including multiple system atrophy, a progressive, degenerative disorder.
Hereditary ataxias
Some types of ataxia and some conditions that cause ataxia are hereditary. If you have one of these conditions, you were born with a defect in a certain gene that makes abnormal proteins. The abnormal proteins hamper the function of nerve cells, primarily in your cerebellum and spinal cord, and cause them to degenerate. As the disease progresses, coordination problems worsen.
You can inherit a genetic ataxia from either a dominant gene from one parent (autosomal dominant disorder) or a recessive gene from each parent (autosomal recessive disorder). In the latter case, it's possible neither parent has the disorder (silent mutation), so there may be no obvious family history.
Different gene defects cause different types of ataxia, most of which are progressive. Each type causes poor coordination, but each has specific signs and symptoms.
Autosomal dominant ataxias
These include:
Spinocerebellar ataxias. Researchers have labeled more than 20 autosomal dominant ataxia genes, and the number is likely to continue to grow. Cerebellar ataxia and cerebellar degeneration are common to all types, but other signs and symptoms, as well as age of onset, differ depending on the specific gene mutation.
Episodic ataxia. There are seven recognized types of ataxia that are episodic rather than progressive — EA1 through EA7. EA1 and EA2 are the most common. EA1 involves brief ataxic episodes that may last seconds or minutes. The episodes are triggered by stress, being startled or sudden movement, and often are associated with muscle twitching.
EA2 involves longer episodes, usually lasting from 30 minutes to six hours, that also are triggered by stress. With this type of ataxia, you may experience dizziness (vertigo), fatigue and muscle weakness during your episodes. In some cases of episodic ataxia, symptoms resolve in later life.
Episodic ataxia doesn't shorten life span, and symptoms may respond to medication.
Autosomal recessive ataxias
These include:
Friedreich's ataxia. This, the most common hereditary ataxia, involves damage to your cerebellum, spinal cord and peripheral nerves. Peripheral nerves carry signals from your brain and spinal cord to your muscles. In most cases, signs and symptoms appear before the age of 25.
The rate of disease progression varies. The first indication generally is difficulty walking (gait ataxia). The condition typically progresses to the arms and trunk. Muscles weaken and waste away over time, causing deformities, particularly in your feet, lower legs and hands.
Other signs and symptoms that may develop as the disease progresses include slow, slurred speech (dysarthria); fatigue; rapid, involuntary eye movements (nystagmus); spinal curvature (scoliosis); hearing loss; and heart disease, including heart enlargement (cardiomyopathy) and heart failure.
Ataxia-telangiectasia. This rare, progressive childhood disease causes degeneration in the brain and other body systems. The disease causes immune system breakdown (immunodeficiency disease), which increases susceptibility to other diseases. It affects various organs.
Telangiectasias are tiny red "spider" veins that may appear in the corners of your child's eyes or on the ears and cheeks. Although they're characteristic of the disease, your child may not develop them. Delayed motor skill development, poor balance and slurred speech are typically the first indications of the disease. Recurrent sinus and respiratory infections are common.
Children with ataxia-telangiectasia are at high risk of developing cancer, particularly leukemia or lymphoma. Most people with the disease need a wheelchair by their teens and die in their teens or early 20s.
Congenital cerebellar ataxia. This type of ataxia results from damage to the cerebellum that's present at birth.
Wilson disease. People with this condition accumulate copper in their brains, livers and other organs, which can cause neurological problems, including ataxia.
PREPARING FOR YOUR APPOINTMENT
You're likely to start by seeing your family doctor or a general practitioner. However, in some cases, your doctor may refer you immediately to a neurologist.
Here's some information to help you get ready for your appointment.
What you can do
Be aware of any pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.
Write down your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment.
Write down key personal information, including major stresses or recent life changes.
Make a list of all medications, vitamins or supplements you're taking.
Take a family member or friend along, if possible. Someone who accompanies you may remember something 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 ataxia, some basic questions to ask include:
What is likely causing my symptoms or condition?
Other than the most likely cause, what are other possible causes?
What tests do I need?
Is my condition likely temporary or chronic?
What is the best course of action?
Are there devices that can help me with coordination?
What are the alternatives to the primary approach you're suggesting?
I have other health conditions. How can I best manage them together?
Are there restrictions I need to follow?
Should I see a specialist?
Is there a generic alternative to the medicine you're prescribing?
Are there brochures or other printed material I can take with me? What websites do you recommend?
Can I participate in any research studies related to ataxia?
Don't hesitate to ask other questions.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, such as:
When did your symptoms begin?
Are your symptoms continuous or occasional?
How severe are your symptoms?
What seems to improve your symptoms?
What seems to worsen your symptoms?
Do you have family members who have had these types of symptoms?
Do you use alcohol or drugs?
Have you been exposed to toxins?
Have you had a virus recently?
What you can do in the meantime
Don't drink alcohol or take recreational drugs, which can make your ataxia worse.
TESTS AND DIAGNOSIS
If you have ataxia, your doctor will look for a treatable cause. Besides conducting a physical exam and a neurological exam, including checking your memory and concentration, vision, hearing, balance, coordination and reflexes, your doctor may request laboratory tests, including:
Imaging studies. A computerized tomography (CT) scan or magnetic resonance imaging (MRI) of your brain may help determine potential causes. An MRI can sometimes show shrinkage of the cerebellum and other brain structures in people with ataxia.
Lumbar puncture (spinal tap). A needle is inserted into your lower back (lumbar region) between two lumbar bones (vertebrae) to remove a sample of cerebrospinal fluid. The fluid, which surrounds and protects your brain and spinal cord, is sent to a laboratory for testing.
Genetic testing. Your doctor may recommend genetic testing to determine whether you or your child has the gene mutation that causes one of the hereditary ataxic conditions. Gene tests are available for many but not all of the hereditary ataxias.
TREATMENTS AND DRUGS
There's no treatment specifically for ataxia. In some cases, treating the underlying cause resolves the ataxia. In other cases, such as ataxia that results from chickenpox or other viral infection, it's likely to resolve on its own over time. Your doctor may recommend adaptive devices or therapies to help with your ataxia.
Adaptive devices
For ataxia caused by conditions such as multiple sclerosis or cerebral palsy, ataxia might not be treatable. In that case, your doctor may be able to recommend adaptive devices. They include:
Canes or walkers for walking
Modified utensils for eating
Communication aids for speaking
Therapies
You might benefit from certain therapies, including:
Physical therapy to help you build strength and enhance your mobility
Occupational therapy to help you with daily living tasks, such as feeding yourself
Speech therapy to improve speech and aid swallowing
COPING AND SUPPORT
The challenges you face when living with ataxia, such as loss of independence, or having a child with the condition, may make you feel alone or lead to depression and anxiety. Talking to a counselor or therapist may lessen your sense of isolation and help you cope. Or you may find encouragement and understanding in a support group, either for ataxia or for your underlying condition, such as cancer or multiple sclerosis.
Although support groups aren't for everyone, they can be good sources of information. Group members often know about the latest treatments and tend to share their own experiences. If you're interested, your doctor may be able to recommend a group in your area.
ATHLETE's FOOT
ATHLETE's FOOT
Athlete's foot (tinea pedis) is a fungal infection that usually begins between the toes. It occurs most commonly in people whose feet have become very sweaty while confined within tight-fitting shoes.
Signs and symptoms of athlete's foot include a scaly rash that usually causes itching, stinging and burning. Athlete's foot is contagious and can be spread via contaminated floors, towels or clothing.
Athlete's foot is closely related to other fungal infections such as ringworm and jock itch. It can be treated with over-the-counter antifungal medications, but the infection often recurs. Prescription medications also are available.
SYMPTOMS
Athlete's foot usually causes a scaly red rash that typically begins in between the toes. Itching is often the worst right after you take off your shoes and socks. Some types of athlete's foot feature blisters or ulcers. The moccasin variety of athlete's feet causes chronic dryness and scaling on the soles that extends up the sides of the feet. It can be mistaken for eczema or even as dry skin.
The infection can affect one or both feet and can spread to your hand — especially if you scratch or pick at the infected parts of your feet.
When to see a doctor
If you have a rash on your foot that doesn't improve within a few weeks after self-treatment, see your doctor. Seek medical advice sooner if you have diabetes and suspect you have athlete's foot or if you notice excessive redness, swelling, drainage or fever.
CAUSES
Athlete's foot is caused by the same type of fungus that causes ringworm and jock itch. Damp socks and shoes and warm, humid conditions favor the organisms' growth.
Athlete's foot is contagious and can be spread by contact with an infected person or from contact with contaminated surfaces, such as towels, floors and shoes.
RISK FACTORS
You are at higher risk of athlete's foot if you:
Are a man
Frequently wear damp socks or tight-fitting shoes
Share mats, rugs, bed linens, clothes or shoes with someone who has a fungal infection
Walk barefoot in public areas where the infection can spread, such as locker rooms, saunas, swimming pools, communal baths and showers
Have a weakened immune system
COMPLICATIONS
Your athlete's foot infection can spread to other parts of your body, including:
Your hand. People who scratch or pick at the infected parts of their feet may develop a similar infection in one of their hands.
Your nails. The fungi associated with athlete's foot can also infect your toenails, a location that tends to be more resistant to treatment.
Your groin. Jock itch is often caused by the same fungus that results in athlete's foot. It's common for the infection to spread from the feet to the groin as the fungus can travel on your hands or on a towel.
PREPARING FOR YOUR APPOINTMENT
Your family doctor or a skin specialist (dermatologist) can diagnose athlete's foot. You don't need any special preparations for an appointment to diagnose athlete's foot.
What you can do
Before your appointment, you might want to write down a list of questions to ask your doctor. Examples include:
What might be causing the signs and symptoms?
Are tests needed to confirm the diagnosis?
What is the best treatment?
Is this condition temporary or chronic?
Is there a generic alternative to the medicine you're prescribing?
Can I wait to see if the condition goes away on its own?
What can I do to prevent the infection from spreading?
What skin care routines do you recommend while the condition heals?
What to expect from your doctor
Your doctor is likely to ask you a number of questions, such as:
When did you first notice your symptoms?
What did the rash look like when it first started?
Is the rash painful or itchy?
What, if anything, makes it better?
What, if anything, makes it worse?
Does a family member also have athlete's foot?
Have you spent time at swimming pools, locker rooms, saunas or other places where athlete's foot might be spread?
TESTS AND DIAGNOSIS
In some cases, your doctor may be able to diagnose athlete's foot simply by looking at it. To help confirm the diagnosis and rule out other conditions, your doctor might:
Take skin scrapings or samples from the infected area and view them under a microscope
View your feet under black light from a Wood's light
Send a small sample of your skin to a lab to be tested
TREATMENTS AND DRUGS
If your athlete's foot is mild, your doctor may suggest using an over-the-counter antifungal ointment, lotion, powder or spray. If your athlete's foot doesn't respond, you may need a prescription-strength medication to apply to your feet. Severe infections may require antifungal pills that you take by mouth.
LIFESTYLE AND HOME REMEDIES
These tips can help you avoid athlete's foot or ease the symptoms if infection occurs:
Keep your feet dry, especially between your toes. Go barefoot to let your feet air out as much as possible when you're home.
Change socks regularly. If your feet sweat a lot, change your socks when they get wet.
Wear light, well-ventilated shoes. Avoid shoes made of synthetic material, such as vinyl or rubber.
Alternate pairs of shoes. Don't wear the same pair every day so that you give your shoes time to dry between wearings.
Protect your feet in public places. Wear waterproof sandals or shower shoes in communal showers, pools, fitness centers and other public areas.
Treat your feet. Use powder, preferably antifungal, on your feet daily.
Don't share shoes. Sharing risks spreading a fungal infection.
ATRIAL FIBRILLATION
ATRIAL FIBRILLATION
Atrial fibrillation is an irregular and often rapid heart rate that commonly causes poor blood flow to the body.
During atrial fibrillation, the heart's two upper chambers (the atria) beat chaotically and irregularly — out of coordination with the two lower chambers (the ventricles) of the heart. Atrial fibrillation symptoms often include heart palpitations, shortness of breath and weakness.
Episodes of atrial fibrillation can come and go, or you may develop atrial fibrillation that doesn't go away and may require treatment. Although atrial fibrillation itself usually isn't life-threatening, it is a serious medical condition that sometimes requires emergency treatment. It can lead to complications. Atrial fibrillation may lead to blood clots forming in the heart that may circulate to other organs and lead to blocked blood flow (ischemia).
Treatments for atrial fibrillation may include medications and other interventions to try to alter the heart's electrical system.
SYMPTOMS
A heart in atrial fibrillation doesn't beat efficiently. It may not be able to pump enough blood out to your body with each heartbeat.
Some people with atrial fibrillation have no symptoms and are unaware of their condition until it's discovered during a physical examination. Those who do have atrial fibrillation symptoms may experience signs and symptoms such as:
Palpitations, which are sensations of a racing, uncomfortable, irregular heartbeat or a flip-flopping in your chest
Weakness
Reduced ability to exercise
Fatigue
Lightheadedness
Dizziness
Confusion
Shortness of breath
Chest pain
Atrial fibrillation may be:
Occasional. In this case it's called paroxysmal (par-ok-SIZ-mul) atrial fibrillation. You may have symptoms that come and go, lasting for a few minutes to hours and then stopping on their own.
Persistent. With this type of atrial fibrillation, your heart rhythm doesn't go back to normal on its own. If you have persistent atrial fibrillation, you'll need treatment such as an electrical shock or medications in order to restore your heart rhythm.
Permanent. In this type of atrial fibrillation, the normal heart rhythm can't be restored. You'll have atrial fibrillation permanently, and you'll often require medications to control your heart rate. Most people with permanent atrial fibrillation will require blood thinners to prevent blood clots.
When to see a doctor
If you have any symptoms of atrial fibrillation, make an appointment with your doctor. Your doctor may order an electrocardiogram to determine if your symptoms are related to atrial fibrillation or another heart rhythm disorder (arrhythmia).
If you have chest pain, seek emergency medical assistance immediately. Chest pain could signal that you're having a heart attack.
CAUSES
Atrial fibrillation is an irregular and often rapid heart rate that occurs when the two upper chambers of your heart (atria) experience chaotic electrical signals.
Your heart consists of four chambers — two upper chambers (atria) and two lower chambers (ventricles). Within the upper right chamber of your heart (right atrium) is a group of cells called the sinus node. This is your heart's natural pacemaker. The sinus node produces the impulse that normally starts each heartbeat.
Normally, the impulse travels first through the atria and then through a connecting pathway between the upper and lower chambers of your heart called the atrioventricular (AV) node. As the signal passes from the sinus node through the atria, they contract, pumping blood from your atria into the ventricles below. As the signal passes through the AV node to the ventricles, it signals the ventricles to contract, pumping blood out to your body.
In atrial fibrillation, the upper chambers of your heart (atria) experience chaotic electrical signals. As a result, they quiver. The AV node — the electrical connection between the atria and the ventricles — is bombarded with impulses trying to get through to the ventricles. The ventricles also beat rapidly, but not as rapidly as the atria, as not all the impulses get through. The reason is that the AV node is like a highway on-ramp — only so many vehicles can get on at one time.
The result is a fast and irregular heart rhythm. The heart rate in atrial fibrillation may range from 100 to 175 beats a minute. The normal range for a heart rate is 60 to 100 beats a minute.
Possible causes of atrial fibrillation
Abnormalities or damage to the heart's structure are the most common cause of atrial fibrillation. Possible causes of atrial fibrillation include:
High blood pressure
Heart attacks
Coronary artery disease
Abnormal heart valves
Heart defects you're born with (congenital)
An overactive thyroid gland or other metabolic imbalance
Exposure to stimulants, such as medications, caffeine or tobacco, or to alcohol
Sick sinus syndrome — improper functioning of the heart's natural pacemaker
Lung diseases
Previous heart surgery
Viral infections
Stress due to pneumonia, surgery or other illnesses
Sleep apnea
However, some people who have atrial fibrillation don't have any heart defects or damage, a condition called lone atrial fibrillation. In lone atrial fibrillation, the cause is often unclear, and serious complications are rare.
Atrial flutter
Atrial flutter is similar to atrial fibrillation, but the rhythm in your atria is more organized and less chaotic than the abnormal patterns common with atrial fibrillation. Sometimes you may have atrial flutter that develops into atrial fibrillation and vice versa.
The risk factors for and the symptoms and causes of atrial flutter are similar to those of atrial fibrillation. For example, strokes are also a concern in someone with atrial flutter. As with atrial fibrillation, atrial flutter is usually not life-threatening when it's properly treated.
RISK FACTORS
Certain factors may increase your risk of developing atrial fibrillation.
These include:
Age. The older you are, the greater your risk of developing atrial fibrillation.
Heart disease. Anyone with heart disease — such as heart valve problems, congenital heart disease, congestive heart failure, coronary artery disease, or a history of heart attack or heart surgery — has an increased risk of atrial fibrillation.
High blood pressure. Having high blood pressure, especially if it's not well-controlled with lifestyle changes or medications, can increase your risk of atrial fibrillation.
Other chronic conditions. People with certain chronic conditions such as thyroid problems, sleep apnea, metabolic syndrome, diabetes, chronic kidney disease or lung disease have an increased risk of atrial fibrillation.
Drinking alcohol. For some people, drinking alcohol can trigger an episode of atrial fibrillation. Binge drinking may put you at an even higher risk.
Obesity. People who are obese are at higher risk of developing atrial fibrillation.
Family history. An increased risk of atrial fibrillation is present in some families.
COMPLICATIONS
Sometimes atrial fibrillation can lead to the following complications:
Stroke. In atrial fibrillation, the chaotic rhythm may cause blood to pool in your heart's upper chambers (atria) and form clots. If a blood clot forms, it could dislodge from your heart and travel to your brain. There it might block blood flow, causing a stroke.
The risk of stroke in atrial fibrillation depends on your age (you have a higher risk as you age) and on whether you have high blood pressure, diabetes, a history of heart failure or previous stroke, and other factors. Certain medications, such as blood thinners, can greatly lower your risk of stroke or the damage to other organs caused by blood clots.
Heart failure. Atrial fibrillation, especially if not controlled, may weaken the heart and lead to heart failure — a condition in which your heart can't circulate enough blood to meet your body's needs.
PREPARING FOR YOUR APPOINTMENT
If you think you may have atrial fibrillation, it is critical that you make an appointment with your family doctor. If atrial fibrillation is found early, your treatment may be easier and more effective. However, you may be referred to a doctor trained in heart conditions (cardiologist).
Because appointments can be brief, and because there's often a lot to discuss, it's a good idea to be 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 dietary intake. You may need to do this if your doctor orders blood tests.
Write down any symptoms you're experiencing, including any that may seem unrelated to atrial fibrillation.
Write down key personal information, including any family history of heart disease, stroke, high blood pressure or diabetes, and 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 understand and 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.
Your time with your doctor is limited, so preparing a list of questions 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 atrial fibrillation, some basic questions to ask your doctor include:
What is likely causing my symptoms or condition?
What are other possible causes for my symptoms or condition?
What kinds of tests will I need?
What's the most appropriate treatment?
What foods should I eat or avoid?
What's an appropriate level of physical activity?
How often should I be screened for heart disease or other complications of atrial fibrillation?
What are the alternatives to the primary approach that you're suggesting?
I have other health conditions. How can I best manage them together?
Are there any restrictions that I need to follow?
Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist? (You may need to ask your insurance provider directly for information about coverage.)
Is there a generic alternative to the medicine you're prescribing?
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 save 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
To diagnose atrial fibrillation, your doctor may review your signs and symptoms, review your medical history, and conduct a physical examination. Your doctor may order several tests to diagnose your condition, including:
Electrocardiogram (ECG). An ECG uses small sensors (electrodes) attached to your chest and arms to record electrical signals as they travel through your heart. This test is a primary tool for diagnosing atrial fibrillation.
Holter monitor. This portable ECG device is carried in your pocket or worn on a belt or shoulder strap. It records your heart's activity for 24 hours or longer, which provides your doctor with a prolonged look at your heart rhythms.
Event recorder. This portable ECG device is intended to monitor your heart activity over a few weeks to a few months. You activate it only when you experience symptoms of a fast heart rate.
When you feel symptoms, you push a button, and an ECG strip of the preceding few minutes and following few minutes is recorded. This permits your doctor to determine your heart rhythm at the time of your symptoms.
Echocardiogram. In this noninvasive test, sound waves are used to produce a video image of your heart. Sound waves are directed at your heart from a wand-like device (transducer) that's held on your chest (transthoracic echocardiogram). The sound waves that bounce off your heart are reflected through your chest wall and processed electronically to provide video images of your heart in motion, to detect underlying structural heart disease.
Doctors may conduct a type of echocardiogram in which they insert a flexible tube with a transducer attached and guide it down your throat into your esophagus (transesophageal echocardiography). In this test, sound waves are used to produce images of your heart, which may be seen more clearly with this type of echocardiogram. Doctors may use this test to detect blood clots that may have formed in your heart.
Blood tests. These help your doctor rule out thyroid problems or other substances in your blood that may lead to atrial fibrillation.
Chest X-ray. X-ray images help your doctor see the condition of your lungs and heart. Your doctor can also use an X-ray to diagnose conditions other than atrial fibrillation that may explain your signs and symptoms.
TREATMENTS AND DRUGS
The atrial fibrillation treatment that is most appropriate for you will depend on how long you've had atrial fibrillation, how bothersome your symptoms are and the underlying cause of your atrial fibrillation. Generally, the treatment goals for atrial fibrillation are to:
Reset the rhythm or control the rate
Prevent blood clots
The strategy you and your doctor choose depends on many factors, including whether you have other problems with your heart and if you're able to take medications that can control your heart rhythm. In some cases, you may need a more invasive treatment, such as surgery or medical procedures using catheters.
In some people, a specific event or an underlying condition, such as a thyroid disorder, may trigger atrial fibrillation. Treating the condition causing atrial fibrillation may help relieve your heart rhythm problems. If your symptoms are bothersome or if this is your first episode of atrial fibrillation, your doctor may attempt to reset the rhythm.
Resetting your heart's rhythm
Ideally, to treat atrial fibrillation, the heart rate and rhythm are reset to normal. To correct your condition, doctors may be able to reset your heart to its regular rhythm (sinus rhythm) using a procedure called cardioversion, depending on the underlying cause of atrial fibrillation and how long you've had it. Cardioversion can be conducted in two ways:
Electrical cardioversion. In this brief procedure, an electrical shock is delivered to your heart through paddles or patches placed on your chest. The shock stops your heart's electrical activity momentarily. When your heart begins again, the hope is that it resumes its normal rhythm. The procedure is performed during sedation, so you shouldn't feel the electric shock.
Cardioversion with drugs. This form of cardioversion uses medications called anti-arrhythmics to help restore normal sinus rhythm. Depending on your heart condition, your doctor may recommend trying intravenous or oral medications to return your heart to normal rhythm.
This is often done in the hospital with continuous monitoring of your heart rate. If your heart rhythm returns to normal, your doctor often will prescribe the same anti-arrhythmic medication or a similar one to try to prevent more spells of atrial fibrillation.
Before cardioversion, you may be given a blood-thinning medication such as warfarin (Coumadin) for several weeks to reduce the risk of blood clots and stroke. Unless the episode of atrial fibrillation lasted less than 48 hours, you'll need to take warfarin for at least four weeks after cardioversion to prevent a blood clot from forming even after your heart is back in normal rhythm.
Or, instead of taking blood-thinning medications, you may have a test called transesophageal echocardiography — which can tell your doctor if you have any heart blood clots — just before cardioversion.
Maintaining a normal heart rhythm
After electrical cardioversion, your doctor may prescribe anti-arrhythmic medications to help prevent future episodes of atrial fibrillation. Medications may include:
Dofetilide (Tikosyn)
Flecainide
Propafenone (Rythmol)
Amiodarone (Cordarone, Pacerone)
Although these drugs may help maintain a normal heart rhythm, they can cause side effects, including:
Nausea
Dizziness
Fatigue
Rarely, they may cause ventricular arrhythmias — life-threatening rhythm disturbances originating in the heart's lower chambers. These medications may be needed indefinitely. Even with medications, the chance of another episode of atrial fibrillation is high.
Heart rate control
You may be prescribed medications to control your heart rate and restore it to a normal rate. Heart rate control can be achieved through several medications.
The medication digoxin (Lanoxin) may control heart rate at rest, but not as well during activity. Most people require additional or alternative medications, such as calcium channel blockers or beta blockers.
Beta blockers may cause side effects such as worsening of heart failure and low blood pressure (hypotension). Calcium channel blockers can also cause side effects, and may need to be avoided if you have heart failure or low blood pressure.
Catheter and surgical procedures
Sometimes medications or cardioversion to control atrial fibrillation doesn't work. In those cases, your doctor may recommend a procedure to destroy the area of heart tissue that's causing the erratic electrical signals and restore your heart to a normal rhythm. These options can include:
Catheter ablation. In many people who have atrial fibrillation and an otherwise normal heart, atrial fibrillation is caused by rapidly discharging triggers, or "hot spots." These hot spots are like abnormal pacemaker cells that fire so rapidly that the upper chambers of your heart quiver instead of beating efficiently.
In catheter ablation, a doctor inserts long, thin tubes (catheters) into your groin and guides them through blood vessels to your heart. Electrodes at the catheter tips can use radiofrequency energy, extreme cold (cryotherapy) or heat to destroy these hot spots, scarring the tissue so that the erratic signals are normalized. This corrects the arrhythmia without the need for medications or implantable devices.
Surgical maze procedure. The maze procedure is conducted during an open-heart surgery. Using a scalpel, doctors create several precise incisions in the upper chambers of your heart to create a pattern of scar tissue. Because scar tissue doesn't carry electricity, it interferes with stray electrical impulses that cause atrial fibrillation. Radiofrequency or cryotherapy also can be used to create the scars, and there are several variations of the surgical maze technique.
These procedures have a high success rate, but atrial fibrillation may recur. Some people may need catheter ablation or other treatment if atrial fibrillation recurs.
Because the surgical maze procedure requires open-heart surgery, it's generally reserved for people who don't respond to other treatments or when it can be done during other necessary heart surgery, such as coronary artery bypass surgery or heart valve repair.
Atrioventricular (AV) node ablation. If medications or other forms of catheter ablation don't work, or if you have side effects or are not a good candidate for other procedures, AV node ablation may be another option. The procedure involves applying radiofrequency energy to the pathway connecting the upper chambers (atria) and lower chambers (ventricles) of your heart (AV node) through a catheter to destroy this small area of tissue.
The procedure prevents the atria from sending electrical impulses to the ventricles. The atria continue to fibrillate, though. A pacemaker is then implanted to keep the ventricles beating properly. After AV node ablation, you'll need to continue to take blood-thinning medications to reduce the risk of stroke because your heart rhythm is still atrial fibrillation.
Preventing blood clots
Many people with atrial fibrillation or those who are undergoing certain treatments for atrial fibrillation are at especially high risk of blood clots that can lead to stroke. The risk is even higher if other heart disease is present along with atrial fibrillation. Your doctor may prescribe blood-thinning medications (anticoagulants) such as:
Warfarin (Coumadin). Warfarin may be prescribed to prevent blood clots. If you're prescribed warfarin, carefully follow your doctor's instructions. Warfarin is a powerful medication that may cause dangerous bleeding. You'll need to have regular blood tests to monitor warfarin's effects.
Newer anticoagulants. Several newer blood-thinning medications (anticoagulants) are available. These medications are shorter acting than warfarin and don't require monitoring. It's very important to take these medications exactly as prescribed. You shouldn't take the newer anticoagulants if you have a mechanical heart valve.
Dabigatran (Pradaxa) is an anticoagulant medication that's as effective as warfarin at preventing blood clots that can lead to strokes, and doesn't require blood tests to make sure you're getting the proper dose.
Rivaroxaban (Xarelto) is another anticoagulant medication that's as effective as warfarin for preventing strokes. Rivaroxaban is a once-daily medication.
Apixaban (Eliquis) is another anticoagulant medication that's as effective as warfarin for preventing strokes.
Talk to your doctor about taking one of these newer anticoagulants as an alternative to warfarin if you're concerned about your risk of stroke. Follow your doctor's dosing instructions carefully and don't stop taking any of these medications without talking to your doctor first.
Many people have spells of atrial fibrillation and don't even know it — so you may need lifelong anticoagulants even after your rhythm has been restored to normal.
LIFESTYLE AND HOME REMEDIES
To prevent atrial fibrillation, it's important to live a heart-healthy lifestyle to reduce your risk of heart disease. A healthy lifestyle may include:
Eating a heart-healthy diet
Increasing your physical activity
Avoiding smoking
Keeping a healthy weight
Limiting or avoiding caffeine and alcohol
Reducing stress, as intense stress and anger can cause heart rhythm problems
Using over-the-counter medications with caution, as some cold and cough medications contain stimulants that may trigger a rapid heartbeat
ATRIAL FLUTTER
ATRIAL FLUTTER
In atrial flutter, your heart's upper chambers (atria) beat too quickly. This causes the heart to beat in a fast, regular rhythm.
Atrial flutter is a type of heart rhythm disorder (arrhythmia) caused by problems in your heart's electrical system.
Atrial flutter is similar to atrial fibrillation, a common heart rhythm disorder. However, the rhythm in your atria is more organized and less chaotic in atrial flutter than are the abnormal patterns common with atrial fibrillation. Sometimes you may have periods of both atrial flutter and atrial fibrillation.
Atrial flutter differs as described above from Atrial fibrillation, which is an irregular and often rapid heart rate that commonly causes poor blood flow to the body.
During atrial fibrillation, the heart's two upper chambers (the atria) beat chaotically and irregularly — out of coordination with the two lower chambers (the ventricles) of the heart. Atrial fibrillation symptoms often include heart palpitations, shortness of breath and weakness.
Episodes of atrial fibrillation can come and go, or you may develop atrial fibrillation that doesn't go away and may require treatment. Although atrial fibrillation itself usually isn't life-threatening, it is a serious medical condition that sometimes requires emergency treatment. It can lead to complications. Atrial fibrillation may lead to blood clots forming in the heart that may circulate to other organs and lead to blocked blood flow (ischemia).
Treatments for atrial fibrillation may include medications and other interventions to try to alter the heart's electrical system.
SYMPTOMS
A heart in atrial fibrillation doesn't beat efficiently. It may not be able to pump enough blood out to your body with each heartbeat.
Some people with atrial fibrillation have no symptoms and are unaware of their condition until it's discovered during a physical examination. Those who do have atrial fibrillation symptoms may experience signs and symptoms such as:
Palpitations, which are sensations of a racing, uncomfortable, irregular heartbeat or a flip-flopping in your chest
Weakness
Reduced ability to exercise
Fatigue
Lightheadedness
Dizziness
Confusion
Shortness of breath
Chest pain
Atrial fibrillation may be:
Occasional. In this case it's called paroxysmal (par-ok-SIZ-mul) atrial fibrillation. You may have symptoms that come and go, lasting for a few minutes to hours and then stopping on their own.
Persistent. With this type of atrial fibrillation, your heart rhythm doesn't go back to normal on its own. If you have persistent atrial fibrillation, you'll need treatment such as an electrical shock or medications in order to restore your heart rhythm.
Permanent. In this type of atrial fibrillation, the normal heart rhythm can't be restored. You'll have atrial fibrillation permanently, and you'll often require medications to control your heart rate. Most people with permanent atrial fibrillation will require blood thinners to prevent blood clots.
When to see a doctor
If you have any symptoms of atrial fibrillation, make an appointment with your doctor. Your doctor may order an electrocardiogram to determine if your symptoms are related to atrial fibrillation or another heart rhythm disorder (arrhythmia).
If you have chest pain, seek emergency medical assistance immediately. Chest pain could signal that you're having a heart attack.
CAUSES
Atrial fibrillation is an irregular and often rapid heart rate that occurs when the two upper chambers of your heart (atria) experience chaotic electrical signals.
Your heart consists of four chambers — two upper chambers (atria) and two lower chambers (ventricles). Within the upper right chamber of your heart (right atrium) is a group of cells called the sinus node. This is your heart's natural pacemaker. The sinus node produces the impulse that normally starts each heartbeat.
Normally, the impulse travels first through the atria and then through a connecting pathway between the upper and lower chambers of your heart called the atrioventricular (AV) node. As the signal passes from the sinus node through the atria, they contract, pumping blood from your atria into the ventricles below. As the signal passes through the AV node to the ventricles, it signals the ventricles to contract, pumping blood out to your body.
In atrial fibrillation, the upper chambers of your heart (atria) experience chaotic electrical signals. As a result, they quiver. The AV node — the electrical connection between the atria and the ventricles — is bombarded with impulses trying to get through to the ventricles. The ventricles also beat rapidly, but not as rapidly as the atria, as not all the impulses get through. The reason is that the AV node is like a highway on-ramp — only so many vehicles can get on at one time.
The result is a fast and irregular heart rhythm. The heart rate in atrial fibrillation may range from 100 to 175 beats a minute. The normal range for a heart rate is 60 to 100 beats a minute.
Possible causes of atrial fibrillation
Abnormalities or damage to the heart's structure are the most common cause of atrial fibrillation. Possible causes of atrial fibrillation include:
High blood pressure
Heart attacks
Coronary artery disease
Abnormal heart valves
Heart defects you're born with (congenital)
An overactive thyroid gland or other metabolic imbalance
Exposure to stimulants, such as medications, caffeine or tobacco, or to alcohol
Sick sinus syndrome — improper functioning of the heart's natural pacemaker
Lung diseases
Previous heart surgery
Viral infections
Stress due to pneumonia, surgery or other illnesses
Sleep apnea
However, some people who have atrial fibrillation don't have any heart defects or damage, a condition called lone atrial fibrillation. In lone atrial fibrillation, the cause is often unclear, and serious complications are rare.
Atrial flutter
Atrial flutter is similar to atrial fibrillation, but the rhythm in your atria is more organized and less chaotic than the abnormal patterns common with atrial fibrillation. Sometimes you may have atrial flutter that develops into atrial fibrillation and vice versa.
The risk factors for and the symptoms and causes of atrial flutter are similar to those of atrial fibrillation. For example, strokes are also a concern in someone with atrial flutter. As with atrial fibrillation, atrial flutter is usually not life-threatening when it's properly treated.
RISK FACTORS
Certain factors may increase your risk of developing atrial fibrillation.
These include:
Age. The older you are, the greater your risk of developing atrial fibrillation.
Heart disease. Anyone with heart disease — such as heart valve problems, congenital heart disease, congestive heart failure, coronary artery disease, or a history of heart attack or heart surgery — has an increased risk of atrial fibrillation.
High blood pressure. Having high blood pressure, especially if it's not well-controlled with lifestyle changes or medications, can increase your risk of atrial fibrillation.
Other chronic conditions. People with certain chronic conditions such as thyroid problems, sleep apnea, metabolic syndrome, diabetes, chronic kidney disease or lung disease have an increased risk of atrial fibrillation.
Drinking alcohol. For some people, drinking alcohol can trigger an episode of atrial fibrillation. Binge drinking may put you at an even higher risk.
Obesity. People who are obese are at higher risk of developing atrial fibrillation.
Family history. An increased risk of atrial fibrillation is present in some families.
COMPLICATIONS
Sometimes atrial fibrillation can lead to the following complications:
Stroke. In atrial fibrillation, the chaotic rhythm may cause blood to pool in your heart's upper chambers (atria) and form clots. If a blood clot forms, it could dislodge from your heart and travel to your brain. There it might block blood flow, causing a stroke.
The risk of stroke in atrial fibrillation depends on your age (you have a higher risk as you age) and on whether you have high blood pressure, diabetes, a history of heart failure or previous stroke, and other factors. Certain medications, such as blood thinners, can greatly lower your risk of stroke or the damage to other organs caused by blood clots.
Heart failure. Atrial fibrillation, especially if not controlled, may weaken the heart and lead to heart failure — a condition in which your heart can't circulate enough blood to meet your body's needs.
PREPARING FOR YOUR APPOINTMENT
If you think you may have atrial fibrillation, it is critical that you make an appointment with your family doctor. If atrial fibrillation is found early, your treatment may be easier and more effective. However, you may be referred to a doctor trained in heart conditions (cardiologist).
Because appointments can be brief, and because there's often a lot to discuss, it's a good idea to be 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 dietary intake. You may need to do this if your doctor orders blood tests.
Write down any symptoms you're experiencing, including any that may seem unrelated to atrial fibrillation.
Write down key personal information, including any family history of heart disease, stroke, high blood pressure or diabetes, and 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 understand and 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.
Your time with your doctor is limited, so preparing a list of questions 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 atrial fibrillation, some basic questions to ask your doctor include:
What is likely causing my symptoms or condition?
What are other possible causes for my symptoms or condition?
What kinds of tests will I need?
What's the most appropriate treatment?
What foods should I eat or avoid?
What's an appropriate level of physical activity?
How often should I be screened for heart disease or other complications of atrial fibrillation?
What are the alternatives to the primary approach that you're suggesting?
I have other health conditions. How can I best manage them together?
Are there any restrictions that I need to follow?
Should I see a specialist? What will that cost, and will my insurance cover seeing a specialist? (You may need to ask your insurance provider directly for information about coverage.)
Is there a generic alternative to the medicine you're prescribing?
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 save 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
To diagnose atrial fibrillation, your doctor may review your signs and symptoms, review your medical history, and conduct a physical examination. Your doctor may order several tests to diagnose your condition, including:
Electrocardiogram (ECG). An ECG uses small sensors (electrodes) attached to your chest and arms to record electrical signals as they travel through your heart. This test is a primary tool for diagnosing atrial fibrillation.
Holter monitor. This portable ECG device is carried in your pocket or worn on a belt or shoulder strap. It records your heart's activity for 24 hours or longer, which provides your doctor with a prolonged look at your heart rhythms.
Event recorder. This portable ECG device is intended to monitor your heart activity over a few weeks to a few months. You activate it only when you experience symptoms of a fast heart rate.
When you feel symptoms, you push a button, and an ECG strip of the preceding few minutes and following few minutes is recorded. This permits your doctor to determine your heart rhythm at the time of your symptoms.
Echocardiogram. In this noninvasive test, sound waves are used to produce a video image of your heart. Sound waves are directed at your heart from a wand-like device (transducer) that's held on your chest (transthoracic echocardiogram). The sound waves that bounce off your heart are reflected through your chest wall and processed electronically to provide video images of your heart in motion, to detect underlying structural heart disease.
Doctors may conduct a type of echocardiogram in which they insert a flexible tube with a transducer attached and guide it down your throat into your esophagus (transesophageal echocardiography). In this test, sound waves are used to produce images of your heart, which may be seen more clearly with this type of echocardiogram. Doctors may use this test to detect blood clots that may have formed in your heart.
Blood tests. These help your doctor rule out thyroid problems or other substances in your blood that may lead to atrial fibrillation.
Chest X-ray. X-ray images help your doctor see the condition of your lungs and heart. Your doctor can also use an X-ray to diagnose conditions other than atrial fibrillation that may explain your signs and symptoms.
TREATMENTS AND DRUGS
The atrial fibrillation treatment that is most appropriate for you will depend on how long you've had atrial fibrillation, how bothersome your symptoms are and the underlying cause of your atrial fibrillation. Generally, the treatment goals for atrial fibrillation are to:
Reset the rhythm or control the rate
Prevent blood clots
The strategy you and your doctor choose depends on many factors, including whether you have other problems with your heart and if you're able to take medications that can control your heart rhythm. In some cases, you may need a more invasive treatment, such as surgery or medical procedures using catheters.
In some people, a specific event or an underlying condition, such as a thyroid disorder, may trigger atrial fibrillation. Treating the condition causing atrial fibrillation may help relieve your heart rhythm problems. If your symptoms are bothersome or if this is your first episode of atrial fibrillation, your doctor may attempt to reset the rhythm.
Resetting your heart's rhythm
Ideally, to treat atrial fibrillation, the heart rate and rhythm are reset to normal. To correct your condition, doctors may be able to reset your heart to its regular rhythm (sinus rhythm) using a procedure called cardioversion, depending on the underlying cause of atrial fibrillation and how long you've had it. Cardioversion can be conducted in two ways:
Electrical cardioversion. In this brief procedure, an electrical shock is delivered to your heart through paddles or patches placed on your chest. The shock stops your heart's electrical activity momentarily. When your heart begins again, the hope is that it resumes its normal rhythm. The procedure is performed during sedation, so you shouldn't feel the electric shock.
Cardioversion with drugs. This form of cardioversion uses medications called anti-arrhythmics to help restore normal sinus rhythm. Depending on your heart condition, your doctor may recommend trying intravenous or oral medications to return your heart to normal rhythm.
This is often done in the hospital with continuous monitoring of your heart rate. If your heart rhythm returns to normal, your doctor often will prescribe the same anti-arrhythmic medication or a similar one to try to prevent more spells of atrial fibrillation.
Before cardioversion, you may be given a blood-thinning medication such as warfarin (Coumadin) for several weeks to reduce the risk of blood clots and stroke. Unless the episode of atrial fibrillation lasted less than 48 hours, you'll need to take warfarin for at least four weeks after cardioversion to prevent a blood clot from forming even after your heart is back in normal rhythm.
Or, instead of taking blood-thinning medications, you may have a test called transesophageal echocardiography — which can tell your doctor if you have any heart blood clots — just before cardioversion.
Maintaining a normal heart rhythm
After electrical cardioversion, your doctor may prescribe anti-arrhythmic medications to help prevent future episodes of atrial fibrillation. Medications may include:
Dofetilide (Tikosyn)
Flecainide
Propafenone (Rythmol)
Amiodarone (Cordarone, Pacerone)
Although these drugs may help maintain a normal heart rhythm, they can cause side effects, including:
Nausea
Dizziness
Fatigue
Rarely, they may cause ventricular arrhythmias — life-threatening rhythm disturbances originating in the heart's lower chambers. These medications may be needed indefinitely. Even with medications, the chance of another episode of atrial fibrillation is high.
Heart rate control
You may be prescribed medications to control your heart rate and restore it to a normal rate. Heart rate control can be achieved through several medications.
The medication digoxin (Lanoxin) may control heart rate at rest, but not as well during activity. Most people require additional or alternative medications, such as calcium channel blockers or beta blockers.
Beta blockers may cause side effects such as worsening of heart failure and low blood pressure (hypotension). Calcium channel blockers can also cause side effects, and may need to be avoided if you have heart failure or low blood pressure.
Catheter and surgical procedures
Sometimes medications or cardioversion to control atrial fibrillation doesn't work. In those cases, your doctor may recommend a procedure to destroy the area of heart tissue that's causing the erratic electrical signals and restore your heart to a normal rhythm. These options can include:
Catheter ablation. In many people who have atrial fibrillation and an otherwise normal heart, atrial fibrillation is caused by rapidly discharging triggers, or "hot spots." These hot spots are like abnormal pacemaker cells that fire so rapidly that the upper chambers of your heart quiver instead of beating efficiently.
In catheter ablation, a doctor inserts long, thin tubes (catheters) into your groin and guides them through blood vessels to your heart. Electrodes at the catheter tips can use radiofrequency energy, extreme cold (cryotherapy) or heat to destroy these hot spots, scarring the tissue so that the erratic signals are normalized. This corrects the arrhythmia without the need for medications or implantable devices.
Surgical maze procedure. The maze procedure is conducted during an open-heart surgery. Using a scalpel, doctors create several precise incisions in the upper chambers of your heart to create a pattern of scar tissue. Because scar tissue doesn't carry electricity, it interferes with stray electrical impulses that cause atrial fibrillation. Radiofrequency or cryotherapy also can be used to create the scars, and there are several variations of the surgical maze technique.
These procedures have a high success rate, but atrial fibrillation may recur. Some people may need catheter ablation or other treatment if atrial fibrillation recurs.
Because the surgical maze procedure requires open-heart surgery, it's generally reserved for people who don't respond to other treatments or when it can be done during other necessary heart surgery, such as coronary artery bypass surgery or heart valve repair.
Atrioventricular (AV) node ablation. If medications or other forms of catheter ablation don't work, or if you have side effects or are not a good candidate for other procedures, AV node ablation may be another option. The procedure involves applying radiofrequency energy to the pathway connecting the upper chambers (atria) and lower chambers (ventricles) of your heart (AV node) through a catheter to destroy this small area of tissue.
The procedure prevents the atria from sending electrical impulses to the ventricles. The atria continue to fibrillate, though. A pacemaker is then implanted to keep the ventricles beating properly. After AV node ablation, you'll need to continue to take blood-thinning medications to reduce the risk of stroke because your heart rhythm is still atrial fibrillation.
Preventing blood clots
Many people with atrial fibrillation or those who are undergoing certain treatments for atrial fibrillation are at especially high risk of blood clots that can lead to stroke. The risk is even higher if other heart disease is present along with atrial fibrillation. Your doctor may prescribe blood-thinning medications (anticoagulants) such as:
Warfarin (Coumadin). Warfarin may be prescribed to prevent blood clots. If you're prescribed warfarin, carefully follow your doctor's instructions. Warfarin is a powerful medication that may cause dangerous bleeding. You'll need to have regular blood tests to monitor warfarin's effects.
Newer anticoagulants. Several newer blood-thinning medications (anticoagulants) are available. These medications are shorter acting than warfarin and don't require monitoring. It's very important to take these medications exactly as prescribed. You shouldn't take the newer anticoagulants if you have a mechanical heart valve.
Dabigatran (Pradaxa) is an anticoagulant medication that's as effective as warfarin at preventing blood clots that can lead to strokes, and doesn't require blood tests to make sure you're getting the proper dose.
Rivaroxaban (Xarelto) is another anticoagulant medication that's as effective as warfarin for preventing strokes. Rivaroxaban is a once-daily medication.
Apixaban (Eliquis) is another anticoagulant medication that's as effective as warfarin for preventing strokes.
Talk to your doctor about taking one of these newer anticoagulants as an alternative to warfarin if you're concerned about your risk of stroke. Follow your doctor's dosing instructions carefully and don't stop taking any of these medications without talking to your doctor first.
Many people have spells of atrial fibrillation and don't even know it — so you may need lifelong anticoagulants even after your rhythm has been restored to normal.
LIFESTYLE AND HOME REMEDIES
To prevent atrial fibrillation, it's important to live a heart-healthy lifestyle to reduce your risk of heart disease. A healthy lifestyle may include:
Eating a heart-healthy diet
Increasing your physical activity
Avoiding smoking
Keeping a healthy weight
Limiting or avoiding caffeine and alcohol
Reducing stress, as intense stress and anger can cause heart rhythm problems
Using over-the-counter medications with caution, as some cold and cough medications contain stimulants that may trigger a rapid heartbeat
ATRIAL SEPTAL DEFECT (ASD)
ATRIAL SEPTAL DEFECT (ASD)
An atrial septal defect (ASD) is a hole in the wall between the two upper chambers of your heart (atria). The condition is present from birth (congenital). Small atrial septal defects may close on their own during infancy or early childhood.
Large and long-standing atrial septal defects can damage your heart and lungs. Small defects may never cause a problem and may be found incidentally. An adult who has had an undetected atrial septal defect for decades may have a shortened life span from heart failure or high blood pressure that affects the arteries in the lungs (pulmonary hypertension). Surgery may be necessary to repair atrial septal defects to prevent complications.
SYMPTOMS
Many babies born with atrial septal defects don't have associated signs or symptoms. In adults, signs or symptoms usually begin by age 30, but in some cases signs and symptoms may not occur until decades later.
Atrial septal defect signs and symptoms may include:
Shortness of breath, especially when exercising
Fatigue
Swelling of legs, feet or abdomen
Heart palpitations or skipped beats
Frequent lung infections
Stroke
Heart murmur, a whooshing sound that can be heard through a stethoscope
When to see a doctor
Contact your doctor if you or your child has any of these signs or symptoms:
Shortness of breath
Tiring easily, especially after activity
Swelling of legs, feet or abdomen
Heart palpitations or skipped beats
These could be signs or symptoms of heart failure or another complication of congenital heart disease.
CAUSES
Doctors know that heart defects present at birth (congenital) arise from errors early in the heart's development, but there's often no clear cause. Genetics and environmental factors may play a role.
An atrial septal defect (ASD) allows freshly oxygenated blood to flow from the left upper chamber of the heart (left atrium) into the right upper chamber of the heart (right atrium). There, it mixes with deoxygenated blood and is pumped to the lungs, even though it's already refreshed with oxygen.
If the atrial septal defect is large, this extra blood volume can overfill the lungs and overwork the heart. If not treated, the right side of the heart eventually enlarges and weakens. If this process continues, the blood pressure in your lungs increases as well, leading to pulmonary hypertension.
Atrial septal defects can be several types, including:
Secundum. This is the most common type of ASD, and occurs in the middle of the wall between the atria (atrial septum).
Primum. This defect occurs in the lower part of the atrial septum, and may occur with other congenital heart problems.
Sinus venosus. This rare defect occurs in the upper part of the atrial septum.
Coronary sinus. In this rare defect, part of the wall between the coronary sinus — which is part of the vein system of the heart — and the left atrium is missing.
RISK FACTORS
It's not known why atrial septal defects occur, but congenital heart defects appear to run in families and sometimes occur with other genetic problems, such as Down syndrome. If you have a heart defect, or you have a child with a heart defect, a genetic counselor can estimate the odds that any future children will have one.
Some conditions that you have or that occur during pregnancy may increase your risk of having a baby with a heart defect, including:
Rubella infection. Becoming infected with rubella (German measles) during the first few months of your pregnancy can increase the risk of fetal heart defects.
Drug, tobacco or alcohol use, or exposure to certain substances. Use of certain medications, tobacco, alcohol or drugs, such as cocaine, during pregnancy can harm the developing fetus.
Diabetes or lupus. If you have diabetes or lupus, you may be more likely to have a baby with a heart defect.
Obesity. Being extremely overweight (obese) may play a role in increasing the risk of having a baby with a birth defect.
Phenylketonuria (PKU). If you have PKU and aren't following your PKU meal plan, you may be more likely to have a baby with a heart defect.
COMPLICATIONS
A small atrial septal defect may never cause any problems. Small atrial septal defects often close during infancy.
Larger defects can cause mild to life-threatening problems, including:
Right-sided heart failure
Heart rhythm abnormalities (arrhythmias)
Increased risk of a stroke
Less common serious complications may include:
Pulmonary hypertension. If a large atrial septal defect goes untreated, increased blood flow to your lungs increases the blood pressure in the lung arteries (pulmonary hypertension).
Eisenmenger syndrome. In rare cases, pulmonary hypertension can cause permanent lung damage. This complication, called Eisenmenger syndrome, usually develops over many years and occurs only in a small percentage of people with large atrial septal defects.
Treatment can prevent or help manage many of these complications.
Atrial septal defect and pregnancy
Most women with an atrial septal defect can tolerate pregnancy without any problems. However, having a larger defect or having complications such as heart failure, arrhythmias or pulmonary hypertension can increase your risk of complications during pregnancy. Doctors strongly advise women with Eisenmenger syndrome not to become pregnant because it can endanger their lives.
The risk of congenital heart disease is higher for children of parents with congenital heart disease, whether in the father or the mother. Anyone with a congenital heart defect, repaired or not, who is considering starting a family should carefully discuss it beforehand with a doctor. Some medications may need to be stopped or adjusted before you become pregnant because they can cause serious problems for a developing fetus.
PREPARING FOR YOUR APPOINTMENT
If your doctor suspects an atrial septal defect, you or your child will likely be referred to a doctor trained in heart disorders (cardiologist).
Because appointments can be brief, and there's often a lot to discuss, it's a good idea to arrive well-prepared. Here's some information to help you get ready for your appointment, and know 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.
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.
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 atrial septal defect, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
Are there other possible causes for my symptoms?
What kinds of tests do I need? Do these tests require any special preparation?
Is this condition temporary or long lasting?
What are my treatment options?
What are the risks of cardiac catheterization or surgery?
Are there any alternatives to the primary approach that you're suggesting?
I have other health conditions. How can I best manage them together?
Are there any activity restrictions that I need to follow?
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 the symptoms first begin?
Have the symptoms been continuous or occasional?
Do symptoms get worse with exercise?
Does anything else seem to make the symptoms worse?
Is there anything that seems to improve the symptoms?
Is there a family history of heart problems?
Is there a family history of birth defects?
TESTS AND DIAGNOSIS
Your child's doctor may first suspect an atrial septal defect or other heart defect during a regular checkup if he or she hears a heart murmur while listening to your child's heart using a stethoscope. Or an atrial septal defect may be found when an ultrasound exam of the heart (echocardiogram) is done for another reason.
If your doctor suspects you have a heart defect, your doctor may request one or more of the following tests:
Echocardiogram.This is the most commonly used test to diagnose an atrial septal defect. Some atrial septal defects are found during an echocardiogram done for another reason.
In echocardiography, sound waves are used to produce a video image of the heart. It allows your doctor to see your heart's chambers and measure their pumping strength. This test also checks heart valves and looks for any signs of heart defects. Doctors may use this test to evaluate your condition and determine your treatment plan.
Chest X-ray. An X-ray image helps your doctor to see the condition of your heart and lungs. An X-ray may identify conditions other than a heart defect that may explain your signs or symptoms.
Electrocardiogram (ECG). This test records the electrical activity of your heart and helps identify heart rhythm problems.
Cardiac catheterization. In this test, a thin, flexible tube (catheter) is inserted into a blood vessel at the groin or arm and guided to your heart. Through catheterization, doctors can diagnose congenital heart defects, test how well your heart is pumping and check the function of your heart valves. Using catheterization, the blood pressure in your lungs also can be measured.
However, this test usually isn't needed to diagnose atrial septal defect. Doctors may also use catheterization techniques to repair heart defects.
Magnetic resonance imaging (MRI). MRI is a technique that uses a magnetic field and radio waves to create 3-D images of your heart and other organs and tissues within your body. Your doctor may request an MRI if echocardiography can't definitively diagnose an atrial septal defect.
Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed images of your heart. A CT scan may be used to diagnose an atrial septal defect if echocardiography hasn't definitely diagnosed an atrial septal defect.
TREATMENTS AND DRUGS
Many atrial septal defects close on their own during childhood. For those that don't close, some small atrial septal defects don't cause any problems and may not require any treatment. But many persistent atrial septal defects eventually require surgery to be corrected.
Medical monitoring
If your child has an atrial septal defect, your child's cardiologist may recommend monitoring it for a period of time to see if it closes on its own. Your child's doctor will decide when your child needs treatment, depending on your child's condition and whether your child has any other congenital heart defects.
Medications
Medications won't repair the hole, but they may be used to reduce some of the signs and symptoms that can accompany an atrial septal defect. Drugs may also be used to reduce the risk of complications after surgery. Medications may include those to keep the heartbeat regular (beta blockers) or to reduce the risk of blood clots (anticoagulants).
Surgery
Many doctors recommend repairing an atrial septal defect diagnosed during childhood to prevent complications as an adult. Doctors may recommend surgery to repair medium- to large-sized atrial septal defects. However, surgery isn't recommended if you have severe pulmonary hypertension.
For adults and children, surgery involves plugging or patching the abnormal opening between the atria. Doctors will evaluate your condition and determine which procedure is most appropriate. Atrial septal defects can be repaired using two methods:
Cardiac catheterization. In this procedure, doctors insert a thin tube (catheter) into a blood vessel in the groin and guide it to the heart using imaging techniques. Through the catheter, doctors set a mesh patch or plug into place to close the hole. The heart tissue grows around the mesh, permanently sealing the hole.
This type of procedure may be performed to repair secundum atrial septal defects. Some large secundum atrial septal defects may not be able to be repaired through cardiac catheterization, and may require open-heart surgery.
Open-heart surgery. This type of surgery is done under general anesthesia and requires the use of a heart-lung machine. Through an incision in the chest, surgeons use patches to close the hole. This procedure is the preferred treatment for certain types of atrial septal defects (primum, sinus venosus and coronary sinus), and these types of atrial defects can only be repaired through open-heart surgery.
This procedure may also be conducted using small incisions (minimally invasive surgery) for some types of atrial septal defects.
Doctors use imaging techniques after the defect has been repaired to check the repaired area.
Follow-up care
Follow-up care depends on the type of defect and whether other defects are present. For simple atrial septal defects closed during childhood, only occasional follow-up care is needed.Adults who've had atrial septal defect repair need to have regular follow-up appointments to check for complications, such as pulmonary hypertension, arrhythmias, heart failure or valve problems.
LIFESTYLE AND HOME REMEDIES
In most cases, atrial septal defects can't be prevented. If you're planning to become pregnant, schedule a preconception visit with your health care provider. This visit should include:
Getting tested for immunity to rubella. If you're not immune, ask your doctor about getting vaccinated.
Going over your current health conditions and medications. You'll need to carefully monitor certain health problems during pregnancy. Your doctor also may recommend adjusting or stopping certain medications before you become pregnant.
Reviewing your family medical history. If you have a family history of heart defects or other genetic disorders, consider talking with a genetic counselor to determine what the risk might be before getting pregnant.
ATRIOVENTRICULAR CANAL DEFECT
ATRIOVENTRICULAR CANAL DEFECT
Atrioventricular canal defect is a combination of several abnormalities in the heart present at birth (congenital abnormalities). This defect, which is sometimes called endocardial cushion defect or atrioventricular septal defect, occurs when there's a hole between the chambers of the heart and problems with the valves that regulate blood flow in the heart.
Atrioventricular canal defect allows extra blood to circulate to the lungs. Ensuing problems overwork the heart and cause it to enlarge.
Atrioventricular canal defect is often associated with Down syndrome. If left untreated, atrioventricular canal defect may cause heart failure and high blood pressure in the lungs. To fix this defect, doctors often recommend surgery during the first year of life to close the hole and reconstruct the valves.
SYMPTOMS
There are two common types of atrioventricular canal defect — partial and complete. The partial form involves only the two upper chambers of the heart. The complete form allows blood to travel freely among all four chambers of the heart. In either type, extra blood circulates in the lungs.
Complete atrioventricular canal defect
Signs and symptoms of complete atrioventricular canal defect usually develop in the first several weeks of life. They include:
Difficulty breathing (dyspnea)
Lack of appetite
Poor weight gain
Bluish discoloration of the lips and skin (cyanosis)
If your baby has complete atrioventricular canal defect, he or she may also develop signs and symptoms of heart failure, including:
Fatigue
Wheezing
Swelling (edema) in the legs, ankles and feet
Sudden weight gain from fluid retention
Excessive sweating
Decreased alertness
Irregular or rapid heartbeat
Partial atrioventricular canal defect
Signs and symptoms of a partial atrioventricular canal defect may not appear until early adulthood. When they do become noticeable, signs and symptoms may be related to complications that develop as a result of the defect, and may include:
Abnormal heartbeat (arrhythmia)
Heart valve problems
Heart failure
High blood pressure in the lungs (pulmonary hypertension)
When to see a doctor
Contact your doctor if you or your child develops any of the following signs or symptoms. These could be indications of heart failure or another complication of atrioventricular canal defect:
Poor appetite
Failure to gain weight, in infants and children
Shortness of breath
Easily tiring
Swelling of the legs, ankles or feet
Bluish discoloration of the skin
Some babies with the partial form of atrioventricular canal defect may not have any signs or symptoms for weeks, months or even years, depending on the severity of the defect. But, anytime the signs or symptoms above start to appear, seek medical care.
CAUSES
Atrioventricular canal defect occurs during fetal growth when your baby's heart is developing. While some factors, such as Down syndrome, may increase the risk of atrioventricular canal defect, in most cases the cause is unknown.
The normal-functioning heart
Your heart is divided into four chambers, two on the right and two on the left. In performing its basic job — pumping blood throughout your body — your heart uses its left and right sides for different tasks. The right side moves blood into vessels that lead to your lungs. In your lungs, oxygen enriches your blood, which circulates to your heart's left side. The left side of your heart pumps blood into a large vessel called the aorta, which circulates blood to the rest of your body. Valves control the flow of blood into and out of the chambers of your heart. These valves open to allow blood to move to the next chamber or to one of the arteries, and they close to keep blood from flowing backward.
What happens in atrioventricular canal defect
In partial atrioventricular canal defect, a hole exists in the wall (septum) that separates the upper chambers (atria) of the heart. Also, the mitral valve between the upper and lower left chambers often has a defect called a cleft that causes it to leak (mitral valve regurgitation).
In complete atrioventricular canal defect, there's a large hole in the center of the heart where the walls between the upper chambers (atria) and lower chambers (ventricles) meet. Instead of two separate valves — one on the right (tricuspid) and one on the left (mitral) — one large common valve exists between the upper and lower chambers. And, this valve may not close tightly.
Oxygen-rich and oxygen-poor blood mix through the hole in the septum, and the abnormal valves leak blood into the heart's lower chambers (ventricles). These problems make the heart work harder, causing it to enlarge.
RISK FACTORS
Although the exact cause of atrioventricular canal defect is unknown, several factors may increase the risk of a congenital heart defect, such as:
Down syndrome in the baby. Down syndrome is a genetic condition resulting from an extra 21st chromosome.
German measles (rubella) or another viral illness during early pregnancy.
Having a parent who had a congenital heart defect.
Drinking alcohol during pregnancy.
Poorly controlled diabetes during pregnancy.
Taking some types of medications during pregnancy. Check with your doctor before taking any drugs while you're pregnant and even when you're trying to get pregnant.
COMPLICATIONS
Treating an atrioventricular canal defect helps your child avoid potential complications, such as:
Enlargement of the heart. Increased blood flow through the heart forces it to work harder than normal, causing it to enlarge.
Heart failure. Untreated, atrioventricular canal defect will usually result in heart failure — a condition in which the heart is unable to pump enough blood to meet the body's needs.
High blood pressure in the lungs (pulmonary hypertension). When the heart's left ventricle weakens and can't pump out enough blood, the increase in pressure backs up through the pulmonary veins to the arteries in the lungs, causing high blood pressure in the lungs.
Pneumonia. If your baby has an untreated atrioventricular canal defect, he or she may have recurrent bouts of pneumonia — a serious lung infection.
Complications later in life
Although treatment greatly improves the outlook for children with atrioventricular canal defect, some who have corrective surgery may still be at risk of the following associated conditions later in life:
Leaky heart valves (regurgitation)
Narrowing of the heart valves (stenosis)
Heart rhythm abnormalities (arrhythmias)
Breathing difficulties associated with damage to the lungs (pulmonary vascular disease)
Common signs and symptoms of these complications include shortness of breath, fatigue and a rapid, fluttering heartbeat, among others. In some cases, such as a leaky heart valve, a second surgery may be needed.
PREPARING FOR YOUR APPOINTMENT
You're likely to first mention your concerns to your child's doctor or, in the case of a partial defect that's gone unnoticed into adulthood, your primary care physician. However, you or your child may then be referred to a doctor who specializes in disorders of the heart (cardiologist).
Because appointments can be brief, and there's often a lot of ground to cover, it's a good idea to arrive 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 or your child experiences, including any that may seem unrelated to the reason for which you scheduled the appointment.
Make a list of all medications, vitamins and supplements that you or your child takes. Write down the dose usually taken, as well.
Write down questions to ask your doctor.
Preparing a list of questions can help you make the most of your time with your doctor, and ensure that you cover all of the points that are important to you. For atrioventricular canal defect, some basic questions to ask your doctor include:
What's the most likely cause of my or my baby's symptoms?
Are there other possible causes for these symptoms?
What kinds of tests are needed? Do these tests require any special preparation?
What treatments are available for atrioventricular canal defect, and which do you recommend?
What are the risks of surgery?
Are there any alternatives to surgery?
My child or I have other health conditions. How can we best manage these conditions together?
Are there any activity restrictions after the surgery?
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 anytime you don't understand something.
What to expect from your doctor
Your doctor or your child's doctor is likely to ask you a number of questions, such as:
When did you or your child first notice symptoms?
Have the symptoms been continuous or occasional?
Does anything seem to improve these symptoms?
What, if anything, appears to worsen the symptoms?
Is there a family history of congenital heart disease?
TESTS AND DIAGNOSIS
It's possible your doctor may diagnose your baby's atrioventricular canal defect while you're pregnant.
If your baby has a partial atrioventricular canal defect, his or her doctor may not detect that anything's wrong right away. However, if your baby has a complete atrioventricular canal defect, signs and symptoms usually become noticeable within the first few weeks of life.
Tests that help diagnose an atrioventricular canal defect include:
Physical exam. Your baby's doctor may suspect a heart defect such as atrioventricular canal defect if your baby is having trouble breathing or having difficulty feeding and gaining weight. Your doctor may also suspect a heart defect if he or she hears a heart murmur — an abnormal whooshing sound caused by turbulent blood flow.
Echocardiogram. Doctors typically use an echocardiogram to diagnose atrioventricular canal defect. This test uses high-pitched sound waves that bounce off the heart to produce moving images that the doctor can view on a video screen. In a baby with atrioventricular canal defect, the echocardiogram reveals a hole in the wall between the heart chambers and abnormal valves. Because this test can track blood flow, it also shows blood moving through the hole from the left side to the right side of the heart, allowing oxygen-rich and oxygen-poor blood to mix.
Cardiac catheterization. In some cases, doctors may use cardiac catheterization to diagnose atrioventricular canal defect. During this procedure, the doctor inserts a thin flexible tube (catheter) into an artery or vein in the groin and advances it up to the heart. A dye is injected through the catheter to make the heart structures visible on X-ray pictures. The catheter also allows the doctor to measure pressure in the chambers of the heart and in the blood vessels.
TREATMENTS AND DRUGS
Surgery is necessary to fix both complete and partial atrioventricular canal defects. During the procedure, the hole in the septum is closed using one or two patches. The patches remain in the heart permanently, becoming part of the septum as the heart's lining grows over it. The surgeon also separates the one large heart valve between the upper and lower chambers into two separate valves.
For a partial atrioventricular canal defect, the surgery also involves repair of the mitral valve so it will close tightly. If repair isn't possible, the valve may need to be replaced instead.
If your baby has complete atrioventricular canal defect, the surgery also includes separation of the single valve into two valves, one on the left side and one on the right side of the repaired septum. If reconstruction of the single valve into two valves isn't possible, heart valve replacement may be necessary.
After surgery
If the atrioventricular canal defect has been successfully repaired with surgery, your child will likely lead a normal life, often with no activity restrictions.
However, your child will need lifelong follow-up care with a heart doctor (cardiologist) who specializes in congenital heart disease. The recommendation for follow-up is usually once a year, unless you have lingering problems, such as a leaky heart valve. In that case, follow-up will be more frequent.
Your child may also need to take preventive antibiotics before certain dental procedures and other surgical procedures if he or she is at risk of severe complications of endocarditis, a bacterial infection of the lining of the heart. Typically, this is when your child has some remaining defects after surgery, has received an artificial valve or has had repair with artificial (prosthetic) material.
Many people who have corrective surgery for atrioventricular canal defect don't need additional surgery. However, some complications, such as heart valve leaks, may require treatment.
Pregnancy
When an atrioventricular canal defect has been surgically corrected before any permanent lung damage has occurred, women can generally expect to have normal pregnancies. Pregnancy is not recommended, however, if serious heart or lung damage occurred before surgery. An evaluation by a cardiologist is advised before women with repaired or unrepaired atrioventricular canal defect attempt pregnancy.
LIFESTYLE AND HOME REMEDIES
In most cases, atrioventricular canal defect can't be prevented. If you have a family history of heart defects or if you already have a child with a congenital heart defect, talk with a genetic counselor and a cardiologist before getting pregnant again.
COPING AND SUPPORT
Caring for a child with a congenital heart defect can be scary and challenging. Here are some strategies that may help make it easier:
Seek support. Ask for help from family members and friends. Talk with your child's cardiologist about support groups and other types of assistance that are available near you.
Record your baby's health history. You may want to write down your child's diagnosis, medications, surgery and other procedures and the dates they were performed, the name and phone number of your child's cardiologist, and any other important information about your child's care. It's also helpful to include a copy of the operative report from your child's surgeon in your records. This information will help you recall the care your child has received, and it will be useful for doctors who are unfamiliar with your baby to review his or her health history. This information will also help as your child transitions from pediatric doctors to adult doctors.
Talk about your concerns. As your child grows, you may worry about activities in which he or she can safely participate. Many children will have no limitations, but talk with the cardiologist about which activities are best for your child. If some are off-limits, encourage your child in other pursuits rather than focusing on what he or she can't do. If other issues about your child's health concern you, discuss them with your child's cardiologist, too.
Although every circumstance is different, remember that many children with congenital heart defects grow up to lead healthy lives.
BACK PAIN
BACK PAIN
Back pain is a common complaint. Most people in the United States will experience low back pain at least once during their lives. Back pain is one of the most common reasons people go to the doctor or miss work.
On the bright side, you can take measures to prevent or lessen most back pain episodes. If prevention fails, simple home treatment and proper body mechanics will often heal your back within a few weeks and keep it functional for the long haul. Surgery is rarely needed to treat back pain.
SYMPTOMS
Symptoms of back pain may include:
Muscle ache
Shooting or stabbing pain
Pain that radiates down your leg
Limited flexibility or range of motion of the back
Inability to stand up straight
When to see a doctor
Most back pain gradually improves with home treatment and self-care. Although the pain may take several weeks to disappear completely, you should notice some improvement within the first 72 hours of self-care. If not, see your doctor.
In rare cases, back pain can signal a serious medical problem. Seek immediate care if your back pain:
Causes new bowel or bladder problems
Is associated with pain or throbbing (pulsation) in the abdomen, or fever
Follows a fall, blow to your back or other injury
Contact a doctor if your back pain:
Is constant or intense, especially at night or when you lie down
Spreads down one or both legs, especially if the pain extends below the knee
Causes weakness, numbness or tingling in one or both legs
Is accompanied by unexplained weight loss
Occurs with swelling or redness on your back
Also, see your doctor if you start having back pain for the first time after age 50, or if you have a history of cancer, osteoporosis, steroid use, or drug or alcohol abuse.
CAUSES
Back pain often develops without a specific cause that your doctor can identify with a test or imaging study. Conditions commonly linked to back pain include:
Muscle or ligament strain. Repeated heavy lifting or a sudden awkward movement may strain back muscles and spinal ligaments. If you're in poor physical condition, constant strain on your back may cause painful muscle spasms.
Bulging or ruptured disks. Disks act as cushions between the individual bones (vertebrae) in your spine. Sometimes, the soft material inside a disk may bulge out of place or rupture and press on a nerve. The presence of a bulging or ruptured disk on an X-ray doesn't automatically equal back pain, though. Disk disease is often found incidentally; many people who don't have back pain turn out to have bulging or ruptured disks when they undergo spine X-rays for some other reason.
Arthritis. Osteoarthritis can affect the lower back. In some cases, arthritis in the spine can lead to a narrowing of the space around the spinal cord, a condition called spinal stenosis.
Skeletal irregularities. Back pain can occur if your spine curves in an abnormal way. Scoliosis, a condition in which your spine curves to the side, also may lead to back pain, but generally only if the scoliosis is quite severe.
Osteoporosis. Compression fractures of your spine's vertebrae can occur if your bones become porous and brittle.
RISK FACTORS
Anyone can develop back pain, even children and teens. Although excess weight, lack of exercise and improper lifting are often blamed for back pain, research looking at these possible risk factors hasn't yet provided any clear-cut answers.
One group that does appear to have a greater risk of back pain are people with certain psychological issues, such as depression and anxiety, though the reasons why there's an increased risk aren't known.
PREPARING FOR YOUR APPOINTMENT
If you have back pain that's lasted for at least a few days and isn't improving, make an appointment with your family doctor or primary care provider.
Here's some information to help you prepare for your appointment and what to expect from your doctor.
What you can do
Write down key personal information, including any mental or emotional stressors in your life.
Make a list of your key medical information, including any other conditions for which you're being treated and the names of any medications, vitamins or supplements you're taking.
Note any recent injuries that may have damaged your back.
Take a family member or friend along, if possible. Someone who accompanies you may remember something that you missed or forgot.
Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.
For back pain, some basic questions to ask your doctor include:
What is the most likely cause of my back pain?
Do I need any diagnostic tests?
What treatment approach do you recommend?
If you're recommending medications, what are the possible side effects?
I have other medical conditions. How can I best manage these conditions together?
How long will I need treatment?
What self-care measures should I be taking?
Is there anything else I can do to help prevent a recurrence of back pain?
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 having back pain?
How often do you have back pain?
How much is your pain limiting your ability to function?
Do you have any other signs or symptoms in addition to back pain?
Do you do heavy physical work?
Do you exercise regularly? If yes, with what types of activities?
How often do you feel blue or depressed?
How much stress or conflict do you experience on a daily basis?
Do you sleep well most of the time?
What treatments or self-care measures have you tried so far? Has anything helped?
Are you currently being treated or have you recently been treated for any other medical conditions?
What you can do in the meantime
While you're waiting for your appointment, you may benefit from applying heat, such as with a heating pad or hot bath, for short periods of time to improve blood flow to the area and relax the muscles. Be careful not to sleep with a heating pad on, as this can cause burns. The application of cold with an ice or cold gel pack can also provide back pain relief. Choose whichever — hot or cold — gives you the most relief.
Try to keep to your normal activities as much as possible, unless your work normally requires heavy lifting. If a particular activity increases your pain, stop doing that activity.
TESTS AND DIAGNOSIS
Diagnostic tests aren't usually necessary to confirm the cause of your back pain. However, if you do see your doctor for back pain, he or she will examine your back and assess your ability to sit, stand, walk and lift your legs. Your doctor may also test your reflexes with a rubber reflex hammer.
These assessments help determine where the pain comes from, how much you can move before pain forces you to stop and whether you have muscle spasms. They will also help rule out more-serious causes of back pain.
If there is reason to suspect a specific condition may be causing your back pain, your doctor may order one or more tests:
X-ray. These images show the alignment of your bones and whether you have arthritis or broken bones. X-ray images won't directly show problems with your spinal cord, muscles, nerves or disks.
Magnetic resonance imaging (MRI) or computerized tomography (CT) scans. These scans can generate images that may reveal herniated disks or problems with bones, muscles, tissue, tendons, nerves, ligaments and blood vessels.
Bone scan. In rare cases, your doctor may use a bone scan to look for bone tumors or compression fractures caused by osteoporosis.
Nerve studies (electromyography, or EMG). This test measures the electrical impulses produced by the nerves and the responses of your muscles. This test can confirm nerve compression caused by herniated disks or narrowing of your spinal canal (spinal stenosis).
TREATMENTS AND DRUGS
Most back pain gets better with a few weeks of home treatment and careful attention. Over-the-counter pain relievers may be all that you need to improve your pain. A short period of bed rest is OK, but more than a couple of days actually does more harm than good. Continue your daily activities as much as you can tolerate. Light activity, such as walking and daily activities of living, is usually OK. But, if an activity increases your pain, stop doing that activity. If home treatments aren't working after several weeks, your doctor may suggest stronger medications or other therapies.
Medications
Your doctor is likely to recommend pain relievers such as acetaminophen (Tylenol, others) or nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve). Both types of medications are effective at relieving back pain. Take these medications as directed by your doctor, because overuse can cause serious side effects. If mild to moderate back pain doesn't get better with over-the-counter pain relievers, your doctor may also prescribe a muscle relaxant. Muscle relaxants can cause dizziness and may make you very sleepy.
Narcotics, such as codeine or hydrocodone, may be used for a short period of time with close supervision by your doctor.
Low doses of certain types of antidepressants — particularly tricyclic antidepressants, such as amitriptyline — have been shown to relieve chronic back pain, independent of their effect on depression.
Education
Right now, there's no commonly accepted program to teach people with back pain how to manage the condition effectively. That means education may be a class, a talk with your doctor, written material or a video. What's important is that education emphasizes the importance of staying active, reducing stress and worry, and teaching ways to avoid future injury. However, it's also important for your doctor to explain that your back pain may recur, especially during the first year after the initial episode, but that the same self-care measures will be able to help again.
Physical therapy and exercise
Physical therapy is the cornerstone of back pain treatment. A physical therapist can apply a variety of treatments, such as heat, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain. As pain improves, the therapist can teach you specific exercises that may help increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques can help prevent pain from returning.
Injections
If other measures don't relieve your pain and if your pain radiates down your leg, your doctor may inject cortisone — an anti-inflammatory medication — into the space around your spinal cord (epidural space). A cortisone injection helps decrease inflammation around the nerve roots, but the pain relief usually lasts less than a few months.
In some cases, your doctor may inject numbing medication and cortisone into or near the structures believed to be causing your back pain, such as the facet joints of the vertebrae. Located on the sides, top and bottom of each vertebra, these joints connect the vertebrae to one another and stabilize the spine while still allowing flexibility.
Surgery
Few people ever need surgery for back pain. If you have unrelenting pain associated with radiating leg pain or progressive muscle weakness caused by nerve compression, you may benefit from surgical intervention. Otherwise, surgery usually is reserved for pain related to structural anatomical problems that haven't responded to intensive conservative therapy measures.
LIFESTYLE AND HOME REMEDIES
You may be able to avoid back pain by improving your physical condition and learning and practicing proper body mechanics.
To keep your back healthy and strong:
Exercise. Regular low-impact aerobic activities — those that don't strain or jolt your back — can increase strength and endurance in your back and allow your muscles to function better. Walking and swimming are good choices. Talk with your doctor about which activities are best for you.
Build muscle strength and flexibility. Abdominal and back muscle exercises (core-strengthening exercises) help condition these muscles so that they work together like a natural corset for your back. Flexibility in your hips and upper legs aligns your pelvic bones to improve how your back feels. Your doctor or physical therapist can let you know which exercises are right for you.
Maintain a healthy weight. Being overweight puts strain on your back muscles. If you're overweight, trimming down can prevent back pain.
Use proper body mechanics:
Stand smart. Maintain a neutral pelvic position. If you must stand for long periods of time, alternate placing your feet on a low footstool to take some of the load off your lower back. Good posture can reduce the amount of stress placed on back muscles.
Sit smart. Choose a seat with good lower back support, arm rests and a swivel base. Consider placing a pillow or rolled towel in the small of your back to maintain its normal curve. Keep your knees and hips level. Change your position frequently, ideally at least once every half hour.
Lift smart. Let your legs do the work. Move straight up and down. Keep your back straight and bend only at the knees. Hold the load close to your body. Avoid lifting and twisting simultaneously. Find a lifting partner if the object is heavy or awkward. Learning to lift properly may be more effective at preventing a recurrence of back pain than a first episode.
Buyer beware
Because back pain is such a common problem, there are numerous products available that promise to prevent or relieve your back pain. But, there's no definitive evidence that special shoes, shoe inserts, back supports, specially designed furniture or stress management programs can help. In addition, there doesn't appear to be one type of mattress that's best for people with back pain. It's probably a matter of what feels most comfortable to you.
ALTERNATIVE MEDICINE
A number of alternative treatments are available that may help ease symptoms of back pain. Always discuss the benefits and risks with your doctor before starting any new alternative therapy.
Chiropractic care. Back pain is one of the most common reasons that people see a chiropractor.
Acupuncture. A practitioner of acupuncture inserts sterilized stainless steel needles into the skin at specific points on the body. Some people with low back pain report that acupuncture helps relieve their symptoms.
Massage. If your back pain is caused by tense or overworked muscles, massage therapy may help.
Yoga. There are several types of yoga, a broad discipline that involves practicing specific postures or poses, breathing exercises and relaxation techniques. Results of a few clinical trials suggest that yoga offers some benefit for people with back pain.
BACTERIAL VAGINOSIS
BACTERIAL VAGINOSIS
Bacterial vaginosis is a type of vaginal inflammation that results from the overgrowth of one of several types of bacteria normally present in the vagina, upsetting the natural balance of vaginal bacteria.
Women in their reproductive years are most commonly affected by bacterial vaginosis, but any woman can experience the condition. Doctors don't know exactly why bacterial vaginosis develops, but certain activities, such as unprotected sexual intercourse or frequent douching, put you at higher risk of the condition.
SYMPTOMS
Bacterial vaginosis signs and symptoms may include:
Vaginal discharge that's thin and grayish white
Foul-smelling "fishy" vaginal odor, especially after sexual intercourse
Vaginal itching
Burning during urination
However, many women with bacterial vaginosis have no signs or symptoms at all.
When to see a doctor
You probably need to see your doctor if you have new vaginal symptoms and:
You've never had a vaginal infection. Seeing your doctor will establish the cause and help you learn to identify signs and symptoms.
You've had vaginal infections before, but these symptoms seem different.
You've had multiple sex partners or a recent new partner. You could have a sexually transmitted infection. Signs and symptoms of some sexually transmitted infections are similar to those of bacterial vaginosis.
You've tried self-treatment for a yeast infection with an over-the-counter anti-yeast medication and your symptoms persist, you have a fever, or you have a particularly unpleasant vaginal odor.
CAUSES
Bacterial vaginosis results from an overgrowth of one of several organisms normally present in your vagina. Usually, "good" bacteria (lactobacilli) outnumber "bad" bacteria (anaerobes) in your vagina. But if anaerobic bacteria become too numerous, they upset the natural balance of microorganisms in your vagina, resulting in bacterial vaginosis.
RISK FACTORS
Risk factors for bacterial vaginosis include:
Multiple sex partners or a new sex partner. The link between sexual activity and bacterial vaginosis isn't entirely clear, but bacterial vaginosis occurs more often in women who have multiple sex partners or a new sex partner. Bacterial vaginosis also seems to occur more frequently in women who have sex with women.
Douching. The practice of rinsing out your vagina with water or a cleansing agent (douching) upsets the natural balance of your vaginal environment. This can lead to an overgrowth of anaerobic bacteria, which in turn can result in bacterial vaginosis. Since the vagina is self-cleaning, douching isn't necessary.
Natural lack of lactobacilli bacteria. If your natural vaginal environment doesn't produce enough of the good lactobacilli bacteria, you're more likely to develop bacterial vaginosis.
COMPLICATIONS
Generally, bacterial vaginosis doesn't cause complications. But under certain circumstances, having bacterial vaginosis may lead to:
Preterm birth. In pregnant women, bacterial vaginosis is linked to premature deliveries and low birth weight babies.
Sexually transmitted infections. Having bacterial vaginosis makes women more susceptible to sexually transmitted infections, such as HIV, herpes simplex virus, chlamydia or gonorrhea. If you have HIV, bacterial vaginosis increases the odds that you'll pass the virus on to your partner.
Infection risk after gynecologic surgery. Having bacterial vaginosis may be associated with a greater chance of developing a post-surgical infection after procedures such as hysterectomy or dilation and curettage (D&C).
Pelvic inflammatory disease (PID). Bacterial vaginosis can sometimes cause PID, an infection of the uterus and the fallopian tubes that can increase the risk of infertility.
PREPARING FOR YOUR APPOINTMENT
So that your primary care doctor or gynecologist can observe and evaluate any vaginal discharge you have, don't schedule your appointment during your period. Avoid using tampons and vaginal deodorant sprays, and don't douche or have sex for 24 hours before your appointment.
What you can do
Because appointments can be brief, and it may be difficult to remember everything you want to discuss, it's a good idea to prepare in advance of your appointment.
Make a list of any symptoms you're experiencing. Include all of your symptoms, even if you don't think they're related.
Make a list of any medications, vitamins, herbs or other supplements you take. Include how often you take them and the doses.
Take a notepad or electronic device with you. Use it to make notes of important information during your visit.
Prepare a list of questions to ask your doctor. List your most important questions first, in case time runs out.
For bacterial vaginosis, some basic questions to ask your doctor include:
Can I do anything to prevent bacterial vaginosis?
What signs and symptoms should I look for?
Do I need to take medicine?
Does my partner also need to be tested or treated?
Are there any special instructions for taking the medicine?
Are there any over-the-counter products that will treat my condition?
What can I do if my symptoms return after treatment?
Don't hesitate to ask questions during your appointment if you don't understand something.
Questions your doctor may ask
Be prepared to answer questions your doctor may have, such as:
What symptoms are you experiencing?
How long have you had your symptoms?
Do you notice a strong vaginal odor?
Have you ever been treated for a vaginal infection?
Have you tried any over-the-counter products to treat your condition?
Have you recently taken antibiotics for any reason?
Are you sexually active?
Are you pregnant?
Do you use scented soap or bubble bath?
Do you douche or use feminine hygiene spray?
TESTS AND DIAGNOSIS
To diagnose bacterial vaginosis, your doctor may:
Ask questions about your medical history. Specifically, your doctor may ask about any previous vaginal infections or sexually transmitted infections.
Perform a pelvic exam. During a pelvic exam, your doctor visually examines your external genitalia for signs of vaginal infection and inserts two fingers into your vagina while pressing on your abdomen with the other hand to check your pelvic organs for unusual characteristics that may indicate disease.
Take a sample of vaginal secretions. This may be done to check for an overgrowth of anaerobic bacteria in your vaginal flora. Your doctor may examine the vaginal secretions under a microscope, looking for "clue cells," vaginal cells covered with bacteria that are a sign of bacterial vaginosis. Your doctor may also check the acidity of your vaginal environment by placing a pH test strip in your vagina. A vaginal pH of 4.5 or higher is another sign of bacterial vaginosis.
TREATMENTS AND DRUGS
To treat bacterial vaginosis, your doctor may prescribe one of the following medications:
Metronidazole (Flagyl, Metrogel-Vaginal, others). This medicine may be taken orally — as a pill that you swallow. Metronidazole is also available for use topically, as a gel that you insert into your vagina. To avoid the potential for stomach upset, abdominal pain or nausea while using this medication, avoid alcohol during treatment and for at least one day after completing treatment — check the instructions on the product.
Clindamycin (Cleocin, Clindesse, others). This medicine is available as a cream that you insert into your vagina. One effect of using clindamycin cream is that it may weaken latex condoms during treatment and for at least three days after you stop using the cream.
Tinidazole (Tindamax). This medication is taken orally. Tinidazole has the same potential for stomach upset and nausea as oral metronidazole does, so avoid alcohol during treatment and for at least one day after completing treatment.
Generally, it's not necessary to treat a woman's male sexual partner, but bacterial vaginosis can spread between female sexual partners. Female partners should seek testing and, if indicated, treatment of bacterial vaginosis. It's especially important for pregnant women with symptoms to be treated, as this may decrease the risk of premature delivery or low birth weight.
Take your medicine or use the cream or gel for as long as your doctor prescribes it — even if your symptoms go away. Stopping treatment early may increase the likelihood of recurrence.
Recurrence
Despite effective treatments for bacterial vaginosis, recurrence of symptoms within three to 12 months is common. Researchers are exploring treatment regimens for recurrent bacterial vaginosis. If your symptoms recur soon after treatment, talk with your doctor about treatment options, one of which is extended-use metronidazole therapy.
A self-help approach is lactobacillus colonization therapy — which attempts to boost the number of good bacteria in your vagina and re-establish a balanced vaginal environment — possibly accomplished by eating certain types of yogurt or other foods containing lactobacilli. However, research to determine the benefits and risks of probiotic therapy is lacking.
LIFESTYLE AND HOME REMEDIES
To help prevent bacterial vaginosis:
Minimize vaginal irritation. Stay out of hot tubs and whirlpool spas. Rinse soap from your outer genital area after a shower, and dry the area well to prevent irritation. Use mild, nondeodorant soaps and unscented tampons or pads.
Don't douche. Your vagina doesn't require cleansing other than normal bathing. Repetitive douching disrupts the normal organisms that reside in the vagina and can actually increase your risk of vaginal infection. Douching won't clear up a vaginal infection.
Avoid a sexually transmitted infection. Use a male latex condom, limit your number of sex partners or abstain from intercourse to minimize your risk of a sexually transmitted infection.
EHRLICHIOSIS
EHRLICHIOSIS
Ehrlichiosis
Ehrlichiosis is a bacterial illness transmitted by ticks that causes flu-like symptoms. The signs and symptoms of ehrlichiosis range from mild body aches to severe fever and usually appear within a week or two of a tick bite. If treated quickly with appropriate antibiotics, ehrlichiosis generally improves within a few days.
Another tick-borne infection — anaplasmosis — is closely related to ehrlichiosis. But the two have distinct differences and are caused by different microorganisms.
The best way to prevent these infections is to avoid tick bites. Tick repellents, thorough body checks after being outside and proper removal of ticks give you the best chance of avoiding ehrlichiosis.
SYMPTOMS
If a tick carrying the bacterium that causes ehrlichiosis has been feeding on you for at least 24 hours, the following flu-like signs and symptoms may appear within five to 14 days of the bite:
Mild fever
Headache
Chills
Muscle aches
Nausea
Vomiting
Diarrhea
Joint pain
Confusion
Rash
Cough
Some people infected with ehrlichiosis may have symptoms so mild that they never seek medical attention, and the body fights off the illness on its own. But untreated ehrlichiosis with persistent symptoms can result in an illness serious enough to require hospitalization.
When to see a doctor
It may take 14 days after a tick bite for you to begin showing signs and symptoms of ehrlichiosis. If you get symptoms within two weeks of a tick bite, see your doctor. If you experience any of the above symptoms soon after you've been in an area known to have ticks, see your doctor. Be sure to tell your doctor that you recently received a tick bite or visited an area with a high population of ticks.
CAUSES
Ehrlichiosis is caused by Ehrlichia chaffeensis bacteria and is transmitted primarily by the Lone Star tick.
Ticks feed on blood, latching onto a host and feeding until they're swollen to many times their normal size. During feeding, ticks that carry disease-producing bacteria can transmit the bacteria to a healthy host. Or they may pick up bacteria themselves if the host, such as a white-tailed deer or a coyote, is infected.
Usually, to get ehrlichiosis, you must be bitten by an infected tick. The bacteria enter your skin through the bite and eventually make their way into your bloodstream.
Before bacteria can be transmitted, a tick must be attached and feeding for at least 24 hours. An attached tick with a swollen appearance may indicate that the tick has been feeding long enough to have transmitted bacteria. Removing ticks as soon as possible may prevent infection.
It's also possible that ehrlichiosis may be transmitted through blood transfusions, from mother to fetus and through direct contact with an infected, slaughtered animal.
RISK FACTORS
Ehrlichiosis spreads when an infected tick, primarily the Lone Star tick, bites you and feeds on you for 24 hours or longer. The following factors may increase your risk of getting tick-borne infections:
Being outdoors in warm weather. Most cases of ehrlichiosis occur in the spring and summer months when populations of the Lone Star tick are at their peak and people are outside for activities such as hiking, golfing, gardening and camping.
Living in or visiting an area with a high tick population. You are at greater risk if you are in an area with a high Lone Star tick population. In the United States, Lone Star ticks are most common in southeastern, eastern and south-central states.
Being male. Ehrlichiosis infections are more common in males, likely because of increased time outdoors for work and recreation.
COMPLICATIONS
Ehrlichiosis can have serious effects on an otherwise healthy adult or child if you don't seek prompt treatment.
People with weakened immune systems are at an even higher risk of more-serious and potentially life-threatening consequences. Serious complications of untreated infection include:
Kidney failure
Respiratory failure
Heart failure
Seizures
Coma
PREPARING FOR YOUR APPOINTMENT
You're likely to first see your primary care physician or possibly an emergency room doctor, depending on the severity of your signs and symptoms. However, you may then be referred to a doctor who specializes in infectious diseases.
If you have time before your appointment to prepare, it's helpful to have certain information at hand. Here's what you can do to help get ready for your appointment, and what you can 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.
Write down key personal information, including any recent travel to areas where ticks might be common.
Make a list of all medications, vitamins and supplements that you're taking, with dose information.
Write down questions to ask your doctor.
Preparing a list of questions can help you make the most of your time with your doctor. For erhlichiosis, some basic questions to ask your doctor include:
Did a tick bite cause these symptoms?
Are there other possible causes for my symptoms?
What tests do I need?
Does this infection have lasting effects?
What treatments are available, and which do you recommend?
What types of side effects can I expect from treatment?
Are there any alternatives to the primary approach you're suggesting?
I have other health conditions. How can I best manage them together?
Is there a generic alternative to the medicine you're prescribing?
Can I get this infection again from another tick bite?
What can I do to prevent this type of infection in the future?
Are there brochures or other printed material I can take with me? What websites do you recommend?
Don't hesitate to ask your doctor any other relevant questions.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, such as:
When did you begin experiencing symptoms?
Have your symptoms been continuous or occasional?
How severe are your symptoms?
Have you traveled recently?
Have you been hiking, golfing or participating in other outdoor activities recently?
Have you found any ticks on you? If yes, when?
Have you had any problems with antibiotics in the past?
TESTS AND DIAGNOSIS
Tick-borne infections are difficult to diagnose based solely on signs and symptoms because the signs and symptoms, such as fever and muscle aches, are similar to many other common conditions.
Abnormal findings on a number of blood tests, combined with your history of possible exposure, may lead your doctor to suspect a tick-borne illness. If you have ehrlichiosis, your blood tests will likely show:
A low white blood cell count — these cells are the body's disease fighters
A low platelet count — platelets are essential to blood clotting
Abnormal liver function
In addition, there are other possible blood tests that may be done if you live in an area where they're available. These tests include:
Polymerase chain reaction (PCR) test. This test helps identify specific genes unique to ehrlichiosis. However, if you've already started treatment, the results of this test may be affected.
Indirect fluorescent antibody (IFA) test. This test, not used as commonly as the PCR test, measures the amount of antibody you have in your blood to the bacteria that causes ehrlichiosis.
If you live in an area where ticks are common, your doctor may start you on antibiotics before the results of the blood tests return because earlier treatment results in a better outcome for some tick-borne diseases.
TREATMENTS AND DRUGS
If your doctor suspects that you have ehrlichiosis or another tick-borne illness, you'll likely receive a prescription for the antibiotic doxycycline (Doryx, Periostat, others). You'll generally take the antibiotic for seven to 10 days and should see signs and symptoms begin to subside within two days. Your doctor may have you take antibiotics for a longer period if you're severely ill.
If you're pregnant, your doctor may prescribe the antibiotic rifampin (Rifadin, Rimactane) instead, because doxycycline isn't recommended during pregnancy.
LIFESTYLE AND HOME REMEDIES
The best way to steer clear of ehrlichiosis is to avoid tick bites.
Most ticks attach themselves to your lower legs and feet as you walk or work in grassy, wooded areas or overgrown fields. After a tick attaches to your body, it usually crawls upward to find a location to burrow into your skin. You may find a tick on the back of your knees, groin, underarms, ears, back of your neck and elsewhere.
If you remove a tick in the first 24 hours after attachment, you reduce your risk of infection. While you may not be able to avoid going into areas where ticks are present, the following tips can make it easier to discover and remove ticks before they attach to your skin:
Wear light-colored clothing. Ticks are dark colored. Light clothing helps you and others notice ticks on your clothing before they can attach themselves to your skin.
Avoid open-toed shoes or sandals. Ticks generally live in grassy areas or fields and can attach themselves to your feet and legs when you brush by. Wearing open-toed shoes or sandals increases the risk of a tick attaching to your bare skin and working its way under your clothes, out of sight from detection.
Apply repellent. Products containing DEET (Off! Deep Woods, Repel) or permethrin (Repel Permanone) often repel ticks. You can use DEET on your skin or clothing, but follow recommendations on the label. For children, use a DEET repellent containing less than 30 percent DEET, and use the product with caution. Don't use DEET on your or on children's hands or faces. Permethrin is for use on clothing only.
Wear long pants and a long-sleeved shirt. The less skin you expose, the less area a tick has to bite. For added protection, wear shirts, pants and socks with permethrin impregnated in the fabric.
Tuck your shirt into your pants and your pants into your socks. By doing this, ticks will be less able to crawl onto exposed skin. However, be aware that if ticks get on your clothing, they'll climb upward until they reach exposed skin. Check your clothing often while you're outdoors.
Stay on clear trails whenever possible. Ticks prefer grassy areas and may be less common on well-beaten paths.
Pull back long hair. Ticks may attach to dangling hair and work their way to your neck or scalp. Pulling back long hair helps you see ticks better on your neck and limits the chance of them attaching in the first place.
Inspect your body. Do a complete visual inspection of your body. Be sure to check your head and neck because ticks will continue to climb upward until they find a suitable burrowing site. Use your hands to feel through your hair and in areas you can't see when you return from your outing or garden.
Ticks can be as small as a strawberry seed, and they usually attach to hidden skin. Be sure to check all the possibilities. A shower alone will rarely dislodge attached ticks from your head and body.
Inspect your clothes and gear. Check your clothes, backpacks and other gear when you get home to look for ticks that hitched a ride. Spinning your clothes in the dryer for 20 minutes will kill any ticks you missed.
Don't forget your pets. Do a daily inspection for ticks on any pet that spends time outdoors.
BAD BREATH (HALITOSIS)
BAD BREATH (HALITOSIS)
Bad breath, also called halitosis, can be embarrassing and in some cases may even cause anxiety. It's no wonder that store shelves are overflowing with gum, mints, mouthwashes and other products designed to fight bad breath. But many of these products are only temporary measures because they don't address the cause of the problem.
Certain foods, health conditions and habits are among the causes of bad breath. In many cases, you can improve bad breath with consistent proper dental hygiene. If simple self-care techniques don't solve the problem, see your dentist or physician to be sure a more serious condition isn't causing your bad breath.
SYMPTOMS
Bad breath odors vary, depending on the source or the underlying cause. Some people worry too much about their breath even though they have little or no mouth odor, while others have bad breath and don't know it. Because it's difficult to assess how your own breath smells, ask a close friend or relative to confirm your bad-breath questions.
When to see a doctor
If you have bad breath, review your oral hygiene habits. Try making lifestyle changes, such as brushing your teeth and tongue after eating, using dental floss, and drinking plenty of water.
If your bad breath persists after making such changes, see your dentist. If your dentist suspects a more serious condition is causing your bad breath, he or she may refer you to a physician to find the cause of the odor.
CAUSES
Most bad breath starts in your mouth, and there are many possible causes. They include:
Food. The breakdown of food particles in and around your teeth can increase bacteria and cause a foul odor. Eating certain foods, such as onions, garlic, and other vegetables and spices, also can cause bad breath. After you digest these foods, they enter your bloodstream, are carried to your lungs and affect your breath.
Tobacco products. Smoking causes its own unpleasant mouth odor. Smokers and oral tobacco users are also more likely to have gum disease, another source of bad breath.
Poor dental hygiene. If you don't brush and floss daily, food particles remain in your mouth, causing bad breath. A colorless, sticky film of bacteria (plaque) forms on your teeth and if not brushed away, plaque can irritate your gums (gingivitis) and eventually form plaque-filled pockets between your teeth and gums (periodontitis). The uneven surface of the tongue also can trap bacteria that produce odors. And dentures that aren't cleaned regularly or don't fit properly can harbor odor-causing bacteria and food particles.
Dry mouth. Saliva helps cleanse your mouth, removing particles that may cause bad odors. A condition called dry mouth — also known as xerostomia (zeer-o-STOE-me-ah) — can contribute to bad breath because production of saliva is decreased. Dry mouth naturally occurs during sleep, leading to "morning breath," and is made worse if you sleep with your mouth open. Some medications can lead to a chronic dry mouth, as can a problem with your salivary glands and some diseases.
Infections in your mouth. Bad breath can be caused by surgical wounds after oral surgery, such as tooth removal, or as a result of tooth decay, gum disease or mouth sores.
Other mouth, nose and throat conditions. Bad breath can occasionally stem from small stones that form in the tonsils and are covered with bacteria that produce odorous chemicals. Infections or chronic inflammation in the nose, sinuses or throat, which can contribute to postnasal drip, also can cause bad breath.
Medications. Some medications can indirectly produce bad breath by contributing to dry mouth. Others can be broken down in the body to release chemicals that can be carried on your breath.
Other causes. Diseases, such as some cancers, and conditions such as metabolic disorders, can cause a distinctive breath odor as a result of chemicals they produce. Chronic reflux of stomach acids (gastroesophageal reflux disease) can be associated with bad breath. Bad breath in young children may be caused by a foreign body, such as a small toy or piece of food, lodged in a nostril.
PREPARING FOR YOUR APPOINTMENT
If you're going to have your bad breath evaluated by your dentist, the following tips will help:
Dentists generally prefer morning appointments for testing bad breath to reduce the chances that foods you eat during the day will hinder the exam.
Don't eat, drink, chew gum or smoke for three hours before your appointment.
Don't wear perfume, scented lotions, or scented lipstick or lip gloss to your appointment, as these products could mask any odors.
If you've taken antibiotics within the last month, check with your dentist to see if your appointment needs to be rescheduled.
What to expect from your dentist
Your dentist will likely start with an evaluation of your medical history, asking questions such as:
When did you first begin to experience bad breath?
Is your bad breath occasional or continuous?
How often do you brush your teeth or clean your dentures?
How often do you floss?
What kinds of foods do you eat?
What medications and supplements do you take?
What health conditions do you have?
Do you breathe through your mouth?
Do you snore?
Do you have allergies or sinus problems?
What do you suspect might be causing your bad breath?
Have other people noticed and commented on your bad breath?
TESTS AND DIAGNOSIS
Your dentist will likely smell both the breath from your mouth and the breath from your nose and rate the odor on a scale. Because the back of the tongue is most often the source of the smell, your dentist may also scrape it and rate its odor.
There are sophisticated detectors that can identify the chemicals responsible for bad breath, but these aren't always available.
TREATMENTS AND DRUGS
To reduce bad breath, help avoid cavities and lower your risk of gum disease, consistently practice good oral hygiene. Further treatment for bad breath can vary, depending on the cause. If your bad breath is thought to be caused by an underlying health condition, your dentist will likely refer you to your primary care physician.
For causes related to oral health, your dentist will work with you to help you better control that condition. Dental measures may include:
Mouth rinses and toothpastes. If your bad breath is due to a buildup of bacteria (plaque) on your teeth, your dentist may recommend a mouth rinse that kills the bacteria. Mouth rinses containing cetylpyridinium chloride and those with chlorhexidine can prevent production of odors that cause bad breath. Your dentist may also recommend a toothpaste that contains an antibacterial agent to kill the bacteria that cause plaque buildup.
Treatment of dental disease. If your dentist discovers that you have gum disease, you may be referred to a gum specialist (periodontist). Gum disease can cause the gums to pull away from the teeth, leaving deep pockets that accumulate odor-causing bacteria. Sometimes these bacteria can be removed only by professional cleaning. Your dentist might also recommend replacing faulty tooth restorations, which can be a breeding ground for bacteria.
LIFESTYLE AND HOME REMEDIES
To reduce or prevent bad breath:
Brush your teeth after you eat. Keep a toothbrush at work to use after eating. Brush using a fluoride-containing toothpaste at least twice a day, especially after meals. Toothpaste with antibacterial properties has been shown to reduce bad breath odors.
Floss at least once a day. Proper flossing removes food particles and plaque from between your teeth, helping to control bad breath.
Brush your tongue. Your tongue harbors bacteria, so carefully brushing it may help reduce odors. People who have a coated tongue from a significant overgrowth of bacteria (from smoking or dry mouth, for example) may benefit from using a tongue scraper. Or use a toothbrush that has a built-in tongue cleaner.
Clean your dentures or dental appliances. If you wear a bridge or a partial or complete denture, clean it thoroughly at least once a day or as directed by your dentist. If you have a dental retainer or mouth guard, clean it each time before you put it in your mouth. Your dentist can recommend the best cleaning product.
Avoid dry mouth. To keep your mouth moist, avoid tobacco and drink plenty of water — not coffee, soft drinks or alcohol, which can lead to a drier mouth. Chew gum or suck on candy — preferably sugarless — to stimulate saliva. If you have chronic dry mouth, your dentist or physician may prescribe an artificial saliva preparation or an oral medication that stimulates the flow of saliva.
Adjust your diet. Avoid food and beverages that can cause bad breath. Avoid sticky, sugary foods.
Regularly get a new toothbrush. Change your toothbrush when it becomes frayed, about every three to four months, and choose a soft-bristled toothbrush.
Schedule regular dental checkups. See your dentist on a regular basis — generally once or twice a year — to have your teeth or dentures examined and cleaned.
BAKER's CYST
BAKER's CYST
A Baker's cyst is a fluid-filled cyst that causes a bulge and a feeling of tightness behind your knee. The pain can get worse when you fully flex or extend your knee or when you're active.
A Baker's cyst, also called a popliteal (pop-luh-TEE-ul) cyst, is usually the result of a problem with your knee joint, such as arthritis or a cartilage tear. Both conditions can cause your knee to produce too much fluid, which can lead to a Baker's cyst.
Although a Baker's cyst may cause swelling and make you uncomfortable, treating the probable underlying problem usually provides relief.
SYMPTOMS
In some cases, a Baker's cyst causes no pain, and you may not notice it. If you do have signs and symptoms, they might include:
Swelling behind your knee, and sometimes in your leg
Knee pain
Stiffness and inability to fully flex the knee
Your symptoms may be worse after you've been active or if you've been standing for a long time.
When to see a doctor
If you have pain and swelling behind your knee, see your doctor. Though unlikely, a bulge behind your knee may be a sign of a condition more serious than a fluid-filled cyst.
CAUSES
A lubricating fluid called synovial (sih-NO-vee-ul) fluid helps your leg swing smoothly and reduces friction between the moving parts of your knee.
But sometimes the knee produces too much synovial fluid, resulting in buildup of fluid in an area on the back of your knee (popliteal bursa), causing a Baker's cyst. This can happen because of:
Inflammation of the knee joint, such as occurs with various types of arthritis
A knee injury, such as a cartilage tear
COMPLICATIONS
Rarely, a Baker's cyst bursts and synovial fluid leaks into the calf region, causing:
Sharp pain in your knee
Swelling in the calf
Sometimes, redness of your calf or a feeling of water running down your calf
These signs and symptoms closely resemble those of a blood clot in a vein in your leg. If you have swelling and redness of your calf, you'll need prompt medical evaluation to rule out a more serious cause of your symptoms.
PREPARING FOR YOUR APPOINTMENT
Here's some information to help you prepare for your appointment.
What you can do
Write down symptoms you have, including any that may seem unrelated to the reason for which you scheduled the appointment.
Write down key personal information, including recent life changes.
List all medications, vitamins and supplements you're taking.
Write down questions to ask your doctor.
Your time with your doctor may be limited, so preparing a list of questions can help you make the most of your time together. For a Baker's cyst, some basic questions to ask your doctor include:
What caused this cyst to develop?
What tests do I need? Do these tests require special preparation?
Is a Baker's cyst temporary or long lasting?
What treatments are available, and which do you recommend?
What side effects can I expect from treatment?
What steps can I take on my own that might help?
Do I need to limit my activity? If so, how much and for how long?
I have other health conditions. How can I best manage these conditions together?
Don't hesitate to ask other questions.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, such as:
When did your symptoms begin?
Do you feel pain or stiffness all the time, or does the pain come and go with activity?
Does your knee swell, feel unstable or lock?
How severe are your symptoms?
Does anything seem to improve your symptoms?
What, if anything, appears to worsen your symptoms?
TESTS AND DIAGNOSIS
A Baker's cyst can often be diagnosed with a physical exam. However, because some of the signs and symptoms of a Baker's cyst mimic those of more-serious conditions, such as a blood clot, aneurysm or tumor, your doctor may order noninvasive imaging tests, including:
Ultrasound
X-ray
Magnetic resonance imaging (MRI)
TREATMENTS AND DRUGS
Sometimes a Baker's cyst will disappear on its own. However, if the cyst is large and causes pain, your doctor may recommend the following treatments:
Medication. Your doctor may inject a corticosteroid medication, such as cortisone, into your knee to reduce inflammation. This may relieve pain, but it doesn't always prevent recurrence of the cyst.
Fluid drainage. Your doctor may drain the fluid from the knee joint using a needle. This is called needle aspiration and is often performed under ultrasound guidance.
Physical therapy. Icing, a compression wrap and crutches may help reduce pain and swelling. Gentle range-of-motion and strengthening exercises for the muscles around your knee also may help to reduce your symptoms and preserve knee function.
If possible, doctors treat the underlying cause of the cyst. If your doctor determines that a cartilage tear is causing the overproduction of synovial fluid, he or she may recommend surgery to remove or repair the torn cartilage.
Baker's cysts associated with osteoarthritis usually improve with treatment of the arthritis. Surgical intervention is rarely needed.
LIFESTYLE AND HOME REMEDIES
If your doctor determines that arthritis is causing the cyst, he or she may advise you to take some or all of the following steps:
Follow the R.I.C.E. principles. These letters stand for rest, ice, compression and elevation. Rest your leg. Ice your knee. Compress your knee with a wrap, sleeve or brace. And elevate your leg when possible, especially at night.
Try over-the-counter pain-relieving medications. Drugs such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, others), acetaminophen (Tylenol, others) and aspirin can help relieve pain. Follow the dosing instructions on the package. Don't take more than the recommend dosage.
Reduce your physical activity. Doing so will reduce irritation of your knee joint. Your doctor can offer you guidance on how long you need to reduce your activity levels, and he or she may be able to suggest alternative forms of exercise you can do in the meantime.
FOLLICULITIS (BARBERS ITCH)
FOLLICULITIS (BARBERS ITCH)
Folliculitis is a common skin condition in which hair follicles become inflamed. It's usually caused by a bacterial or fungal infection. At first it may look like small red bumps or white-headed pimples around hair follicles — the tiny pockets from which each hair grows. The infection can spread and turn into non-healing, crusty sores.
The condition isn't life-threatening, but it can be itchy, sore and embarrassing. Severe infections can cause permanent hair loss and scarring.
If you have a mild case, it'll likely clear in a few days with basic self-care measures. For more serious or recurring folliculitis, you may need to see a doctor.
Certain types of folliculitis are known as hot tub rash, razor bumps and barber's itch.
SYMPTOMS
Folliculitis signs and symptoms include:
Clusters of small red bumps or white-headed pimples that develop around hair follicles
Pus-filled blisters that break open and crust over
Red and inflamed skin
Itchy or burning skin
Tenderness or pain
A large swollen bump or mass
When to see a doctor
Make an appointment with your doctor if your condition is widespread or the signs and symptoms don't go away after a few days. You may need an antibiotic or an antifungal medication to help control the problem.
Types of superficial folliculitis
Superficial forms of folliculitis include:
Bacterial folliculitis. This common type is marked by itchy, white, pus-filled bumps. When bacterial folliculitis affects a man's beard area, it's called barber's itch. It occurs when hair follicles become infected with bacteria, usually Staphylococcus aureus (staph). Staph bacteria live on the skin all the time. But they generally cause problems only when they enter your body through a cut or other wound.
Hot tub folliculitis (pseudomonas folliculitis). This type is caused by pseudomonas bacteria. You may be exposed to these bacteria in many places, including hot tubs and heated pools in which the chlorine and pH levels aren't well-regulated. You may develop a rash of red, round, itchy bumps one to four days after exposure. These may later develop into small pus-filled blisters (pustules).
The rash is likely to be worse in areas where your swimsuit held contaminated water against the skin or where skin — such as the back of the thighs — came in direct contact with a contaminated surface.
Barber's itch (pseudofolliculitis barbae). This is an inflammation caused by ingrowing hairs. It mainly affects black men who shave and is most noticeable on the face and neck. People who get bikini waxes may develop barber's itch in the groin area. This condition may leave dark raised scars (keloids).
Pityrosporum (pit-ih-ROS-puh-rum) folliculitis. This type is especially common in teens and adult men. It's caused by a yeast infection and produces chronic, red, itchy pustules on the back and chest and sometimes on the neck, shoulders, upper arms and face.
Types of deep folliculitis
Deep folliculitis, where the whole hair follicle is involved, comes in various forms:
Sycosis barbae. This type affects men who have begun to shave. At first, small pustules appear on the upper lip, chin and jaw. They become more prevalent over days and weeks as shaving continues. Severe sycosis barbae may cause scarring.
Gram-negative folliculitis. This type sometimes develops if you're receiving long-term antibiotic therapy for acne. Antibiotics alter the normal balance of bacteria in the nose. This leads to an overgrowth of harmful organisms called gram-negative bacteria. In most people, this doesn't cause problems, and the bacteria in the nose return to normal once antibiotics are stopped. In a few people, the gram-negative bacteria spread to the skin around the nose and mouth. This can cause new, severe acne.
Boils (furuncles) and carbuncles. These occur when hair follicles become deeply infected with staph bacteria. A boil usually appears suddenly as a painful pink or red bump. The surrounding skin also may be red and swollen. The bump then fills with pus and grows larger and more painful before it finally ruptures and drains. Small boils usually heal without scarring. A large boil may leave a scar.
A carbuncle is a cluster of boils. It usually appears on the back of the neck, shoulders, back or thighs. A carbuncle causes a deeper and more severe infection than does a single boil. As a result, it develops and heals more slowly and is likely to leave a scar.
Eosinophilic (e-o-sin-o-FILL-ik) folliculitis. This type mainly affects people with HIV/AIDS. Symptoms include intense itching and recurring patches of inflamed, pus-filled sores on the scalp, face, neck and upper chest. The sores usually spread and often leave areas of darker than normal skin (hyperpigmentation) when they heal. The exact cause of eosinophilic folliculitis isn't known. But it may involve the same yeast-like fungus responsible for pityrosporum folliculitis.
CAUSES
Folliculitis is caused by an infection of hair follicles, usually from the bacteria Staphylococcus aureus. Folliculitis may also be caused by viruses, fungi and even an inflammation from ingrown hairs.
The condition is classified as either superficial or deep, based on how much of the hair follicle it involves. Deep folliculitis is usually more severe.
Follicles are densest on your scalp, and they occur everywhere on your body except your palms, soles, lips and mucous membranes. Damaged follicles are at risk of infection.
The most common causes of follicle damage are:
Friction from shaving or tight clothing
Heat and sweat, such as that caused by wearing rubber gloves or waders
Certain skin conditions, such as dermatitis and acne
Injuries to your skin, such as from scrapes or surgical wounds
Coverings on your skin, such as plastic dressings or adhesive tape
RISK FACTORS
Anyone can develop folliculitis. But certain factors make you more susceptible to the condition, including:
Having a medical condition that reduces your resistance to infection, such as diabetes, chronic leukemia and HIV/AIDS
Having acne or dermatitis
Past damage to your skin, as from injury or surgery
Taking some medications, such as steroid creams or long-term antibiotic therapy for acne
Being overweight
Regularly wearing clothing that traps heat and sweat, such as rubber gloves or high boots
Soaking in a hot tub that's not maintained well
Shaving
COMPLICATIONS
Possible complications of folliculitis include:
Recurrent or spreading infection
Large, itchy patches of infected skin (plaques)
Boils under the skin (furunculosis)
Permanent skin damage, such as scarring or dark spots
Destruction of hair follicles and permanent hair loss
PREPARING FOR YOUR APPOINTMENT
You're likely to start by seeing your primary care doctor. He or she may refer you to a doctor who specializes in skin disorders (dermatologist).
To get the most from your appointment, it's a good idea to be well-prepared. Here's some information to help you get ready.
What you can do
List any symptoms you're experiencing, including those that seem unrelated to your skin condition.
List key personal information, including any major stresses or recent life changes.
List all medications, vitamins and supplements you're taking.
List questions to ask your doctor.
For folliculitis, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
What are other possible causes for my symptoms?
Do I need any tests?
What's the best treatment for my condition?
I have these other health conditions. How can I best manage them together?
What types of side effects can I expect from treatment?
Is there a generic alternative to the medicine you're prescribing me?
Do you have any relevant brochures or other printed material that I can take home with me? What websites do you recommend?
What will determine whether I should plan for a follow-up visit?
Don't hesitate to ask any other questions that occur to you 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:
How long have you had this skin infection?
Do you have a history of dermatitis?
Does your work or a hobby expose your hands to heat and moisture, such as from wearing rubber gloves?
Were you in a hot tub or a heated swimming pool a day or two before you noticed your skin rash?
Have your symptoms been continuous or occasional?
Does your skin itch? Is it painful to the touch?
Does anything seem to improve your symptoms?
Does anything make your symptoms worse?
What you can do in the meantime
Sometimes folliculitis goes away without medical treatment. Self-care measures, such as warm compresses and anti-itch creams, can help relieve your signs and symptoms.
TESTS AND DIAGNOSIS
Your doctor is likely to diagnose folliculitis by looking at your skin and reviewing your clinical history. If the usual treatments don't clear up your infection, he or she may use a swab to take a sample of your infected skin. This is sent to a laboratory to help determine what's causing the infection. Rarely, a skin biopsy may be done to rule out other conditions.
TREATMENTS AND DRUGS
The treatments you receive for folliculitis depend on the type and severity of your condition, what self-care measures you've already tried and your preferences for treatment. Even if treatment helps, the infection may come back.
Medications
Creams or pills to control infection. For mild infections, your doctor may recommend the antibiotic cream mupirocin (Bactroban). Oral antibiotics aren't routinely used for folliculitis. But for a severe or recurrent infection, your doctor may prescribe them.
Creams, shampoos or pills to fight fungal infections. Antifungals are for infections caused by yeast rather than bacteria, such as pityrosporum folliculitis. Antibiotics aren't helpful in treating this type.
Creams or pills to reduce inflammation. If you have mild eosinophilic folliculitis, your doctor may suggest you try a steroid cream. If your condition is severe, he or she may prescribe oral corticosteroids. Such drugs can have serious side effects and should be used for as brief a time as possible.
If you have HIV/AIDS, you may see improvement in your eosinophilic folliculitis symptoms after antiretroviral therapy.
Other interventions
Minor surgery. If you have a large boil or a carbuncle, your doctor may make a small incision in it to drain the pus. This may relieve pain, speed recovery and help lessen scarring. Your doctor may then cover the area with sterile gauze in case pus continues to drain.
Light therapy with a medicated cream. Also called photodynamic therapy, this technique has helped people with folliculitis that did not clear up with other treatments. In a study of seven people who each had one treatment of photodynamic therapy, six people showed significant improvement four weeks later. In another study of one man, the technique completely cleared his folliculitis. And he remained free of symptoms 15 months after the last treatment.
Laser hair removal. If other treatments fail, laser therapy may clear up the infection. This method is expensive and may require several treatments. It permanently reduces the density of the hair in the treated area. Other possible side effects include discolored skin, scarring and blistering.
LIFESTYLE AND HOME REMEDIES
You can try to prevent folliculitis from coming back with these tips:
Avoid tight clothes. It helps to reduce friction between your skin and clothing.
Dry out your rubber gloves between uses. If you wear rubber gloves regularly, after each use turn them inside out, rinse with soap and water, and dry thoroughly.
Avoid shaving, if possible. For men with barber's itch, growing a beard may be a good option if you don't need a clean-shaven face.
Shave with care. Use an electric razor or a clean, sharp blade every time you shave. Adopt habits such as:
Washing your skin with warm water and a mild facial cleanser before shaving
Using a wash cloth or cleansing pad in a gentle circular motion
Applying lubricating shaving cream or gel for five to 10 minutes before shaving to soften the hair
Applying moisturizing lotion after you shave
Generally, men with barber's itch have been advised to shave in the direction of hair growth. But a study found that men who shaved against the grain saw their rash improve. Experiment to see what works for you. You may even want to consider hair-removing products (depilatories) or other methods of hair removal.
Use only clean hot tubs and heated pools. And if you own a hot tub or a heated pool, clean it regularly and add chlorine as recommended.
BARRETT's ESOPHAGUS
BARRETT's ESOPHAGUS
In Barrett's esophagus, tissue in the tube connecting your mouth and stomach (esophagus) is replaced by tissue similar to the intestinal lining.
Barrett's esophagus is most often diagnosed in people who have long-term gastroesophageal reflux disease (GERD) — a chronic regurgitation of acid from the stomach into the lower esophagus. Only a small percentage of people with GERD will develop Barrett's esophagus.
Barrett's esophagus is associated with an increased risk of developing esophageal cancer. Although the risk is small, it's important to have regular checkups for precancerous cells. If precancerous cells are discovered, they can be treated to prevent esophageal cancer.
SYMPTOMS
The tissue changes that characterize Barrett's esophagus cause no symptoms. The signs and symptoms that you experience are generally due to GERD and may include:
Frequent heartburn
Difficulty swallowing food
Less commonly, chest pain
Many people with Barrett's esophagus have no signs or symptoms.
When to see a doctor
If you've had trouble with heartburn and acid reflux for more than five years, ask your doctor about your risk of Barrett's esophagus.
Seek immediate help if you:
Have chest pain, which may be a symptom of a heart attack
Have difficulty swallowing
Are vomiting red blood or blood that looks like coffee grounds
Are passing black, tarry or bloody stools
CAUSES
The exact cause of Barrett's esophagus isn't known. Most people with Barrett's esophagus have long-standing GERD. In GERD, stomach contents wash back into the esophagus, damaging esophagus tissue. As the esophagus tries to heal itself, the cells can change to the type of cells found in Barrett's esophagus.
However, some people diagnosed with Barrett's esophagus have never experienced heartburn or acid reflux. It's not clear what causes Barrett's esophagus in these people.
RISK FACTORS
Factors that increase your risk of Barrett's esophagus include:
Chronic heartburn and acid reflux. Having GERD for more than five years or having GERD that requires regular medication and being older than age 50 can increase the risk of Barrett's esophagus. Your risk may be further increased if you are age 30 or younger when chronic GERD develops.
Age. Barrett's esophagus can occur at any age but is more common in older adults.
Being a man. Men are more likely to develop Barrett's esophagus.
Being white. White people have a greater risk of the disease than do people of other races.
Being overweight. Body fat around your abdomen further increases your risk.
Smoking.
COMPLICATIONS
People with Barrett's esophagus have an increased risk of esophageal cancer. The risk is small, especially in people whose lab tests show no precancerous changes (dysplasia) in their esophagus cells. Most people with Barrett's esophagus will never develop esophageal cancer.
PREPARING FOR YOUR APPOINTMENT
Barrett's esophagus is most often diagnosed in people with GERD who are being examined for GERD complications. If your doctor discovers Barrett's esophagus on an endoscopy exam, you may be referred to a doctor who treats digestive diseases (gastroenterologist).
What you can do
Be aware of any pre-appointment restrictions, such as not eating solid food on the day before your appointment.
Write down your symptoms, including any that may seem unrelated to the reason why you scheduled the appointment.
Make a list of all your medications, vitamins and supplements.
Write down your key medical information, including other conditions.
Ask a relative or friend to accompany you to help you remember what the doctor says.
Write down questions to ask your doctor.
Questions to ask your doctor
Do my lab reports show abnormal tissue (dysplasia)? If so, what is the grade of my dysplasia?
How much of my esophagus is affected?
How often should I be screened for changes to my esophagus?
What is my risk of esophageal cancer?
What are the treatment options?
Do I need to make diet or other lifestyle changes?
I have other health conditions. How can I best manage these conditions together?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other 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 make time to go over points you want to spend more time on. You may be asked:
When did you first begin experiencing symptoms? How severe are they?
Are your symptoms continuous or occasional?
What, if anything, seems to improve or worsen your symptoms?
Do you experience acid reflux symptoms?
Do you take any medications for reflux or indigestion?
Do you have difficulty swallowing?
Have you lost weight?
TESTS AND DIAGNOSIS
Endoscopy is generally used to determine if you have Barrett's esophagus.
A lighted tube with a camera at the end (endoscope) is passed down your throat to check for signs of changing esophagus tissue. Normal esophagus tissue appears pale and glossy. In Barrett's esophagus, the tissue appears red and velvety.
Your doctor is likely to remove a small tissue sample (biopsy). The biopsy can be examined to determine the degree of tissue change.
Determining the degree of tissue change
A doctor who specializes in examining tissue in a laboratory (pathologist) determines the degree of dysplasia in your esophagus cells. Your tissue may be classified as:
No dysplasia, if Barrett's esophagus is present but no precancerous changes are found in the cells.
Low-grade dysplasia, if cells show small signs of precancerous changes.
High-grade dysplasia, if cells show many changes. High-grade dysplasia is thought to be the final step before cells change into esophageal cancer.
TREATMENTS AND DRUGS
Treatment for Barrett's esophagus depends on the degree of dysplasia found in your esophagus cells and your overall health.
No dysplasia or low-grade dysplasia
Your doctor will likely recommend:
Periodic endoscopy to monitor the cells in your esophagus. If your biopsies show no dysplasia, you'll probably have a follow-up endoscopy in one year and then every three years if no changes occur. If low-grade dysplasia is found, your doctor may recommend another endoscopy in six months or a year.
Treatment for GERD. Medication and lifestyle changes can ease your signs and symptoms. Surgery to tighten the sphincter that controls the flow of stomach acid may be an option. Treating GERD doesn't treat the underlying Barrett's esophagus but can help make it easier to detect dysplasia.
High-grade dysplasia
High-grade dysplasia is thought to be a precursor to esophageal cancer. For this reason, your doctor may recommend:
Endoscopic resection, which uses an endoscope to remove damaged cells.
Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Radiofrequency ablation may be recommended after endoscopic resection.
Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. The cells are allowed to warm up and then frozen again. The cycle of freezing and thawing damages the abnormal cells.
Photodynamic therapy, which destroys abnormal cells by making them sensitive to light.
Surgery in which the damaged part of your esophagus is removed and the remaining portion is attached to your stomach.
If you have treatment other than surgery to remove your esophagus, your doctor is likely to recommend medication to reduce acid and help your esophagus heal.
LIFESTYLE AND HOME REMEDIES
Lifestyle changes can ease symptoms of GERD, which may underlie Barrett's esophagus. Consider:
Maintaining a healthy weight.
Avoiding tightfitting clothes, which can put pressure on your abdomen and aggravate reflux.
Eliminating foods and drinks that trigger your heartburn.
Stopping smoking.
Avoiding stooping or bending, especially soon after eating.
Avoiding lying down after eating. Wait at least three hours after eating to lie down or go to bed.
Raising the head of your bed. Place wooden blocks under your bed to elevate your head. Aim for an elevation of 6 to 8 inches. Raising your head by using only pillows isn't a good alternative.
COPING AND SUPPORT
If you've been diagnosed with Barrett's esophagus, you may worry about your risk of esophageal cancer. The risk of developing cancer is very small. If you experience anxiety, consider:
Activities that help you relax, such as exercise or listening to music
Healthy lifestyle choices, to ease any GERD symptoms and improve your overall health
BASAL CELL CARCINOMA
BASAL CELL CARCINOMA
Basal cell carcinoma is a type of skin cancer. Basal cell carcinoma begins in the basal cells — a type of cell within the skin that produces new skin cells as old ones die off.
Basal cell carcinoma often appears as a waxy bump, though it can take other forms. Basal cell carcinoma occurs most often on areas of the skin that are often exposed to the sun, such as your face and neck.
Most basal cell carcinomas are thought to be caused by long-term exposure to ultraviolet (UV) radiation from sunlight. Avoiding the sun and using sunscreen may help protect against basal cell carcinoma.
SYMPTOMS
Basal cell carcinomas usually develop on sun-exposed parts of your body, especially your head and neck. A much smaller number occur on the trunk and legs. Yet basal cell carcinomas can also occur on parts of your body that are rarely exposed to sunlight.
Although a general warning sign of skin cancer is a sore that won't heal or that repeatedly bleeds and scabs over, basal cell cancer may also appear as:
A pearly white or waxy bump, often with visible blood vessels, on your face, ears or neck. The bump may bleed and develop a crust. In darker skinned people, this type of cancer may be brown or black.
A flat, scaly, brown or flesh-colored patch on your back or chest. Over time, these patches can grow quite large.
More rarely, a white, waxy scar. This type of basal cell carcinoma is easy to overlook, but it may be a sign of a particularly invasive and disfiguring cancer called morpheaform basal cell carcinoma.
When to see a doctor
Make an appointment with your doctor if you have any signs or symptoms that worry you.
CAUSES
Basal cell carcinoma occurs when one of the skin's basal cells develops a mutation in its DNA. Basal cells are found at the bottom of the epidermis — the outermost layer of skin. Basal cells produce new skin cells. As new skin cells are produced, they push older cells toward the skin's surface, where the old cells die and are sloughed off.
The process of creating new skin cells is controlled by a basal cell's DNA. A mutation in the DNA causes a basal cell to multiply rapidly and continue growing when it would normally die. Eventually the accumulating abnormal cells may form a cancerous tumor.
Ultraviolet light and other causes
Much of the damage to DNA in basal cells is thought to result from ultraviolet (UV) radiation found in sunlight and in commercial tanning lamps and tanning beds. But sun exposure doesn't explain skin cancers that develop on skin not ordinarily exposed to sunlight. This indicates that other factors may contribute to your risk of skin cancer, such as being exposed to toxic substances or having a condition that weakens your immune system.
RISK FACTORS
Factors that increase your risk of basal cell carcinoma include:
Chronic sun exposure. A lot of time spent in the sun — or in commercial tanning booths — increases the risk of basal cell carcinoma. The threat is greater if you live in a sunny or high-altitude climate, both of which expose you to more UV radiation. The risk is also higher if most of your exposure occurred before the age of 18. Your risk is greater if you have had at least one blistering sunburn.
Exposure to radiation. Psoralen plus ultraviolet A (PUVA) treatments for psoriasis may increase your risk of basal cell carcinoma and other forms of skin cancer. Having undergone radiation treatments for childhood acne or other conditions also may increase your risk of basal cell carcinoma.
Fair skin. If you have very light skin or you freckle or sunburn easily, you're more likely to develop skin cancer than is someone with a darker complexion. Basal cell carcinoma is rare in black people.
Your sex. Men are more likely to develop basal cell carcinoma than women are.
Your age. Because basal cell carcinomas often take decades to develop, the majority of basal cell carcinomas occur in people age 50 or older.
A personal or family history of skin cancer. If you've had basal cell carcinoma one or more times, you have a good chance of developing it again. If you have a family history of skin cancer, you may have an increased risk of developing basal cell carcinoma.
Immune-suppressing drugs. Taking medications that suppress your immune system, especially after transplant surgery, significantly increases your risk of skin cancer. Cancers in people with a weakened immune system generally are more aggressive than they are in otherwise healthy people.
Exposure to arsenic. Arsenic, a toxic metal that's found widely in the environment, increases the risk of basal cell carcinoma and other cancers. Everyone has some arsenic exposure because it occurs naturally in the soil, air and groundwater. But people who may be exposed to higher levels of arsenic include farmers, refinery workers, and people who drink contaminated well water or live near smelting plants.
Inherited syndromes that cause skin cancer. Certain rare genetic diseases increase the risk of basal cell carcinoma. Nevoid basal cell carcinoma syndrome (Gorlin-Goltz syndrome) causes numerous basal cell carcinomas, as well as pitting on the hands and feet and spine abnormalities. Xeroderma pigmentosum causes an extreme sensitivity to sunlight and a high risk of skin cancer because people with this condition have little or no ability to repair damage to the skin from ultraviolet light.
COMPLICATIONS
Complications of basal cell carcinoma can include:
A risk of recurrence. Basal cell carcinomas commonly recur. Even after successful treatment, they may recur, often in the same place.
An increased risk of other types of skin cancer. A history of basal cell carcinoma may also increase the chance of developing other types of skin cancer, such as squamous cell carcinoma and melanoma.
Cancer that spreads beyond the skin. Rare, aggressive forms of basal cell carcinoma can invade and destroy nearby muscles, nerves and bone. Very rarely, basal cell carcinoma can spread to other areas of the body.
PREPARING FOR YOUR APPOINTMENT
If you have a skin wound or lesion that concerns you, make an appointment with your doctor. He or she may recommend that you see a doctor who specializes in the diagnosis and treatment of skin conditions (dermatologist).
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 your medical history, including other conditions for which you've been treated. Be sure to include any radiation therapy you may have received, even years ago.
Note any personal history of exposure to excessive UV light, including sunlight or tanning beds. For example, tell your doctor if you have worked as an outdoor lifeguard or spent lots of time at the beach.
Make a list of immediate family members who have had skin cancer, to the best of your ability. Skin cancer in a parent, grandparent, aunt, uncle or sibling is important history to share with your doctor.
Make a list of your medications and natural remedies. Include any prescription or over-the-counter medications you're taking, as well as all vitamins, supplements or herbal remedies.
Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.
Find a family member or friend who can join you for your appointment. Although skin cancer is usually highly treatable, just hearing the word "cancer" can make it difficult for most people to focus on what the doctor says next. Take someone along who can help take in all the information.
Below are some basic questions to ask your doctor about basal cell carcinoma. If any additional questions occur to you during your visit, don't hesitate to ask.
Do I have skin cancer? What kind?
How is this type of skin cancer different from other types?
Has my cancer spread?
What treatment approach do you recommend?
What are the possible side effects of this treatment?
Will I have a scar after treatment?
Am I at risk of this condition recurring?
Am I at risk of other types of skin cancer?
How often will I need follow-up visits after I finish treatment?
Are my family members at risk of skin cancer?
Are there brochures or other printed material that I can take with me? What websites do you recommend?
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 points you want to talk about in-depth. Your doctor may ask:
When did you first notice this skin growth or lesion?
Has it grown significantly since you first found it?
Is the growth or lesion painful?
Do you have any other growths or lesions that concern you?
Have you had a previous skin cancer?
Has anyone in your family had skin cancer? What kind?
How much exposure to the sun or tanning beds did you have as a child and teenager?
How much exposure to the sun or tanning beds do you have now?
Are you currently taking any medications?
Are you currently or have you previously used herbal remedies?
Have you ever received radiation therapy for a medical condition?
Have you ever taken medications that suppress your immune system?
What other significant medical conditions have you been treated for, including in your childhood?
Do you or did you smoke? How much?
Do you now have or have you ever had a job that may have exposed you to pesticides or herbicides?
Do you now rely or have you ever relied on well water as your primary water source?
Do you take precautions to stay safe in the sun, such as avoiding midday sun and using sunscreen?
Do you examine your own skin on a regular basis?
TESTS AND DIAGNOSIS
To diagnose basal cell carcinoma, your doctor may:
Examine your skin. Your doctor will examine the suspicious area on your skin. He or she will also look over the rest of your body for other unusual areas of skin.
Remove a sample of skin for testing. Your doctor may do a skin biopsy, which involves removing a small sample of the unusual skin for testing in a laboratory. This will reveal whether you have skin cancer and, if so, what type of skin cancer. The type of skin biopsy you undergo will depend on your situation.
TREATMENTS AND DRUGS
A number of treatments are available for basal cell carcinoma. What treatment is best for you depends on the type, location and severity of your cancer. Some commonly used basal cell carcinoma treatments include:
Electrodesiccation and curettage (ED&C). ED&C involves removing the surface of the skin cancer with a scraping instrument (curette) and then searing the base of the cancer with an electric needle. This treatment is often used for small cancers located on your legs and ears. ED&C can leave an oozing, crusty scab that heals over several weeks.
Surgical excision. In this procedure, your doctor cuts out the cancerous tissue and a surrounding margin of healthy skin. In some cases, you may have a wide excision, which involves removing additional normal skin around the cancer. A surgical excision may be an option if you have a large basal cell carcinoma. To minimize scarring, especially on your face, consult a doctor skilled in skin reconstruction.
Freezing. This involves killing cancerous cells by freezing them with liquid nitrogen (cryosurgery). It's useful for cancers that are very thin and don't extend deep into the skin.
Mohs surgery. During the procedure, your doctor removes the cancer cells layer by layer, examining each layer under the microscope until no abnormal cells remain. This allows the entire growth to be removed without taking an excessive amount of surrounding healthy tissue. This is an effective treatment for recurring basal cell carcinomas and those that are large, deep, fast-growing, morpheaform or on your face.
Topical treatments. Basal cell carcinoma that is superficial and doesn't extend very far into the skin may be treated with creams or ointments. The drugs imiquimod (Aldara) and fluorouracil (Carac, Fluoroplex, Efudex) are used for several weeks to treat certain basal cell carcinomas that are limited to the surface of the skin.
Medication for advanced cancer. Basal cell carcinoma that spreads to other areas of the body (metastasizes) may be treated with vismodegib (Erivedge). This medication may also be an option for people whose cancers haven't responded to other treatments.
Vismodegib blocks signals that allow basal cell carcinomas to continue growing.
LIFESTYLE AND HOME REMEDIES
You may reduce your risk of basal cell carcinoma if you:
Avoid the midday sun. Avoid the sun when its rays are the strongest. For most places, this is between about 10 a.m. and 4 p.m. Because the sun's rays are strongest during this period, try to schedule outdoor activities for other times of the day, even in winter. You absorb UV radiation year-round, and clouds offer little protection from damaging rays.
Use sunscreen year-round. Choose a sunscreen that blocks both UVA and UVB types of radiation from the sun and has an SPF of at least 15. Apply sunscreen generously, and reapply every two hours — or more often if you're swimming or perspiring. The American Academy of Dermatology recommends using a broad-spectrum sunscreen with an SPF of 30 or more. Even the best sunscreen might be less effective than the SPF number on the bottle would lead you to believe if it isn't applied thoroughly or thickly enough, or if it's perspired away or washed off while swimming.
Wear protective clothing. Wear protective clothing. Sunscreens don't provide complete protection from UV rays, so wear tightly woven clothing that covers your arms and legs, and a broad-brimmed hat, which provides more protection than a baseball cap or visor does. Some companies also sell photoprotective clothing. And don't forget sunglasses. Look for a pair that provides full protection from both UVA and UVB rays.
Avoid tanning beds. Tanning beds emit UV radiation, which can increase the risk of skin cancer.
Become familiar with your skin so that you'll notice changes. Examine your skin so that you become familiar with what your skin normally looks like. This way, you may be more likely to notice any skin changes. With the help of mirrors, check your face, neck, ears and scalp. Examine your chest and trunk, and the tops and undersides of your arms and hands. Examine both the front and back of your legs, and your feet, including the soles and the spaces between your toes. Also check your genital area, and between your buttocks. If you notice anything unusual, point it out to your doctor at your next appointment.
Ask your doctor about screening. If you've already had skin cancer, you have an increased risk of a second cancer. Talk with your dermatologist about how often you should be screened for a recurrence and whether you should do periodic skin checks on your own.
BED BUG BITE
BED BUG BITE
Bedbugs are small, reddish-brown parasitic insects that bite the exposed skin of sleeping humans and animals to feed on their blood. Although bedbugs aren't known to spread disease, they can cause other public health and economic issues.
About the size of an apple seed, bedbugs hide in the cracks and crevices of beds, box springs, headboards, bed frames and any other objects around a bed. The risk of encountering bedbugs increases if you spend time in places with high turnovers of nighttime guests — such as hotels, hospitals or homeless shelters.
If you have bedbugs in your home, professional extermination is recommended.
SYMPTOMS
It can be difficult to distinguish bedbug bites from other insect bites or rashes. In general, the sites of bedbug bites usually are:
Red, often with a darker red spot in the middle
Itchy
Arranged in a rough line or in a cluster
Located on the face, neck, arms and hands
Some people have no reaction to bedbug bites, while others experience an allergic reaction that can include severe itching, blisters or hives.
When to see a doctor
If you experience allergic reactions or severe skin reactions to bedbug bites, see your doctor for professional treatment.
CAUSES
Bedbug infestations may be linked to:
Increased international travel
Changes in pest control practices
Insecticide resistance
Where do they hide?
Bedbug infestations usually occur around or near where people sleep. They hide in the cracks and crevices of:
Mattresses
Box springs
Bed frames
Headboards
Objects or clutter near beds
They can also be found:
Under peeling paint and loose wallpaper
Under carpeting near baseboards
In upholstered furniture seams
Under light switch plates or electrical outlets
How do they spread?
Bedbugs are great hitchhikers. They can move from one site to another by traveling on clothing, luggage, furniture, bedding and boxes.
Bedbugs can crawl about as fast as a ladybug, and can easily travel between floors and rooms in hotels or apartment complexes.
Sign of uncleanliness?
Bedbugs don't care if their environment is clean or dirty. All they need is a warm host and plenty of hiding places.
RISK FACTORS
Bedbugs are more common in crowded lodgings that experience high turnover in occupancy, such as:
Apartment complexes
Dorm rooms
Homeless shelters
Hotels
Cruise ships
Trains and buses
Refugee camps
PREPARING FOR YOUR APPOINTMENT
Most bedbug bites require no medical treatment. Talk to your doctor if you experience an allergic reaction to the bites or if you develop a skin infection after scratching the bites.
What you can do
You may want to prepare a list that includes:
A detailed description of your symptoms
History of recent international travel
History of recent hotel stays
All the medications and supplements you take
What to expect from your doctor
Your doctor will carefully examine your bite sites and ask questions about the types of insects you might have been exposed to recently.
TESTS AND DIAGNOSIS
If you suspect that you're being bitten by bedbugs, immediately inspect your home for the insects. Thoroughly examine crevices in walls, mattresses and furniture. You may need to perform your inspection at night when bedbugs are active.
Look for these signs:
Dark specks. Typically found along mattress seams, these specks are bedbug excrement.
Empty exoskeletons. Bedbugs molt five times before becoming adults. These empty skins are pale yellow.
Rusty or reddish stains. You may find small smears of blood on your bed sheets where you accidentally crushed a bedbug.
TREATMENTS AND DRUGS
The itchy red spots associated with bedbug bites usually disappear on their own within a week or two. You might speed your recovery by using:
A skin cream containing hydrocortisone (Cortaid)
An oral antihistamine, such as diphenhydramine (Benadryl)
If you develop a skin infection from scratching bedbug bites, your doctor may prescribe an antibiotic.
Treating your home
Once your symptoms are treated, you must tackle the underlying infestation. This can be difficult because bedbugs hide so well and can live several months without eating. Your best bet may be to hire a professional exterminator, who may use a combination of pesticides and nonchemical treatments.
Nonchemical treatments may include:
Vacuuming. A thorough vacuuming of cracks and crevices can physically remove bedbugs from an area. Empty the vacuum after each use.
Laundering. Washing and drying items in a dryer on a high setting will kill bedbugs in clothing or linens.
Freezing. Bedbugs are also vulnerable to temperatures below 32 F (0 C), but you'd need to leave the items outdoors or in the freezer for several days.
Some professional exterminators use portable devices to raise the temperature of a room to a lethal temperature. All stages of bedbugs can be killed at 122 F (50 C). In some cases, you may have to throw out heavily infested items such as mattresses or couches.
LIFESTYLE AND HOME REMEDIES
Preventing bites
Cover up. Because bedbugs don't tend to burrow under clothing, you may be able to avoid bites by wearing pajamas that cover as much skin as possible.
Bug spray. Insect repellents designed to protect against mosquitoes or ticks aren't very effective against bedbugs.
Mosquito netting. Bed nets impregnated with the pesticide permethrin may help protect sleepers against bedbug bites. However, this practice may be helping bedbugs develop resistance to this pesticide.
Preventing infestations
Secondhand items. Inspect used mattresses and upholstered furniture carefully before bringing them into your home.
Hotel precautions. Check mattress seams for bedbug excrement and place your luggage on tables or dressers instead of on the floor.
Birds and bats. Eliminate any neighboring bird and bat habitats that may serve as a refuge for bedbugs.
BED SORES
BED SORES
Bedsores — also called pressure sores or pressure ulcers — are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone.
People most at risk of bedsores are those with a medical condition that limits their ability to change positions, requires them to use a wheelchair or confines them to a bed for a long time.
Bedsores can develop quickly and are often difficult to treat. Several things can help prevent some bedsores and help with healing.
SYMPTOMS
Bedsores fall into one of four stages based on their severity. The National Pressure Ulcer Advisory Panel, a professional organization that promotes the prevention and treatment of pressure ulcers, defines each stage as follows:
Stage I
The beginning stage of a pressure sore has the following characteristics:
The skin is not broken.
The skin appears red on people with lighter skin color, and the skin doesn't briefly lighten (blanch) when touched.
On people with darker skin, the skin may show discoloration, and it doesn't blanch when touched.
The site may be tender, painful, firm, soft, warm or cool compared with the surrounding skin.
Stage II
At stage II:
The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost.
The wound may be shallow and pinkish or red.
The wound may look like a fluid-filled blister or a ruptured blister.
Stage III
At stage III, the ulcer is a deep wound:
The loss of skin usually exposes some fat.
The ulcer looks crater-like.
The bottom of the wound may have some yellowish dead tissue.
The damage may extend beyond the primary wound below layers of healthy skin.
Stage IV
A stage IV ulcer shows large-scale loss of tissue:
The wound may expose muscle, bone or tendons.
The bottom of the wound likely contains dead tissue that's yellowish or dark and crusty.
The damage often extends beyond the primary wound below layers of healthy skin.
Unstageable
A pressure ulcer is considered unstageable if its surface is covered with yellow, brown, black or dead tissue. It’s not possible to see how deep the wound is.
Deep tissue injury
A deep tissue injury may have the following characteristics:
The skin is purple or maroon but the skin is not broken.
A blood-filled blister is present.
The area is painful, firm or mushy.
The area is warm or cool compared with the surrounding skin.
In people with darker skin, a shiny patch or a change in skin tone may develop.
Common sites of pressure sores
For people who use a wheelchair, pressure sores often occur on skin over the following sites:
Tailbone or buttocks
Shoulder blades and spine
Backs of arms and legs where they rest against the chair
For people who are confined to a bed, common sites include the following:
Back or sides of the head
Rim of the ears
Shoulders or shoulder blades
Hip, lower back or tailbone
Heels, ankles and skin behind the knees
When to see a doctor
If you notice early signs or symptoms of a pressure ulcer, change your position to relieve the pressure on the area. If you don't see improvement in 24 to 48 hours, contact your doctor. Seek immediate medical care if you show signs of infection, such as fever, drainage or a foul odor from a sore, or increased heat and redness in the surrounding skin.
CAUSES
Bedsores are caused by pressure against the skin that limits blood flow to the skin and nearby tissues. Other factors related to limited mobility can make the skin vulnerable to damage and contribute to the development of pressure sores. Three primary contributing factors are:
Sustained pressure. When your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or a bed, the pressure may be greater than the pressure of the blood flowing in the tiny vessels (capillaries) that deliver oxygen and other nutrients to tissues. Without these essential nutrients, skin cells and tissues are damaged and may eventually die.
This kind of pressure tends to happen in areas that aren't well-padded with muscle or fat and that lie over a bone, such as your spine, tailbone, shoulder blades, hips, heels and elbows.
Friction. Friction is the resistance to motion. It may occur when the skin is dragged across a surface, such as when you change position or a care provider moves you. The friction may be even greater if the skin is moist. Friction may make fragile skin more vulnerable to injury.
Shear. Shear occurs when two surfaces move in the opposite direction. For example, when a hospital bed is elevated at the head, you can slide down in bed. As the tailbone moves down, the skin over the bone may stay in place — essentially pulling in the opposite direction. This motion may injure tissue and blood vessels, making the site more vulnerable to damage from sustained pressure.
RISK FACTORS
People are at risk of developing pressure sores if they have difficulty moving and are unable to easily change position while seated or in bed. Immobility may be due to:
Generally poor health or weakness
Paralysis
Injury or illness that requires bed rest or wheelchair use
Recovery after surgery
Sedation
Coma
Other factors that increase the risk of pressure sores include:
Age. The skin of older adults is generally more fragile, thinner, less elastic and drier than the skin of younger adults. Also, older adults usually produce new skin cells more slowly. These factors make skin vulnerable to damage.
Lack of sensory perception. Spinal cord injuries, neurological disorders and other conditions can result in a loss of sensation. An inability to feel pain or discomfort can result in not being aware of bedsores or the need to change position.
Weight loss. Weight loss is common during prolonged illnesses, and muscle atrophy and wasting are common in people with paralysis. The loss of fat and muscle results in less cushioning between bones and a bed or a wheelchair.
Poor nutrition and hydration. People need enough fluids, calories, protein, vitamins and minerals in their daily diet to maintain healthy skin and prevent the breakdown of tissues.
Excess moisture or dryness. Skin that is moist from sweat or lack of bladder control is more likely to be injured and increases the friction between the skin and clothing or bedding. Very dry skin increases friction as well.
Bowel incontinence. Bacteria from fecal matter can cause serious local infections and lead to life-threatening infections affecting the whole body.
Medical conditions affecting blood flow. Health problems that can affect blood flow, such as diabetes and vascular disease, increase the risk of tissue damage.
Smoking. Smoking reduces blood flow and limits the amount of oxygen in the blood. Smokers tend to develop more-severe wounds, and their wounds heal more slowly.
Limited alertness. People whose mental awareness is lessened by disease, trauma or medications may be unable to take the actions needed to prevent or care for pressure sores.
Muscle spasms. People who have frequent muscle spasms or other involuntary muscle movement may be at increased risk of pressure sores from frequent friction and shearing.
COMPLICATIONS
Complications of pressure ulcers include:
Sepsis. Sepsis occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure.
Cellulitis. Cellulitis is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. Cellulitis can lead to life-threatening complications.
Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteomyelitis) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications.
Cancer. Another complication is the development of a type of squamous cell carcinoma that develops in chronic, nonhealing wounds (Marjolin ulcer). This type of cancer is aggressive and usually requires surgery.
TESTS AND DIAGNOSIS
Evaluating a bedsore
To evaluate a bedsore, your doctor will:
Determine the size and depth of the ulcer
Check for bleeding, fluids or debris in the wound that can indicate severe infection
Try to detect odors indicating an infection or dead tissue
Check the area around the wound for signs of spreading tissue damage or infection
Check for other pressure sores on the body
Questions from the doctor
When did the pressure sore first appear?
What is the degree of pain?
Have you had pressure sores in the past?
How were they managed, and what was the outcome of treatment?
What kind of care assistance is available to you?
What is your routine for changing positions?
What medical conditions have you been diagnosed with, and what is your current treatment?
What is your normal daily diet?
How much water and other fluids do you drink each day?
Tests
Your doctor may order the following tests:
Blood tests to check your health
Tissue cultures to diagnose a bacterial or fungal infection in a wound that doesn't heal with treatment or is already at stage IV
Tissue cultures to check for cancerous tissue in a chronic, nonhealing wound
TREATMENTS AND DRUGS
Stage I and II bedsores usually heal within several weeks to months with conservative care of the wound and ongoing, appropriate general care. Stage III and IV bedsores are more difficult to treat.
Treatment team
Addressing the many aspects of wound care usually requires a multidisciplinary approach. Members of your care team may include:
A primary care physician who oversees the treatment plan
A physician specializing in wound care
Nurses or medical assistants who provide both care and education for managing wounds
A social worker who helps you or your family access appropriate resources and addresses emotional concerns related to long-term recovery
A physical therapist who helps with improving mobility
A dietitian who monitors your nutritional needs and recommends an appropriate diet
A neurosurgeon, orthopedic surgeon or plastic surgeon, depending on whether you need surgery and what type
Reducing pressure
The first step in treating a bedsore is reducing the pressure that caused it. Strategies include the following:
Repositioning. If you have a pressure sore, you need to be repositioned regularly and placed in correct positions. If you use a wheelchair, try shifting your weight every 15 minutes or so. Ask for help with repositioning every hour. If you're confined to a bed, change positions every two hours.
If you have enough upper body strength, try repositioning yourself using a device such as a trapeze bar. Caregivers can use bed linens to help lift and reposition you. This can reduce friction and shearing.
Using support surfaces. Use a mattress, bed and special cushions that help you lie in an appropriate position, relieve pressure on any sores and protect vulnerable skin. If you are in a wheelchair, use a cushion. Styles include foam, air filled and water filled. Select one that suits your condition, body type and mobility.
Cleaning and dressing wounds
Care that helps with healing of the wound includes the following:
Cleaning. It's essential to keep wounds clean to prevent infection. If the affected skin is not broken (a stage I wound), gently wash it with water and mild soap and pat dry. Clean open sores with a saltwater (saline) solution each time the dressing is changed.
Applying dressings. A dressing promotes healing by keeping a wound moist, creating a barrier against infection and keeping the surrounding skin dry. Dressing choices include films, gauzes, gels, foams and treated coverings. A combination of dressings may be used.
Your doctor selects a dressing based on a number of factors, such as the size and severity of the wound, the amount of discharge, and the ease of placing and removing the dressing.
Removing damaged tissue
To heal properly, wounds need to be free of damaged, dead or infected tissue. Removing this tissue (debridement) is accomplished with a number of methods, depending on the severity of the wound, your overall condition and the treatment goals.
Surgical debridement involves cutting away dead tissue.
Mechanical debridement loosens and removes wound debris. This may be done with a pressurized irrigation device, low-frequency mist ultrasound or specialized dressings.
Autolytic debridement enhances the body's natural process of using enzymes to break down dead tissue. This method may be used on smaller, uninfected wounds and involves special dressings to keep the wound moist and clean.
Enzymatic debridement involves applying chemical enzymes and appropriate dressings to break down dead tissue.
Other interventions
Other interventions that may be used are:
Pain management. Pressure ulcers can be painful. Nonsteroidal anti-inflammatory drugs — such as ibuprofen (Motrin IB, Advil, others) and naproxen (Aleve, others) — may reduce pain. These may be very helpful before or after repositioning, debridement procedures and dressing changes. Topical pain medications also may be used during debridement and dressing changes.
Antibiotics. Infected pressure sores that aren't responding to other interventions may be treated with topical or oral antibiotics.
A healthy diet. To promote wound healing, your doctor or dietitian may recommend an increase in calories and fluids, a high-protein diet, and an increase in foods rich in vitamins and minerals. You may be advised to take dietary supplements, such as vitamin C and zinc.
Management of incontinence. Urinary or bowel incontinence may cause excess moisture and bacteria on the skin, increasing the risk of infection. Managing incontinence may help improve healing. Strategies include frequently scheduled help with urinating, frequent diaper changes, protective lotions on healthy skin, and urinary catheters or rectal tubes.
Muscle spasm relief. Spasm-related friction or shearing can cause or worsen bedsores. Muscle relaxants — such as diazepam (Valium), tizanidine (Zanaflex), dantrolene (Dantrium) and baclofen (Gablofen, Lioresal) — may inhibit muscle spasms and help sores heal.
Negative pressure therapy (vacuum-assisted closure, or VAC). This therapy uses a device that applies suction to a clean wound. It may help healing in some types of pressure sores.
Surgery
A pressure sore that fails to heal may require surgery. The goals of surgery include improving the hygiene and appearance of the sore, preventing or treating infection, reducing fluid loss through the wound, and lowering the risk of cancer.
If you need surgery, the type of procedure depends mainly on the location of the wound and whether it has scar tissue from a previous operation. In general, most pressure sores are repaired using a pad of your muscle, skin or other tissue to cover the wound and cushion the affected bone (flap reconstruction).
LIFESTYLE AND HOME REMEDIES
Bedsores are easier to prevent than to treat, but that doesn't mean the process is easy or uncomplicated. And wounds may still develop with consistent, appropriate preventive care.
Your doctor and other members of the care team can help develop a good strategy, whether it's personal care with at-home assistance, professional care in a hospital or some other situation.
Position changes are key to preventing pressure sores. These changes need to be frequent, repositioning needs to avoid stress on the skin, and body positions need to minimize pressure on vulnerable areas. Other strategies include taking good care of your skin, maintaining good nutrition, quitting smoking and exercising daily.
Repositioning in a wheelchair
Consider the following recommendations related to repositioning in a wheelchair:
Shift your weight frequently. If you use a wheelchair, try shifting your weight about every 15 minutes. Ask for help with repositioning about once an hour.
Lift yourself, if possible. If you have enough upper body strength, do wheelchair pushups — raising your body off the seat by pushing on the arms of the chair.
Look into a specialty wheelchair. Some wheelchairs allow you to tilt them, which can relieve pressure.
Select a cushion that relieves pressure. Use cushions to relieve pressure and help ensure your body is well-positioned in the chair. Various cushions are available, such as foam, gel, water filled and air filled. A physical therapist can advise you on how to place them and their role in regular repositioning.
Repositioning in a bed
Consider the following recommendations when repositioning in a bed:
Reposition yourself frequently. Change your body position every two hours.
Look into devices to help you reposition. If you have enough upper body strength, try repositioning yourself using a device such as a trapeze bar. Caregivers can use bed linens to help lift and reposition you. This can reduce friction and shearing.
Try a specialized mattress. Use special cushions, a foam mattress pad, an air-filled mattress or a water-filled mattress to help with positioning, relieving pressure and protecting vulnerable areas. Your doctor or other care team members can recommend an appropriate mattress or surface.
Adjust the elevation of your bed. If your hospital bed can be elevated at the head, raise it no more than 30 degrees. This helps prevent shearing.
Use cushions to protect bony areas. Protect bony areas with proper positioning and cushioning. Rather than lying directly on a hip, lie at an angle with cushions supporting the back or front. You can also use cushions to relieve pressure against and between the knees and ankles. You can cushion or ''float'' your heels with cushions below the calves.
Skin care
Protecting and monitoring the condition of your skin is important for preventing pressure sores and identifying stage I sores early so that you can treat them before they worsen.
Clean the affected skin. Clean the skin with mild soap and warm water or a no-rinse cleanser. Gently pat dry.
Protect the skin. Use talcum powder to protect skin vulnerable to excess moisture. Apply lotion to dry skin. Change bedding and clothing frequently. Watch for buttons on the clothing and wrinkles in the bedding that irritate the skin.
Inspect the skin daily. Inspect the skin daily to identify vulnerable areas or early signs of pressure sores. You will probably need the help of a care provider to do a thorough skin inspection. If you have enough mobility, you may be able to do this with the help of a mirror.
Manage incontinence to keep the skin dry. If you have urinary or bowel incontinence, take steps to prevent exposing the skin to moisture and bacteria. Your care may include frequently scheduled help with urinating, frequent diaper changes, protective lotions on healthy skin, or urinary catheters or rectal tubes.
Nutrition
Your doctor, a dietitian or other members of the care team can recommend nutritional changes to help improve the health of your skin.
Choose a healthy diet. You may need to increase the amount of calories, protein, vitamins and minerals in your diet. You may be advised to take dietary supplements, such as vitamin C and zinc.
Drink enough to keep the skin hydrated. Good hydration is important for maintaining healthy skin. Your care team can advise you on how much to drink and signs of poor hydration. These include decreased urine output, darker urine, dry or sticky mouth, thirst, dry skin, and constipation.
Ask for help if eating is difficult. If you have limited mobility or significant weakness, you may need help with eating in order to get adequate nutrition.
Other strategies
Other important strategies that can help decrease the risk of bedsores include the following:
Quit smoking. If you smoke, quit. Talk to your doctor if you need help.
Stay active. Limited mobility is a key factor in causing pressure sores. Daily exercise matched to your abilities can help maintain healthy skin. A physical therapist can recommend an appropriate exercise program that improves blood flow, builds up vital muscle tissue, stimulates appetite and strengthens the body.
COPING AND SUPPORT
Treating and preventing pressure sores is demanding on you, your family members and caregivers. Issues that may need to be addressed by your doctor, the nursing staff and a social worker include the following:
Community services. A social worker can help identify community groups that provide services, education and support for people dealing with long-term caregiving or terminal illnesses.
End-of-life care. When someone is approaching death, physicians and nurses specializing in end-of-life care (palliative care) can help a patient and his or her family determine treatment goals. At this time, goals may include managing pain and providing comfort.
Residential care. People with limited mobility who live in residential or nursing care facilities are at increased risk of developing pressure sores. Family and friends of people living in these facilities can be advocates for the residents and work with nursing staff to ensure proper preventive care.
BED WETTING
BED WETTING
Soggy sheets and pajamas — and an embarrassed child — are a familiar scene in many homes. But don't despair. Bed-wetting isn't a sign of toilet training gone bad. It's often just a normal part of a child's development.
Bed-wetting is also known as nighttime incontinence or nocturnal enuresis. Generally, bed-wetting before age 7 isn't a concern. At this age, your child may still be developing nighttime bladder control.
If bed-wetting continues, treat the problem with patience and understanding. Bladder training, moisture alarms or medication may help reduce bed-wetting.
SYMPTOMS
Bed-wetting is involuntary urination while asleep after the age at which staying dry at night can be reasonably expected.
Most kids are fully toilet trained by age 5, but there's really no target date for developing complete bladder control. Between the ages of 5 and 7, bed-wetting remains a problem for some children. After 7 years of age, a small number of children still wet the bed.
When to see a doctor
Most children outgrow bed-wetting on their own — but some need a little help. In other cases, bed-wetting may be a sign of an underlying condition that needs medical attention.
Consult your child's doctor if:
Your child still wets the bed after age 7
Your child starts to wet the bed after a few months or more of being dry at night
Bed-wetting is accompanied by painful urination, unusual thirst, pink or red urine, hard stools, or snoring
CAUSES
No one knows for sure what causes bed-wetting, but various factors may play a role:
A small bladder. Your child's bladder may not be developed enough to hold urine produced during the night.
Inability to recognize a full bladder. If the nerves that control the bladder are slow to mature, a full bladder may not wake your child — especially if your child is a deep sleeper.
A hormone imbalance. During childhood, some kids don't produce enough anti-diuretic hormone (ADH) to slow nighttime urine production.
Stress. Stressful events — such as becoming a big brother or sister, starting a new school, or sleeping away from home — may trigger bed-wetting.
Urinary tract infection. This infection can make it difficult for your child to control urination. Signs and symptoms may include bed-wetting, daytime accidents, frequent urination, red or pink urine, and pain during urination.
Sleep apnea. Sometimes bed-wetting is a sign of obstructive sleep apnea, a condition in which the child's breathing is interrupted during sleep — often due to inflamed or enlarged tonsils or adenoids. Other signs and symptoms may include snoring, frequent ear and sinus infections, sore throat, or daytime drowsiness.
Diabetes. For a child who's usually dry at night, bed-wetting may be the first sign of diabetes. Other signs and symptoms may include passing large amounts of urine at once, increased thirst, fatigue and weight loss in spite of a good appetite.
Chronic constipation. The same muscles are used to control urine and stool elimination. When constipation is long term, these muscles can become dysfunctional and contribute to bed-wetting at night.
A structural problem in the urinary tract or nervous system. Rarely, bed-wetting is related to a defect in the child's neurological system or urinary system.
RISK FACTORS
Several factors have been associated with an increased risk of bed-wetting, including:
Being male. Bed-wetting can affect anyone, but it's twice as common in boys as girls.
Family history. If one or both of a child's parents wet the bed as children, their child has a significant chance of wetting the bed, too.
Attention-deficit/hyperactivity disorder (ADHD). Bed-wetting is more common in children who have ADHD.
COMPLICATIONS
Although frustrating, bed-wetting without a physical cause doesn't pose any health risks. However, bed-wetting can create some issues for your child, including:
Guilt and embarrassment, which can lead to low self-esteem
Loss of opportunities for social activities, such as sleepovers and camp
Rashes on the child's bottom and genital area — especially if your child sleeps in wet underwear
PREPARING FOR YOUR APPOINTMENT
You're likely to start by seeing your child's pediatrician. However, he or she may refer you to a doctor who specializes in urinary disorders (pediatric urologist or nephrologist).
Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
Before your appointment, make a list of:
Any signs or symptoms, including any major ones that may seem unrelated to bed-wetting. Consider keeping a diary of your child's bathroom visits. Note when your child goes to the toilet and whether he or she felt a sense of urgency to urinate. Also note how much fluid your child drinks, especially after dinner.
Key personal information, including any major stresses or recent life changes.
All medications, vitamins and other supplements that your child is taking, and the dosages.
Questions to ask your child's doctor so you can make the most of your time together.
For bed-wetting, some basic questions to ask your doctor include:
What's causing my child to wet the bed?
When might he or she outgrow wetting the bed?
What treatments are available, and which do you recommend?
Are there any side effects?
Are there any alternatives to the primary approach that you're suggesting?
Should my child follow any drinking restrictions?
Are there any brochures or other printed material that I can have? What websites do you recommend?
Don't hesitate to ask questions anytime during your appointment.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Be ready to answer them to reserve time to go over any points you want to focus on. Your doctor may ask:
Is there a family history of bed-wetting?
Has your child always wet the bed, or did it begin recently?
How often does your child wet the bed?
Are there periods of time when your child does not wet the bed?
Is your child dry during the day?
Is your child having stool accidents?
Does your child complain of pain or other symptoms when urinating?
Is your child facing any major life changes or other stresses?
If you're separated or divorced, does your child alternate living at each parent's home, and does the bed-wetting occur in both homes?
TESTS AND DIAGNOSIS
Your child will need a physical exam. Depending on the circumstances, your doctor may recommend:
Urine tests to check for signs of an infection or diabetes
X-rays or other imaging tests of the kidneys or bladder, if the doctor suspects a structural problem with your child's urinary tract or another health concern
Other types of tests or assessments, if other health issues are suspected
TREATMENTS AND DRUGS
Most children outgrow bed-wetting on their own. If there's a family history of bed-wetting, your child will probably stop bed-wetting around the age the parent stopped bed-wetting.
If your child isn't especially bothered or embarrassed by an occasional wet night, traditional home remedies may work well. However, if your grade schooler is terrified about wetting the bed during a sleepover, he or she may be more motivated to try additional treatments. The child's and parents' motivation can impact the selection of treatment and its success.
If found, underlying causes of bed-wetting, such as constipation or sleep apnea, should be addressed before other treatment.
Moisture alarms
These small, battery-operated devices — available without a prescription at most pharmacies — connect to a moisture-sensitive pad on your child's pajamas or bedding. When the pad senses wetness, the alarm goes off.
Ideally, the moisture alarm sounds just as your child begins to urinate — in time to help your child wake, stop the urine stream and get to the toilet. If your child is a heavy sleeper, another person may need to listen for the alarm and wake the child.
If you try a moisture alarm, give it plenty of time. It often takes at least two weeks to see any type of response and up to 16 weeks to enjoy dry nights. Moisture alarms are effective for many children, carry a low risk of relapse or side effects, and may provide a better long-term solution than medication does. These devices are not typically covered by insurance.
Medication
As a last resort, your child's doctor may prescribe medication to stop bed-wetting. Certain types of medication can:
Slow nighttime urine production. The drug desmopressin (DDAVP, others) boosts levels of a natural hormone (anti-diuretic hormone, or ADH) that forces the body to make less urine at night. But drinking too much liquid with the medication can cause problems with low sodium levels in the blood and the potential for seizures. So drinking only 8 ounces (237 milliliters) of fluids with and after the medication is recommended. Don't give your child this medication if he or she has a headache, has vomited or feels nauseated. Desmopressin also may be used in short-term situations, such as going to camp.
According to the Food and Drug Administration, nasal spray formulations of desmopressin (DDAVP Nasal Spray, DDAVP Rhinal Tube, others) are no longer recommended for treatment of bed-wetting due to the risk of serious side effects.
Calm the bladder. If your child has a small bladder, an anticholinergic drug such as oxybutynin (Ditropan XL) may help reduce bladder contractions and increase bladder capacity. This medication is usually used in combination with other medications and is generally recommended only when other treatments have failed.
Sometimes a combination of medications is most effective. There are no guarantees, however, and medication doesn't cure the problem. Bed-wetting typically resumes when medication is stopped.
LIFESTYLE AND HOME REMEDIES
Here are changes you can make at home that may help:
Limit how much your child drinks in the evening. It's important to get enough fluids, so there's no need to limit how much your child drinks in a day. However, encourage your child to focus on drinking liquids in the morning and early afternoon, which may reduce thirst in the evening. But don't limit evening fluids if your child participates in sports practice or games in the evenings.
Avoid beverages and foods with caffeine. Beverages with caffeine are discouraged for children at any time of day. Because caffeine may stimulate the bladder, it's especially discouraged in the evening.
Encourage double voiding before bed. Double voiding is urinating at the beginning of the bedtime routine and then again just before falling asleep. Remind your child that it's OK to use the toilet during the night if needed. Use small night lights, so your child can easily find the way between the bedroom and bathroom.
Encourage regular toilet use throughout the day. During the day and evening, suggest that your child urinate every two hours or so, or at least often enough to avoid a feeling of urgency.
Treat constipation. If constipation is a problem for your child, your doctor may recommend a stool softener.
Prevent rashes. To prevent a rash caused by wet underpants, help your child rinse his or her bottom and genital area every morning. It also may help to cover the affected area with a protective moisture barrier ointment or cream at bedtime. Ask your pediatrician for product recommendations.
ALTERNATIVE MEDICINE
Some people are interested in trying alternative medicine to treat bed-wetting. Alternative medicine is the use of a nonconventional approach instead of conventional medicine. Others may want to try complementary medicine — a nonconventional approach used along with conventional medicine — to treat bed-wetting.
Several therapies, such as hypnosis and acupuncture, have limited evidence of effectiveness, and others don't have evidence to support their use.
Hypnosis. Small trials of hypnosis coupled with suggestions of waking up in a dry bed or visiting the toilet in the night found that this therapy may help some children stay dry throughout the night, but more research is needed.
Acupuncture. This treatment involves the insertion of fine needles in specific parts of the body. Acupuncture may be effective for some children, but more research is needed.
Diet. Some people believe that certain foods affect bladder function and that removing these foods from the diet could help decrease bed-wetting. The evidence is uncertain and more research is needed.
Chiropractic therapy. The idea behind chiropractic therapy is that if the spine is out of alignment, normal bodily functions will be affected. However, there's little evidence regarding the use of chiropractic therapy for the treatment of bed-wetting.
Homeopathy and herbs. Although some people are interested in homeopathic remedies and herbal products, none of these has proved effective in clinical trials.
Be sure to talk to your child's doctor before starting any complementary or alternative therapy. If you choose a nonconventional approach, ask the doctor if it's safe for your child and make sure it won't interact with any medications your child may take.
COPING AND SUPPORT
Children don't wet the bed to irritate their parents. Try to be patient as you and your child work through the problem together.
Be sensitive to your child's feelings. If your child is stressed or anxious, encourage him or her to express those feelings. Offer support and encouragement if your child has anxiety about stressful events. When your child feels calm and secure, bed-wetting may become a thing of the past. If needed, talk to your doctor about additional strategies for dealing with stress.
Plan for easy cleanup. Cover your child's mattress with a plastic cover. Use thick, absorbent underwear at night to help contain the urine. Keep extra bedding and pajamas handy. However, avoid the long-term use of diapers or disposable pull-up underwear.
Enlist your child's help. Perhaps your child can rinse his or her wet underwear and pajamas or place these items in a specific container for washing. Taking responsibility for bed-wetting may help your child feel more control over the situation.
Celebrate effort. Bed-wetting is involuntary, so it doesn't make sense to punish or tease your child for wetting the bed or reward him or her for staying dry. Instead, praise your child for following the bedtime routine and helping clean up after accidents. Use a sticker reward system if you think this might help motivate your child.
With reassurance, support and understanding, your child can look forward to the dry nights ahead.
BEE STINGS
BEE STINGS
Bee stings are a common outdoor nuisance. In most cases, bee stings are just annoying, and home treatment is all that's necessary to ease the pain of bee stings. But if you're allergic to bee stings or you get stung numerous times, you may have a more serious reaction that requires emergency treatment.
You can take several steps to avoid bee stings — as well as hornet and wasp stings — and find out how to treat them if you do get stung.
SYMPTOMS
Bee stings can produce different reactions, ranging from temporary pain and discomfort to a severe allergic reaction. Having one type of reaction doesn't mean you'll always have the same reaction every time you're stung.
Mild reaction
Most of the time, bee sting symptoms are minor and include:
Instant, sharp burning pain at the sting site
A red welt at the sting area
A small, white spot where the stinger punctured the skin
Slight swelling around the sting area
In most people, swelling and pain go away within a few hours.
Moderate reaction
Some people who get stung by a bee or other insect have a bit stronger reaction, with signs and symptoms such as:
Extreme redness
Swelling at the site of the sting that gradually enlarges over the next day or two
Moderate reactions tend to resolve over five to 10 days. Having a moderate reaction doesn't mean you'll have a severe allergic reaction the next time you're stung. But some people develop similar moderate reactions each time they're stung. If this happens to you, talk to your doctor about treatment and prevention, especially if the reaction becomes more severe each time.
Severe allergic reaction
A severe allergic reaction (anaphylaxis) to bee stings is potentially life-threatening and requires emergency treatment. A small percentage of people who are stung by a bee or other insect quickly develop anaphylaxis. Signs and symptoms of anaphylaxis include:
Skin reactions, including hives and itching and flushed or pale skin
Difficulty breathing
Swelling of the throat and tongue
A weak, rapid pulse
Nausea, vomiting or diarrhea
Dizziness or fainting
Loss of consciousness
People who have a severe allergic reaction to a bee sting have a 30 to 60 percent chance of anaphylaxis the next time they're stung. Talk to your doctor or an allergy specialist about prevention measures such as immunotherapy to avoid a similar reaction in case you get stung again.
Multiple bee stings
Generally, insects such as bees and wasps aren't aggressive and only sting in self-defense. In most cases, this results in one or perhaps a few stings. However, in some cases a person will disrupt a hive or swarm of bees and get multiple stings. Some types of bees — such as Africanized honeybees — are more likely than are other bees to swarm, stinging in a group.
If you get stung more than a dozen times, the accumulation of venom may induce a toxic reaction and make you feel quite sick. Signs and symptoms include:
Nausea, vomiting or diarrhea
Headache
Vertigo
Feeling faint or fainting
Convulsions
Fever
Multiple stings can be a medical emergency in children, older adults, and people who have heart or breathing problems.
When to see a doctor
In most cases, bee stings don't require a visit to your doctor. In more-severe cases, you'll need immediate care.
Call 911 or other emergency services if:
You're having a serious reaction to a bee sting that suggests anaphylaxis, even if it's just one or two signs or symptoms
If you were prescribed an emergency epinephrine autoinjector (EpiPen, Twinject), use it right away as your doctor directed.
Seek prompt medical care if:
You've been swarmed by bees and have multiple stings
Make an appointment to see your doctor if:
Bee sting symptoms don't go away within a few days
You've had other symptoms of an allergic response to a bee sting
CAUSES
Bee sting venom contains proteins that affect skin cells and the immune system, causing pain and swelling around the sting area. In people with a bee sting allergy, bee venom can trigger a more serious immune system reaction.
RISK FACTORS
You're at increased risk of bee stings if:
You live in an area where bees are especially active or with beehives nearby
Your work or hobbies require spending time outside
You're more likely to have an allergic reaction to bee stings if you've had an allergic reaction to a bee sting in the past, even if it was minor.
Adults tend to have more-severe reactions than children do and are more likely to die of anaphylaxis than children are.
PREPARING FOR YOUR APPOINTMENT
Bee and other insect stings are a common cause of anaphylaxis. If you've had a serious reaction to a bee sting but did not seek emergency treatment, consult your doctor. He or she may refer you to an allergy specialist (allergist) who can determine whether you're allergic to bee or other insect venom and can help you find ways to prevent future allergic reactions.
Your doctor or allergist will do a thorough physical examination and will want to know:
When and where you were stung
What symptoms you had after getting stung
Whether you've had an allergic reaction to an insect sting in the past, even if it was minor
Whether you have other allergies, such as hay fever
What medications you take, including herbal remedies
Any health problems you have
Some questions you might want to ask your doctor include:
What do I do if I get stung again?
If I have an allergic reaction, do I need to use emergency medication such as an epinephrine autoinjector (EpiPen, Twinject)?
How can I prevent this reaction from happening again?
Don't hesitate to ask other questions, as well.
TESTS AND DIAGNOSIS
If you've had a reaction to bee stings that suggests you might be allergic to bee venom, your doctor may suggest one or both of the following tests:
Skin test. During skin testing, a small amount of allergen extract (in this case, bee venom) is injected into the skin of your arm or upper back. This test is safe and won't cause any serious reactions. If you're allergic to bee stings, you'll develop a raised bump on your skin at the test site.
Allergy blood test. A blood test can measure your immune system's response to bee venom by measuring the amount of allergy-causing antibodies in your bloodstream. A blood sample is sent to a medical laboratory, where it can be tested for evidence of sensitivity to possible allergens.
Allergy skin tests and allergy blood tests are often used together to diagnose insect allergies. Your doctor may also want to test you for allergies to yellow jackets, hornets and wasps — which can cause allergic reactions similar to those of bee stings.
TREATMENTS AND DRUGS
For ordinary bee stings that do not cause an allergic reaction, home treatment is enough. Multiple stings or an allergic reaction, on the other hand, can be a medical emergency that requires immediate treatment.
Treatment for minor reactions
To sting, a bee jabs a barbed stinger into the skin. Removing the stinger and its attached venom sac right away will keep more venom from being released.
Remove the stinger as soon as you can, as it takes only seconds for all of the venom to enter your body. Get the stinger out any way you can, such as with your fingernails or a tweezer.
Wash the sting area with soap and water.
Apply cold compresses or ice to relieve pain and ease swelling.
Treatment for moderate reactions
The following steps may help ease the swelling and itching often associated with large local reactions:
Remove the stinger as soon as possible.
Wash the area with soap and water.
Apply cold compresses or ice.
Apply hydrocortisone cream or calamine lotion to ease redness, itching or swelling.
If itching or swelling is bothersome, take an oral antihistamine that contains diphenhydramine (Benadryl) or chlorpheniramine (Chlor-Trimeton).
Avoid scratching the sting area. This will worsen itching and swelling and increase your risk of infection.
Emergency treatment for allergic reactions
During an anaphylactic attack, an emergency medical team may perform cardiopulmonary resuscitation (CPR) if you stop breathing or your heart stops beating. You may be given medications including:
Epinephrine (adrenaline) to reduce your body's allergic response
Oxygen, to help you breathe
Intravenous (IV) antihistamines and cortisone to reduce inflammation of your air passages and improve breathing
A beta agonist (such as albuterol) to relieve breathing symptoms
Epinephrine autoinjector
If you're allergic to bee stings, your doctor is likely to prescribe an emergency epinephrine autoinjector (EpiPen, Twinject). You'll need to have it with you at all times. An autoinjector is a combined syringe and concealed needle that injects a single dose of medication when pressed against your thigh. Always be sure to replace epinephrine by its expiration date.
Be sure you know how to use the autoinjector. Also, make sure the people closest to you know how to administer the drug — if they're with you in an anaphylactic emergency, they could save your life. Medical personnel called in to respond to a severe anaphylactic reaction also may give you an epinephrine injection or another medication.
Consider wearing an alert bracelet that identifies your allergy to bee or other insect stings.
Allergy shots
Bee and other insect stings are a common cause of anaphylaxis. If you've had a serious reaction to a bee sting, your doctor likely will refer you to an allergist for allergy testing and consideration of allergy shots (immunotherapy). These shots, generally given regularly for a few years, can reduce or eliminate your allergic response to bee venom.
LIFESTYLE AND HOME REMEDIES
Prevention strategies can help you minimize your chance of getting stung by bees.
Minimize your exposure:
Take care when drinking sweet beverages outside. Wide, open cups may be your best option because you can see if a bee is in them. Inspect cans and straws before drinking from them.
Tightly cover food containers and trash cans.
Clear away garbage, fallen fruit, and dog or other animal feces (flies can attract wasps).
Wear close-toed shoes when walking outside.
Don't wear bright colors or floral prints, which can attract bees.
Don't wear loose clothing, which can trap bees between the cloth and your skin.
When driving, keep your windows rolled up.
Be careful when mowing the lawn or trimming vegetation, activities that might arouse insects in a beehive or wasp nest.
Have hives and nests near your home removed by a professional.
Know what to do when you're exposed to bees:
If a few bees are flying around you, stay calm and slowly walk away from the area. Swatting at an insect may cause it to sting.
If a bee or wasp stings you, or many insects start to fly around, cover your mouth and nose and quickly leave the area. When a bee stings, it releases a chemical that attracts other bees. If you can, get into a building or closed vehicle.
BEHCET's DISEASE
BEHCET's DISEASE
Behcet's disease, also called Behcet's syndrome, is a rare disorder that causes inflammation in blood vessels throughout your body. The inflammation of Behcet's disease leads to numerous symptoms that may initially seem unrelated. The signs and symptoms of Behcet's disease — which may include mouth sores, eye inflammation, skin rashes and lesions, and genital sores — vary from person to person and may come and go on their own.
The exact cause of Behcet's is unknown, but it may be an autoimmune disorder, which means the body's immune system mistakenly attacks some of its own healthy cells. Both genetic and environmental factors may be responsible for Behcet's disease.
Treatment aims to reduce the signs and symptoms of Behcet's disease and to prevent serious complications, such as blindness.
SYMPTOMS
Behcet's disease symptoms vary from person to person. Behcet's disease may disappear and recur on its own. The signs and symptoms that you may experience depend on which parts of your body are affected by the inflammation of Behcet's disease. Areas commonly affected by Behcet's disease include:
Mouth. Painful mouth sores, that look similar to canker sores, are the most common sign of Behcet's disease. Sores begin as raised, round lesions in the mouth that quickly turn into painful ulcers. The sores heal usually in about one to three weeks, though they do recur.
Skin. Skin lesions may occur in people with Behcet's disease. Skin problems can vary. Some people may develop acne-like sores on their bodies. Others may develop red, raised and tender nodules on their skin, especially on the lower legs.
Genitals. People with Behcet's disease may develop sores on their genitals. The sores commonly occur on the scrotum or the vulva. Sores appear as red, ulcerated lesions. The genital sores are usually painful and may leave scars.
Eyes. Behcet's disease may cause inflammation in the eye — a condition called uveitis (u-vee-I-tis). In people with Behcet's disease, uveitis causes redness, pain and blurred vision in one or both eyes and may come and go. Inflammation that occurs in the blood vessels of the retina is a serious complication of the disorder.
Joints. Joint swelling and pain often affect the knees in people with Behcet's disease. The ankles, elbows or wrists also may be involved. Signs and symptoms may last one to three weeks and go away on their own.
Vascular system. Inflammation in veins and large arteries may occur in Behcet's disease, causing redness, pain and swelling in the arms or legs when a blood clot results. In fact, many of the signs and symptoms of Behcet's are believed to be caused by inflammation of the blood vessels (vasculitis). Inflammation in the large arteries can lead to complications, such as aneurysms and narrowing or blockage of the vessel.
Digestive system. Behcet's disease may cause a variety of signs and symptoms that affect the digestive system, including abdominal pain, diarrhea or bleeding.
Brain. Behcet's disease may cause inflammation in the brain and nervous system that leads to headache, fever, disorientation, poor balance or stroke.
When to see a doctor
Make an appointment with your doctor if you notice any unusual signs and symptoms that might indicate Behcet's disease. If you've been diagnosed with Behcet's disease, see your doctor if you notice any new signs and symptoms.
CAUSES
Doctors don't know what causes Behcet's disease. However, a combination of genetic and environmental factors likely plays a role. Several genes have been found to be associated with the disease. Some researchers believe a virus or bacterium may trigger Behcet's disease in people who have certain genes that make them susceptible to Behcet's.
RISK FACTORS
Factors that may increase your risk of Behcet's include:
Age. Behcet's disease commonly affects men and women in their 20s and 30s, though children and older adults also can develop the condition.
Location. Although the disease occurs worldwide, people from countries in the Middle East and Far East, including Turkey, Iran, Japan and China, are more likely to develop Behcet's.
Sex. While Behcet's disease occurs in both men and women, the disease is usually more severe in men.
Genes. Having certain genes is associated with a higher risk of developing Behcet's.
COMPLICATIONS
Behcet's disease typically comes and goes in unpredictable cycles. Symptoms may become less severe over time.
Though treatment can't cure Behcet's disease, it often can control signs and symptoms and reduce the risk of complications. For instance, untreated uveitis can lead to decreased vision or even blindness. People with eye signs and symptoms of Behcet's disease should be carefully monitored by an eye doctor because treatment can help prevent this complication. Other complications of Behcet's disease depend on the specific set of signs and symptoms you're experiencing.
PREPARING FOR YOUR APPOINTMENT
You're likely to start by seeing your primary care doctor if you have signs and symptoms of Behcet's disease. But, because Behcet's disease is rare, and some of the signs and symptoms are similar to those of other disorders, you may need to see a specialist, such as a doctor who treats arthritis and other rheumatic illnesses (rheumatologist), before getting the diagnosis of Behcet's disease.
If a rheumatologist wasn't involved in your diagnosis, you may be referred to a rheumatologist for the management of Behcet's. Depending on your signs and symptoms, you may also need to see an eye doctor (ophthalmologist) for eye problems, a gynecologist or a urologist for genital sores, a dermatologist for skin problems, a gastroenterologist for digestive difficulties, or a neurologist for symptoms that involve the brain or central nervous system.
Because appointments can be brief and there's often a lot of ground to cover, it's a good idea to be prepared. Here's some information to help you get ready, 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. Also, write down key personal information, including any major stresses or recent life changes.
Make a list of all medications, vitamins and supplements that you're taking.
If possible, bring a family member or friend with you. 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 visit. List your questions from most important to least important in case time runs out. For Behcet's, some basic questions to ask your doctor include:
What do you think is causing my symptoms?
Are there any other possible causes for my symptoms?
Do I need any special tests?
Is this condition temporary?
What treatments are available? Which do you recommend?
I have another health condition. How can I best manage these conditions together?
Are there any brochures or other printed material that I can take with me? What websites or organizations do you recommend for gathering more information?
In addition to the questions that you've prepared, don't hesitate to ask additional 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 discuss points you want to spend more time on. Your doctor may ask:
What types of signs and symptoms have you been having?
How severe are your symptoms?
When did you begin experiencing symptoms?
Do you have symptoms all the time, or do they come and go?
Does anything seem to improve your symptoms?
What, if anything, appears to worsen your symptoms?
Is there anyone in your family who has a similar illness?
TESTS AND DIAGNOSIS
No tests can determine definitively whether or not you have Behcet's disease. Instead, your doctor relies primarily on your signs and symptoms to diagnose Behcet's disease. Your doctor may conduct blood tests or other laboratory tests to rule out other diseases and conditions.
Criteria have been established for the diagnosis of Behcet's disease, but these aren't always essential for the diagnosis of the disease. Your doctor may use other factors for your diagnosis. The classification criteria require:
Mouth sores. Because nearly everyone with Behcet's will have mouth sores at some point, this sign is generally necessary for a diagnosis. The diagnostic criteria require mouth sores that have recurred at least three times in 12 months.
In addition, you must have at least two additional signs, such as:
Genital sores. Sores that recur may indicate Behcet's disease.
Eye problems. An ophthalmologist can identify signs of inflammation in your eyes.
Skin sores. A variety of rashes or acne-like sores may be caused by Behcet's disease.
Positive pathergy test. In a pathergy test, your doctor inserts a sterile needle into your skin and then examines the area one to two days later. If the pathergy test is positive, a small red bump forms under your skin where the needle was inserted. This indicates your immune system is overreacting to a minor injury.
TREATMENTS AND DRUGS
No cure exists for Behcet's disease. If your signs and symptoms of Behcet's disease are mild, your doctor may offer medications to control temporary flares in pain and inflammation. You may not need to take medication between flares. But if your signs and symptoms are more severe, your doctor may advise medications to control the signs and symptoms of Behcet's disease throughout your body, in addition to medications for the temporary flares. Several factors, including your age and sex, may influence the specific treatment your doctor recommends.
Treatments for individual signs and symptoms of Behcet's disease
Behcet's disease may come and go on its own in periods of flares and remissions. Your doctor works to control any signs and symptoms you experience during flares with medications such as:
Skin creams, gels and ointments. Topical medicines are applied directly to skin and genital sores in order to reduce inflammation and pain. These types of medications usually contain a corticosteroid drug that reduces inflammation or an anesthetic to relieve pain.
Mouth rinses. Special mouthwashes that contain corticosteroids and other agents to reduce the pain of mouth sores may ease your discomfort.
Eyedrops. Eyedrops containing corticosteroids or other anti-inflammatory medicines can relieve pain and redness in your eyes if inflammation is mild.
Systemic treatments for Behcet's disease
If topical medications don't help control skin rashes, or oral or genital ulcers, a medication called colchicine (Colcrys) is often recommended. Arthritis symptoms also may improve with colchicine.
Severe cases of Behcet's disease require treatments to control damage from the disease between flares. If you have moderate to severe Behcet's disease, your doctor may prescribe:
Corticosteroids to control inflammation. Corticosteroids, such as prednisone, in combination with other medications may reduce the inflammation caused by Behcet's disease. The signs and symptoms of Behcet's disease tend to recur when corticosteroids are used alone, so doctors often prescribe them with another medication to suppress the activity of your immune system (immunosuppressives). Side effects of corticosteroids include weight gain, persistent heartburn, high blood pressure and bone thinning (osteoporosis).
Medications that suppress your immune system. Immunosuppressive drugs suppress your immune system, which overreacts in Behcet's disease. By stopping your immune system from attacking normal, healthy tissues in your body, immunosuppressive drugs reduce the inflammation that your immune system causes. Immunosuppressive drugs that may play a role in controlling Behcet's disease include azathioprine (Imuran, Azasan), cyclosporine (Gengraf, Neoral, Sandimmune) and cyclophosphamide (Cytoxan). Since these medications suppress the actions of your immune system, they may increase your risk of infection. Other possible side effects include liver and kidney problems, low blood counts, and high blood pressure.
Medications that alter your immune system's response. Interferon alfa-2b (Intron A) regulates the activity of your immune system to control inflammation. It may help control skin sores, joint pain and eye inflammation in people with Behcet's disease. Side effects include flu-like signs and symptoms, such as muscle pain and fatigue. Interferon alfa-2b may be combined with other medications.
Medications that block a substance called tumor necrosis factor (TNF), such as infliximab (Remicade) and etanercept (Enbrel), are effective in treating some of the manifestations of Behcet's, especially for people who have more-severe or resistant symptoms. Side effects may include headache, skin rash and an increased risk of upper respiratory infections.
Other drugs that have been used to treat Behcet's disease include thalidomide (Thalomid), mycophenolate mofetil (CellCept) and chlorambucil (Leukeran).
COPING AND SUPPORT
The unpredictability of Behcet's disease can make it particularly frustrating. Taking good care of yourself may help you better cope with the ups and downs of Behcet's disease. Your approach to caring for yourself will depend on what signs and symptoms you're feeling on a particular day. In general, try to:
Rest during flares. When certain signs and symptoms such as mouth sores and joint pain appear, take time for yourself. Be flexible and adjust your schedule when possible so that you can rest when you need it. It's also a good idea to keep stress to a minimum, because stress can aggravate your symptoms.
Be active when you have the energy. Moderate exercise, such as walking or swimming, can make you feel better between Behcet's disease flares. Exercise strengthens your body, helps keep your joints flexible and can improve your mood.
Connect with others. Because Behcet's is a rare disorder, it may be difficult to find others with the disease nearby. However, ask your doctor about support groups in your area. If it's not possible to connect with someone close, the American Behcet's Disease Association offers message boards and chat rooms where you can connect with other people who have Behcet's.
BELL's PALSY
BELL's PALSY
Bell's palsy causes sudden weakness in your facial muscles. This makes half of your face appear to droop. Your smile is one-sided, and your eye on that side resists closing.
Bell's palsy, also known as facial palsy, can occur at any age. The exact cause is unknown, but it's believed to be the result of swelling and inflammation of the nerve that controls the muscles on one side of your face. It may be a reaction that occurs after a viral infection.
For most people, Bell's palsy is temporary. Symptoms usually start to improve within a few weeks, with complete recovery in about six months. A small number of people continue to have some Bell's palsy symptoms for life. Rarely, Bell's palsy can recur.
SYMPTOMS
Signs and symptoms of Bell's palsy come on suddenly and may include:
Rapid onset of mild weakness to total paralysis on one side of your face — occurring within hours to days
Facial droop and difficulty making facial expressions, such as closing your eye or smiling
Drooling
Pain around the jaw or in or behind your ear on the affected side
Increased sensitivity to sound on the affected side
Headache
A decrease in your ability to taste
Changes in the amount of tears and saliva you produce
In rare cases, Bell's palsy can affect the nerves on both sides of your face.
When to see a doctor
Seek immediate medical help if you experience any type of paralysis because you may be having a stroke. Bell's palsy is not caused by a stroke.
See your doctor if you experience facial weakness or drooping to determine the underlying cause and severity of the illness.
CAUSES
Although the exact reason Bell's palsy occurs isn't clear, it's often linked to exposure to a viral infection. Viruses that have been linked to Bell's palsy include the virus that causes:
Cold sores and genital herpes (herpes simplex)
Chickenpox and shingles (herpes zoster)
Mononucleosis (Epstein-Barr)
Cytomegalovirus infections
Respiratory illnesses (adenovirus)
German measles (rubella)
Mumps (mumps virus)
Flu (influenza B)
Hand-foot-and-mouth disease (coxsackievirus)
With Bell's palsy, the nerve that controls your facial muscles, which passes through a narrow corridor of bone on its way to your face, becomes inflamed and swollen — usually related to a viral infection. Besides facial muscles, the nerve affects tears, saliva, taste and a small bone in the middle of your ear.
RISK FACTORS
Bell's palsy occurs more often in people who:
Are pregnant, especially during the third trimester, or who are in the first week after giving birth
Have an upper respiratory infection, such as the flu or a cold
Have diabetes
Also, some people who have recurrent attacks of Bell's palsy, which are rare, have a family history of recurrent attacks. In those cases, there may be a genetic predisposition to Bell's palsy.
COMPLICATIONS
A mild case of Bell's palsy normally disappears within a month, but recovery from a more severe case involving total paralysis varies. Complications may include:
Irreversible damage to your facial nerve
Misdirected regrowth of nerve fibers, resulting in involuntary contraction of certain muscles when you're trying to move others (synkinesis) — for example, when you smile, the eye on the affected side may close
Partial or complete blindness of the eye that won't close due to excessive dryness and scratching of the cornea, the clear protective covering of the eye
PREPARING FOR YOUR APPOINTMENT
You'll likely 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 immediately to a neurologist.
It's good to prepare for your appointment. Here's some information to help you get ready.
What you can do
Write down any symptoms you're experiencing. Be sure to include any that may seem unrelated to the reason for which you scheduled the appointment.
Write down key personal information. Have you had any major stresses or life changes recently? Sharing this type of information may help your doctor to make a diagnosis.
Make a list of all medications. Include the dosage amount of any medications you're taking, and don't forget to write down any vitamins or supplements that you're taking, too.
Take a family member or friend along, if possible. Sometimes it can be difficult to remember all of the information during an appointment. Someone who accompanies you may remember something that you missed or forgot.
Write down questions you want to ask your doctor.
Preparing a list of questions will help you make the most of your time with your doctor. For Bell's palsy, some basic questions to ask your doctor include:
What's the most likely cause of my symptoms?
Are there any other possible causes for my symptoms?
What kinds of tests do I need?
Is this condition likely temporary or long lasting?
What treatments are available for Bell's palsy? Which do you recommend?
Are there alternatives to the primary approach that you're suggesting?
I have other health conditions. How can I best manage these conditions together?
Are there any brochures or other printed material that I can take home with me? What websites do you recommend?
Don't hesitate to ask any additional questions that occur to you during your appointment.
What to expect from your doctor
Be prepared to answer questions from your doctor, such as:
When did you begin having 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?
Have any of your relatives ever had Bell's palsy or problems with facial paralysis?
Have you had any symptoms of a more generalized infection?
What you can do in the meantime
If you have facial pain:
Take over-the-counter pain relievers. Aspirin, ibuprofen (Advil, Motrin IB, others) or acetaminophen (Tylenol, others) can help with pain.
Apply moist heat. Putting a washcloth soaked in warm water on your face several times a day may help relieve pain.
If your eye won't close completely, try these tips:
Use your finger to close your eye repeatedly throughout the day.
Use lubricating eyedrops.
Wear eyeglasses during the day to protect your eye.
Wear an eye patch at night.
TESTS AND DIAGNOSIS
There's no specific test for Bell's palsy. Your doctor will look at your face and ask you to move your facial muscles by closing your eyes, lifting your brow, showing your teeth and frowning, among other movements.
Other conditions — such as a stroke, infections, Lyme disease and tumors — can also cause facial muscle weakness, mimicking Bell's palsy. If it's not clear why you're having the symptoms you are, your doctor may recommend other tests, including:
Electromyography (EMG). This test can confirm the presence of nerve damage and determine its severity. An EMG measures the electrical activity of a muscle in response to stimulation and the nature and speed of the conduction of electrical impulses along a nerve.
Imaging scans. Magnetic resonance imaging (MRI) or computerized tomography (CT) may be needed on occasion to rule out other possible sources of pressure on the facial nerve, such as a tumor or skull fracture.
TREATMENTS AND DRUGS
Most people with Bell's palsy recover fully — with or without treatment. There's no one-size-fits-all treatment for Bell's palsy, but your doctor may suggest medications or physical therapy to help speed your recovery. Surgery is rarely an option for Bell's palsy.
Medications
Commonly used medications to treat Bell's palsy include:
Corticosteroids, such as prednisone, are powerful anti-inflammatory agents. If they can reduce the swelling of the facial nerve, it will fit more comfortably within the bony corridor that surrounds it. Corticosteroids may work best if they're started within several days of when your symptoms started.
Antiviral drugs. The role of antivirals remains unsettled. Antivirals alone have shown no benefit compared with placebo. Antivirals added to steroids are also unlikely to be beneficial.
However, despite this, valacyclovir (Valtrex) is sometimes given in combination with prednisone in people with severe facial palsy.
Physical therapy
Paralyzed muscles can shrink and shorten, causing permanent contractures. A physical therapist can teach you how to massage and exercise your facial muscles to help prevent this from occurring.
Surgery
In the past, decompression surgery was used to relieve the pressure on the facial nerve by opening the bony passage that the nerve passes through. Today, decompression surgery isn't recommended. Facial nerve injury and permanent hearing loss are possible risks associated with this surgery.
In rare cases, plastic surgery may be needed to correct lasting facial nerve problems.
LIFESTYLE AND HOME REMEDIES
Home treatment may include:
Protecting the eye you can't close. Using lubricating eyedrops during the day and an eye ointment at night will help keep your eye moist. Wearing glasses or goggles during the day and an eye patch at night can protect your eye from getting poked or scratched.
Taking over-the-counter pain relievers. Aspirin, ibuprofen (Advil, Motrin IB, others) or acetaminophen (Tylenol, others) may help ease your pain.
Applying moist heat. Putting a washcloth soaked in warm water on your face several times a day may help relieve pain.
Doing your physical therapy exercises. Massaging and exercising your face according to your physical therapist's advice may help relax your facial muscles.
ALTERNATIVE MEDICINE
Although there's little scientific evidence to support the use of alternative medicine for people with Bell's palsy, some people with the condition may benefit from the following:
Relaxation techniques. Relaxing by using techniques such as meditation and yoga may relieve muscle tension and chronic pain.
Acupuncture. Placing thin needles into a specific point in your skin helps stimulate nerves and muscles, which may offer some relief.
Biofeedback training. By teaching you to use your thoughts to control your body, you may help gain better control over your facial muscles.
Vitamin therapy. Vitamins B-12, B-6 and zinc may help nerve growth.
BERGER's DISEASE
BERGER's DISEASE
IgA nephropathy also known as Berger's disease, is a kidney disease that occurs when an antibody called immunoglobulin A (IgA) lodges in your kidneys. This results in local inflammation that, over time, may hamper your kidneys' ability to filter waste, excess water and electrolytes from your blood. Kidney damage may be indicated by blood and protein in your urine, high blood pressure and swollen feet.
IgA nephropathy usually progresses slowly over many years, but the course of the disease in each person is uncertain. Some people leak blood in their urine without developing problems, some eventually achieve complete remission, and others develop end-stage kidney failure.
No cure exists for IgA nephropathy, but certain medications can slow its course. Keeping your blood pressure under control and reducing your cholesterol levels also slow disease progression.
SYMPTOMS
IgA nephropathy usually doesn't cause symptoms in the early stages. The disease can go unnoticed for decades and is sometimes first suspected when routine tests reveal protein and red blood cells in your urine that can't be seen without a microscope (microscopic hematuria).
Signs and symptoms of IgA nephropathy when kidney function is impaired include:
Cola- or tea-colored urine (caused by red blood cells in the urine)
Repeated episodes of cola- or tea-colored urine, sometimes even visible blood in your urine, usually during or after an upper respiratory or other type of infection
Pain in the side(s) of your back below your ribs (flank)
Foam in the toilet water from protein in your urine
Swelling (edema) in your hands and feet
High blood pressure
When to see a doctor
Make an appointment with your doctor if you notice blood in your urine. Urinary bleeding may be caused by strenuous exercise, some foods, medications or a urinary tract infection. But prolonged or repeated bleeding may indicate a serious medical problem and should always be evaluated. Also see your doctor if your urine is foamy or if you develop sudden swelling in your hands and feet.
CAUSES
Your kidneys are two bean-shaped, fist-sized organs located at the small of your back, one on each side of your spine. Each kidney contains tiny blood vessels (glomeruli) that filter waste, excess water and other substances from your blood as they pass through your kidneys. The filtered blood re-enters your bloodstream, while the waste material passes into your bladder and out of your body when you urinate.
Immunoglobulin A (IgA) is an antibody that plays a key role in your immune system by attacking invading pathogens and fighting infections. But in IgA nephropathy, this antibody collects in the glomeruli, causing inflammation (glomerulonephritis) and gradually affecting their filtering ability.
Researchers don't know exactly what causes IgA deposits in the kidneys, but these conditions or factors may be associated with the development of IgA nephropathy:
Genes, because IgA nephropathy is more common in some families and in certain ethnic groups
Liver diseases, including cirrhosis, a condition in which scar tissue replaces normal tissue within the liver, and chronic hepatitis B and C infections
Celiac disease, a digestive condition triggered by eating gluten, a protein found in most grains
Dermatitis herpetiformis, an itchy, blistering skin disease that stems from gluten intolerance
Infections, including HIV infection and some bacterial infections
RISK FACTORS
Although the exact cause of IgA nephropathy is unknown, these factors may increase your risk of developing this condition:
Your sex. In North America and western Europe, IgA nephropathy affects at least twice as many men as it does women.
Ethnicity. IgA nephropathy is more common in Caucasians and Asians than it is in blacks.
Family history. In some cases, IgA nephropathy appears to run in families, indicating that genetic factors may contribute to the disease.
COMPLICATIONS
The course of IgA nephropathy varies from person to person. Some people have the disease for years with few problems. In fact, many cases may go undiagnosed. Other people develop one or more of the following complications:
High blood pressure. Damage to your kidneys from IgA deposits can raise your blood pressure, and high blood pressure can cause further damage to your kidneys.
High cholesterol. High levels of cholesterol may increase your risk of a heart attack.
Acute kidney failure. If your kidneys lose their filtering ability due to IgA deposits, waste products build up quickly in your blood.
Chronic kidney failure. IgA nephropathy can cause your kidneys to gradually stop functioning. In such cases, permanent dialysis or a kidney transplant is needed to sustain life.
Nephrotic syndrome. This is a group of problems that can be caused by damage to the glomeruli, including high urine protein levels, low blood protein levels, high cholesterol and lipids, and swelling of your eyelids, feet and abdomen.
PREPARING FOR YOUR APPOINTMENT
If you have signs and symptoms of IgA nephropathy, you're likely to start by seeing your primary care doctor. However, you may then be referred to a doctor who specializes in treating kidney disorders (nephrologist).
What you can do
To get ready for your appointment:
Ask about any pre-appointment restrictions, such as fasting for a blood test, when you make the appointment.
Make a list of any symptoms you're experiencing, including any that may seem unrelated to the reason for your appointment.
Make a list of all medications and doses, including any over-the-counter drugs, vitamins, herbs or other supplements that you're taking — or take the original bottles to your appointment.
Ask a family member or friend to go with you to help you remember all of the information provided during your appointment.
Prepare questions to ask your doctor.
Questions you might want to ask your doctor include:
What tests do I need to determine if I have IgA nephropathy?
What is a kidney biopsy and how is it done?
Is this condition temporary or long lasting?
What are the chances that I'll develop kidney failure? Is there any way to know?
What's the best course of action? How long will I have to take medications?
What are the alternatives to the primary approach that you're suggesting?
Can this disease be managed with diet and lifestyle changes alone?
I have other health conditions. How can I best manage these conditions together?
I've had urinary tract infections in the past. Could these previous infections be a factor?
Do you have any printed materials on this condition? Is there a website you can recommend where I can learn more?
What to expect from your doctor
Your doctor is likely to ask you several questions. Be ready to answer them so you can reserve time to go over points you want to focus on. For example, your doctor may ask:
When did you begin experiencing symptoms?
Have your symptoms been continuous or occasional?
How severe are your symptoms?
Does anything seem to improve your symptoms?
What, if anything, appears to worsen your symptoms?
TESTS AND DIAGNOSIS
IgA nephropathy is often detected after you notice blood in your urine or when a routine test shows you have protein or blood in your urine. These could be signs of several types of kidney disease. To identify your problem, these tests may be performed:
Urine test. Blood or protein in the urine may be the first sign of IgA nephropathy. This may be discovered as part of a routine checkup. If your doctor suspects that you have problems with your kidneys, you may need to collect your urine for a 24-hour period for additional kidney function tests.
Blood tests. If you have kidney disease, such as IgA nephropathy, a blood test may show increased blood levels of the waste product creatinine.
Iothalamate clearance test. Your doctor may also recommend an iothalamate clearance test, which uses a special contrast agent to track how well your kidneys are filtering wastes.
Kidney imaging. Ultrasound or X-rays also may be used to evaluate the shape or size of your kidneys. A cystoscopy can rule out other causes of bleeding in the urinary tract.
Kidney biopsy. The only way for your doctor to confirm a diagnosis of IgA nephropathy is with a kidney biopsy. This procedure involves using a special biopsy needle to extract small pieces of kidney tissue for microscopic examination to determine if there are IgA deposits in the glomeruli.
TREATMENTS AND DRUGS
There's no cure for IgA nephropathy and no definitive way of knowing what course the disease will take. Some people experience complete remission and others live normal lives with low-grade blood or protein in their urine (hematuria or proteinuria).
Treatment with a number of medications can slow the progress of the disease and help you manage symptoms such as high blood pressure, protein in the urine (proteinuria), and swelling (edema) in your hands and feet.
Medications used to treat IgA nephropathy include:
High blood pressure medications. A common complication of IgA nephropathy is high blood pressure. Taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) can lower your blood pressure and reduce the amount of protein (albumin) in your urine.
Omega-3 fatty acids. These beneficial fats, available in dietary fish oil supplements, may reduce inflammation in the glomeruli without harmful side effects. Get advice from your doctor before you start using supplements.
Immunosuppressants. Corticosteroid medications, such as prednisone, and other potent drugs that suppress the immune response (immunosuppressants) may be used to help protect your kidney function. But these drugs can cause a range of serious side effects, such as high blood pressure or high blood sugar, so their benefits must be carefully weighed against the risks.
Statin therapy. Cholesterol-lowering medications may help to slow the damage to your kidneys.
Mycophenolate mofetil (CellCept). Most studies so far have failed to show a benefit for using this medication, but it has been used successfully in some people who have persistent protein in their urine despite treatment with medications that lower blood pressure.
The ultimate goal is to avoid the need for kidney dialysis or kidney transplantation. But in more advanced cases, dialysis or transplant may be necessary.
LIFESTYLE AND HOME REMEDIES
Because the cause of IgA nephropathy isn't known, it's not possible to prevent it. But if you have a family history of IgA nephropathy, talk with your doctor to find out what steps you can take to keep your kidneys healthy, such as reducing high blood pressure and keeping your cholesterol at healthy levels.
COPING AND SUPPORT
Coping with severe forms of IgA nephropathy can be challenging. But you don't have to do it alone. If you have questions or need guidance, talk with a member of your health care team.
You might also benefit from joining a support group, which can provide both empathetic listening and helpful information. To find out about support groups in your area that deal with kidney disease, ask your doctor. Or contact the National Kidney Foundation (NKF) to learn about PEERS Lending Support, a national, telephone-based peer support program from NKF. Call 855-653-7337 to participate.
BILE REFLUX
BILE REFLUX
Bile reflux occurs when bile — a digestive liquid produced in your liver — backs up (refluxes) into your stomach and the tube that connects your mouth and stomach (esophagus).
Bile reflux may accompany acid reflux, the medical term for the backwash of stomach acids into your esophagus. However, bile acid reflux and acid reflux are separate conditions.