Overview Disease Topics
General Diseases Overview:
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You should always consult with your personal medical provider for any medical conditions or concerns and discuss with your medical provider diagnosis, medical options, and treatments.
Kidney Stones (nephrolithiasis)
Kidney stones, one of the most painful of the urologic disorders, have beset humans for centuries. Scientists have found evidence of kidney stones in a 7,000-year-old Egyptian mummy. Unfortunately, kidney stones are one of the most common disorders of the urinary tract. Each year, people make almost 3 million visits to health care providers and more than half a million people go to emergency rooms for kidney stone problems.
Most kidney stones pass out of the body without any intervention by a physician. Stones that cause lasting symptoms or other complications may be treated by various techniques, most of which do not involve major surgery. Also, research advances have led to a better understanding of the many factors that promote stone formation and thus better treatments for preventing stones.
Introduction to the Urinary Tract
The urinary tract, or system, consists of the kidneys, ureters, bladder, and urethra. The kidneys are two bean-shaped organs located below the ribs toward the middle of the back, one on each side of the spine. The kidneys remove extra water and wastes from the blood, producing urine. They also keep a stable balance of salts and other substances in the blood. The kidneys produce hormones that help build strong bones and form red blood cells.
Narrow tubes called ureters carry urine from the kidneys to the bladder, an oval-shaped chamber in the lower abdomen. Like a balloon, the bladder's elastic walls stretch and expand to store urine. They flatten together when urine is emptied through the urethra to outside the body.
What is a kidney stone?
A kidney stone is a hard mass developed from crystals that separate from the urine within the urinary tract. Normally, urine contains chemicals that prevent or inhibit the crystals from forming. These inhibitors do not seem to work for everyone, however, so some people form stones. If the crystals remain tiny enough, they will travel through the urinary tract and pass out of the body in the urine without being noticed.
Kidney stones may contain various combinations of chemicals.
The most common type of stone contains calcium in combination with either oxalate or phosphate. These chemicals are part of a person's normal diet and make up important parts of the body, such as bones and muscles.
A less common type of stone is caused by infection in the urinary tract. This type of stone is called a struvite or infection stone. Another type of stone, uric acid stones, are a bit less common, and cystine stones are rare.
Urolithiasis is the medical term used to describe stones occurring in the urinary tract. Other frequently used terms are urinary tract stone disease and nephrolithiasis. Doctors also use terms that describe the location of the stone in the urinary tract. For example, a ureteral stone-or ureterolithiasis-is a kidney stone found in the ureter. To keep things simple, the general term kidney stones is used throughout this fact sheet.
Gallstones and kidney stones are not related. They form in different areas of the body. Someone with a gallstone is not necessarily more likely to develop kidney stones.
Who gets kidney stones?
For unknown reasons, the number of people in the United States with kidney stones has been increasing over the past 30 years. In the late 1970s, less than 4 percent of the population had stone-forming disease. By the early 1990s, the portion of the population with the disease had increased to more than 5 percent.
Caucasians are more prone to develop kidney stones than African Americans. Stones occur more frequently in men. The prevalence of kidney stones rises dramatically as men enter their 40s and continues to rise into their 70s. For women, the prevalence of kidney stones peaks in their 50s. Once a person gets more than one stone, other stones are likely to develop.
What causes kidney stones?
Doctors do not always know what causes a stone to form. While certain foods may promote stone formation in people who are susceptible, scientists do not believe that eating any specific food causes stones to form in people who are not susceptible.
A person with a family history of kidney stones may be more likely to develop stones. Urinary tract infections, kidney disorders such as cystic kidney diseases, and certain metabolic disorders such as hyperparathyroidism are also linked to stone formation.
In addition, more than 70 percent of people with a rare hereditary disease called renal tubular acidosis develop kidney stones.
Cystinuria and hyperoxaluria are two other rare, inherited metabolic disorders that often cause kidney stones. In cystinuria, too much of the amino acid cystine, which does not dissolve in urine, is voided, leading to the formation of stones made of cystine. In patients with hyperoxaluria, the body produces too much oxalate, a salt. When the urine contains more oxalate than can be dissolved, the crystals settle out and form stones.
Hypercalciuria is inherited, and it may be the cause of stones in more than half of patients. Calcium is absorbed from food in excess and is lost into the urine. This high level of calcium in the urine causes crystals of calcium oxalate or calcium phosphate to form in the kidneys or elsewhere in the urinary tract.
Other causes of kidney stones are hyperuricosuria, which is a disorder of uric acid metabolism; gout; excess intake of vitamin D; urinary tract infections; and blockage of the urinary tract. Certain diuretics, commonly called water pills, and calcium-based antacids may increase the risk of forming kidney stones by increasing the amount of calcium in the urine.
Calcium oxalate stones may also form in people who have chronic inflammation of the bowel or who have had an intestinal bypass operation, or ostomy surgery. As mentioned earlier, struvite stones can form in people who have had a urinary tract infection. People who take the protease inhibitor indinavir, a medicine used to treat HIV infection, may also be at increased risk of developing kidney stones.
Foods and Drinks Containing Oxalate
People prone to forming calcium oxalate stones may be asked by their doctor to limit or avoid certain foods if their urine contains an excess of oxalate.
High-oxalate foods-higher to lower
- swiss chard
- wheat germ
- soybean crackers
- black Indian tea
- sweet potatoes
Foods that have medium amounts of oxalate may be eaten in limited amounts.
Medium-oxalate foods-higher to lower
- green pepper
- red raspberries
- fruit cake
Source: The Oxalosis and Hyperoxaluria Foundation
What are the symptoms of kidney stones?
Kidney stones often do not cause any symptoms. Usually, the first symptom of a kidney stone is extreme pain, which begins suddenly when a stone moves in the urinary tract and blocks the flow of urine. Typically, a person feels a sharp, cramping pain in the back and side in the area of the kidney or in the lower abdomen. Sometimes nausea and vomiting occur. Later, pain may spread to the groin.
If the stone is too large to pass easily, pain continues as the muscles in the wall of the narrow ureter try to squeeze the stone into the bladder. As the stone moves and the body tries to push it out, blood may appear in the urine, making the urine pink. As the stone moves down the ureter, closer to the bladder, a person may feel the need to urinate more often or feel a burning sensation during urination.
If fever and chills accompany any of these symptoms, an infection may be present. In this case, a person should contact a doctor immediately.
How are kidney stones diagnosed?
Sometimes "silent" stones-those that do not cause symptoms-are found on x rays taken during a general health exam. If the stones are small, they will often pass out of the body unnoticed. Often, kidney stones are found on an x ray or ultrasound taken of someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone's size and location. Blood and urine tests help detect any abnormal substance that might promote stone formation.
The doctor may decide to scan the urinary system using a special test called a computerized tomography (CT) scan or an intravenous pyelogram (IVP). The results of all these tests help determine the proper treatment.
Preventing Kidney Stones
A person who has had more than one kidney stone may be likely to form another; so, if possible, prevention is important. To help determine their cause, the doctor will order laboratory tests, including urine and blood tests. The doctor will also ask about the patient's medical history, occupation, and eating habits. If a stone has been removed, or if the patient has passed a stone and saved it, a stone analysis by the laboratory may help the doctor in planning treatment.
The doctor may ask the patient to collect urine for 24 hours after a stone has passed or been removed. For a 24-hour urine collection, the patient is given a large container, which is to be refrigerated between trips to the bathroom. The collection is used to measure urine volume and levels of acidity, calcium, sodium, uric acid, oxalate, citrate, and creatinine-a product of muscle metabolism. The doctor will use this information to determine the cause of the stone. A second 24-hour urine collection may be needed to determine whether the prescribed treatment is working.
How are kidney stones treated?
Fortunately, surgery is not usually necessary. Most kidney stones can pass through the urinary system with plenty of water-2 to 3 quarts a day-to help move the stone along. Often, the patient can stay home during this process, drinking fluids and taking pain medication as needed. The doctor usually asks the patient to save the passed stone(s) for testing. It can be caught in a cup or tea strainer used only for this purpose.
A simple and most important lifestyle change to prevent stones is to drink more liquids-water is best. Someone who tends to form stones should try to drink enough liquids throughout the day to produce at least 2 quarts of urine in every 24-hour period.
In the past, people who form calcium stones were told to avoid dairy products and other foods with high calcium content. Recent studies have shown that foods high in calcium, including dairy products, may help prevent calcium stones. Taking calcium in pill form, however, may increase the risk of developing stones.
Patients may be told to avoid food with added vitamin D and certain types of antacids that have a calcium base. Someone who has highly acidic urine may need to eat less meat, fish, and poultry. These foods increase the amount of acid in the urine.
To prevent cystine stones, a person should drink enough water each day to dilute the concentration of cystine that escapes into the urine, which may be difficult. More than a gallon of water may be needed every 24 hours, and a third of that must be drunk during the night.
A doctor may prescribe certain medications to help prevent calcium and uric acid stones. These medicines control the amount of acid or alkali in the urine, key factors in crystal formation. The medicine allopurinol may also be useful in some cases of hyperuricosuria.
Doctors usually try to control hypercalciuria, and thus prevent calcium stones, by prescribing certain diuretics, such as hydrochlorothiazide. These medicines decrease the amount of calcium released by the kidneys into the urine by favoring calcium retention in bone. They work best when sodium intake is low.
Rarely, patients with hypercalciuria are given the medicine sodium cellulose phosphate, which binds calcium in the intestines and prevents it from leaking into the urine.
If cystine stones cannot be controlled by drinking more fluids, a doctor may prescribe medicines such as Thiola and Cuprimine, which help reduce the amount of cystine in the urine.
For struvite stones that have been totally removed, the first line of prevention is to keep the urine free of bacteria that can cause infection. A patient's urine will be tested regularly to ensure no bacteria are present.
If struvite stones cannot be removed, a doctor may prescribe a medicine called acetohydroxamic acid (AHA). AHA is used with long-term antibiotic medicines to prevent the infection that leads to stone growth.
People with hyperparathyroidism sometimes develop calcium stones. Treatment in these cases is usually surgery to remove the parathyroid glands, which are located in the neck. In most cases, only one of the glands is enlarged. Removing the glands cures the patient's problem with hyperparathyroidism and kidney stones.
Surgery may be needed to remove a kidney stone if it:
- does not pass after a reasonable period of time and causes constant pain
- is too large to pass on its own or is caught in a difficult place
- blocks the flow of urine
- causes an ongoing urinary tract infection
- damages kidney tissue or causes constant bleeding
- has grown larger, as seen on follow-up x rays
Until 20 years ago, open surgery was necessary to remove a stone. The surgery required a recovery time of 4 to 6 weeks. Today, treatment for these stones is greatly improved, and many options do not require major open surgery and can be performed in an outpatient setting.
Extracorporeal Shock Wave Lithotripsy
Extracorporeal shock wave lithotripsy (ESWL) is the most frequently used procedure for the treatment of kidney stones. In ESWL, shock waves that are created outside the body travel through the skin and body tissues until they hit the denser stones. The stones break down into small particles and are easily passed through the urinary tract in the urine.
Several types of ESWL devices exist. Most devices use either x rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of ESWL procedures, anesthesia is needed.
In many cases, ESWL may be done on an outpatient basis. Recovery time is relatively short, and most people can resume normal activities in a few days.
Complications may occur with ESWL. Some patients have blood in their urine for a few days after treatment. Bruising and minor discomfort in the back or abdomen from the shock waves can occur. To reduce the risk of complications, doctors usually tell patients to avoid taking aspirin and other medicines that affect blood clotting for several weeks before treatment.
Sometimes, the shattered stone particles cause minor blockage as they pass through the urinary tract and cause discomfort. In some cases, the doctor will insert a small tube called a stent through the bladder into the ureter to help the fragments pass. Sometimes the stone is not completely shattered with one treatment, and additional treatments may be needed.
As with any interventional, surgical procedure, potential risks and complications should be discussed with the doctor before making a treatment decision.
Sometimes a procedure called percutaneous nephrolithotomy is recommended to remove a stone. This treatment is often used when the stone is quite large or in a location that does not allow effective use of ESWL.
In this procedure, the surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney. Using an instrument called a nephroscope, the surgeon locates and removes the stone. For large stones, some type of energy probe-ultrasonic or electrohydraulic-may be needed to break the stone into small pieces. Often, patients stay in the hospital for several days and may have a small tube called a nephrostomy tube left in the kidney during the healing process.
One advantage of percutaneous nephrolithotomy is that the surgeon can remove some of the stone fragments directly instead of relying solely on their natural passage from the kidney.
Ureteroscopic Stone Removal
Although some stones in the ureters can be treated with ESWL, ureteroscopy may be needed for mid- and lower-ureter stones. No incision is made in this procedure. Instead, the surgeon passes a small fiberoptic instrument called a ureteroscope through the urethra and bladder into the ureter. The surgeon then locates the stone and either removes it with a cage-like device or shatters it with a special instrument that produces a form of shock wave. A small tube or stent may be left in the ureter for a few days to help urine flow. Before fiber optics made ureteroscopy possible, physicians used a similar "blind basket" extraction method. But this technique is rarely used now because of the higher risks of damage to the ureters.
The Division of Kidney, Urologic, and Hematologic Diseases of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) funds research on the causes, treatments, and prevention of kidney stones. The NIDDK is part of the National Institutes of Health in Bethesda, MD.
New medicines and the growing field of lithotripsy have greatly improved the treatment of kidney stones. Still, NIDDK researchers and grantees seek to answer questions such as
- Why do some people continue to have painful stones?
- How can doctors predict, or screen, those at risk for getting stones?
- What are the long-term effects of lithotripsy?
- Do genes play a role in stone formation?
- What is the natural substance(s) found in urine that blocks stone formation?
Researchers are also developing new medicines with fewer side effects.
Points to Remember
- A person with a family history of stones or a personal history of more than one stone may be more likely to develop more stones.
- A good first step to prevent the formation of any type of stone is to drink plenty of liquids-water is best.
- Someone who is at risk for developing stones may need certain blood and urine tests to determine which factors can best be altered to reduce that risk.
- Some people will need medicines to prevent stones from forming.
- People with chronic urinary tract infections and stones will often need a stone removed if the doctor determines that the stone is causing the infection. Patients must receive careful follow-up to be sure that the infection has cleared.
The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory.
American Urological Association Foundation
1000 Corporate Boulevard
Linthicum, MD 21090
Phone: 1-866-RING-AUA (746-4282) or 410-689-3700
National Kidney Foundation
30 East 33rd Street
New York, NY 10016
Phone: 1-800-622-9010 or 212-889-2210
For Information About Hyperparathyroidism:
National Endocrine and Metabolic Diseases Information Service
National Institute of Diabetes and Digestive and Kidney Diseases
National Institutes of Health
6 Information Way
Bethesda, MD 20892-3569
For Information About Gout:
National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 1-877-22-NIAMS (226-4267) or 301-495-4484
Allergic conjunctivitis is inflammation of the tissue lining the eyelids (conjuctiva) due to a reaction from allergy-causing substances such as pollen and dander.
Symptoms may be seasonal and can include:
- Red eyes
- Dilated vessels in the clear tissue covering white of the eye
- Intense itching or burning eyes
- Puffy eyelids, especially in the morning
- Tearing (watery eyes)
- Stringy eye discharge
If home-care measures do not help, treatment by the health care provider may be necessary. This may include:
- Antihistamine or anti-inflammatory drops that are placed into the eye
- Mild eye steroid preparations applied directly on the surface of the eye (for severe reactions)
- Eye drops that prevent certain white blood cells called mast cells from releasing histamine; these drops are given in combination with antihistamines for moderate to severe reactions
When your eyes are exposed to anything to which you are allergic, histamine is released and the blood vessels in the conjunctiva become swollen (the conjunctiva is the clear membrane that covers the "white" of the eye). Reddening of the eyes develops quickly and is accompanied by itching and tearing.
Allergies tend to run in families, although no obvious mode of inheritance is recognized. The incidence of allergy is difficult to determine, because many different conditions are often lumped under the term allergy. Keep in mind that rubbing the eyes makes the situation worse.
Your doctor may look for the following:
- Certain white blood cells, called eosinophils, in scrapings, secretions, or discharge
- Small, raised bumps on the inside of the eyelids (papillary conjunctivitis)
- Positive skin test for suspected allergens (See: Allergy testing)
Treatment usually relieves the symptoms. However, the condition tends to recur if exposure to the offending agent continues.
Prevention of allergic conjunctivitis is best accomplished by avoiding the allergen, if it is known. In many cases, however, this is impossible since the allergy-causing agents are everywhere nearly all the time.
There are no serious complications; persistent discomfort is common.
Call for an appointment with your health care provider if you experience allergic conjunctivitis and it is unresponsive to over-the-counter treatment.
Respiratory tract infections, including the common cold
and acute sinusitis, affect millions of individuals every
year. Colds are caused by viruses, are easily spread from
person to person, and are usually short-lived. Sinusitis (infection
of the paranasal sinuses) usually occurs as a result of a cold but
also can result from swelling of the nasal passages, obstruction
from a medical device or a nasal deformity, or as part of a general
infectious process in the body. Acute sinusitis may be caused by
viruses, bacteria, or, rarely, a fungus infection. Antibiotics may be
used to treat bacterial sinusitis. It is important to understand that
antibiotics do not help a cold or viral sinusitis. Using antibiotics
improperly (such as for a viral infection) can cause resistant
bacteria (that cannot be killed by the usual antibiotics) to form,
leading to antibiotic-resistant infections.
Signs and Symptoms
• Nasal obstruction
• Pain in the face over sinus areas (near
the nose, above the teeth, the forehead)
• Thick and purulent (filled with pus) nasal
discharge from both nostrils that may be
worse on one side
• Cough and sore throat (from nasal
drainage irritating the throat)
• Fatigue and feeling generally unwell
Usually the medical history and physical examination are all that is necessary to diagnose sinusitis. Sometimes x-ray studies, including computed tomography (CT) scan, may be used to confirm the diagnosis and look for causes of sinusitis. Occasionally a sample of the sinus contents (also called sinus aspiration) may be taken for laboratory examination to determine the cause.
• Drink plenty of fluids.
• Get lots of rest and appropriate sleep.
• Inhaling steam may help to ease congestion of the sinuses.
• Temporary use of an over-the-counter nasal spray may help relieve congestion, but these should not be used for more than 5 days at a time.
• See your doctor if your symptoms last more than a few days.
• Antibiotics may be prescribed if bacterial sinusitis is suspected. It is important to take the full course of antibiotics as prescribed by your doctor. Do not skip doses or stop taking the medication when you begin to feel better.
• Seek medical attention immediately if you develop a high fever, stiff neck, severe headache, tender swelling near the eyes, or changes in your mental status such as confusion or delirium.
The primary goal when treating sinusitis is to decrease the inflammation in the nose and sinus openings to improve sinus drainage. This may include a combination of medical treatments. Your healthcare provider will treat an infection, if present, and try to reduce the symptoms of a runny or congested nose. Here a few recommended treatments today:
Steroid Nasal Spray
A prescription steroid nasal spray can decrease nasal inflammation and mucus production. This will decrease symptoms of nasal congestion and improve sinus drainage. A steroid nasal spray does not provide immediate relief of symptoms and may require several weeks of routine use to be effective. If you have chronic sinusitis, you may benefit from continued daily use of this medication. If you have occasional sinusitis episodes, you may only require periodic use.The combination of nasal wash and nasal steroid sprays can be highly effective for many patients with nasal and sinus problems. Several steroid nasal sprays are available and include:
Vancenase DS AQ® (beclomethasone)
Rhinocort® (budesonide )
When used properly, steroid nasal sprays are safe and effective, however, nasal dryness and bleeding are possible side effects when using these medications.
Antibiotics are medicines designed to treat bacterial infections. In some cases of sinusitis, but certainly not all, the underlying cause will be a bacterial infection. Such an infection can be difficult to treat because the bacteria thrive in the warm, moist and dark areas of the sinus cavities. These infections usually respond to antibiotic treatment, however, you may need to continue treatment for one to three weeks or longer. The choice of antibiotic depends on several factors such as: drug allergies, past use of antibiotics and your symptoms. In some cases, your health care provider can collect mucus from your nose and send it to the laboratory for culture to confirm the presence of bacteria. This test can also help in the selection of the proper antibiotic to fight the infection. The majority of episodes of sinusitis (upper airway infection) are succesfully treated without the use of antibiotics by simply treating the thick mucus and nasal inflammation. Inappropriate use of antibiotics can lead to bacterial resistance and side effects, thus these medications must be used carefully and thoughtfully.
These medicines, available as tablet, syrup or nasal spray, help unblock the openings of the sinuses and temporarily reduce symptoms of nasal congestion. Common over the counter decongestants include Sudafed® and Dimetapp® (pseudoephedrine). Combination decongestant/antihistamine medicines are available over the counter. Read the label to see what is in the over the counter medicine you are buying and discuss the medicine with your healthcare provider. Topical nasal decongestants (sprays) can be highly effective in the immediate shrinking of swollen nasal tissue. However these sprays should be used only for 2 to 3 consecutive days because more prolonged use can cause rebound nasal congestion with increased symptoms. Systemic decongestants have the same effect of decreasing the swelling of the lining of the nose and promoting drainage of the sinuses. However, since higher concentrations are present in the bloodstream, systemic dcongestants are more likely to cause side-effects. These may include high blood pressure, anxiety, sleeplessness, prostate problems in men, and the "jitters". You should always discuss the use of these medications with your physician.
Antihistamines are medicines deisgned to counter the actions of histamine, the main chemical produced in the body in allergic reactions. Antihistamines in tablet or syrup form may help reduce the allergic symptoms of sneezing, itchy eyes and nose, and may reduce mucus production. Your health care provider may elect to add this type of medicine to your treatment, particularly if allergies are present. Common over-the-counter antihistamines include:
Newer classes of prescription antihistamines do not cause drowsiness. They include:
A medication to relieve pain and lessen fever may help in sinusitis, especially for acute episodes. Your healthcare provider may recommend a medication such as Tylenol® (acetaminophen), aspirin or ibuprofen, or prescribe a stronger medicine. Because some people with asthma are sensitive to aspirin or ibuprofen, check with your clinician before taking this medicine.
Systemic steroids are sometimes required to treat severe nasal and sinus inflammation, such as nasal polyps. These medicines can be in pill or syrup form, as well as injected in a muscle or into a vein. Systemic steroids are very powerful medicines that can help nasal and sinus conditions. However, many potential side effects are possible, and include: cataract formation, high blood pressure, high blood sugar, mood changes, stomach irritation, bone loss (osteoporosis), vision change, and menstrual irregularities. These side-effects are always possible when using systemic steroids but become more of concern with longterm use. Most commonly systemic steroids will be prescribed as a pill in a "tapering" fashion. This means that your dose of steroid will be slowly decreased before completely stopping the medication. This approach also helps avoid some related complications..
Age-Related Macular Degeneration
Age-related macular degeneration (AMD) is a disease
of the eye that is the leading cause of blindness for
people aged 65 years and older and affects more than
10 million Americans. AMD is caused by a deterioration of
the retina—the layer of the eye that contains cells that relay
images through the optic nerve to the brain. The center of the
retina is called the macula and is responsible for the detailed
central vision that allows people to read, drive, and recognize
faces. If the macula starts to break down, areas in the center of
the visual field start to look blurred.
Risk factors for AMD include older age, white race,
and smoking. There is no cure for AMD, but therapies are
available that can slow the disease.
There are 2 types of AMD: wet and dry. Dry AMD is more common and is associated
with small, yellow deposits (drusen) in the macula. Dry AMD causes the macula to
lose its function. The most common symptom of dry AMD is blurred central vision that
worsens slowly. If dry AMD affects only one eye, symptoms may not be noticeable.
Wet AMD accounts for approximately 15% of all cases of the disease. In wet AMD,
abnormal blood vessels beneath the macula start to leak fluid, causing the retina to
become distorted. This type of AMD can be severe and rapid. A common symptom of
wet AMD is that straight lines appear wavy, and central vision degrades rapidly. Laser
therapy to prevent the blood vessels from leaking is one form of therapy for wet AMD
that your eye doctor may recommend. Unfortunately, recurrences after laser treatment
are common. New anti-VEGF (anti-vascular endothelial growth factor) injectable drug therapies
are also available and being studied today, with evidence of improvement of vision and inhibiting progression of disease. Wet AMD can be treated with laser surgery, photodynamic therapy, and
anti-VEGF intravitreal injections. None of these treatments is a cure for wet AMD.
The disease and loss of vision may progress despite treatment. Verteporfin (Visudyne ®) injection is used in combination with photodynamic therapy (PDT; treatment with a laser light) to treat abnormal growth of leaky blood vessels in the eye caused by wet age-related macular degeneration (AMD), pathologic myopia (a serious form of nearsightedness that worsens with time), or histoplasmosis (a fungal infection) of the eye. Verteporfin is in a class of medications called photosensitizing agents. When verteporfin is activated by light, it closes up the leaking blood vessels.
Pegaptanib (Macugen ®) and Ranibizumab (Lucentis ®) injection are used to treat wet age-related macular degeneration (AMD). Pegaptanib and Ranibizumab injection is in a class of medications called vascular endothelial growth factor (VEGF) antagonists. It works by blocking abnormal blood vessel growth and leakage in the eye(s) that may cause vision loss in people with wet AMD. Both drugs control wet AMD and improve vision in some patients, but do not cure it. Bevacizumab (Avastin®), a similar drug to Ranibizumab, is also sometimes used to treat wet age-related macular degeneration (AMD).
A screening eye examination, including detailed examination
of the retina, is recommended for all persons 40 years or older.
If your eye doctor discovers drusen or other signs of AMD, it is
important to have frequent eye examinations. Your eye doctor
can provide you with an Amsler grid (a piece of graph paper
with thick, dark lines) that you can use to test your vision each
day. If the lines appear wavy or distorted, you should see your
eye doctor immediately because it may be a sign of wet AMD.
Your eye doctor may recommend the daily use of zinc and
antioxidant vitamins (vitamin C, vitamin E, and beta carotene),
which have been shown to reduce the risk of developing more
severe forms of AMD.
Evaluating and Treating Children's Headaches
Headache is one of the most common and wide-ranging disorders. In fact, the list of differential diagnoses for headache is one of the most extensive ever elucidated for a medical condition: 13 major categories and 129 subcategories.
The term "primary headache" includes migraine, cluster, and tension headaches. "Secondary" headaches are caused by as many as 300 different identifiable pathological processes. Over 90% of headaches are primary.
Prevalence in Children
Headaches are relatively common in children and adolescents. The prevalence of severe recurrent headache in those under the age of 10 is almost 10 per 1,000; it is approximately 46 per 1,000 for those aged 10 to 17.[3,4] If the prevalence of headache of this severity exceeds 2.5%, it stands to reason that relatively minor headaches, which are unreported in most cases, are even more common. When children aged 15 and younger were surveyed about headache, 55% reported experiencing non-migraine headache (almost 7% reported frequent headache and nearly 4% had experienced migraine).
Headaches cause an average of 3.3 missed school days per child each year. Children with headaches may be forced to limit participation in social activities, family events, and school activities. Additionally, when a child develops headache, there is an increased likelihood that he will experience headaches throughout adulthood.
Children's headaches (e.g., migraine) exhibit no gender variation before puberty. In late adolescence, however, twice as many females report recurrent headaches. When adolescents were asked about the frequency of their headaches in the previous month, 74% of girls and 56% of boys reported one or more.
Older headache taxonomies were ill-defined and vague, which made differential diagnoses of headache difficult. In 1988, the International Headache Society refined headache classification by eliciting data about the quality of pain and concurrent symptomatology. Pediatric headache was not a specific subtype, but investigators eventually identified a type of chronic daily headache specific to children--one in which the child experiences simultaneous periodic migraine headache and chronic daily headache. Several well-known types of headache are also possible in children, such as postconcussion and migraine headaches.
When a child has a recurrent headache, certain etiologies are more likely than others. They include post- concussion headache, migraine, tension headache, sinusitis, intracranial mass, eye strain, caffeine withdrawal, pseudotumor cerebri, sleep disorders, hyperthyroidism, hypertension, and temporomandibular joint disease.[4,5] Cluster headaches are rare in children, since they typically manifest after the age of 20.
Minor head trauma is experienced by 2 million people each year. At least 500,000 people require hospitalization as a result of the trauma. Forty-five percent of incidents are caused by auto accidents, and 30% by falls. Children are at high risk for falls, and often suffer headaches caused by minor head trauma. Approximately 30%-90% of patients with mild head injury will experience headache. As many as 30%-50% will develop chronic headache. Thus, if the pharmacist is approached by a parent requesting advice for a child's headache, it is prudent to ask if the child has had a recent fall. The headache typically begins within hours of the injury or the following day. Additional symptoms that indicate post-traumatic headache include dizziness/vertigo, irritability or aggressive behavior without provocation, susceptibility to fatigue, anxiety, insomnia or disturbances of the sleep/wake cycle, and impaired concentration and memory. The headache itself may last for 1-2 weeks, but these ancillary problems may persist for 18 months or, in some cases, as long as a lifetime.
Many experts estimate that as many as 3% of pediatric patients experience migraine headache. However, one survey revealed that 4% of male adolescents and 7% of female adolescents reported headache symptoms consistent with migraine, suggesting that the number may be somewhat higher. Migraine exhibits a strong familial tendency. Migraine typically manifests as a throb on one side of the head lasting 6-8 hours, but may persist longer. Patients may also experience concomitant symptoms such as nausea, vomiting, phonophobia and photophobia.
Identification of migraine triggers for a specific individual can be valuable in helping avoid further attacks. The list of potential triggers includes environmental factors (e.g., sunlight, loud noises, stagnant air, odors), foods (e.g., some cheeses, chocolate, food preservatives), lifestyle choices (e.g., changing one's sleep patterns, missing a meal), and psychosocial stress.
Some patients notice a migraine prodrome beginning 24 hours before onset of the headache. The prodrome may include fluid retention and unpredictable alterations in energy level, mental alertness, and appetite.
Many migraine sufferers may experience an aura 15-60 minutes before onset of pain, possibly as a result of ischemia.[5,8] Vision problems are common, beginning as a set of bright visual obstructions. Some patients describe the changes as geometric patterns (e.g., triangles) marching in from both edges of the visual field. The vision then becomes temporarily obscured. The onset of visual changes does not always signal a migraine, however. They may also occur alone.
At least 40% of those who experience tension headaches report an onset prior to the age of 20. Tension headache is characterized by a dull, vise-like pain.
Sinus infections are a frequent cause of headache, often occurring as sequelae of the common cold. Sinus headache is a dull, constant pressure. Markers for infected sinuses include recent history of an upper respiratory infection, persistent frontal headache, facial pain, tenderness over the sinus, and a change in severity of pain depending on the position of the head.
Parents of children with recurrent headaches often fear that their child has a brain tumor. Fortunately, this is seldom the case. While it is true that headache is often the first sign of a brain tumor and eventually develops in 70% of those with a brain tumor, most children with tumors develop further abnormalities within 4 months. Clues to a tumor-induced headache are intermittency, seizures, worsening pain with exertion or positional changes, frequency at night or in the morning after awakening, pain that does not pulse but is a deep ache, and the effectiveness of analgesics to relieve the pain.[4,5]
Children are often prone to engage in activities such as prolonged reading, watching television, or viewing a computer screen. Excessive computer usage in children may be related to homework, but is more often a result of playing video games or surfing the Web. The pharmacist may ask about the child's recreational activities when inquiring about the nature of a headache. Ophthalmological headache is a dull frontal headache, often bilateral.
Caffeine addiction produces a constellation of adverse reactions; withdrawal from caffeine is also bothersome. Headache is the most common withdrawal symptom. When the patient is no longer subjected to the vasoconstrictor effect of caffeine, the patient experiences rebound vasodilation. Inquire about caffeine use by the child (e.g., excessive soft drink consumption), and the possibility that within the past 24 hours the child has undergone recent withdrawal from caffeine use.
Warning Signs for Referral
The parent should be urged to take the child to a physician if the history of the headache includes seizures, accelerating frequency, behavioral changes, reduced visual acuity, nausea or vomiting, frequent nighttime awakenings with headache, worsening severity, sensitivity to light, altered mental state, or changes in pain when waking, coughing, straining, or with changing the position of the head. Neck stiffness, fever, or rash are warning signs which may signal systemic illness (e.g., meningitis, encephalitis, Lyme disease).[9,10]
Intense headache of sudden onset ("thunderclap headache"). First described in 1986, the original theory for causation of thunderclap headache was hemorrhage into the wall of an unruptured saccal/ cerebral aneurysm. Researchers later hypothesized that simple expansion of the aneurysm might be responsible. Further investigation revealed that "thunderclap headache" may present in the absence of aneurysm and may herald the development of regular episodes of migraine or tension headache. Despite the differential issues regarding underlying pathology, virtually all experts on headache recommend immediate referral for any patient complaining of this type of sudden pain.
When Your Child Has a Headache
Headache is usually not a serious condition. Almost all adults have experienced headaches, and most have successfully used nonprescription products. Over 99% of headaches are simple, self-treatable conditions that do not reflect any dangerous condition. Although many children suffer from headaches, occasionally they may be a sign of a more serious problem. Under certain circumstances, headaches in children should be checked by a physician.
The duration of the headache is also important. Generally, headaches that last for more than five days in a child require a physician visit. However, the younger the child, the shorter the time allowed for self-treatment.
Finally, if your child has a sore throat along with the headache, it is important to see a physician promptly, since this may indicate a serious condition such as strep throat that may require prescription therapy.
Finally, if your child has a sore throat along with the headache, it is important to see a physician promptly, since this may indicate a serious condition such as strep throat that may require prescription therapy
Management for Migraine
The management plan for migraine relief in children and adolescents is based on goals: Goals for Management of Migraines") established by the American Academy of Neurology (Silberstein, 2000) and several general principles: General Principles of Management of Migraines in Children and Adolescents"). The most significant concept within this framework is that the plan is individualized based on the symptoms, responses to treatment, and patient/family preference for treatment options. Often a variety of treatment options must be tried before the combination that provides optimal relief is found. These treatment options are categorized into four main approaches: nonpharmacologic interventions, pharmacologic interventions, bio-behavioral modalities, and complementary and alternative interventions. Generally, the interventions are initiated in a stepwise fashion in the order listed above.
Management: Nonpharmacologic interventions
Nonpharmacologic options are effective in treating children/adolescents and are initiated before pharmacologic therapy is considered (Damen et al 2006, Lewis et al 2005, Unger 2006).
Maintenance of a Headache Calendar
- Maintenance of a headache calendar can assist with trigger identification and allows for management plan adjustment based on an individual's response to interventions.
- Adjustment of lifestyle habits should include maintenance of routine patterns of sleeping, eating, and exercise.
Sleep: Children with Migraines Tend to Have Sleep Disturbances
- A child should sleep 8 to 10 hours nightly with scheduled bedtime and awakening. Some adjustment can be made on weekends, but the regular bedtime should be resumed on Sunday night (Powers & Andrasik, 2005).
- Adolescents can sleep later on weekends as well but should plan to awaken briefly at the regular time, get out of bed, drink juice or eat a snack, and go back to sleep (Unger, 2006).
- A quiet routine before bedtime is recommended. Young children should avoid frightening books, movies and television shows. Night lights or white noise might help.
Nutrition and Dietary Patterns
- The child should eat three meals and one to two snacks a day at routine times. Breakfast should not be skipped.
- In general, avoidance diets are not recommended for children or adolescents unless a trigger has been identified.
- About one third of children report that certain foods trigger headaches. Chocolate, citrus fruits, and cheeses are common triggers; processed meats, yogurt, fried foods, monosodium glutamate, aspartame, and alcoholic beverages are known triggers as well (Lewis et al., 2005).
- Caffeine should be avoided because it is linked to sleep disturbances and mood disruptions, both headache triggers (Lewis et al., 2005).
- Inadequate hydration should be avoided. Adolescents are encouraged to drink 2 liters (L) of noncaffeinated liquids, ideally water, per day, increasing to 3 L a day during the summer and periods of exertion (Powers & Andrasik, 2005).
- Children and adolescences are encouraged to participate with family or friends in at least 30 minutes of enjoyable, aerobic activity 3 to 7 days a week.
Prioritization of Activities and Evaluation of Performance Expectations
- Excessive or unrealistic expectations of performance in school, athletics, and other activities may contribute to migraines. Sport performance and college acceptance are two common stressors. If after-school activities are excessive, consideration should be given to eliminating some of the activities.
Management: Pharmacologic Interventions
Few well-designed trials have evaluated the acute pharmacologic management of migraine in children (Damen et al 2005, Lewis et al 2004). For this reason, ibuprofen and naproxen are the only medications approved by the U.S. Food and Drug Administration (FDA) for the acute treatment of migraines in children from 2 to 18 years of age (Lewis et al., 2005), although a variety of agents are commonly utilized ( Table 1 ).
Table 1. Medications for Acute/Abortive Migraine Therapy
|Generic name||Brand name||Type of drug||Amount per dose (maximum/dose)|
|Acetaminophen||Tylenol||Analgesic||15 mg/kg PO (1000 mg)|
|Ibuprofen||Advil/Motrin||NSAID||10 mg/kg PO (800 mg)|
|Naproxen||Aleve||NSAID||5-7 mg/kg PO (500 mg)|
|Ketorolac*||Toradol||NSAID||0.5 mg/kg IM/IV (30 mg)|
|Sumatriptan*||Imitrex||Triptan||25-100 mg PO|
|5-20 mg IN; 6 mg SQ|
|Rizatriptan*||Maxalt||Triptan||5-10 mg PO|
|Zolmitriptan*||Zomig||Triptan||1.25-2.5 mg PO|
|Dihydroergotamine*||Migranal||Ergot||0.1 mg IV (6-9 y) 0.2 mg IV (9-12 y) 0.3 mg IV (12-16 y)|
|Prochlorperazine*||Compazine||Antiemetic||0.1-0.15 mg/kg IM (10 mg)|
IM, Intramuscular; IN, intranasal; IV, intravenous; NSAID, nonsteroidal anti-inflammatory drug; PO, by mouth; SQ, subcutaneous.
Data from Lewis et al 2005, Robertson and Shilkofski 2005; Tarascon Pocket Pharmacopoeia, 2007; and Unger (2006).
*Not approved by the U.S. Food and Drug Administration for use in children and adolescents with migraine headaches.
Migraine preventive medications, when given, should decrease the number, intensity, and duration of headaches, improve how patients respond to acute treatment, and improve the quality of life (Lewis et al., 2004). In general, prophylactic medications are considered when patients have more than four headaches per month or the headaches are so severe that they interrupt normal activities (Damen, Bruijn, Verhagen, et al., 2006). To minimize adverse effects, prophylactic medications are started at the lowest dose and titrated upward as needed (Unger, 2006). Unfortunately, because of the lack of evidence, the FDA has not approved any preventive migraine medications in children. Given the available evidence, the medications listed in Table 2 can be considered (Unger, 2006).
Table 2. Oral Medications for Prophylactic Migraine Therapy
|Generic name||Brand name||Type of drug||Amount per day (maximum per day)|
|Propranolol*||Inderal||ß-blocker||1-4 mg/kg/day bid-tid; 40 mg bid max adult dose to start (240 mg max adult dose)|
|Amitriptyline*||Elavil||Tricylclic||0.1-2 mg/kg/day q HS; 0.25 mg/kg/d max to start; need to titrate; >1 mg/kg/day give bid and monitor EKG (75 mg)|
|Valproic acid*||Depakote||Anticonvulsant||15-30 mg/kg/day bid; 250 mg bid max to start in adult (1000 mg)|
|Topiramate*||Topamax||Anticonvulsant||2-3 mg/kg/day bid; 25 mg q HS max to start; need to titrate; >50 mg, give bid (200 mg)|
|Cyproheptadine*||Periactin||Antihistamine||0.25-0.4 mg/kg/day bid-tid (2-6 yo, 12 mg) (7-14 yo, 16 mg) (adult, 32 mg)|
bid, Twice a day; EKG, electrocardiogram; HS, at bedtime; q, every; tid, three times a day; yo, year old.
Data from Lewis et al 2005, Robertson and Shilkofski 2005, Tarascon Pocket Pharmacopoeia 2007, Unger 2006.
*Not approved by the U.S Food and Drug Administration for use in children and adolescents with migraine headaches.
Emergency Department Care for Headache in Children Pediatrics, Headache; Kirsten A Bechtel, MD, Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital
- Migraine and tension headache
- The goals of therapy are to relieve pain, alleviate nausea, and promote sleep.
- Vasoconstrictive agents may be helpful, especially if the onset of headache has been recent.
- Narcotic and nonnarcotic analgesics, sedatives, and antiemetics are helpful adjunctive therapy.
- The treatment of sinusitis includes appropriate antibiotic coverage, analgesics (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen), and nasal decongestants.
- Head trauma, intracranial mass/abscess
- In the event of intracranial hemorrhage or an intracranial mass causing headache, appropriate airway management, with the goal of adequate oxygenation and hyperventilation to reduce cerebral blood flow and lower intracranial pressure is the immediate goal. Subsequent surgery is necessary to evacuate the lesion.
- Analgesics are useful for chronic postconcussive headaches.
- To alleviate the increased intracranial pressure associated with pseudotumor cerebri, a lumbar puncture is used to reduce the volume of CSF. Carbonic anhydrase inhibitors decrease the production of CSF.
- The treatment goal of meningeal inflammation is to treat the underlying cause, such as HTN (antihypertensives), infection (antibiotics), or subarachnoid hemorrhage (surgical evacuation of intracranial hemorrhage; nimodipine can be used to reduce vasospasm).
- Consultation with a surgeon is appropriate for headache caused by mass lesions, intracranial hemorrhage, or abscess.
MedicationIf the diagnosis is not a surgical condition that requires immediate operative treatment, the emphasis of medical therapy should be to provide analgesia and to treat the underlying cause of headache. In patients with migraine, tension, and posttraumatic headache, the goals of therapy are to relieve pain, alleviate nausea, and promote sleep. Vasoconstrictive agents may also be helpful, especially if the onset of the migraine headache is recent.
These agents are indicated for the treatment of mild to moderate pain and headache. They are the mainstays of headache treatment
- Sztajnrycer M, Jauch EC. Unusual headaches. Emerg Med Clin North Am 1998;16(4):741-760.
- Saper JR. Headache disorders. Med Clin North Am 1999;83(3):663-690.
- Holden EW, Levy JD, Deichmann MM, et al. Recurrent Pediatric Headaches: Assessment and intervention. J Dev Behav Pediatr 1998;19(2):109-116.
- Smith MS. Comprehensive evaluation and treatment of recurrent pediatric headache. Pediatr Ann 1995;24(9):453-457.
- Coutin IB, Glass SF. Recognizing uncommon headache syndromes. Am Fam Physician 1996;54(7):2247-2252.
- Weight DG. Minor head trauma. Psychiatr Clin North Am 1998;21(3):609-624.
- Evans RW. Diagnostic testing for the evaluation of headaches. Neurol Clin 1996;14(1):1-26.
- Weiss J. Assessing and managing the patient with headaches. Nurse Pract 1999;24(7):18-20,23-5,28-9,36-7.
- Newman LC, Lipton RB. Emergency department evaluation of headache. Neurol Clin 1998;16(2):285-303.
- Craig JJ, Patterson VH. Headaches in the accident and emergency department. Br J Hosp Med 1997;57(5):202-206.
US Pharmacist. 2002;27(10)
Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways become sore and swollen. That makes them very sensitive, and they may react strongly to things that you are allergic to or find irritating. When your airways react, they get narrower and your lungs get less air. This can cause wheezing, coughing, chest tightness and trouble breathing, especially early in the morning or at night.
When your asthma symptoms become worse than usual, it's called an asthma attack. In a severe asthma attack, the airways can close so much that your vital organs do not get enough oxygen. People can die from severe asthma attacks.
Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms.
Common asthma symptoms include:
- Coughing. Coughing from asthma is often worse at night or early in the morning, making it hard to sleep.
- Wheezing. Wheezing is a whistling or squeaky sound that occurs when you breathe.
- Chest tightness. This may feel like something is squeezing or sitting on your chest.
- Shortness of breath. Some people who have asthma say they can't catch their breath or they feel out of breath. You may feel like you can't get air out of your lungs.
Not all people who have asthma have these symptoms. Likewise, having these symptoms doesn't always mean that you have asthma. A lung function test done along with a medical history (including type and frequency of your symptoms) and physical exam, is the best way to diagnose asthma for certain.
The types of asthma symptoms you have, how often they occur, and how severe they are may vary over time. Sometimes your symptoms may just annoy you. Other times they may be troublesome enough to limit your daily routine.
Severe symptoms can threaten your life. It's vital to treat symptoms when you first notice them so they don't become severe.
With proper treatment, most people who have asthma can expect to have few, if any, symptoms either during the day or at night.
What Causes Asthma Symptoms To Occur?
A number of things can bring about or worsen asthma symptoms. Your doctor will help you find out which things (sometimes called triggers) may cause your asthma to flare up if you come in contact with them. Triggers may include:
- Allergens found in dust, animal fur, cockroaches, mold, and pollens from trees, grasses, and flowers
- Irritants such as cigarette smoke, air pollution, chemicals or dust in the workplace, compounds in home décor products, and sprays (such as hairspray)
- Certain medicines such as aspirin or other nonsteroidal anti-inflammatory drugs and nonselective beta-blockers
- Sulfites in foods and drinks
- Viral upper respiratory infections such as colds
- Exercise (physical activity)
Other health conditions—such as runny nose, sinus infections, reflux disease, psychological stress, and sleep apnea—can make asthma more difficult to manage. These conditions need treatment as part of an overall asthma care plan.
Asthma is different for each person. Some of the factors listed may not affect you. Other factors that do affect you may not be on the list. Talk to your doctor about the things that seem to make your asthma worse.
Asthma is a long-term disease that can't be cured. The goal of asthma treatment is to control the disease. Good asthma control will:
- Prevent chronic and troublesome symptoms such as coughing and shortness of breath
- Reduce your need of quick-relief medicines (see below)
- Help you maintain good lung function
- Let you maintain your normal activity levels and sleep through the night
- Prevent asthma attacks that could result in your going to the emergency room or being admitted to the hospital for treatment
To reach this goal, you should actively partner with your doctor to manage your asthma or your child's asthma. Children aged 10 or older—and younger children who are able—also should take an active role in their asthma care.
Taking an active role to control your asthma involves working with your doctor and other clinicians on your health care team to create and follow an asthma action plan. It also means avoiding factors that can make your asthma flare up and treating other conditions that can interfere with asthma management.
An asthma action plan gives guidance on taking your medicines properly, avoiding factors that worsen you asthma, tracking your level of asthma control, responding to worsening asthma, and seeking emergency care when needed.
Asthma is treated with two types of medicines: long-term control and quick-relief medicines. Long-term control medicines help reduce airway inflammation and prevent asthma symptoms. Quick-relief, or "rescue," medicines relieve asthma symptoms that may flare up.
Your initial asthma treatment will depend on how severe your disease is. Followup asthma treatment will depend on how well your asthma action plan is working to control your symptoms and prevent you from having asthma attacks.
Your level of asthma control can vary over time and with changes in your home, school, or work environments that alter how often you are exposed to the factors that can make your asthma worse. Your doctor may need to increase your medicine if your asthma doesn't stay under control.
On the other hand, if your asthma is well controlled for several months, your doctor may be able to decrease your medicine. These adjustments either up or down to your medicine will help you maintain the best control possible with the least amount of medicine necessary.
Asthma treatment for certain groups of people, such as children, pregnant women, or those for whom exercise brings on asthma symptoms, will need to be adjusted to meet their special needs.
You can work with your doctor to create a personal written asthma action plan. The asthma action plan shows your daily treatment, such as what kind of medicines to take and when to take them. The plan explains when to call the doctor or go to the emergency room.
If your child has asthma, all of the people who care for him or her should know about the child's asthma action plan. This includes babysitters and workers at daycare centers, schools, and camps. These caretakers can help your child follow his or her action plan.
Avoid Things That Can Worsen Your Asthma
A number of common things (sometimes called asthma triggers) can set off or worsen your asthma symptoms. Once you know what these factors are, you can take steps to control many of them.
For example, if exposure to pollens or air pollution makes your asthma worse, try to limit time outdoors when the levels of these substances are high in the outdoor air. If animal fur sets off your asthma symptoms, keep pets with fur out of your home or bedroom. The NHLBI offers many useful tips for controlling things that make your asthma worse.
If your asthma symptoms are clearly linked to allergies, and you can't avoid exposure to those allergens, then your doctor may advise you to get allergy shots for the specific allergens that bother your asthma. You may need to see a specialist if you're thinking about getting allergy shots. These shots may lessen or prevent your asthma symptoms, but they can't cure your asthma.
Several health conditions can make asthma more difficult to manage. These conditions include runny nose, sinus infections, reflux disease, psychological stress, and sleep apnea. Your doctor will treat these conditions as well.
Your doctor will consider many things when deciding which asthma medicines are best for you. Doctors usually use a stepwise approach to prescribing medicines. Your doctor will check to see how well a medicine works for you; he or she will make changes in the dose or medicine, as needed.
Asthma medicines can be taken in pill form, but most are taken using a device called an inhaler. An inhaler allows the medicine to go right to your lungs.
Not all inhalers are used the same way. Ask your doctor and other clinicians on your health care team to show you the right way to use your inhaler. Ask them to review the way you use your inhaler at every visit.
Long-Term Control Medicines
Most people who have asthma need to take long-term control medicines daily to help prevent symptoms. The most effective long-term medicines reduce airway inflammation.
These medicines are taken over the long term to prevent symptoms from starting. They don't give you quick relief from symptoms.
Inhaled corticosteroids. Inhaled corticosteroids are the preferred medicines for long-term control of asthma. These medicines are the most effective long-term control medicine to relieve airway inflammation and swelling that makes the airways sensitive to certain substances that are breathed in.
Reducing inflammation helps prevent the chain reaction that causes asthma symptoms. Most people who take these medicines daily find they greatly reduce how severe symptoms are and how often they occur.
Inhaled corticosteroids are generally safe when taken as prescribed. They're very different from the illegal anabolic steroids taken by some athletes. Inhaled corticosteroids aren't habit-forming, even if you take them every day for many years.
But, like many other medicines, inhaled corticosteroids can have side effects. Most doctors agree that the benefits of taking inhaled corticosteroids and preventing asthma attacks far outweigh the risks of side effects.
One common side effect from inhaled corticosteroids is a mouth infection called thrush. You can use a spacer or holding chamber to avoid thrush. A spacer or holding chamber is attached to your inhaler when taking medicine to keep the medicine from landing in your mouth or on the back of your throat.
Work with your health care team if you have any questions about how to use a spacer or holding chamber. Rinsing your mouth out with water after taking inhaled corticosteroids also can lower your risk of thrush.
If you have severe asthma, you may have to take corticosteroid pills or liquid for short periods to get your asthma under control. If taken for long periods, these medicines raise your risk for cataracts and osteoporosis (OS-te-o-po-RO-sis). A cataract is the clouding of the lens in your eye. Osteoporosis is a disorder that makes your bones weak and more likely to break.
Your doctor may have you add another long-term control asthma medicine to lower your dose of corticosteroids. Or, your doctor may suggest you take calcium and vitamin D pills to protect your bones.
Other long-term control medicines. Other long-term control medicines include:
- Inhaled long-acting beta2-agonists These medicines open the airways and may be added to low-dose inhaled corticosteroids to improve asthma control. An inhaled long-acting beta2-agonist shouldn't be used alone.
- Leukotriene modifiers These medicines are taken by mouth. They help block the chain reaction that increases inflammation in your airways.
- Cromolyn and nedocromil. These inhaled medicines also help prevent inflammation and can be used to treat asthma of mild severity.
- Theophylline This medicine is taken by mouth and helps open the airways.
If your doctor prescribes a long-term control medicine, take it every day to control your asthma. Your asthma symptoms will likely return or get worse if you stop taking your medicine.
Long-term control medicines can have side effects. Talk to your doctor about these side effects and ways to monitor or avoid them.
All people who have asthma need a quick-relief medicine to help relieve asthma symptoms that may flare up. Inhaled short-acting beta2-agonists are the first choice for quick relief.
These medicines act quickly to relax tight muscles around your airways when you're having a flareup. This allows the airways to open up so air can flow through them.
You should take your quick-relief medicine when you first notice your asthma symptoms. If you use this medicine more than 2 days a week, talk with your doctor about how well controlled your asthma is. You may need to make changes in your asthma action plan.
Carry your quick-relief inhaler with you at all times in case you need it. If your child has asthma, make sure that anyone caring for him or her and the child's school has the child's quick-relief medicines. They should understand when and how to use them and when to seek medical care for your child.
You shouldn't use quick-relief medicines in place of prescribed long-term control medicines. Quick-relief medicines don't reduce inflammation
Migraine is a recurrent headache disorder with intense pain that may be unilateral (one-sided) and accompanied by nausea or vomiting as well as photosensitivity (sensitivity to light) and phonosensitivity (sensitivity to sound). The lifetime prevalence is 25% in women and 8% in men. Migraine also affects about 5% to 10% of children and adolescents. Some people who have migraine headaches experience an aura (temporary disturbance of the senses or muscles) in the minutes before the onset of pain. The aura may consist of seeing flashing lights, having numbness or tingling in the face or extremities, having a disturbed sense of smell, or having difficulty speaking. However, only about one-third of individuals who have migraine headaches experience auras. Migraines are painful but fortunately are not life-threatening.
The exact cause of migraine headaches is unknown. Current research suggests that inflammation in the blood vessels of the brain causes them to swell and press on nearby nerves, causing pain. This inflammation may arise in or be stimulated by signals from the trigeminal nerve (the main sensory nerve of the face).
Many individuals with migraine headaches can identify triggers that cause or aggravate the headache. Because there is no cure, avoiding triggers may help to reduce the frequency or severity of migraine headaches. Some triggers include
- Stress and anxiety
- Changes in the weather
- Caffeine (too much or too little), chocolate, or alcohol (often red wine)
- Lack of sleep or too much sleep
- Hormonal changes during the menstrual cycle
- Skipped meals
- Certain foods that contain nitrates (such as luncheon meats, hot dogs), tyramine (such as aged cheeses, smoked fish), monosodium glutamate (MSG), or aspartame
The medical history and physical examination are the most important. Your physician will need to know about all of the medications you are taking, including over-the-counter medicines. Discuss with your physician if you need to take pain medication more than 3 days a week or more than 10 days in a month since you may be experiencing rebound (a cycle of headache pain that recurs when each dose of medication wears off). Rarely, imaging studies are used to make certain that your headaches are not caused by a problem other than migraines.
There are 2 medication strategies used to treat migraine headaches. Treating the pain at the onset offers the best relief.
- Over-the-counter analgesics (pain relievers) such as aspirin, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen
- Prescription drugs called triptans are used for headaches not relieved by over-the-counter medications. These are generally not used for people who have high blood pressure or heart disease.
For those whose headaches are not adequately relieved with these medications, the second medication strategy involves medications prescribed prophylactically (taken everyday for prevention). These medications are normally prescribed to treat other disorders but have been successful at reducing the frequency or severity of migraine headaches.
- Blood pressure medications such as beta blockers or calcium channel blockers
- Antidepressant medications such as amitriptyline or venlafaxine
- Anticonvulsant medications such as divalproex or topiramate
Why does my child wet the bed?
Many children wet the bed until they are 5 years old, or even older. In most cases, the cause is physical and not the child’s fault. The child’s bladder might be too small. Or the amount of urine produced overnight is too much for the bladder to hold. As a result, the bladder fills up before the night is over. Some children sleep too deeply or take longer to learn bladder control. Children don’t wet the bed on purpose. Bedwetting is a medical problem, not a behavior problem. Scolding and punishment will not help a child stay dry.
Bedwetting may run in the family. If both parents wet the bed as children, their child is likely to have the same problem. If only one parent has a history of bedwetting, the child has about a fifty-fifty chance of having the problem. Some children wet the bed even if neither parent ever did.
Bedwetting may be caused by an infection or a nerve disease. Children with nerve disease often also have daytime wetting.
A child who has been dry for several months or even years may return to wetting the bed. The cause might be emotional stress, such as loss of a loved one, problems at school, a new sibling, or even training too early.
How can I help my child stay dry?
The answer is rarely easy. Try skipping drinks before bedtime. Avoid drinks with caffeine, like colas or tea. These drinks speed up urine production. Give your child one drink with dinner. Explain that it will be the last drink before going to bed. Make sure your child uses the bathroom just before bed. Many children will still wet the bed, but these steps are a place to start.
Your child may feel bad about wetting the bed. Let your child know he isn’t to blame. Let her help take off the wet sheets and put them in the washer, but don’t make this a punishment. Be supportive. Praise your child for dry nights.
Be patient. Most children grow out of bedwetting. Some children just take more time than others.
Should I take my child to the doctor?
If your child is younger than 5, don’t worry about bedwetting. Many children do not stay dry at night until age 7. Most children outgrow wetting the bed. A single episode of bedwetting should not cause alarm, even in an older child.
If your child is 7 years old or older and wets the bed more than two or three times in a week, a doctor may be able to help. If both day and night wetting occur after age 5, your child should see a doctor before age 7.
The doctor will ask questions about your child’s health and the wetting problem. Your child will likely be asked for a urine sample. The doctor uses the sample to look for signs of infection. By testing the reflexes in the child’s legs and feet, the doctor can check for nerve damage. Sometimes bedwetting is a sign of diabetes, a condition that can cause frequent urination.
If your child has an infection, the doctor can prescribe medicine. In most cases, the doctor finds that the child is normal and healthy. If your child is basically healthy, a variety of ways are available to help your child stop wetting the bed.
What treatments can help my child stay dry?
Talk with your doctor about ways to help your child. Many choices exist. Let your child help decide which ones to try.
Bladder training can help your child hold urine longer. Write down what times your child urinates during the day. Then figure out the times between trips to the bathroom. After a day or two, have your child try to wait an extra 15 minutes before using the bathroom. If the child usually goes to the bathroom at 3:30 p.m., have him wait until 3:45. Slowly make the times longer and longer. This method is designed for children with small bladders. It helps stretch the bladder to hold more urine. Be patient. Bladder training can take several weeks, or even months.
A small moisture alarm can be put in the child’s bed or underwear. The alarm triggers a bell or buzzer with the first drops of urine. The sound wakes the child. Your child can then stop the flow of urine, get up, and use the bathroom. Waking also teaches the child how a full bladder feels.
Two kinds of medicine are available for treating bedwetting. One medicine slows down how fast your body makes urine. The other medicine helps the bladder relax so it can hold more urine. These medicines often work well. Remember wetting may return when the child stops taking the medicine. If this occurs, keeping the child on medicine for a longer time helps.
Points to Remember
- Normal, healthy children may wet the bed.
- Bedwetting may be a sign of infection or other problems.
- Many children are dry at night by the time they are 5 years old. Others take longer to stay dry.
- Scolding and punishment do not help a child stop bedwetting.
- If your child is 7 or older and wets the bed more than two or three times a week, a doctor may be able to help.
- Treatments include bladder training, alarms, and medicines.
- Most children grow out of bedwetting naturally.
National Kidney and Urologic Diseases Information Clearinghouse
What is attention deficit hyperactivity disorder?
Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood disorders and can continue through adolescence and adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity).ADHD has three subtypes:1
- Predominantly hyperactive-impulsive
- Most symptoms (six or more) are in the hyperactivity-impulsivity categories.
- Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.
- Predominantly inattentive
- The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.
- Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD.
- Combined hyperactive-impulsive and inattentive
- Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present.
- Most children have the combined type of ADHD.
Treatments can relieve many of the disorder's symptoms, but there is no cure. With treatment, most people with ADHD can be successful in school and lead productive lives. Researchers are developing more effective treatments and interventions, and using new tools such as brain imaging, to better understand ADHD and to find more effective ways to treat and prevent it.
What are the symptoms of ADHD in children?
Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. It is normal for all children to be inattentive, hyperactive, or impulsive sometimes, but for children with ADHD, these behaviors are more severe and occur more often. To be diagnosed with the disorder, a child must have symptoms for 6 or more months and to a degree that is greater than other children of the same age.Children who have symptoms of inattention may:
- Be easily distracted, miss details, forget things, and frequently switch from one activity to another
- Have difficulty focusing on one thing
- Become bored with a task after only a few minutes, unless they are doing something enjoyable
- Have difficulty focusing attention on organizing and completing a task or learning something new
- Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
- Not seem to listen when spoken to
- Daydream, become easily confused, and move slowly
- Have difficulty processing information as quickly and accurately as others
- Struggle to follow instructions.
- Fidget and squirm in their seats
- Talk nonstop
- Dash around, touching or playing with anything and everything in sight
- Have trouble sitting still during dinner, school, and story time
- Be constantly in motion
- Have difficulty doing quiet tasks or activities.
- Be very impatient
- Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
- Have difficulty waiting for things they want or waiting their turns in games
- Often interrupt conversations or others' activities.
Parents and teachers can miss the fact that children with symptoms of inattention have the disorder because they are often quiet and less likely to act out. They may sit quietly, seeming to work, but they are often not paying attention to what they are doing. They may get along well with other children, compared with those with the other subtypes, who tend to have social problems. But children with the inattentive kind of ADHD are not the only ones whose disorders can be missed. For example, adults may think that children with the hyperactive and impulsive subtypes just have emotional or disciplinary problems.
What Causes ADHD?
Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD.
Genes. Inherited from our parents, genes are the "blueprints" for who we are. Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several genes that may make people more likely to develop the disorder.2,3 Knowing the genes involved may one day help researchers prevent the disorder before symptoms develop. Learning about specific genes could also lead to better treatments.
Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. This NIMH research showed that the difference was not permanent, however, and as children with this gene grew up, the brain developed to a normal level of thickness. Their ADHD symptoms also improved.4
Environmental factors. Studies suggest a potential link between cigarette smoking and alcohol use during pregnancy and ADHD in children.5,6 In addition, preschoolers who are exposed to high levels of lead, which can sometimes be found in plumbing fixtures or paint in old buildings, may have a higher risk of developing ADHD.7
Brain injuries. Children who have suffered a brain injury may show some behaviors similar to those of ADHD. However, only a small percentage of children with ADHD have suffered a traumatic brain injury.
Sugar. The idea that refined sugar causes ADHD or makes symptoms worse is popular, but more research discounts this theory than supports it. In one study, researchers gave children foods containing either sugar or a sugar substitute every other day. The children who received sugar showed no different behavior or learning capabilities than those who received the sugar substitute.8 Another study in which children were given higher than average amounts of sugar or sugar substitutes showed similar results.9
In another study, children who were considered sugar-sensitive by their mothers were given the sugar substitute aspartame, also known as Nutrasweet. Although all the children got aspartame, half their mothers were told their children were given sugar, and the other half were told their children were given aspartame. The mothers who thought their children had gotten sugar rated them as more hyperactive than the other children and were more critical of their behavior, compared to mothers who thought their children received aspartame.10
Food additives. Recent British research indicates a possible link between consumption of certain food additives like artificial colors or preservatives, and an increase in activity.11 Research is under way to confirm the findings and to learn more about how food additives may affect hyperactivity.
How is ADHD diagnosed?
Children mature at different rates and have different personalities, temperaments, and energy levels. Most children get distracted, act impulsively, and struggle to concentrate at one time or another. Sometimes, these normal factors may be mistaken for ADHD. ADHD symptoms usually appear early in life, often between the ages of 3 and 6, and because symptoms vary from person to person, the disorder can be hard to diagnose. Parents may first notice that their child loses interest in things sooner than other children, or seems constantly "out of control." Often, teachers notice the symptoms first, when a child has trouble following rules, or frequently "spaces out" in the classroom or on the playground.
No single test can diagnose a child as having ADHD. Instead, a licensed health professional needs to gather information about the child, and his or her behavior and environment. A family may want to first talk with the child's pediatrician. Some pediatricians can assess the child themselves, but many will refer the family to a mental health specialist with experience in childhood mental disorders such as ADHD. The pediatrician or mental health specialist will first try to rule out other possibilities for the symptoms. For example, certain situations, events, or health conditions may cause temporary behaviors in a child that seem like ADHD.Between them, the referring pediatrician and specialist will determine if a child:
- Is experiencing undetected seizures that could be associated with other medical conditions
- Has a middle ear infection that is causing hearing problems
- Has any undetected hearing or vision problems
- Has any medical problems that affect thinking and behavior
- Has any learning disabilities
- Has anxiety or depression, or other psychiatric problems that might cause ADHD-like symptoms
- Has been affected by a significant and sudden change, such as the death of a family member, a divorce, or parent's job loss.
A specialist will also check school and medical records for clues, to see if the child's home or school settings appear unusually stressful or disrupted, and gather information from the child's parents and teachers. Coaches, babysitters, and other adults who know the child well also may be consulted.The specialist also will ask:
- Are the behaviors excessive and long-term, and do they affect all aspects of the child's life?
- Do they happen more often in this child compared with the child's peers?
- Are the behaviors a continuous problem or a response to a temporary situation?
- Do the behaviors occur in several settings or only in one place, such as the playground, classroom, or home?
The specialist pays close attention to the child's behavior during different situations. Some situations are highly structured, some have less structure. Others would require the child to keep paying attention. Most children with ADHD are better able to control their behaviors in situations where they are getting individual attention and when they are free to focus on enjoyable activities. These types of situations are less important in the assessment. A child also may be evaluated to see how he or she acts in social situations, and may be given tests of intellectual ability and academic achievement to see if he or she has a learning disability.
Finally, if after gathering all this information the child meets the criteria for ADHD, he or she will be diagnosed with the disorder.
How is ADHD treated?
Currently available treatments focus on reducing the symptoms of ADHD and improving functioning. Treatments include medication, various types of psychotherapy, education or training, or a combination of treatments.
The most common type of medication used for treating ADHD is called a "stimulant." Although it may seem unusual to treat ADHD with a medication considered a stimulant, it actually has a calming effect on children with ADHD. Many types of stimulant medications are available. A few other ADHD medications are non-stimulants and work differently than stimulants. For many children, ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. Medication also may improve physical coordination.
However, a one-size-fits-all approach does not apply for all children with ADHD. What works for one child might not work for another. One child might have side effects with a certain medication, while another child may not. Sometimes several different medications or dosages must be tried before finding one that works for a particular child. Any child taking medications must be monitored closely and carefully by caregivers and doctors.
Stimulant medications come in different forms, such as a pill, capsule, liquid, or skin patch. Some medications also come in short-acting, long-acting, or extended release varieties. In each of these varieties, the active ingredient is the same, but it is released differently in the body. Long-acting or extended release forms often allow a child to take the medication just once a day before school, so they don't have to make a daily trip to the school nurse for another dose. Parents and doctors should decide together which medication is best for the child and whether the child needs medication only for school hours or for evenings and weekends, too.
A list of medications and the approved age for use follows. ADHD can be diagnosed and medications prescribed by M.D.s (usually a psychiatrist) and in some states also by clinical psychologists, psychiatric nurse practitioners, and advanced psychiatric nurse specialists. Check with your state's licensing agency for specifics.
|Trade Name||Generic Name||Approved Age|
|Adderall||amphetamine||3 and older|
|Adderall XR||amphetamine (extended release)||6 and older|
|Concerta||methylphenidate (long acting)||6 and older|
|Daytrana||methylphenidate patch||6 and older|
|Desoxyn||methamphetamine hydrochloride||6 and older|
|Dexedrine||dextroamphetamine||3 and older|
|Dextrostat||dextroamphetamine||3 and older|
|Focalin||dexmethylphenidate||6 and older|
|Focalin XR||dexmethylphenidate (extended release)||6 and older|
|Metadate ER||methylphenidate (extended release)||6 and older|
|Metadate CD||methylphenidate (extended release)||6 and older|
|Methylin||methylphenidate (oral solution and chewable tablets)||6 and older|
|Ritalin||methylphenidate||6 and older|
|Ritalin SR||methylphenidate (extended release)||6 and older|
|Ritalin LA||methylphenidate (long acting)||6 and older|
|Strattera||atomoxetine||6 and older|
|Vyvanse||lisdexamfetamine dimesylate||6 and older|
*Not all ADHD medications are approved for use in adults.
NOTE: "extended release" means the medication is released gradually so that a controlled amount enters the body
over a period of time. "Long acting" means the medication stays in the body for a long time.
Over time, this list will grow, as researchers continue to develop new medications for ADHD. Medication guides for each of these medications are available from the U.S. Food and Drug Administration (FDA).
What are the side effects of stimulant medications?
The most commonly reported side effects are decreased appetite, sleep problems, anxiety, and irritability. Some children also report mild stomachaches or headaches. Most side effects are minor and disappear over time or if the dosage level is lowered.
- Decreased appetite. Be sure your child eats healthy meals. If this side effect does not go away, talk to your child's doctor. Also talk to the doctor if you have concerns about your child's growth or weight gain while he or she is taking this medication.
- Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower dose of the medication or a shorter-acting form. The doctor might also suggest giving the medication earlier in the day, or stopping the afternoon or evening dose. Adding a prescription for a low dose of an antidepressant or a blood pressure medication called clonidine sometimes helps with sleep problems. A consistent sleep routine that includes relaxing elements like warm milk, soft music, or quiet activities in dim light, may also help.
- Less common side effects. A few children develop sudden, repetitive movements or sounds called tics. These tics may or may not be noticeable. Changing the medication dosage may make tics go away. Some children also may have a personality change, such as appearing "flat" or without emotion. Talk with your child's doctor if you see any of these side effects.
Are stimulant medications safe?
Under medical supervision, stimulant medications are considered safe. Stimulants do not make children with ADHD feel high, although some kids report feeling slightly different or "funny." Although some parents worry that stimulant medications may lead to substance abuse or dependence, there is little evidence of this.
FDA warning on possible rare side effects
In 2007, the FDA required that all makers of ADHD medications develop Patient Medication Guides that contain information about the risks associated with the medications. The guides must alert patients that the medications may lead to possible cardiovascular (heart and blood) or psychiatric problems. The agency undertook this precaution when a review of data found that ADHD patients with existing heart conditions had a slightly higher risk of strokes, heart attacks, and/or sudden death when taking the medications.
The review also found a slight increased risk, about 1 in 1,000, for medication-related psychiatric problems, such as hearing voices, having hallucinations, becoming suspicious for no reason, or becoming manic (an overly high mood), even in patients without a history of psychiatric problems. The FDA recommends that any treatment plan for ADHD include an initial health history, including family history, and examination for existing cardiovascular and psychiatric problems.
One ADHD medication, the non-stimulant atomoxetine (Strattera), carries another warning. Studies show that children and teenagers who take atomoxetine are more likely to have suicidal thoughts than children and teenagers with ADHD who do not take it. If your child is taking atomoxetine, watch his or her behavior carefully. A child may develop serious symptoms suddenly, so it is important to pay attention to your child's behavior every day. Ask other people who spend a lot of time with your child to tell you if they notice changes in your child's behavior. Call a doctor right away if your child shows any unusual behavior. While taking atomoxetine, your child should see a doctor often, especially at the beginning of treatment, and be sure that your child keeps all appointments with his or her doctor.
Do medications cure ADHD?
Current medications do not cure ADHD. Rather, they control the symptoms for as long as they are taken. Medications can help a child pay attention and complete schoolwork. It is not clear, however, whether medications can help children learn or improve their academic skills. Adding behavioral therapy, counseling, and practical support can help children with ADHD and their families to better cope with everyday problems. Research funded by the National Institute of Mental Health (NIMH) has shown that medication works best when treatment is regularly monitored by the prescribing doctor and the dose is adjusted based on the child's needs.12
Different types of psychotherapy are used for ADHD. Behavioral therapy aims to help a child change his or her behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a child how to monitor his or her own behavior. Learning to give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting, is another goal of behavioral therapy. Parents and teachers also can give positive or negative feedback for certain behaviors. In addition, clear rules, chore lists, and other structured routines can help a child control his or her behavior.
Therapists may teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond appropriately can also be part of social skills training.
How can parents help?
Children with ADHD need guidance and understanding from their parents and teachers to reach their full potential and to succeed in school. Before a child is diagnosed, frustration, blame, and anger may have built up within a family. Parents and children may need special help to overcome bad feelings. Mental health professionals can educate parents about ADHD and how it impacts a family. They also will help the child and his or her parents develop new skills, attitudes, and ways of relating to each other.
Parenting skills training helps parents learn how to use a system of rewards and consequences to change a child's behavior. Parents are taught to give immediate and positive feedback for behaviors they want to encourage, and ignore or redirect behaviors they want to discourage. In some cases, the use of "time-outs" may be used when the child's behavior gets out of control. In a time-out, the child is removed from the upsetting situation and sits alone for a short time to calm down.
Parents are also encouraged to share a pleasant or relaxing activity with the child, to notice and point out what the child does well, and to praise the child's strengths and abilities. They may also learn to structure situations in more positive ways. For example, they may restrict the number of playmates to one or two, so that their child does not become overstimulated. Or, if the child has trouble completing tasks, parents can help their child divide large tasks into smaller, more manageable steps. Also, parents may benefit from learning stress-management techniques to increase their own ability to deal with frustration, so that they can respond calmly to their child's behavior.
Sometimes, the whole family may need therapy. Therapists can help family members find better ways to handle disruptive behaviors and to encourage behavior changes. Finally, support groups help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, to exchange information about recommended specialists and strategies, and to talk with experts.
Tips to Help Kids Stay Organized and Follow Directions
Schedule. Keep the same routine every day, from wake-up time to bedtime. Include time for homework, outdoor play, and indoor activities. Keep the schedule on the refrigerator or on a bulletin board in the kitchen. Write changes on the schedule as far in advance as possible.
Organize everyday items. Have a place for everything, and keep everything in its place. This includes clothing, backpacks, and toys.
Use homework and notebook organizers. Use organizers for school material and supplies. Stress to your child the importance of writing down assignments and bringing home the necessary books.
Be clear and consistent. Children with ADHD need consistent rules they can understand and follow.
Give praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behavior, and praise it.
What conditions can coexist with ADHD?Some children with ADHD also have other illnesses or conditions. For example, they may have one or more of the following:
- A learning disability. A child in preschool with a learning disability may have difficulty understanding certain sounds or words or have problems expressing himself or herself in words. A school-aged child may struggle with reading, spelling, writing, and math.
- Oppositional defiant disorder. Kids with this condition, in which a child is overly stubborn or rebellious, often argue with adults and refuse to obey rules.
- Conduct disorder. This condition includes behaviors in which the child may lie, steal, fight, or bully others. He or she may destroy property, break into homes, or carry or use weapons. These children or teens are also at a higher risk of using illegal substances. Kids with conduct disorder are at risk of getting into trouble at school or with the police.
- Anxiety and depression. Treating ADHD may help to decrease anxiety or some forms of depression.
- Bipolar disorder. Some children with ADHD may also have this condition in which extreme mood swings go from mania (an extremely high elevated mood) to depression in short periods of time.
- Tourette syndrome. Very few children have this brain disorder, but among those who do, many also have ADHD. Some people with Tourette syndrome have nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Others clear their throats, snort, or sniff frequently, or bark out words inappropriately. These behaviors can be controlled with medication.
ADHD also may coexist with a sleep disorder, bed-wetting, substance abuse, or other disorders or illnesses.
For more information on these disorders, visit the NIMH website.
Recognizing ADHD symptoms and seeking help early will lead to better outcomes for both affected children and their families.
How can I work with my child’s school?
If you think your child has ADHD, or a teacher raises concerns, you may be able to request that the school conduct an evaluation to determine whether he or she qualifies for special education services.
Start by speaking with your child's teacher, school counselor, or the school's student support team, to begin an evaluation. Also, each state has a Parent Training and Information Center and a Protection and Advocacy Agency that can help you get an evaluation. A team of professionals conducts the evaluation using a variety of tools and measures. It will look at all areas related to the child's disability.
Once your child has been evaluated, he or she has several options, depending on the specific needs. If special education services are needed and your child is eligible under the Individuals with Disabilities Education Act, the school district must develop an "individualized education program" specifically for your child within 30 days.
If your child is considered not eligible for special education services—and not all children with ADHD are eligible—he or she still can get "free appropriate public education," available to all public-school children with disabilities under Section 504 of the Rehabilitation Act of 1973, regardless of the nature or severity of the disability.
For more information on Section 504 visit the U.S. Department of Education's Office for Civil Rights which enforces Section 504 in programs and activities that receive Federal education funds.
Visit the Department of Education programs for more information about children with disabilities
Transitions can be difficult. Each school year brings a new teacher and new schoolwork, a change that can be especially hard for a child with ADHD who needs routine and structure. Consider telling the teachers that your child has ADHD when he or she starts school or moves to a new class. Additional support will help your child deal with the transition.
Do teens with ADHD have special needs?
Most children with ADHD continue to have symptoms as they enter adolescence. Some children, however, are not diagnosed with ADHD until they reach adolescence. This is more common among children with predominantly inattentive symptoms because they are not necessarily disruptive at home or in school. In these children, the disorder becomes more apparent as academic demands increase and responsibilities mount. For all teens, these years are challenging. But for teens with ADHD, these years may be especially difficult.
Although hyperactivity tends to decrease as a child ages, teens who continue to be hyperactive may feel restless and try to do too many things at once. They may choose tasks or activities that have a quick payoff, rather than those that take more effort, but provide bigger, delayed rewards. Teens with primarily attention deficits struggle with school and other activities in which they are expected to be more self-reliant.
Teens also become more responsible for their own health decisions. When a child with ADHD is young, parents are more likely to be responsible for ensuring that their child maintains treatment. But when the child reaches adolescence, parents have less control, and those with ADHD may have difficulty sticking with treatment.
To help them stay healthy and provide needed structure, teens with ADHD should be given rules that are clear and easy to understand. Helping them stay focused and organized—such as posting a chart listing household chores and responsibilities with spaces to check off completed items—also may help.
Teens with or without ADHD want to be independent and try new things, and sometimes they will break rules. If your teen breaks rules, your response should be as calm and matter-of-fact as possible. Punishment should be used only rarely. Teens with ADHD often have trouble controlling their impulsivity and tempers can flare. Sometimes, a short time-out can be calming.
If your teen asks for later curfews and use of the car, listen to the request, give reasons for your opinions, and listen to your child's opinion. Rules should be clear once they are set, but communication, negotiation, and compromise are helpful along the way. Maintaining treatments, such as medication and behavioral or family therapy, also can help with managing your teenager's ADHD.
What about teens and driving?
Although many teens engage in risky behaviors, those with ADHD, especially untreated ADHD, are more likely to take more risks. In fact, in their first few years of driving, teens with ADHD are involved in nearly four times as many car accidents as those who do not have ADHD. They are also more likely to cause injury in accidents, and they get three times as many speeding tickets as their peers.13
Most states now use a graduated licensing system, in which young drivers, both with and without ADHD, learn about progressively more challenging driving situations.14 The licensing system consists of three stages—learner's permit, during which a licensed adult must always be in the car with the driving teen; intermediate (provisional) license; and full licensure. Parents should make sure that their teens, especially those with ADHD, understand and follow the rules of the road. Repeated driving practice under adult supervision is especially important for teens with ADHD.
Can adults have ADHD?
Some children with ADHD continue to have it as adults. And many adults who have the disorder don't know it. They may feel that it is impossible to get organized, stick to a job, or remember and keep appointments. Daily tasks such as getting up in the morning, preparing to leave the house for work, arriving at work on time, and being productive on the job can be especially challenging for adults with ADHD.
These adults may have a history of failure at school, problems at work, or difficult or failed relationships. Many have had multiple traffic accidents. Like teens, adults with ADHD may seem restless and may try to do several things at once, most of them unsuccessfully. They also tend to prefer "quick fixes," rather than taking the steps needed to achieve greater rewards.
How is ADHD diagnosed in adults?
Like children, adults who suspect they have ADHD should be evaluated by a licensed mental health professional. But the professional may need to consider a wider range of symptoms when assessing adults for ADHD because their symptoms tend to be more varied and possibly not as clear cut as symptoms seen in children.
To be diagnosed with the condition, an adult must have ADHD symptoms that began in childhood and continued throughout adulthood.15 Health professionals use certain rating scales to determine if an adult meets the diagnostic criteria for ADHD. The mental health professional also will look at the person's history of childhood behavior and school experiences, and will interview spouses or partners, parents, close friends, and other associates. The person will also undergo a physical exam and various psychological tests.
For some adults, a diagnosis of ADHD can bring a sense of relief. Adults who have had the disorder since childhood, but who have not been diagnosed, may have developed negative feelings about themselves over the years. Receiving a diagnosis allows them to understand the reasons for their problems, and treatment will allow them to deal with their problems more effectively.
How is ADHD treated in adults?
Much like children with the disorder, adults with ADHD are treated with medication, psychotherapy, or a combination of treatments.
Medications. ADHD medications, including extended-release forms, often are prescribed for adults with ADHD, but not all of these medications are approved for adults.16 However, those not approved for adults still may be prescribed by a doctor on an "off-label" basis.
Although not FDA-approved specifically for the treatment of ADHD, antidepressants are sometimes used to treat adults with ADHD. Older antidepressants, called tricyclics, sometimes are used because they, like stimulants, affect the brain chemicals norepinephrine and dopamine. A newer antidepressant, venlafaxine (Effexor), also may be prescribed for its effect on the brain chemical norepinephrine. And in recent clinical trials, the antidepressant bupropion (Wellbutrin), which affects the brain chemical dopamine, showed benefits for adults with ADHD.17
Adult prescriptions for stimulants and other medications require special considerations. For example, adults often require other medications for physical problems, such as diabetes or high blood pressure, or for anxiety and depression. Some of these medications may interact badly with stimulants. An adult with ADHD should discuss potential medication options with his or her doctor. These and other issues must be taken into account when a medication is prescribed.
Education and psychotherapy. A professional counselor or therapist can help an adult with ADHD learn how to organize his or her life with tools such as a large calendar or date book, lists, reminder notes, and by assigning a special place for keys, bills, and paperwork. Large tasks can be broken down into more manageable, smaller steps so that completing each part of the task provides a sense of accomplishment.
Psychotherapy, including cognitive behavioral therapy, also can help change one's poor self-image by examining the experiences that produced it. The therapist encourages the adult with ADHD to adjust to the life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks.
What efforts are under way to improve treatment?
This is an exciting time in ADHD research. The expansion of knowledge in genetics, brain imaging, and behavioral research is leading to a better understanding of the causes of the disorder, how to prevent it, and how to develop more effective treatments for all age groups.
NIMH has studied ADHD treatments for school-aged children in a large-scale, long-term study called the Multimodal Treatment Study of Children with ADHD (MTA study). NIMH also funded the Preschoolers with ADHD Treatment Study (PATS), which involved more than 300 preschoolers who had been diagnosed with ADHD. The study found that low doses of the stimulant methylphenidate are safe and effective for preschoolers, but the children are more sensitive to the side effects of the medication, including slower than average growth rates.18 Therefore, preschoolers should be closely monitored while taking ADHD medications.19,20
PATS is also looking at the genes of the preschoolers, to see if specific genes affected how the children responded to methylphenidate. Future results may help scientists link variations in genes to differences in how people respond to ADHD medications. For now, the study provides valuable insights into ADHD.21
Other NIMH-sponsored clinical trials on children and adults with ADHD are under way. In addition, NIMH-sponsored scientists continue to look for the biological basis of ADHD, and how differences in genes and brain structure and function may combine with life experiences to produce the disorder.
1 DSM-IV-TR workgroup. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association.
2 Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, Sklar P. Molecular genetics of attention-deficit/hyperactivity disorder. Biological Psychiatry, 2005; 57:1313-1323.
3 Khan SA, Faraone SV. The genetics of attention-deficit/hyperactivity disorder: A literature review of 2005. Current Psychiatry Reports, 2006 Oct; 8:393-397.
4 Shaw P, Gornick M, Lerch J, Addington A, Seal J, Greenstein D, Sharp W, Evans A, Giedd JN, Castellanos FX, Rapoport JL. Polymorphisms of the dopamine D4 receptor, clinical outcome and cortical structure in attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 2007 Aug; 64(8):921-931.
5 Linnet KM, Dalsgaard S, Obel C, Wisborg K, Henriksen TB, Rodriguez A, Kotimaa A, Moilanen I, Thomsen PH, Olsen J, Jarvelin MR. Maternal lifestyle factors in pregnancy risk of attention-deficit/hyperactivity disorder and associated behaviors: review of the current evidence. American Journal of Psychiatry, 2003 Jun; 160(6):1028-1040.
6 Mick E, Biederman J, Faraone SV, Sayer J, Kleinman S. Case-control study of attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use during pregnancy. Journal of the American Academy of Child and Adolescent Psychiatry, 2002 Apr; 41(4):378-385.
7 Braun J, Kahn RS, Froehlich T, Auinger P, Lanphear BP. Exposures to environmental toxicants and attention-deficit/hyperactivity disorder in U.S. children. Environmental Health Perspectives, 2006 Dec; 114(12):1904-1909.
8 Wolraich M, Milich R, Stumbo P, Schultz F. The effects of sucrose ingestion on the behavior of hyperactive boys. Pediatrics, 1985 Apr; 106(4):657-682.
9 Wolraich ML, Lindgren SD, Stumbo PJ, Stegink LD, Appelbaum MI, Kiritsy MC. Effects of diets high in sucrose or aspartame on the behavior and cognitive performance of children. New England Journal of Medicine, 1994 Feb 3; 330(5):301-307.
10 Hoover DW, Milich R. Effects of sugar ingestion expectancies on mother-child interaction. Journal of Abnormal Child Psychology, 1994; 22:501-515.
11 McCann D, Barrett A, Cooper A, Crumpler D, Dalen L, Grimshaw K, Kitchin E, Lok E, Porteous L, Prince E, Sonuga-Barke E, Warner JO. Stevenson J. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. Lancet, 2007 Nov 3; 370(9598):1560-1567.
12 The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit hyperactivity disorder. Archives of General Psychiatry, 1999; 56:1073-1086.
13 Cox DJ, Merkel RL, Moore M, Thorndike F, Muller C, Kovatchev B. Relative benefits of stimulant therapy with OROS methylphenidate versus mixed amphetamine salts extended release in improving the driving performance of adolescent drivers with attention-deficit/hyperactivity disorder. Pediatrics, 2006 Sept; 118(3):e704-e710.
14 U.S. Department of Transportation, National Highway Traffic Safety Administration, Legislative Fact Sheets. Traffic Safety Facts, Laws. Graduated Driver Licensing System. January 2006.
15 Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across the lifespan. Annual Review of Medicine, 2002; 53:113-131.
16 Coghill D, Seth S. Osmotic, controlled-release methylphenidate for the treatment of attention-deficit/hyperactivity disorder. Expert Opinions in Pharmacotherapy, 2006 Oct; 7(15):2119-2138.
17 Wilens TE, Haight BR, Horrigan JP, Hudziak JJ, Rosenthal NE, Connor DF, Hampton KD, Richard NE, Modell JG. Bupropion XL in adults with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled study. Biological Psychiatry, 2005 Apr 1; 57(7):793-801.
18 Swanson J, Greenhill L, Wigal T, Kollins S, Stehli A, Davies M, Chuang S, Vitiello B, Skroballa A, Posner K, Abikoff H, Oatis M, McCracken J, McGough J, Riddle M, Ghouman J, Cunningham C, Wigal S. Stimulant-related reductions in growth rates in the PATS. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1304-1313.
19 Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, McGough J, Wigal S, Wigal T, Vitiello B, Skroballa A, Posner K, Ghuman J, Cunningham C, Davies M, Chuang S, Cooper T. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1284-1293.
20 Wigal T, Greenhill L, Chuang S, McGough J, Vitiello B, Skrobala A, Swanson J, Wigal S, Abikoff H, Kollins S, McCracken J, Riddle M, Posner K, Ghuman J, Davies M, Thorp B, Stehli A. Safety and tolerability of methylphenidate in preschool children with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1294-1303.
21 McGough J, McCracken J, Swanson J, Riddle M, Greenhill L, Kollins S, Greenhill L, Abikoff H, Davies M, Chuang S, Wigal T, Wigal S, Posner K, Skroballa A, Kastelic E, Ghouman J, Cunningham C, Shigawa S, Moyzis R, Vitiello B. Pharmacogenetics of methylphenidate response in preschoolers with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1314-1322.
Ear Infections in Children
An ear infection is an inflammation of the middle ear, usually caused by bacteria, that occurs when fluid builds up behind the eardrum. Anyone can get an ear infection, but children get them more often than adults. Three out of four children will have at least one ear infection by their third birthday. In fact, ear infections are the most common reason parents bring their child to a doctor. The scientific name for an ear infection is otitis media (OM).
Symptoms There are three main types of ear infections. Each has a different combination of symptoms.
- Acute otitis media (AOM) is the most common ear infection. Parts of the middle ear are infected and swollen and fluid is trapped behind the eardrum. This causes pain in the ear—commonly called an earache. Your child might also have a fever.
- Otitis media with effusion (OME) sometimes happens after an ear infection has run its course and fluid stays trapped behind the eardrum. A child with OME may have no symptoms, but a doctor will be able to see the fluid behind the eardrum with a special instrument.
- Chronic otitis media with effusion (COME) happens when fluid remains in the middle ear for a long time or returns over and over again, even though there is no infection. COME makes it harder for children to fight new infections and also can affect their hearing.
Most ear infections happen to children before they’ve learned how to talk. If your child isn’t old enough to say “My ear hurts,” here are a few things to look for:
- Tugging or pulling at the ear(s)
- Fussiness and crying
- Trouble sleeping
- Fever (especially in infants and younger children)
- Fluid draining from the ear
- Clumsiness or problems with balance
- Trouble hearing or responding to quiet sounds
An ear infection usually is caused by bacteria and often begins after a child has a sore throat, cold, or other upper respiratory infection. If the upper respiratory infection is bacterial, these same bacteria may spread to the middle ear; if the upper respiratory infection is caused by a virus, such as a cold, bacteria may be drawn to the microbe-friendly environment and move into the middle ear as a secondary infection. Because of the infection, fluid builds up behind the eardrum.
The ear has three major parts:
- the outer ear
- the middle ear
- inner ear
The outer ear, also called the pinna, includes everything we see on the outside—the curved flap of the ear leading down to the earlobe—but it also includes the ear canal, which begins at the opening to the ear and extends to the eardrum. The eardrum is a membrane that separates the outer ear from the middle ear.
The middle ear—which is where ear infections occur—is located between the eardrum and the inner ear. Within the middle ear are three tiny bones called the malleus, incus, and stapes that transmit sound vibrations from the eardrum to the inner ear. The bones of the middle ear are surrounded by air.
The inner ear contains the labyrinth, which help us keep our balance. The cochlea, a part of the labyrinth, is a snail-shaped organ that converts sound vibrations from the middle ear into electrical signals. The auditory nerve carries these signals from the cochlea to the brain.
Other nearby parts of the ear also can be involved in ear infections. The eustachian tube is a small passageway that connects the upper part of the throat to the middle ear. Its job is to supply fresh air to the middle ear, drain fluid, and keep air pressure at a steady level between the nose and the ear.
Adenoids are small pads of tissue located behind the back of the nose, above the throat, and near the eustachian tubes. Adenoids are mostly made up of immune system cells. They fight off infection by trapping bacteria that enter through the mouth.
- There are several reasons why children are more likely than adults to get ear infections.
Eustachian tubes are smaller and more level in children than they are in adults. This makes it difficult for fluid to drain out of the ear, even under normal conditions. If the eustachian tubes are swollen or blocked with mucus due to a cold or other respiratory illness, fluid may not be able to drain.
A child’s immune system isn’t as effective as an adult’s because it’s still developing. This makes it harder for children to fight infections.
As part of the immune system, the adenoids respond to bacteria passing through the nose and mouth. Sometimes bacteria get trapped in the adenoids, causing a chronic infection that can then pass on to the eustachian tubes and the middle ear.
Diagnosis of middle ear infection
The first thing a doctor will do is ask you about your child’s health.
- Has your child had a head cold or sore throat recently?
- Is he/she having trouble sleeping?
- Is he/she pulling at his/her ears?
If an ear infection seems likely, the simplest way for a doctor to tell is to use a lighted instrument, called an otoscope, to look at the eardrum. A red, bulging eardrum indicates an infection.
A doctor also may use a pneumatic otoscope, which blows a puff of air into the ear canal, to check for fluid behind the eardrum. A normal eardrum will move back and forth more easily than an eardrum with fluid behind it.
Tympanometry, which uses sound tones and air pressure, is a diagnostic test a doctor might use if the diagnosis still isn’t clear. A tympanometer is a small, soft plug that contains a tiny microphone and speaker as well as a device that varies air pressure in the ear. It measures how flexible the eardrum is at different pressures.
Treatment of Acute Middle Ear Infection
Many doctors will prescribe an antibiotic, such as amoxicillin, to be taken over seven to 10 days. Your doctor also may recommend over-the-counter pain relievers such as acetaminophen or ibuprofen, or eardrops, to help with fever and pain. (Because aspirin is considered a major preventable risk factor for Reye’s syndrome, a child who has a fever or other flu-like symptoms should not be given aspirin unless instructed to by your doctor.)
If your doctor isn’t able to make a definite diagnosis of OM and your child doesn’t have severe ear pain or a fever, your doctor might ask you to wait a day to see if the earache goes away. Sometimes ear pain isn’t caused by infection, and some ear infections may get better without antibiotics. Using antibiotics cautiously and with good reason helps prevent the development of bacteria that become resistant to antibiotics.
If your doctor prescribes an antibiotic, it’s important to make sure your child takes it exactly as prescribed and for the full amount of time. Even though your child may seem better in a few days, the infection still hasn’t completely cleared from the ear. Stopping the medicine too soon could allow the infection to come back. It’s also important to return for your child’s follow-up visit, so that the doctor can check if the infection is gone.
Your child should start feeling better within a few days of treatment after visiting the doctor. If it’s been several days and your child still seems sick, call your doctor. Your child might need a different antibiotic. Once the infection clears, fluid may still remain in the middle ear but usually disappears within three to six weeks.
To keep a middle ear infection from coming back, it helps to limit some of the factors that might put your child at risk, such as:
- not being around people who smoke
- not going to bed with a bottle
In spite of these precautions, some children may continue to have middle ear infections, sometimes as many as five or six a year. Your doctor may want to wait for several months to see if things get better on their own but, if the infections keep coming back and antibiotics aren’t helping, many doctors will recommend a surgical procedure that places a small ventilation tube in the eardrum to improve air flow and prevent fluid backup in the middle ear. The most commonly used tubes stay in place for six to nine months and require follow-up visits until they fall out.
If placement of the tubes still doesn’t prevent infections, a doctor may consider removing the adenoids to prevent infection from spreading to the eustachian tubes.
Currently, the best way to prevent ear infections is to reduce the risk factors associated with them. Here are some things you might want to do to lower your child’s risk for ear infections.
- Vaccinate your child against the flu. Make sure your child gets the influenza, or flu, vaccine every year.
It is recommended that you vaccinate your child with the 13-valent pneumococcal conjugate vaccine (PCV13). The PCV13 protects against more types of infection-causing bacteria than the previous vaccine, the PCV7. If your child already has begun PCV7 vaccination, consult your physician about how to transition to PCV13.
The Centers for Disease Control and Prevention (CDC) recommends that children under age 2 be vaccinated, starting at 2 months of age. Studies have shown that vaccinated children get far fewer ear infections than children who aren’t vaccinated. The vaccine is strongly recommended for children in daycare.
- Wash hands frequently. Washing hands prevents the spread of germs and can help keep your child from catching a cold or the flu.
- Avoid exposing your baby to cigarette smoke. Studies have shown that babies who are around smokers have more ear infections.
- Never put your baby down for a nap, or for the night, with a bottle.
- Don’t allow sick children to spend time together. As much as possible, limit your child’s exposure to other children when your child or your child’s playmates are sick.
Researchers sponsored by the National Institute on Deafness and Other Communication Disorders (NIDCD) are exploring many areas to improve the prevention, diagnosis, and treatment of middle ear infections. For example:
- finding better ways to predict which children are at higher risk of developing an ear infection could lead to successful prevention tactics
- Another area that needs exploration is why some children have more ear infections than others. For example, Native American and Hispanic children have more infections than do children in other ethnic groups. What kinds of preventive measures could be taken to lower the risks?
- Doctors also are beginning to learn more about what happens in the ears of children who have recurring ear infections. They have identified colonies of antibiotic-resistant bacteria, called biofilms that are present in the middle ears of most children with chronic ear infections. Understanding how to attack and kill these biofilms would be one way to successfully treat chronic ear infections and avoid surgery.
- Understanding the impact that ear infections have on a child’s speech and language development is another important area of study. Creating more accurate methods to diagnose middle ear infections would help doctors prescribe more targeted treatments. Researchers also are evaluating drugs currently being used to treat ear infections, and developing new, more effective and easier ways to administer medicines.
- NIDCD-supported investigators continue to explore vaccines against some of the most common bacteria and viruses that cause middle ear infections, such as nontypeable Haemophilus influenzae (NTHi) and Moraxella catarrhalis. One team is conducting studies on a method for delivering a possible vaccine without a needle.
For more information, additional addresses and phone numbers, or a printed list of organizations, contact:
NIDCD Information Clearinghouse
1 Communication Avenue
Bethesda, MD 20892-3456
Toll-free Voice: (800) 241-1044
Toll-free TTY: (800) 241-1055
Fax: (301) 770-8977
National Institute on Deafness and Other Communication Disorders
National Institutes of Health
31 Center Drive, MSC 2320
Bethesda, MD USA 20892-2320
E-mail: firstname.lastname@example.org **Please note: This is a medical informational news site ONLY, and is intended for those purposes only. This site doesnot provide a diagnosis nor suggest any treatments for any specific or personal medical conditions.
You should always consult with your personal medical provider for any medical conditions or concerns and discuss with your medical provider diagnosis, medical options, and treatments.
**Please note: This is a medical informational news site ONLY, and is intended for those purposes only. This site doesnot provide a diagnosis nor suggest any treatments for any specific or personal medical conditions.
Back pain is an all-too-familiar problem that can range from a dull, constant ache to a sudden, sharp pain that leaves you incapacitated. It can come on suddenly—from an accident, a fall, or lifting something heavy—or it can develop slowly, perhaps as the result of age-related changes to the spine. Regardless of how back pain happens or how it feels, you know it when you have it. And chances are, if you don’t have back pain now, you will eventually.
How Common Is Back Pain?
In a 3-month period, about one-fourth of U.S. adults experience at least 1 day of back pain. It is one of our society’s most common medical problems.
What Are the Risk Factors for Back Pain?
Although anyone can have back pain, a number of factors increase your risk. They include:
- Age: The first attack of low back pain typically occurs between the ages of 30 and 40. Back pain becomes more common with age.
- Fitness level: Back pain is more common among people who are not physically fit. Weak back and abdominal muscles may not properly support the spine.
- “Weekend warriors”—people who go out and exercise a lot after being inactive all week—are more likely to suffer painful back injuries than people who make moderate physical activity a daily habit. Studies show that low-impact aerobic exercise is good for the disks that cushion the vertebrae, the individual bones that make up the spine.
- Diet: A diet high in calories and fat, combined with an inactive lifestyle, can lead to obesity, which can put stress on the back.
- Heredity: Some causes of back pain, such as ankylosing spondylitis, a form of arthritis that affects the spine, have a genetic component.
- Race: Race can be a factor in back problems. African American women, for example, are two to three times more likely than white women to develop spondylolisthesis, a condition in which a vertebra of the lower spine—also called the lumbar spine—slips out of place.
- The presence of other diseases: Many diseases can cause or contribute to back pain. These include various forms of arthritis, such as osteoarthritis and rheumatoid arthritis, and cancers elsewhere in the body that may spread to the spine.
- Occupational risk factors: Having a job that requires heavy lifting, pushing, or pulling, particularly when this involves twisting or vibrating the spine, can lead to injury and back pain. An inactive job or a desk job may also lead to or contribute to pain, especially if you have poor posture or sit all day in an uncomfortable chair.
- Cigarette smoking: Although smoking may not directly cause back pain, it increases your risk of developing low back pain and low back pain with sciatica. (Sciatica is back pain that radiates to the hip and/or leg due to pressure on a nerve.) For example, smoking may lead to pain by blocking your body’s ability to deliver nutrients to the disks of the lower back. Or repeated coughing due to heavy smoking may cause back pain. It is also possible that smokers are just less physically fit or less healthy than nonsmokers, which increases the likelihood that they will develop back pain. Smoking also increases the risk of osteoporosis, a condition that causes weak, porous bones, which can lead to painful fractures of the vertebrae. Furthermore, smoking can slow healing, prolonging pain for people who have had back injuries, back surgery, or broken bones.
It is important to understand that back pain is a symptom of a medical condition, not a diagnosis itself. Medical problems that can cause back pain include the following:
- Mechanical problems: A mechanical problem is a problem with the way your spine moves or the way you feel when you move your spine in certain ways. Perhaps the most common mechanical cause of back pain is a condition called intervertebral disk degeneration, which simply means that the disks located between the vertebrae of the spine are breaking down with age. As they deteriorate, they lose their cushioning ability. This problem can lead to pain if the back is stressed. Other mechanical causes of back pain include spasms, muscle tension, and ruptured disks, which are also called herniated disks.
- Injuries: Spine injuries such as sprains and fractures can cause either short-lived or chronic pain. Sprains are tears in the ligaments that support the spine, and they can occur from twisting or lifting improperly. Fractured vertebrae are often the result of osteoporosis. Less commonly, back pain may be caused by more severe injuries that result from accidents or falls.
- Acquired conditions and diseases: Many medical problems can cause or contribute to back pain. They include scoliosis, a curvature of the spine that does not usually cause pain until middle age; spondylolisthesis; various forms of arthritis, including osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis; and spinal stenosis, a narrowing of the spinal column that puts pressure on the spinal cord and nerves. Although osteoporosis itself is not painful, it can lead to painful fractures of the vertebrae. Other causes of back pain include pregnancy; kidney stones or infections; endometriosis, which is the buildup of uterine tissue in places outside the uterus; and fibromyalgia, a condition of widespread muscle pain and fatigue.
- Infections and tumors: Although they are not common causes of back pain, infections can cause pain when they involve the vertebrae, a condition called osteomyelitis, or when they involve the disks that cushion the vertebrae, which is called diskitis. Tumors also are relatively rare causes of back pain. Occasionally, tumors begin in the back, but more often they appear in the back as a result of cancer that has spread from elsewhere in the body.
Although the causes of back pain are usually physical, emotional stress can play a role in how severe pain is and how long it lasts. Stress can affect the body in many ways, including causing back muscles to become tense and painful.
One of the best things you can do to prevent back pain is to exercise regularly and keep your back muscles strong. Four specific types of exercises are described in “How Is Back Pain Treated?”. All may help you avoid injury and pain. Exercises that increase balance and strength can decrease your risk of falling and injuring your back or breaking bones. Exercises such as tai chi and yoga—or any weight-bearing exercise that challenges your balance—are good ones to try.
Eating a healthy diet also is important. For one thing, eating to maintain a healthy weight—or to lose weight, if you are overweight—helps you avoid putting unnecessary and injury-causing stress and strain on your back. To keep your spine strong, as with all bones, you need to get enough calcium and vitamin D every day. These nutrients help prevent osteoporosis, which is responsible for a lot of the bone fractures that lead to back pain. Calcium is found in dairy products; green, leafy vegetables; and fortified products, like orange juice. Your skin makes vitamin D when you are in the sun. If you are not outside much, you can obtain vitamin D from your diet: nearly all milk and some other foods are fortified with this nutrient. Most adults don’t get enough calcium and vitamin D, so talk to your doctor about how much you need per day, and consider taking a nutritional supplement or a multivitamin.
Practicing good posture, supporting your back properly, and avoiding heavy lifting when you can may all help you prevent injury. If you do lift something heavy, keep your back straight. Don’t bend over the item; instead, lift it by putting the stress on your legs and hips.
When Should I See a Doctor for Pain?
In most cases, it is not necessary to see a doctor for back pain because pain usually goes away with or without treatment. However, a trip to the doctor is probably a good idea if you have numbness or tingling, if your pain is severe and doesn’t improve with medication and rest, or if you have pain after a fall or an injury. It is also important to see your doctor if you have pain along with any of the following problems: trouble urinating; weakness, pain, or numbness in your legs; fever; or unintentional weight loss. Such symptoms could signal a serious problem that requires treatment soon.
Diagnosing the cause of back pain requires a medical history and a physical exam. If necessary, your doctor may also order medical tests, which may include x rays.
During the medical history, your doctor will ask questions about the nature of your pain and about any health problems you and close family members have or have had.
Questions might include the following:
- Have you fallen or injured your back recently?
- Does your back feel better—or hurt worse—when you lie down?
- Are there any activities or positions that ease or aggravate pain?
- Is your pain worse or better at a certain time of day?
- Do you or any family members have arthritis or other diseases that might affect the spine?
- Have you had back surgery or back pain before?
- Do you have pain, numbness, or tingling down one or both legs?
During the physical exam, your doctor may:
- watch you stand and walk
- check your reflexes to look for slowed or heightened reflexes, either of which might suggest nerve problems
- check for fibromyalgia by examining your back for tender points, which are points on the body that are painful when pressure is applied to them
- check for muscle strength and sensation
- check for signs of nerve root irritation.
Often a doctor can find the cause of your pain with a physical and medical history alone. However, depending on what the history and exam show, your doctor may order medical tests to help find the cause.
Following are some tests your doctor may order:
- X rays: Traditional x rays use low levels of radiation to project a picture onto a piece of film (some newer x rays use electronic imaging techniques). They are often used to view the bones and bony structures in the body. Your doctor may order an x ray if he or she suspects that you have a fracture or osteoarthritis or that your spine is not aligned properly.
- Magnetic resonance imaging (MRI): MRI uses a strong magnetic force instead of radiation to create an image. Unlike an x ray, which shows only bony structures, an MRI scan produces clear pictures of soft tissues, too, such as ligaments, tendons, and blood vessels. Your doctor may order an MRI scan if he or she suspects a problem such as an infection, tumor, inflammation, or pressure on a nerve. An MRI scan, in most instances, is not necessary during the early phases of low back pain unless your doctor identifies certain “red flags” in your history and physical exam. An MRI scan is needed if the pain persists for longer than 3 to 6 weeks or if your doctor feels there may be a need for surgical consultation. Because most low back pain goes away on its own, getting an MRI scan too early may sometimes create confusion for the patient and the doctor.
- Computed tomography (CT) scan: A CT scan allows your doctor to see spinal structures that cannot be seen on traditional x rays. A computer creates a three-dimensional image from a series of two-dimensional pictures that it takes of your back. Your doctor may order a CT scan to look for problems including herniated disks, tumors, or spinal stenosis.
- Blood tests: Although blood tests are not used generally in diagnosing the cause of back pain, your doctor may order them in some cases. Blood tests that might be used include the following:
- Complete blood count (CBC), which could point to problems such as infection or inflammation
- Erythrocyte sedimentation rate (also called sed rate), a measure of inflammation that may suggest infection. The presence of inflammation may also suggest some forms of arthritis or, in rare cases, a tumor.
- C-reactive protein (CRP), another blood test that is used to measure inflammation, may indicate an infection or some forms of arthritis.
- HLA-B27, a test to identify a genetic marker in the blood that is more common in people with ankylosing spondylitis (a form of arthritis that affects the spine and sacroiliac joints) or reactive arthritis (a form of arthritis that occurs following infection in another part of the body, usually the genitourinary tract).
It is important to understand that medical tests alone may not diagnose the cause of back pain. Often, MRI scans of the spine show some type of abnormality, even in people without symptoms. Similarly, even some healthy pain-free people can have elevated sed rates.
Only with a medical history and exam—and sometimes medical tests—can a doctor diagnose the cause of back pain. Many times, the precise cause of back pain is never known. In these cases, it may be comforting to know that most back pain gets better whether or not you find out what is causing it.
What Is the Difference Between Acute and Chronic Pain?
Pain that hits you suddenly—after falling from a ladder, being tackled on the football field, or lifting a load that is too heavy, for example—is acute pain. Acute pain comes on quickly and often leaves just as quickly. To be classified as acute, pain should last no longer than 6 weeks. Acute pain is the most common type of back pain.
Chronic pain, on the other hand, may come on either quickly or slowly, and it lingers a long time. In general, pain that lasts longer than 3 months is considered chronic. Chronic pain is much less common than acute pain.
Treatment for back pain generally depends on what kind of pain you experience: acute or chronic.
Acute Back Pain
Acute back pain usually gets better on its own and without treatment, although you may want to try acetaminophen, aspirin, or ibuprofen to help ease the pain. Perhaps the best advice is to go about your usual activities as much as you can with the assurance that the problem will clear up. Getting up and moving around can help ease stiffness, relieve pain, and have you back doing your regular activities sooner. Exercises or surgery are not usually advisable for acute back pain.
Chronic Back Pain
Treatment for chronic back pain falls into two basic categories: the kind that requires an operation and the kind that does not. In the vast majority of cases, back pain does not require surgery. Doctors will nearly always try nonsurgical treatments before recommending surgery. In a very small percentage of cases—when back pain is caused by a tumor, an infection, or a nerve root problem called cauda equina syndrome, for example—prompt surgery is necessary to ease the pain and prevent further problems.
Following are some of the more commonly used treatments for chronic back pain.
- Hot or cold: Hot or cold packs—or sometimes a combination of the two—can be soothing to chronically sore, stiff backs. Heat dilates the blood vessels, both improving the supply of oxygen that the blood takes to the back and reducing muscle spasms. Heat also alters the sensation of pain. Cold may reduce inflammation by decreasing the size of blood vessels and the flow of blood to the area. Although cold may feel painful against the skin, it numbs deep pain. Applying heat or cold may relieve pain, but it does not cure the cause of chronic back pain.
- Exercise: Although exercise is usually not advisable for acute back pain, proper exercise can help ease chronic pain and perhaps reduce the risk of it returning.
The following four types of exercise are important to general physical fitness and may be helpful for certain specific causes of back pain:
- Flexion: The purposes of flexion exercises, which are exercises in which you bend forward, are to (1) widen the spaces between the vertebrae, thereby reducing pressure on the nerves; (2) stretch muscles of the back and hips; and (3) strengthen abdominal and buttock muscles. Many doctors think that strengthening the muscles of the abdomen will reduce the load on the spine. One word of caution: If your back pain is caused by a herniated disk, check with your doctor before performing flexion exercises because they may increase pressure within the disk, making the problem worse.
- Extension: With extension exercises, you bend backward. They may minimize radiating pain, which is pain you can feel in other parts of the body besides where it originates. Examples of extension exercises are leg lifting and raising the trunk, each exercise performed while lying prone. The theory behind these exercises is that they open up the spinal canal in places and develop muscles that support the spine.
- Stretching: The goal of stretching exercises, as their name suggests, is to stretch and improve the extension of muscles and other soft tissues of the back. This can reduce back stiffness and improve range of motion.
- Aerobic: Aerobic exercise is the type that gets your heart pumping faster and keeps your heart rate elevated for a while. For fitness, it is important to get at least 30 minutes of aerobic (also called cardiovascular) exercise three times a week. Aerobic exercises work the large muscles of the body and include brisk walking, jogging, and swimming. For back problems, you should avoid exercise that requires twisting or vigorous forward flexion, such as aerobic dancing and rowing, because these actions may raise pressure in the disks and actually do more harm than good. In addition, avoid high-impact activities if you have disk disease. If back pain or your fitness level make it impossible to exercise 30 minutes at a time, try three 10-minute sessions to start with and work up to your goal. But first, speak with your doctor or physical therapist about the safest aerobic exercise for you.
Medications: A wide range of medications are used to treat chronic back pain. Some are available over the counter. Others require a doctor’s prescription. The following are the main types of medications used for back pain.
- Analgesics: Analgesic medications are those designed specifically to relieve pain. They include over-the counter acetaminophen (Tylenol1) and aspirin, as well as prescription narcotics, such as oxycodone with acetaminophen (Percocet) or hydrocodone with acetaminophen (Vicodin). Aspirin and acetaminophen are the most commonly used analgesics; narcotics should only be used for a short time for severe pain or pain after surgery. People with muscular back pain or arthritis pain that is not relieved by medications may find topical analgesics helpful. These creams, ointments, and salves are rubbed directly onto the skin over the site of pain. They use one or more of a variety of ingredients to ease pain. Topical analgesics include such products as Zostrix, Icy Hot, and Bengay.
- NSAIDs: Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs that relieve pain and inflammation, both of which may play a role in some cases of back pain. NSAIDs include the nonprescription products ibuprofen (Motrin, Advil), ketoprofen (Actron, Orudis KT), and naproxen sodium (Aleve). More than a dozen others, including a subclass of NSAIDs called COX-2 inhibitors, are available only with a prescription.
All NSAIDs work similarly by blocking substances called prostaglandins that contribute to inflammation and pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body.2
Caution: NSAIDs can cause stomach irritation or, less often, they can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs. Also, NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People age 65 and older and those with any history of ulcers or gastrointestinal bleeding should use NSAIDs with caution.
Side effects of all NSAIDs can include stomach upset and stomach ulcers, heartburn, diarrhea, and fluid retention; however, COX-2 inhibitors are designed to cause fewer stomach ulcers. For unknown reasons, some people seem to respond better to one NSAID than another. It’s important to work with your doctor to choose the one that’s safest and most effective for you.
Other medications: Muscle relaxants and certain antidepressants have also been prescribed for chronic back pain, but their usefulness is questionable. If the cause of back pain is an inflammatory form of arthritis, medications used to treat that specific form of arthritis may be helpful against the pain.
Traction: Traction involves using pulleys and weights to stretch the back. The rationale behind traction is to pull the vertebrae apart to allow a bulging disk to slip back into place. Some people experience pain relief while in traction, but that relief is usually temporary. Once traction is released, the stretch is not sustained and back pain is likely to return. There is no scientific evidence that traction provides any long-term benefits for people with back pain.
Corsets and braces: Corsets and braces include a number of devices, such as elastic bands and stiff supports with metal stays, that are designed to limit the motion of the lumbar spine, provide abdominal support, and correct posture. Although these may be appropriate after certain kinds of surgery, there is little, if any, evidence that corsets and braces help treat chronic low back pain. In fact, by keeping you from using your back muscles, they may actually cause more problems than they solve by causing lower back muscles to weaken from lack of use.
Behavioral modification: Developing a healthy attitude and learning to move your body properly while you do daily activities, particularly those involving heavy lifting, pushing, or pulling, are sometimes part of the treatment plan for people with back pain. Other behavior changes that might help pain include adopting healthy habits, such as exercise, relaxation, and regular sleep, and dropping bad habits, such as smoking and eating poorly.
Injections: When medications and other nonsurgical treatments fail to relieve chronic back pain, doctors may recommend injections for pain relief. Following are some of the most commonly used injections, although some are of questionable value:
Nerve root blocks: If a nerve is inflamed or compressed as it passes from the spinal column between the vertebrae, an injection called a nerve root block may be used to help ease the resulting back and leg pain. The injection contains a steroid medication or anesthetic and is administered to the affected part of the nerve (paraspinal or epidural). Whether the procedure helps or not depends on finding and injecting precisely the right nerve.
Facet joint injections: The facet joints are those where the vertebrae connect to one another, keeping the spine aligned. Although arthritis in the facet joints themselves is rarely the source of back pain, the injection of anesthetics or steroid medications into facet joints is sometimes tried as a way to relieve pain. The effectiveness of these injections is questionable. One study suggests that this treatment is overused and ineffective.
Trigger point injections: In this procedure, an anesthetic is injected into specific areas in the back that are painful when the doctor applies pressure to them. Some doctors add a steroid medication to the injection. Although the injections are commonly used, researchers have found that injecting anesthetics or steroids into trigger points provides no more relief than “dry needling” (inserting a needle and not injecting a medication).
Complementary and alternative treatments: When back pain becomes chronic or when medications and other conventional therapies do not relieve it, many people try complementary and alternative treatments. Although such therapies won’t cure diseases or repair the injuries that cause pain, some people find them useful for managing or relieving pain. Following are some of the most commonly used complementary therapies.
Manipulation: Spinal manipulation refers to procedures in which professionals use their hands to mobilize, adjust, massage, or stimulate the spine or surrounding tissues. This type of therapy is often performed by osteopathic doctors and chiropractors. It tends to be most effective in people with uncomplicated pain and when used with other therapies. Spinal manipulation is not appropriate if you have a medical problem such as osteoporosis, spinal cord compression, or inflammatory arthritis (such as rheumatoid arthritis), or if you are taking blood-thinning medications such as warfarin (Coumadin) or heparin (Calciparine, Liquaemin)
Transcutaneous electrical nerve stimulation (TENS): TENS involves wearing a small box over the painful area that directs mild electrical impulses to nerves there. The theory is that stimulating the nervous system can modify the perception of pain. Early studies of TENS suggested it could elevate the levels of endorphins, the body’s natural pain-numbing chemicals, in the spinal fluid. But subsequent studies of its effectiveness against pain have produced mixed results.
Acupuncture: This ancient Chinese practice has been gaining increasing acceptance and popularity in the United States. Acupuncture is based on the theory that a life force called Qi (pronounced chee) flows through the body along certain channels, which if blocked can cause illness. According to the theory, the insertion of thin needles at precise locations along these channels by practitioners can unblock the flow of Qi, relieving pain and restoring health.
Although few Western-trained doctors would agree with the concept of blocked Qi, some believe that inserting and then stimulating needles (by twisting or passing a low-voltage electrical current through them) may foster the production of the body’s natural pain-numbing chemicals, such as endorphins, serotonin, and acetylcholine.
Acupressure: As with acupuncture, the theory behind acupressure is that it unblocks the flow of Qi. The difference between acupuncture and acupressure is that no needles are used in acupressure. Instead, a therapist applies pressure to points along the channels with his or her hands, elbows, or even feet. (In some cases, patients are taught to do their own acupressure.) Acupressure has not been well studied for back pain.
Rolfing: A type of massage, rolfing involves using strong pressure on deep tissues in the back to relieve tightness of the fascia, a sheath of tissue that covers the muscles, that can cause or contribute to back pain. The theory behind rolfing is that releasing muscles and tissues from the fascia enables the back to align itself properly. So far, the usefulness of rolfing for back pain has not been scientifically proven.
Depending on the diagnosis, surgery may either be the first treatment of choice—although this is rare—or it is reserved for chronic back pain for which other treatments have failed. If you are in constant pain or if pain reoccurs frequently and interferes with your ability to sleep, to function at your job, or to perform daily activities, you may be a candidate for surgery.
In general, two groups of people may require surgery to treat their spinal problems. People in the first group have chronic low back pain and sciatica, and they are often diagnosed with a herniated disk, spinal stenosis, spondylolisthesis, or vertebral fractures with nerve involvement. People in the second group are those with only predominant low back pain (without leg pain). These are people with diskogenic low back pain (degenerative disk disease), in which disks wear with age. Usually, the outcome of spine surgery is much more predictable in people with sciatica than in those with predominant low back pain.
Some of the diagnoses that may need surgery include:
Herniated disks: In this potentially painful problem, the hard outer coating of the disks, which are the circular pieces of connective tissue that cushion the bones of the spine, are damaged, allowing the disks’ jelly-like center to leak, irritating nearby nerves. This causes severe sciatica and nerve pain down the leg. A herniated disk is sometimes called a ruptured disk.
Spinal stenosis: Spinal stenosis is the narrowing of the spinal canal, through which the spinal cord and spinal nerves run. It is often caused by the overgrowth of bone caused by osteoarthritis of the spine. Compression of the nerves caused by spinal stenosis can lead not only to pain, but also to numbness in the legs and the loss of bladder or bowel control. Patients may have difficulty walking any distance and may have severe pain in their legs along with numbness and tingling.
Spondylolisthesis: In this condition, a vertebra of the lumbar spine slips out of place. As the spine tries to stabilize itself, the joints between the slipped vertebra and adjacent vertebrae can become enlarged, pinching nerves as they exit the spinal column. Spondylolisthesis may cause not only low back pain but also severe sciatica leg pain.
Vertebral fractures: These fractures are caused by trauma to the vertebrae of the spine or by crumbling of the vertebrae resulting from osteoporosis. This causes mostly mechanical back pain, but it may also put pressure on the nerves, creating leg pain.
Diskogenic low back pain (degenerative disk disease): Most people’s disks degenerate over a lifetime, but in some, this aging process can become chronically painful, severely interfering with their quality of life.
Following are some of the most commonly performed back surgeries:
For herniated disks:
Laminectomy/diskectomy: In this operation, part of the lamina, a portion of the bone on the back of the vertebrae, is removed, as well as a portion of a ligament. The herniated disk is then removed through the incision, which may extend two or more inches.
Microdiskectomy: As with traditional diskectomy, this procedure involves removing a herniated disk or damaged portion of a disk through an incision in the back. The difference is that the incision is much smaller and the doctor uses a magnifying microscope or lenses to locate the disk through the incision. The smaller incision may reduce pain and the disruption of tissues, and it reduces the size of the surgical scar. It appears to take about the same amount of time to recuperate from a microdiskectomy as from a traditional diskectomy.
Laser surgery: Technological advances in recent decades have led to the use of lasers for operating on patients with herniated disks accompanied by lower back and leg pain. During this procedure, the surgeon inserts a needle in the disk that delivers a few bursts of laser energy to vaporize the tissue in the disk. This reduces its size and relieves pressure on the nerves. Although many patients return to daily activities within 3 to 5 days after laser surgery, pain relief may not be apparent until several weeks or even months after the surgery. The usefulness of laser diskectomy is still being debated.
For spinal stenosis:
Laminectomy: When narrowing of the spine compresses the nerve roots, causing pain or affecting sensation, doctors sometimes open up the spinal column with a procedure called a laminectomy. In a laminectomy, the doctor makes a large incision down the affected area of the spine and removes the lamina and any bone spurs, which are overgrowths of bone that may have formed in the spinal canal as the result of osteoarthritis. The procedure is major surgery that requires a short hospital stay and physical therapy afterwards to help regain strength and mobility.
Spinal fusion: When a slipped vertebra leads to the enlargement of adjacent facet joints, surgical treatment generally involves both laminectomy (as described above) and spinal fusion. In spinal fusion, two or more vertebrae are joined together using bone grafts, screws, and rods to stop slippage of the affected vertebrae. Bone used for grafting comes from another area of the body, usually the hip or pelvis. In some cases, donor bone is used.
Although the surgery is generally successful, either type of graft has its drawbacks. Using your own bone means surgery at a second site on your body. With donor bone, there is a slight risk of disease transmission or tissue rejection, which happens when your immune system attacks the donor tissue. In recent years, a new development has eliminated those risks for some people undergoing spinal fusion: proteins called bone morphogenic proteins are being used to stimulate bone generation, eliminating the need for grafts. The proteins are placed in the affected area of the spine, often in collagen putty or sponges.
Regardless of how spinal fusion is performed, the fused area of the spine becomes immobilized.
For vertebral osteoporotic fractures:
Vertebroplasty: When back pain is caused by a compression fracture of a vertebra caused by osteoporosis or trauma, doctors may make a small incision in the skin over the affected area and inject a cement-like mixture called polymethylacrylate into the fractured vertebra to relieve pain and stabilize the spine.* The procedure is generally performed on an outpatient basis under a mild anesthetic.
*Used only if standard care, rest, corsets and braces, and analgesics fail.
Kyphoplasty: Much like vertebroplasty, kyphoplasty is used to relieve pain and stabilize the spine following fractures caused by osteoporosis. Kyphoplasty is a twostep process. In the first step, the doctor inserts a balloon device to help restore the height and shape of the spine. In the second step, he or she injects polymethylacrylate to repair the fractured vertebra. The procedure is done under anesthesia, and in some cases it is performed on an outpatient basis.
For diskogenic low back pain (degenerative disk disease):
Intradiskal electrothermal therapy (IDET): One of the newest and least invasive therapies for low back pain involves inserting a heating wire through a small incision in the back and into a disk. An electrical current is then passed through the wire to strengthen the collagen fibers that hold the disk together. The procedure is done on an outpatient basis, often under local anesthesia. The usefulness of IDET is debatable.
Spinal fusion: When the degenerated disk is painful, the surgeon may recommend removing it and fusing the disk to help with the pain. This fusion can be done through the abdomen, a procedure known as anterior lumbar interbody fusion, or through the back, called posterior fusion. Theoretically, fusion surgery should eliminate the source of pain; the procedure is successful in about 60 to 70 percent of cases. Fusion for low back pain or any spinal surgeries should only be done as a last resort, and the patient should be fully informed of risks.
Disk replacement: When a disk is herniated, one alternative to a diskectomy, in which the disk is simply removed, is removing the disk and replacing it with a synthetic disk. Replacing the damaged one with an artificial one restores disk height and movement between the vertebrae. Artificial disks come in several designs. Although doctors in Europe had performed disk replacement for more than a decade, the procedure had been experimental in the United States until the Food and Drug Administration approved the Charité® artificial disk for use in 2004.
One major focus of research in recent years has been on the relative efficacy and cost effectiveness of surgical versus nonsurgical treatment of conditions associated with low back and leg pain. A 5-year multicenter study called the Spine Patient Outcomes Research Trial (SPORT) compared the most commonly used standard surgical and nonsurgical treatments for patients with the three most common diagnoses for which spine surgery is performed: intervertebral disk herniation, spinal stenosis, and degenerative spondylisthesis.
Key findings included the following:
Decompressive laminectomy: A surgical procedure called decompressive laminectomy, which involves removing bone and soft tissue to relieve pressure on the nerves, is more effective than nonsurgical treatments for degenerative spondylolisthesis, which can result in spinal stenosis. Two years after enrollment in the SPORT trial, patients with degenerative spondylolisthesis and spinal stenosis who received nonsurgical treatments such as physical therapy, steroid injections, and analgesic medications, reported modest improvement in their condition. However, patients who had the surgery reported significantly reduced pain and improved function. Furthermore, for the surgery group, relief from symptoms came quickly; some reported significant relief as early as 6 weeks after the procedure.
Lumbar diskectomy: The most common surgical procedure for back or leg pain, lumbar diskectomy, offers significant benefits over nonsurgical treatment for herniated disks—at least short term. In one arm of the SPORT trial, 743 patients received surgery and 191 received the usual nonoperative care. The benefits of surgery were seen as early as 6 weeks and were maintained at least 2 years. Consistent with the earlier findings, however, the patients who received nonoperative treatments also improved.
Other research from the SPORT study looked at the factors that go into patients’ decisions whether to pursue surgery for herniated disks. It found that compared with patients who chose nonsurgical treatments, patients who preferred surgery:
- were more definite about their preference than those preferring nonoperative treatment
- experienced longer periods away from work, either because of disability or because of unemployment
- reported higher levels of pain, worse physical and mental functioning, and more disability related to back pain. They were also more likely to be taking narcotic pain medications.
- expected more benefit from having surgery and had a low anticipation of risk from the operation.
Because a patient’s expectations for a therapy are closely linked to his or her response to and ultimate satisfaction with care, this research has important implications for tools to assist people in making informed choices about herniated disk surgery.
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Cervical cancer is a disease in which malignant (cancer) cells form in the tissues of the cervix.
The cervix is the lower, narrow end of the uterus (the hollow, pear-shaped organ where a fetus grows). The cervix leads from the uterus to the vagina (birth canal).
Anatomy of the female reproductive system
The organs in the female reproductive system include the uterus, ovaries, fallopian tubes, cervix, and vagina. The uterus has a muscular outer layer called the myometrium and an inner lining called the endometrium.
Cervical cancer usually develops slowly over time. Before cancer appears in the cervix, the cells of the cervix go through changes known as dysplasia, in which cells that are not normal begin to appear in the cervical tissue. Later, cancer cells start to grow and spread more deeply into the cervix and to surrounding areas.
Cervical cancer in children is rare.
Human papillomavirus (HPV) infection is the major risk factor for development of cervical cancer.
Infection of the cervix with human papillomavirus (HPV) is the most common cause of cervical cancer. Not all women with HPV infection, however, will develop cervical cancer. Women who do not regularly have a Pap smear to detect HPV or abnormal cells in the cervix are at increased risk of cervical cancer.
Other possible risk factors include the following:
- Giving birth to many children.
- Having many sexual partners.
- Having first sexual intercourse at a young age.
- Smoking cigarettes.
- Oral contraceptive use ("the Pill")
- Weakened immune system.
There are usually no noticeable signs of early cervical cancer but it can be detected early with yearly check-ups.
Early cervical cancer may not cause noticeable signs or symptoms. Women should have yearly check-ups, including a Pap smear to check for abnormal cells in the cervix. The prognosis (chance of recovery) is better when the cancer is found early.
Possible signs of cervical cancer include:
- vaginal bleeding
- pelvic pain
These and other symptoms may be caused by cervical cancer. Other conditions may cause the same symptoms.
A doctor should be consulted if any of the following problems occur:
- Vaginal bleeding.
- Unusual vaginal discharge.
- Pelvic pain.
- Pain during sexual intercourse.
Tests that examine the cervix are used to detect (find) and diagnose cervical cancer.
The following procedures may be used:
- Pap smear: A procedure to collect cells from the surface of the cervix and vagina. A piece of cotton, a brush, or a small wooden stick is used to gently scrape cells from the cervix and vagina. The cells are viewed under a microscope to find out if they are abnormal. This procedure is also called a Pap test.
- Human papillomavirus (HPV) test: A laboratory test used to check DNA (genetic material) for certain types of HPV infection. Cells are collected from the cervix and checked to find out if an infection is caused by a type of human papillomavirus that is linked to cervical cancer. This test may be done if the results of a Pap smear show certain abnormal cervical cells. This test is also called the HPV DNA test.
- Colposcopy: A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas. Tissue samples may be taken using a curette (spoon-shaped instrument) and checked under a microscope for signs of disease.
- Biopsy: If abnormal cells are found in a Pap smear, the doctor may do a biopsy. A sample of tissue is cut from the cervix and viewed under a microscope by a pathologist to check for signs of cancer. A biopsy that removes only a small amount of tissue is usually done in the doctor’s office. A woman may need to go to a hospital for a cervical cone biopsy (removal of a larger, cone-shaped sample of cervical tissue).
- Pelvic exam: An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. The doctor or nurse inserts one or two lubricated, gloved fingers of one hand into the vagina and places the other hand over the lower abdomen to feel the size, shape, and position of the uterus and ovaries. A speculum is also inserted into the vagina and the doctor or nurse looks at the vagina and cervix for signs of disease. A Pap test of the cervix is usually done. The doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas.
- Endocervical curettage: A procedure to collect cells or tissue from the cervical canal using a curette (spoon-shaped instrument). Tissue samples may be taken and checked under a microscope for signs of cancer. This procedure is sometimes done at the same time as a colposcopy.
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) depends on the following:
- The patient's age and general health.
- Whether or not the patient has a certain type of human papillomavirus.
- The stage of the cancer (whether it affects part of the cervix, involves the whole cervix, or has spread to the lymph nodes or other places in the body).
- The type of cervical cancer.
- The size of the tumor.
Treatment options depend on the following:
- The stage of the cancer.
- The size of the tumor.
- The patient's desire to have children.
- The patient’s age.
Treatment of cervical cancer during pregnancy depends on the stage of the cancer and the stage of the pregnancy. For cervical cancer found early or for cancer found during the last trimester of pregnancy, treatment may be delayed until after the baby is born.
After cervical cancer has been diagnosed, tests are done to find out if cancer cells have spread within the cervix or to other parts of the body.
The process used to find out if cancer has spread within the cervix or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:
- Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
- CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
- Lymphangiogram: A procedure used to x-ray the lymph system. A dye is injected into the lymph vessels in the feet. The dye travels upward through the lymph nodes and lymph vessels, and x-rays are taken to see if there are any blockages. This test helps find out whether cancer has spread to the lymph nodes.
- Pretreatment surgical staging: Surgery (an operation) is done to find out if the cancer has spread within the cervix or to other parts of the body. In some cases, the cervical cancer can be removed at the same time. Pretreatment surgical staging is usually done only as part of a clinical trial.
- Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
- MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
- Fine-needle aspiration (FNA) biopsy: The removal of tissue or fluid, using a thin needle.
The results of these tests are viewed together with the results of the original tumor biopsy to determine the cervical cancer stage.
There are three ways that cancer spreads in the body.
The three ways that cancer spreads in the body are:
- Through tissue. Cancer invades the surrounding normal tissue.
- Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
- Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.
When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.
The following stages are used for cervical cancer:
Stage 0 (Carcinoma in Situ)
In stage 0, abnormal cells are found in the innermost lining of the cervix. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
In stage I, cancer has formed and is found in the cervix only. Stage I is divided into stages IA and IB, based on the amount of cancer that is found.
Stage IA: A very small amount of cancer that can only be seen with a microscope is found in the tissues of the cervix. Stage IA is divided into stages IA1 and IA2, based on the size of the tumor.
- In stage IA1, the cancer is not more than 3 millimeters deep and not more than 7 millimeters wide.
- In stage IA2, the cancer is more than 3 but not more than 5 millimeters deep, and not more than 7 millimeters wide.
Stage IB: In stage IB, cancer can only be seen with a microscope and is more than 5 millimeters deep or more than 7 millimeters wide, or can be seen without a microscope. Cancer that can be seen without a microscope is divided into stages IB1 and IB2, based on the size of the tumor.
- In stage IB1, the cancer can be seen without a microscope and is not larger than 4 centimeters.
- In stage IB2, the cancer can be seen without a microscope and is larger than 4 centimeters.
In stage II, cancer has spread beyond the cervix but not to the pelvic wall (the tissues that line the part of the body between the hips) or to the lower third of the vagina. Stage II is divided into stages IIA and IIB, based on how far the cancer has spread.
- Stage IIA: Cancer has spread beyond the cervix to the upper two thirds of the vagina but not to tissues around the uterus.
- Stage IIB: Cancer has spread beyond the cervix to the upper two thirds of the vagina and to the tissues around the uterus.
In stage III, cancer has spread to the lower third of the vagina, may have spread to the pelvic wall, and/or has caused the kidney to stop working. Stage III is divided into stages IIIA and IIIB, based on how far the cancer has spread.
- Stage IIIA: Cancer has spread to the lower third of the vagina but not to the pelvic wall.
- Stage IIIB: Cancer has spread to the pelvic wall and/or the tumor has become large enough to block the ureters (the tubes that connect the kidneys to the bladder). This blockage can cause the kidneys to enlarge or stop working. Cancer cells may also have spread to lymph nodes in the pelvis.
In stage IV, cancer has spread to the bladder, rectum, or other parts of the body. Stage IV is divided into stages IVA and IVB, based on where the cancer is found.
- Stage IVA: Cancer has spread to the bladder or rectal wall and may have spread to lymph nodes in the pelvis.
- Stage IVB: Cancer has spread beyond the pelvis and pelvic lymph nodes to other places in the body, such as the abdomen, liver, intestinal tract, or lungs.
Recurrent Cervical Cancer
Recurrent cervical cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the cervix or in other parts of the body.
There are different types of treatment for patients with cervical cancer.
Different types of treatment are available for patients with cervical cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Three types of standard treatment are used:
Surgery (removing the cancer in an operation) is sometimes used to treat cervical cancer. The following surgical procedures may be used:
- Conization: A procedure to remove a cone-shaped piece of tissue from the cervix and cervical canal. A pathologist views the tissue under a microscope to look for cancer cells. Conization may be used to diagnose or treat a cervical condition. This procedure is also called a cone biopsy.
Total hysterectomy: Surgery to remove the uterus, including the cervix. If the uterus and cervix are taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus and cervix are taken out through a large incision (cut) in the abdomen, the operation is called a total abdominal hysterectomy. If the uterus and cervix are taken out through a small incision in the abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy.
The uterus is surgically removed with or without other organs or tissues. In a total hysterectomy, the uterus and cervix are removed. In a total hysterectomy with salpingo-oophorectomy, (a) the uterus plus one (unilateral) ovary and fallopian tube are removed; or (b) the uterus plus both (bilateral) ovaries and fallopian tubes are removed. In a radical hysterectomy, the uterus, cervix, both ovaries, both fallopian tubes, and nearby tissue are removed. These procedures are done using a low transverse incision or a vertical incision.
- Radical hysterectomy: Surgery to remove the uterus, cervix, part of the vagina, and a wide area of ligaments and tissues around these organs. The ovaries, fallopian tubes, or nearby lymph nodes may also be removed.
- Modified radical hysterectomy: Surgery to remove the uterus, cervix, upper part of the vagina, and ligaments and tissues that closely surround these organs. Nearby lymph nodes may also be removed. In this type of surgery, not as many tissues and/or organs are removed as in a radical hysterectomy.
- Bilateral salpingo-oophorectomy: Surgery to remove both ovaries and both fallopian tubes.
- Pelvic exenteration: Surgery to remove the lower colon, rectum, and bladder. In women, the cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body to a collection bag. Plastic surgery may be needed to make an artificial vagina after this operation.
- Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such as carcinoma in situ. This type of treatment is also called cryotherapy.
- Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
- Loop electrosurgical excision procedure (LEEP): A treatment that uses electrical current passed through a thin wire loop as a knife to remove abnormal tissue or cancer.
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.
New types of treatment are being tested in clinical trials.
Patients may want to think about taking part in a clinical trial.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.
Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.
Stage 0 (Carcinoma in Situ) Treatment of stage 0 may include the following:
- Loop electrosurgical excision procedure (LEEP)
- Laser surgery.
- Total hysterectomy for women who cannot or no longer want to have children.
- Internal radiation therapy for women who cannot have surgery.
Stage IA Cervical Cancer Treatment of stage IA cervical cancer may include the following:
- Total hysterectomy with or without bilateral salpingo-oophorectomy.
- Modified radical hysterectomy and removal of lymph nodes.
- Internal radiation therapy.
Stage IB Cervical Cancer Treatment of stage IB cervical cancer may include the following:
- A combination of internal radiation therapy and external radiation therapy.
- Radical hysterectomy and removal of lymph nodes.
- Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy.
- Radiation therapy plus chemotherapy.
Stage IIA Cervical Cancer Treatment of stage IIA cervical cancer may include the following:
- A combination of internal radiation therapy and external radiation therapy plus chemotherapy.
- Radical hysterectomy and removal of lymph nodes.
- Radical hysterectomy and removal of lymph nodes followed by radiation therapy plus chemotherapy.
Stage IIB Cervical Cancer Treatment of stage IIB cervical cancer may include internal and external radiation therapy combined with chemotherapy.
Stage III Cervical Cancer Treatment of stage III cervical cancer may include internal and external radiation therapy combined with chemotherapy.
Stage IVA Cervical Cancer Treatment of stage IVA cervical cancer may include internal and external radiation therapy combined with chemotherapy.
Stage IVB Cervical Cancer Treatment of stage IVB cervical cancer may include the following:
- Radiation therapy as palliative therapy to relieve symptoms caused by the cancer and improve quality of life
- Clinical trials of new anticancer drugs or drug combinations.
Treatment Options for Recurrent Cervical Cancer
Treatment of recurrent cervical cancer may include the following:
- Pelvic exenteration followed by radiation therapy combined with chemotherapy.
- Chemotherapy as palliative therapy to relieve symptoms caused by the cancer and improve quality of life.
- Clinical trials of new anticancer drugs or drug combinations.
Bell's palsy is a form of temporary facial paralysis resulting from damage or trauma to one of the facial nerves. It is the most common cause of facial paralysis. Generally, Bell's palsy affects only one of the paired facial nerves and one side of the face, however, in rare cases, it can affect both sides. The facial nerve-also called the 7th cranial nerve-travels through a narrow, bony canal (called the Fallopian canal) in the skull, beneath the ear, to the muscles on each side of the face. For most of its journey, the nerve is encased in this bony shell.
Each facial nerve directs the muscles on one side of the face, including those that control eye blinking and closing, and facial expressions such as smiling and frowning. Additionally, the facial nerve carries nerve impulses to the lacrimal or tear glands, the salivary glands, and the muscles of a small bone in the middle of the ear called the stapes. The facial nerve also transmits taste sensations from the tongue.
When Bell's palsy occurs, the function of the facial nerve is disrupted, causing an interruption in the messages the brain sends to the facial muscles. This interruption results in facial weakness or paralysis.
Bell's palsy is named after Sir Charles Bell, a 19th century Scottish surgeon who was the first to describe the condition. The disorder, which is not related to stroke, is the most common cause of facial paralysis.
Bell's palsy afflicts approximately 40,000 Americans each year. It affects men and women equally and can occur at any age, but it is less common before age 15 or after age 60. It disproportionately attacks people who have diabetes or upper respiratory ailments such as the flu or a cold.
Bell's palsy occurs when the nerve that controls the facial muscles is swollen, inflamed, or compressed, resulting in facial weakness or paralysis. Exactly what causes this damage, however, is unknown.
Many researchers believe that viral infections such as the virus that causes cold sore virus -- herpes simplex -- can cause the disorder, creating facial nerve swelling and inflammation in reaction to the infection, causing pressure within the Fallopian canal and leading to ischemia (the restriction of blood and oxygen to the nerve cells). In some mild cases (where recovery is rapid), there is damage only to the myelin sheath of the nerve. The myelin sheath is the fatty covering-which acts as an insulator-on nerve fibers in the brain.
The disorder has also been associated with influenza or a flu-like illness, headaches, chronic middle ear infection, high blood pressure, diabetes, sarcoidosis, tumors, Lyme disease, and trauma such as skull fracture or facial injury.
Symptoms of Bell's palsy usually begin suddenly and reach their peak within 48 hours. Symptoms vary from person to person and can range in severity from mild weakness to total paralysis. These symptoms include twitching, weakness, or paralysis, drooping eyelid or corner of the mouth, drooling, dry eye or mouth, impairment of taste, and excessive tearing in the eye. Bell’s palsy often causes significant facial distortion. Other symptoms may include pain or discomfort around the jaw and behind the ear, ringing in one or both ears, headache, loss of taste, hypersensitivity to sound on the affected side, impaired speech, dizziness, and difficulty eating or drinking.
A diagnosis of Bell's palsy is made based on clinical presentation -- including a distorted facial appearance and the inability to move muscles on the affected side of the face -- and by ruling out other possible causes of facial paralysis. There is no specific laboratory test to confirm diagnosis of the disorder.
Generally, a physician will examine the individual for upper and lower facial weakness. In most cases this weakness is limited to one side of the face or occasionally isolated to the forehead, eyelid, or mouth. A test called electromyography (EMG) can confirm the presence of nerve damage and determine the severity and the extent of nerve involvement. Blood tests can sometimes be helpful in diagnosing other concurrent problems such as diabetes and certain infections. A magnetic resonance imaging (MRI) or computed tomography (CT) scan can eliminate other structural causes of pressure on the facial nerve, such as tumors or masses.
Bell's palsy affects each individual differently. Some cases are mild and do not require treatment as the symptoms usually subside on their own within 2 weeks. For others, treatment may include medications and other therapeutic options. If an obvious source is found to cause Bell's palsy (e.g., infection), directed treatment can be beneficial.
Recent studies have shown that steroids such as the steroid prednisone -- used to reduce inflammation and swelling --are effective in treating Bell's palsy. Other drugs such as acyclovir -- used to fight viral herpes infections -- may also have some benefit in shortening the course of the disease. Analgesics such as aspirin, acetaminophen, or ibuprofen may relieve pain. Because of possible drug interactions, individuals taking prescription medicines should always talk to their medical provider before taking any over-the-counter drugs.
Another important factor in treatment is eye protection. Bell's palsy can interrupt the eyelid's natural blinking ability, leaving the eye exposed to irritation and drying. Therefore, keeping the eye moist and protecting the eye from debris and injury, especially at night, is important. Lubricating eye drops, such as artificial tears or eye ointments or gels, and eye patches are also effective.
Physical therapy to stimulate the facial nerve and help maintain muscle tone may be beneficial to some individuals. Facial massage and exercises may help prevent permanent contractures (shrinkage or shortening of muscles) of the paralyzed muscles before recovery takes place. Moist heat applied to the affected side of the face may help reduce pain.
Other therapies that may be useful for some individuals include relaxation techniques, acupuncture, electrical stimulation, biofeedback training, and vitamin therapy (including vitamin B12, B6, and zinc), which may help restore nerve function.
In general, decompression surgery for Bell's palsy -- to relieve pressure on the nerve -- is controversial and is seldom recommended. On rare occasions, cosmetic or reconstructive surgery may be needed to reduce deformities and correct some damage such as an eyelid that will not fully close or a crooked smile.
The prognosis for individuals with Bell's palsy is generally very good. The extent of nerve damage determines the extent of recovery. Improvement is gradual and recovery times vary. With or without treatment, most individuals begin to get better within 2 weeks after the initial onset of symptoms and most recover completely, returning to normal function within 3 to 6 months. For some, however, the symptoms may last longer. In a few cases, the symptoms may never completely disappear. In rare cases, the disorder may recur, either on the same or the opposite side of the face.
The National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health (NIH), is responsible for supporting and conducting research on brain and nervous system disorders, including Bell's palsy. The NINDS conducts research in its laboratories at the NIH, in Bethesda, Maryland, and supports research through grants to major medical institutions across the country. Research of basic science is geared to increase an understanding of how the nervous system works and what causes the system to sometimes become dysfunctional. Part of these research efforts focus on learning more about the circumstances that lead to nerve damage and the conditions that cause injuries and damage to nerves. Knowledge gained from this research may help scientists find the definitive cause of Bell's palsy, and lead to the discovery of new effective treatments for the disorder. Other research is aimed at developing methods to repair damaged nerves and restore full use and strength to injured areas, and finding ways to prevent nerve damage and injuries from occurring.
Reye's syndrome (RS) is primarily a children's disease, although it can occur at any age. It affects all organs of the body but is most harmful to the brain and the liver--causing an acute increase of pressure within the brain and, often, massive accumulations of fat in the liver and other organs. RS is defined as a two-phase illness because it generally occurs in conjunction with a previous viral infection, such as the flu or chicken pox. The disorder commonly occurs during recovery from a viral infection, although it can also develop 3 to 5 days after the onset of the viral illness. RS is often misdiagnosed as encephalitis, meningitis, diabetes, drug overdose, poisoning, sudden infant death syndrome, or psychiatric illness.
Symptoms of RS include:
- persistent or recurrent vomiting
- personality changes such as: irritability or combativeness, disorientation or confusion, delirium, convulsions, and loss of consciousness.
If these symptoms are present during or soon after a viral illness, medical attention should be sought immediately. The symptoms of RS in infants do not follow a typical pattern; for example, vomiting does not always occur.
Epidemiologic evidence indicates that aspirin (salicylate) is the major preventable risk factor for Reye's syndrome. The mechanism by which aspirin and other salicylates trigger Reye's syndrome is not completely understood.
A "Reye's-like" illness may occur in children with genetic metabolic disorders and other toxic disorders. A physician should be consulted before giving a child any aspirin or anti-nausea medicines during a viral illness, which can mask the symptoms of RS.
There is no cure for RS. Successful management, which depends on early diagnosis, is primarily aimed at protecting the brain against irreversible damage by reducing brain swelling, reversing the metabolic injury, preventing complications in the lungs, and anticipating cardiac arrest. It has been learned that several inborn errors of metabolism mimic RS in that the first manifestation of these errors may be an encephalopathy with liver dysfunction. These disorders must be considered in all suspected cases of RS. Some evidence suggests that treatment in the end stages of RS with hypertonic IV glucose solutions may prevent progression of the syndrome.
Recovery from RS is directly related to the severity of the swelling of the brain. Some people recover completely, while others may sustain varying degrees of brain damage. Those cases in which the disorder progresses rapidly and the patient lapses into a coma have a poorer prognosis than those with a less severe course. Statistics indicate that when RS is diagnosed and treated in its early stages, chances of recovery are excellent. When diagnosis and treatment are delayed, the chances for successful recovery and survival are severely reduced. Unless RS is diagnosed and treated successfully, death is common, often within a few days.
Much of the research on RS focuses on answering fundamental questions about the disorder such as how problems in the body's metabolism may trigger the nervous system damage characteristic of RS and what role aspirin plays in this life-threatening disorder. The ultimate goal of this research is to improve scientific understanding, diagnosis and medical treatment of RS.
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Sneezing, scratchy throat, runny nose—everyone knows the first signs of a cold, probably the most common illness known. Although the common cold is usually mild, with symptoms lasting 1 to 2 weeks, it is a leading cause of doctor visits and missed days from school and work in the United States. According to the National Center for Health Statistics (NCHS), 62 million cases of the common cold occur each year. In its most recent survey, NCHS reported that 20 million school days and 22 million days of work are lost annually due to the common cold. The incidence of the common cold decreases with age. Children have about two to six colds a year, while adults average about one to three colds a year.
One reason why there is no cure for the common cold is that more than 200 different viruses can cause cold symptoms. Some, such as rhinoviruses, seldom produce serious illnesses. Others, such as respiratory syncytial virus (RSV), produce mild infections in adults but can lead to severe lower respiratory tract infections in young children. (The lower respiratory tract includes the lungs.)
Rhinoviruses (from the Greek rhin, meaning “nose”) cause an estimated 30 to 50 percent of all colds. Scientists have identified more than 100 distinct rhinovirus types. For example, rhinovirus C was discovered only in 2007 and is found worldwide. Rhinoviruses grow best at temperatures of about 91ºF, the temperature inside the human nose.
Scientists think coronaviruses cause about 10 to 15 percent of all adult colds. They bring on colds primarily in the winter and early spring. Although many coronaviruses infect animals, only five infect humans, causing respiratory tract illness. How important coronaviruses are as a cause of colds is hard to assess because, unlike rhinoviruses, they are difficult to grow in a laboratory.
Adult cold symptoms also are caused by viruses that are responsible for other, more severe illnesses. These viruses are: adenoviruses, coxsackieviruses, echoviruses, orthomyxoviruses (including influenza A and B viruses, which cause flu), paramyxoviruses (including several parainfluenza viruses), RSV, and enteroviruses.
Researchers still haven't identified the causes of 20 to 30 percent of adult colds, presumed to be viral. Because current advances in technology are leading to new tools to diagnose diseases, however, the next decade undoubtedly will bring significantly greater understanding of the causes of the common cold.
The cold season
In the United States, most colds occur during the fall and winter. This may relate to the opening of schools and the start of cold weather, which prompt people to spend more time indoors and increase the chances that viruses will spread from person to person.
Seasonal changes in relative humidity also may affect the occurrence of colds. The most common cold-causing viruses survive better when humidity is low—the colder months of the year. Cold weather also may make the inside lining of your nose drier and more vulnerable to viral infection.
Although a connection exists between the number of cases of the common cold and the fall and winter seasons, there is no experimental evidence that exposure to cold temperatures increases the chances that you will get a cold. There is also no evidence that your chances of getting a cold are related to enlarged tonsils or adenoids.
On the other hand, several research studies show that people who exercise regularly have a significantly reduced number of respiratory tract infections, such as the common cold, compared with those who don't exercise. Research also suggests that allergic diseases that affect the nose or throat and psychological stress may increase your chances of getting infected by cold viruses.
You can get infected by cold viruses by either
- Touching your skin or environmental surfaces, such as office phones, that have cold viruses on them and then touching your eyes or nose
- Inhaling drops of mucus full of cold viruses from the air
Symptoms of the common cold usually begin 2 to 3 days after infection and often include:
- Sore throat
- Mucus buildup in your nose
- Difficulty breathing through your nose
- Swelling of your sinuses
Although fever is uncommon in adults, it is often found in children with colds and can climb to102ºF in infants and young children.
Cold symptoms can last from 2 to 14 days, but if you are like most people, you’ll probably recover in a week to 10 days. If your symptoms return often or last much longer than 2 weeks, you might have an allergy rather than a cold.
High fever, significantly swollen glands, severe sinus pain, and a cough that produces mucus may be signs that you have a complication or more serious illness. If you have any of these signs, you should contact your healthcare provider.
There is no cure for the common cold, but you can get relief from your cold symptoms by
- Resting in bed
- Drinking plenty of fluids
- Gargling with warm salt water or using ice chips, throat sprays, or lozenges for a scratchy or sore throat
- Using a decongestant or saline nasal spray to help relieve nasal symptoms
- Using petroleum jelly to soothe a raw nose
- Taking aspirin or acetaminophen—Tylenol, for example—for headache or fever
Colds occasionally can lead to bacterial infections of your middle ear or sinuses, requiring treatment with antibiotics. However, you should not use antibiotics to treat a cold.
A word of caution: Several studies have linked aspirin use to the development of Reye’s syndrome in children recovering from flu or chickenpox. Reye’s syndrome is a rare but serious illness that usually occurs in children between the ages of 3 and 12 years. It can affect all organs of the body but most often the brain and liver. While most children who survive an episode of Reye’s syndrome do not suffer any lasting affects, the illness can lead to permanent brain damage or death. The American Academy of Pediatrics recommends children and teenagers not be given aspirin or medicine containing aspirin when they have any viral illness such as the common cold. Babies 6 months of age or younger should be given only acetaminophen, such as Tylenol, for pain relief.
Over-the-counter cold medicines
Nonprescription cold remedies, including decongestants and cough suppressants, may relieve some of your cold symptoms but will not prevent or even shorten the length of your cold. Moreover, because most of these medicines have some side effects, such as drowsiness, dizziness, insomnia, or upset stomach, you should take them with care.
Use in children
Health experts have questioned the safety of nonprescription cold medicines in children and whether the benefits justify any possible risks from giving these medicines to children, especially those under 2 years old. In 2008, a Food and Drug Administration (FDA) panel recommended that nonprescription cold medicines not be given to children under 4 years old, because cold medicines don't appear to be effective for these children and may not be safe, especially for those under the age of 2.
Because many cold medicines contain multiple drugs, FDA also recommends being very careful in giving a child more than one cold medicine at a time, so as not to cause harm from too high a dose of cold medicines.
Nonprescription antihistamines may give you some relief from symptoms such as runny nose and watery eyes, which are symptoms commonly associated with colds.
Never take antibiotics to treat a cold, because colds are caused by viruses and antibiotics do not kill viruses. You should use these prescription medicines only if you have a rare bacterial complication, such as sinusitis or ear infection. In addition, you should not use antibiotics “just in case” because they will not prevent bacterial infections.
There are several ways you can keep yourself from getting a cold or passing one on to others:
- Because cold viruses on your hands can easily enter through your eyes and nose, wash your hands often and keep your hands away from those areas of your body.
- If possible, avoid being close to people who have colds.
- If you have a cold, avoid being close to people.
- When you sneeze or cough, cover your nose or mouth and sneeze or cough into your elbow rather than your hand.
Handwashing with soap and water is the simplest and one of the most effective ways to keep from getting colds or giving them to others. During cold season, you should wash your hands often and teach your children to do the same. When water isn’t available, the Centers for Disease Control and Prevention recommends using alcohol-based products made for disinfecting your hands.
Rhinoviruses can live up to 3 hours on your skin. They also can survive for up to 3 hours on objects such as telephones and stair railings. Cleaning these environmental surfaces in your home or place of work with a virus-killing disinfectant when people have colds might help prevent the spread of infection.
Because so many different viruses can cause the common cold, the outlook for developing a vaccine that will prevent spreading of all of them is quite a challenge. Scientists, however, continue to search for a solution to this problem.
Echinacea is a dietary herbal supplement that some people use to treat their colds. Researchers have done studies on how exhinacea works in treating and preventing the common cold, but results have been mixed. Some researcher have found that the herb may help treat a cold if taken in the early stages, but others found that it had no effect.
Three large studies funded by the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health, found that echinacea did not reduce the severity or length of the common cold.
Many people are convinced that taking large quantities of vitamin C will prevent colds or relieve symptoms. To test this theory, researchers have done several large-scale, controlled studies involving children and adults. So far, the data have not shown conclusively that large doses of vitamin C prevent colds. The vitamin may reduce the severity or length of symptoms, but there is no clear evidence of this effect.
In addition, taking large amounts of vitamin C over long periods of time in large amounts may be harmful. Too much vitamin C can cause severe diarrhea, a particular danger for elderly people and small children.
Some people use honey to treat coughs and to soothe a sore throat. A study conducted at the Penn State College of Medicine compared the effectiveness of a little bit of buckwheat honey before bedtime with that of either no treatment or dextromethorphan (DM), the cough suppressant found in many over-the-counter cold medicines. The results of this study suggest that honey may be useful to relieve coughing, but researchers need to do additional studies.
You should never give honey to children under 1 year of age because of the risk of infantile botulism, a serious disease.
Zinc lozenges and lollipops are available over the counter as a remedy for the common cold. However, evidence of their effectiveness has been mixed. A recent review analyzing a series of clinical trials suggests that zinc may slightly reduce the symptoms and duration of the common cold in otherwise healthy people, but the use of zinc lozenges was also associated with an increased risk of side effects such as nausea. Variations in the formulation of lozenges and the amount of zinc they contain also it difficult for health experts to make firm recommendations. Researchers need to do more studies to help find out how much zinc is the most effective, and whether zinc is helpful in all circumstances.
In 2009, the Food and Drug Administration warned consumers to stop using intranasal (in the nose) zinc products because some people reported a loss of smell after using these products.
National Institute of Allergies and Infectious Diseases
National Institutes of Health
Hyperthermia (Heat Stress/Heat Stroke)
Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability or death.
The most common causes are heat stroke and adverse reactions to drugs. Heat stroke is an acute condition of hyperthermia that is caused by prolonged exposure to excessive heat or heat and humidity. The heat-regulating mechanisms of the body eventually become overwhelmed and unable to effectively deal with the heat, causing the body temperature to climb uncontrollably. Hyperthermia is a relatively rare side effect of many drugs, particularly those that affect the central nervous system. Malignant hyperthermia is a rare complication of some types of general anesthesia.
Hyperthermia can be created artificially by drugs or medical devices. Hyperthermia therapy may be used to treat some kinds of cancer and other conditions, most commonly in conjunction with radiotherapy. 
Hyperthermia differs from fever in the mechanism that causes the elevated body temperatures: a fever is caused by a change in the body's temperature set-point.
The opposite of hyperthermia is hypothermia, which occurs when an organism's temperature drops below that required for normal metabolism. Hypothermia is caused by prolonged exposure to low temperatures and is also a medical emergency requiring immediate treatment.
Hyperthermia is defined as a temperature greater than 37.5–38.3 °C (100–101 °F), depending on the reference, that occurs without a change in the body's temperature set-point. 
The normal human body temperature in a healthy adult can be as high as 37.7 °C (99.9 °F) in the late afternoon.  Hyperthermia requires an elevation from the temperature that would otherwise be expected. Such elevations range from mild to extreme; body temperatures above 40 °C (104 °F) can be life-threatening.
The frequency of environmental hyperthermia can vary significantly from year to year depending on factors such as heat waves.
Signs and symptoms
Hot, dry skin is a typical sign of hyperthermia.  The skin may become red and hot as blood vessels dilate in an attempt to increase heat dissipation, sometimes leading to swollen lips. An inability to cool the body through perspiration causes the skin to feel dry.
Other signs and symptoms vary depending on the cause. The dehydration associated with heat stroke can produce nausea, vomiting, headaches, and low blood pressure. This can lead to fainting or dizziness, especially if the person stands suddenly.
In the case of severe heat stroke, the person may become confused or hostile, and may seem intoxicated. Heart rate and respiration rate will increase (tachycardia and tachypnea) as blood pressure drops and the heart attempts to supply enough oxygen to the body. The decrease in blood pressure can then cause blood vessels to contract, resulting in a pale or bluish skin color in advanced cases of heat stroke. Some victims, especially young children, may have seizures. Eventually, as body organs begin to fail, unconsciousness and coma will result.
Heat stroke is due to an environmental exposure to heat, resulting in an abnormally high body temperature.  In severe cases, temperatures can exceed 40 °C (104 °F).  Heat stroke may be non-exertional (classic) or exertional, depending on whether the person has been exercising in the heat. Significant physical exertion on a very hot day can generate heat beyond a healthy body's ability to cool itself, because the heat and humidity of the environment reduce the efficiency of the body's normal cooling mechanisms.  Other factors, such as drinking too little water, drinking alcohol or lack of air conditioning, can exacerbate the condition. Non-exertional heat stroke is predominant in the young and the elderly. It can be precipitated by medications that reduce vasodilation, sweating, and other heat-loss mechanisms, such as anticholinergic drugs, antihistamines, and diuretics.  In this situation, the body's tolerance for the excessive environmental temperatures can be too limited to cope with the heat, even while resting.
Some drugs cause excessive internal heat production, even in normal temperature environments.  The rate of drug-induced hyperthermia is higher where use of these drugs is higher. 
Many psychotropic medications, such as selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and tricyclic antidepressants, can cause hyperthermia.  Serotonin syndrome often presents following exposure to multiple drugs. Similarly, neuroleptic malignant syndrome is an uncommon reaction to neuroleptic agents.  These syndromes are differentiated by the other associated symptoms, such as tremor in serotonin syndrome and "lead-pipe" muscle rigidity in neuroleptic malignant syndrome. 
Many illicit drugs, including amphetamines,  cocaine,  PCP, LSD, and MDMA can produce hyperthermia as an adverse effect. 
Malignant hyperthermia is a rare reaction to common anesthetic agents (such as halothane) or a reaction to the paralytic agent succinylcholine. Malignant hyperthermia is a genetic condition, and can be fatal. 
Personal protective equipment
People working in industry, the military and first responders  must wear Personal Protective Equipment (PPE) to protect themselves from hazardous threats such as chemical agents, gases, fire, small arms and even Improvised Explosive Devices (IEDs). This PPE can include a range of hazmat suits, firefighting turnout gear, body armor and bomb suits, among many other forms. Depending on its design, PPE often ‘encapsulates’ the wearer from a threat and creates what is known as a microclimate,  due to an increase in thermal resistance and decrease in vapor permeability. As a person performs physical work, the body’s natural method of thermoregulation (i.e., sweating) becomes ineffective. This is compounded by increased work rates, high ambient temperatures and humidity levels, and direct exposure to the sun. The net effect is that protection from one or more environmental threats inadvertently brings on the threat of heat stress.
Other possible, but rare, causes of hyperthermia are thyrotoxicosis and the presence of a tumor on the adrenal gland, called a pheochromocytoma, both of which can cause increased heat production.  Damage to the central nervous system, such as from a brain hemorrhage, status epilepticus, and other kinds of damage to the hypothalamus can also cause hyperthermia. 
A fever occurs when the body sets the core temperature to a higher temperature, through the action of the pre-optic region of the anterior hypothalamus. For example, in response to a bacterial or viral infection, the body will raise its temperature, much like raising the temperature setting on a thermostat.
In contrast, hyperthermia occurs when the body temperature rises without a change in the heat control centers.
Some of the gastrointestinal symptoms of acute exertional heat stroke, such as vomiting, diarrhea, and gastrointestinal bleeding, may be caused by barrier dysfunction and subsequent endotoxemia. Ultraendurance athletes have been found to have significantly increased plasma endotoxin levels. Endotoxin stimulates many inflammatory cytokines, which in turn may cause multiorgan dysfunction. Furthermore, monkeys treated with oral antibiotics prior to induction of heat stroke do not become endotoxemic. 
Hyperthermia is generally diagnosed in the presence of an unexpectedly high body temperature and a history that suggests hyperthermia instead of a fever.  Most commonly this means that the elevated temperature has appeared in a person who was working in a hot, humid environment (heat stroke) or who was taking a drug for which hyperthermia is a known side effect (drug-induced hyperthermia). The presence of other signs and symptoms related to hyperthermia syndromes, such as the extrapyramidal symptoms that are characteristic of neuroleptic malginant syndrome, and the absence of signs and symptoms more commonly related to infection-related fevers, are also considered in making the diagnosis.
If fever-reducing drugs lower the body temperature, even if the temperature does not return entirely to normal, then hyperthermia is excluded. 
Treatment for hyperthermia depends on its cause, as the underlying cause must be corrected. Mild hyperthemia caused by exertion on a hot day might be adequately treated through self-care measures, such as drinking water and resting in a cool place. Hyperthermia that results from drug exposures is frequently treated by cessation of that drug, and occasionally by other drugs to counteract them. Fever-reducing drugs such as paracetamol and aspirin have no value in treating hyperthermia. 
When the body temperature is significantly elevated, mechanical methods of cooling are used to remove heat from the body and to restore the body's ability to regulate its own temperatures.  Passive cooling techniques, such as resting in a cool, shady area and removing clothing can be applied immediately. Active cooling methods, such as sponging the head, neck, and trunk with cool water, remove heat from the body and thereby speed the body's return to normal temperatures. Drinking water and turning a fan or dehumidifying air conditioning unit on the affected person may improve the effectiveness of the body's evaporative cooling mechanisms (sweating).
Sitting in a bathtub of tepid or cool water (immersion method) can remove a significant amount of heat in a relatively short period of time. However, immersion in very cold water is counterproductive, as it causes vasoconstriction in the skin and thereby prevents heat from escaping the body core. In exertional heat stroke, studies have shown that although there are practical limitations, cool water immersion is the most effective cooling technique and the biggest predictor of outcome is degree and duration of hyperthermia.  No superior cooling method has been found for nonexertional heat stroke. 
When the body temperature reaches about 40 C, or if the affected person is unconscious or showing signs of confusion, hyperthermia is considered a medical emergency that requires treatment in a proper medical facility. In a hospital, more aggressive cooling measures are available, including intravenous hydration, gastric lavage with iced saline, and even hemodialysis to cool the blood. 
Exposure limits to heat stress are usually set by indices based on the wet bulb globe temperature.
In cases where heat stress is caused by physical exertion, hot environments or wearing protective equipment it can be prevented or mitigated by taking frequent rest breaks, staying hydrated and carefully monitoring body temperature. However, in situations demanding prolonged exposure to a hot environment or wearing protective equipment, a personal cooling system is required as a matter of health and safety. A variety of active or passive technologies personal cooling systems  exist which can be categorized by their power sources and whether they are man or vehicle-mounted.
Due to the broad variety of operating conditions, a personal cooling system must meet specific requirements, such as the rate and duration of cooling, need for physical mobility and autonomy, access to power, and conformance with health & safety regulations. For example, active liquid systems operate on the basis of chilling water and circulating it through a garment that cools the skin surface area that it covers through conduction. This type of system has proven successful in certain Military, Law Enforcement and Industrial applications. Bomb disposal technicians wearing bomb suits to protect against an Improvised Explosive Device (IED) use a small, ice-based chiller unit strapped to their leg with a Liquid Circulating Garment, usually a vest, worn over their torso to maintain their core temperature at safe levels. By contrast, soldiers traveling in combat vehicles can face microclimate temperatures in excess of 150 degrees Fahrenheit and require a multiple-user vehicle-powered cooling system with rapid connection capabilities. Requirements for Hazmat teams, the medical community and workers in heavy-industry will vary further.
1.^ Information from the U.S. National Cancer Institute
2.^ Karakitsos D, Karabinis A (September 2008). "Hypothermia therapy after traumatic brain injury in children". N. Engl. J. Med. 359 (11): 1179–80. PMID 18788094.
3.^ Marx, John (2006). Rosen's emergency medicine: concepts and clinical practice. Mosby/Elsevier. p. 2239. ISBN 9780323028455.
4.^ Axelrod YK, Diringer MN (May 2008). "Temperature management in acute neurologic disorders". Neurol Clin 26 (2): 585–603, xi. doi:10.1016/j.ncl.2008.02.005. PMID 18514828.
5.^ Laupland KB (July 2009). "Fever in the critically ill medical patient". Crit. Care Med. 37 (7 Suppl): S273–8. doi:10.1097/CCM.0b013e3181aa6117. PMID 19535958.
6.^ Manson's Tropical Diseases: Expert Consult. Saunders Ltd. 2008. pp. 1229. ISBN 1-4160-4470-1.
7.^ Trautner BW, Caviness AC, Gerlacher GR, Demmler G, Macias CG (July 2006). "Prospective evaluation of the risk of serious bacterial infection in children who present to the emergency department with hyperpyrexia (temperature of 106 degrees F or higher)". Pediatrics 118 (1): 34–40. doi:10.1542/peds.2005-2823. PMC 2077849. PMID 16818546.
8.^ Fauci, Anthony, et al. (2008). Harrison's Principles of Internal Medicine (17 ed.). McGraw-Hill Professional. pp. 117–121. ISBN 9780071466332.
9.^ Tintinalli, Judith (2004). Emergency Medicine: A Comprehensive Study Guide, Sixth edition. McGraw-Hill Professional. p. 1187. ISBN 0071388753.
10.^ Tintinalli, Judith (2004). Emergency Medicine: A Comprehensive Study Guide, Sixth edition. McGraw-Hill Professional. p. 1818. ISBN 0071388753.
11.^ Marx, John (2006). Rosen's emergency medicine: concepts and clinical practice. Mosby/Elsevier. p. 2894. ISBN 9780323028455.
12.^ Marx, John (2006). Rosen's emergency medicine: concepts and clinical practice. Mosby/Elsevier. p. 2388. ISBN 9780323028455.
13.^ tcloonan (September 2, 2009). "Personal Protective Equipment (PPE) Use: CBRN or Non-CBRN". A National Dialogue for the Quadrennial Homeland Security Review. National Academy of Public Administration. http://www.homelandsecuritydialogue.org/dialogue2/counterterrorism/ideas/personal-protective-equipment-ppe-use-cbrn-or-non-cbrn. Retrieved 23 June 2010.
14.^ (PDF) In-Theatre Microclimate Cooling, US Army Natik Soldier Centre, http://chppm-www.apgea.army.mil/heat/MicroclimateCoolingOptions_May_2007.pdf, retrieved 17 May 2010
15.^ Lambert, Patrick. Role of gastrointestinal permeability in exertional heatstroke. Exercise and Sport Science Reviews. 32(4): 185-190. 2004
16.^ Br J Sports Med 2005: review 17 papers on EHS from 1966-2003
17.^ Bouchama A, Dehbi M. Cooling and hemodynamic management in heatstroke: practical recommendations. Crit Care. 11(3): R54. 2007
Keep it Cool in Hot Weather
Advice for Older People Applies to All
Older people are at high risk for developing heat-related illness because the body’s ability to respond to summer heat can become less efficient with advancing years. Fortunately, the summer can remain safe and enjoyable if you use sound judgment.
Heat stress, heat fatigue, heat syncope (sudden dizziness after exercising in the heat), heat cramps and heat exhaustion are all forms of “hyperthermia,” the general name given to a variety of heat-related illnesses. Symptoms may include headache, nausea, muscle spasms and fatigue after exposure to heat.
If you suspect someone is suffering from a heat-related illness:
• Get the person out of the sun and into a cool place.
• Offer fluids like water, fruit and vegetable juices.
• Urge the person to lie down and rest, preferably in a cool place.
• Encourage them to shower, bathe or sponge off with cool water.
Heat stroke is especially dangerous and requires emergency medical attention. A person with heat stroke has a body temperature above 104° and may have symptoms such as confusion, combativeness, bizarre behavior, faintness, staggering, strong rapid pulse, dry flushed skin, lack of sweating or coma.
Both lifestyle and general health can affect a person’s chance of developing heat-related illness. Lifestyle factors that can increase risk include an extremely hot home, lack of transportation, overdressing and visiting overcrowded places.
Health factors include:
- Age-related changes to the skin such as poor blood circulation and inefficient sweat glands.
- Heart, lung and kidney diseases, and any illness that causes general weakness or fever.
- High blood pressure or other conditions that require changes in diet (for instance, salt-restricted diets).
- Certain medications—including heart and blood pressure drugs, sedatives and tranquilizers—and combinations of medications. Continue taking prescribed medications and consult a doctor.
- Being substantially overweight or underweight.
To avoid heat illness, pay attention to weather reports. Older people, particularly those at special risk, should stay in an air-conditioned place on hot, humid days, especially when there’s an air pollution alert in effect. Don’t exercise or do a lot of activities when it’s hot.
Make sure to dress for the weather. Natural fabrics like cotton can be cooler than synthetic ones. Light colors also reflect the sun and heat better than dark ones.
Remember to drink plenty of liquids on hot, humid days—mostly water or fruit and vegetable juices. Avoid drinks with caffeine or alcohol, which make you lose more fluids.
Mosquitoes are a vector agent that carries mosquito-borne disease, transmitting viruses and parasites from person to person without catching the disease themselves.
Mosquitoes carrying these viruses stay healthy while carrying them because their immune system recognizes them as bad and "chops off" the virus's genetic coding, rendering it harmless. It is currently unknown how they handle parasites so they can safely carry them. Infection of humans occurs when a mosquito bites someone while its immune system is still in the process of destroying the virus's harmful coding.  Female mosquitoes suck blood from people and other animals as part of their eating and breeding habits.
When a mosquito bites, she also injects saliva and anti-coagulants into the blood which may also contain disease-causing viruses or other parasites. This cycle can be interrupted by killing the mosquitoes, isolating infected people from all mosquitoes while they are infectious or vaccinating the exposed population. All three techniques have been used, often in combination, to control mosquito transmitted diseases. Window screens, introduced in the 1880s, were called "the most humane contribution the 19th century made to the preservation of sanity and good temper." 
Mosquitoes are estimated to transmit disease to more than 700 million people annually in Africa, South America, Central America, Mexico and much of Asia with millions of resulting deaths. In Europe, Russia, Greenland, Canada, the United States, Australia, New Zealand, Japan and other temperate and developed countries, mosquito bites are now mostly an irritating nuisance; but still cause some deaths each year.  Historically, before mosquito transmitted diseases were brought under control, they caused tens of thousands of deaths in these countries and hundreds of thousands of infections.  Mosquitoes were shown to be the method by which yellow fever and malaria were transmitted from person to person by Walter Reed, William C. Gorgas and associates in the U.S. Army Medical Corps first in Cuba and then around the Panama Canal in the early 1900s.  Since then other diseases have been shown to be transmitted the same way.
Mosquitoes are a perfect example of one of the many organisms that can host diseases. Of the known 14,000 infectious microorganisms, 600 are shared between animals and humans. Mosquitoes are known to carry many infectious diseases from several different classes of microorganisms, including viruses and parasites. Mosquito born illnesses include Malaria, West Nile Virus, Elephantiasis, Dengue Fever, Yellow Fever etc. These infections are normally rare to certain geographic areas. For instance Dengue Hemorrhagic Fever is a viral, mosquito borne illness usually regarded only as a risk in the tropics. However, cases of Dengue Fever have been popping up in the U.S. along the Texas-Mexican border where it has never been seen before.
The mosquito genus Anopheles carries the malaria parasite (see Plasmodium). Worldwide, malaria is a leading cause of premature mortality, particularly in children under the age of five, with around 2 million deaths annually, according to the Centers for Disease Control.
Some species of mosquito can carry the filariasis worm, a parasite that causes a disfiguring condition (often referred to as elephantiasis) characterized by a great swelling of several parts of the body; worldwide, around 40 million people are living with a filariasis disability.
The viral diseases yellow fever and dengue fever are transmitted mostly by Aedes aegypti mosquitoes.
Other viral diseases like epidemic polyarthritis, Rift Valley fever, Ross River Fever, St. Louis encephalitis, West Nile virus (WNV), Japanese encephalitis, La Crosse encephalitis and several other encephalitis type diseases are carried by several different mosquitoes. Eastern equine encephalitis (EEE) and Western equine encephalitis (WEE) occurs in the United States where it causes disease in humans, horses, and some bird species. Because of the high mortality rate, EEE and WEE are regarded as two of the most serious mosquito-borne diseases in the United States. Symptoms range from mild flu-like illness to encephalitis, coma and death. 
Viruses carried by arthropods such as mosquitoes or ticks are known collectively as arboviruses. West Nile virus was accidentally introduced into the United States in 1999 and by 2003 had spread to almost every state with over 3,000 cases in 2006.
A mosquito's period of feeding is often undetected; the bite only becomes apparent because of the immune reaction it provokes. When a mosquito bites a human, she injects saliva and anti-coagulants. For any given individual, with the initial bite there is no reaction but with subsequent bites the body's immune system develops antibodies and a bite becomes inflamed and itchy within 24 hours. This is the usual reaction in young children. With more bites, the sensitivity of the human immune system increases, and an itchy red hive appears in minutes where the immune response has broken capillary blood vessels and fluid has collected under the skin. This type of reaction is common in older children and adults. Some adults can become desensitized to mosquitoes and have little or no reaction to their bites, while others can become hyper-sensitive with bites causing blistering, bruising, and large inflammatory reactions, a response known as Skeeter Syndrome.
1.Susannah F Locke (1 December 2008). "Bug vs Bug: How do mosquitoes survive deadly viruses unscathed?".
2.History/reason of mosquito control in nj
3.Mosquitoes and Mosquito Repellents: A Clinician's Guide by Mark S. Fradin: Annals of Internal Medicine, 1 June 1998. 128:931-940.
4.The American Plague, by Molly Caldwell Crosby, pg 12, Berkley Books, New York, 2005, ISBN 0-425-21202-5
5.The Path Between the Seas: the Creation of the Panama Canal 1870-1914, by David McCullough,1977, Simon and Shuster, ISBN 0-971-22563-4
6.The American Plague, by Molly Caldwell Crosby, pg 100-202, Berkley Books, New York, 2005, ISBN 0-425-21202-5
7.Mosquito-borne diseases, infectious disease information, NCID, CDC