Introduction

Water normally flows into and out of your ears without causing any problems. You can nearly always shower, bathe, swim, and walk in the rain without a problem — which is remarkable, considering how large and deep an opening your ear provides. You’re protected by your ear’s shape, which tips fluid out, and by its lining, which has acidic properties that protect against bacteria and fungi.

When your ear is exposed to excess moisture, however, water can remain trapped in your ear canal. The skin inside becomes soggy, diluting the acidity that normally prevents infection. A cut in the lining of the ear canal also can allow bacteria to penetrate your skin. When this happens, bacteria and fungi from contaminated water or from objects placed in your ear can grow and cause a condition called swimmer’s ear (acute otitis externa, or external otitis).

Swimmer’s ear is an infection of your outer ear and ear canal. It can be associated with a middle ear infection (otitis media) if the eardrum ruptures.

Usually, self-care steps can relieve the symptoms of swimmer’s ear. However, a severe case of swimmer’s ear will require a trip to your doctor.

Signs and symptoms

Signs and symptoms of swimmer’s ear usually appear within a few days of exposure to contaminated water, and may include:

• Severe pain on moving your outer ear (pinna, or auricle) or pushing on the little “bump” (tragus) in front of your ear.
• Pain or discomfort in or around your ear. Usually only one ear is involved.
• Itching of your outer ear.
• Swelling in your ear or lymph nodes in your neck.
• Feeling of fullness or stuffiness in your ear.
• Pus draining from your ear.
• Decreased or muffled hearing.

Swimmer’s ear may also cause your outer ear to appear red with scaly or flaking skin.

Causes

Causes of swimmer’s ear may include:

• Persistent moisture in your ear from swimming, bathing or living in a humid environment
• Exposure to an infectious organism from swimming in polluted water
• Skin breakage caused by scratching or rubbing your ear with a foreign object (such as a cotton swab or pencil), or attempting to clean earwax (cerumen) from your ear canal
• Bacteria growth fostered by hair sprays or hair dyes in your ear

Risk factors

Swimmer’s ear is common in children and in young adults. You may be at increased risk of infection if a skin condition, such as eczema, causes you to scratch your ears excessively. Earwax buildup or blockage also may increase your risk by trapping water in your ear and increasing the likelihood that you’ll cut the skin while cleaning your ear.

Other ear problems also may increase your risk of swimmer’s ear, including small ear canals that don’t drain well and chronic middle ear infections that moisten and perforate the eardrum.

If you’re an older adult or have an underlying medical condition, such as diabetes, your immune system may be impaired, increasing your risk of swimmer’s ear. If you have poorly managed diabetes, you’re at increased risk of developing severe, painful swimmer’s ear that may be difficult to treat.

When to seek medical advice

Make an appointment with your doctor if you have pain or swelling in your ear or drainage from your ear. Swimmer’s ear is not usually an emergency, but it’s important to see a doctor right away if you have any signs or symptoms of swimmer’s ear and have an underlying disease that may impair your immune system.

Your doctor will examine the inside of your ear and, if indicated, refer you to a doctor who specializes in the care of ear, nose and throat disorders (otolaryngologist).

Call your doctor immediately if an infection that’s already being treated produces new signs or symptoms, especially fever, redness of the skin behind your ear, or increased drainage from or severe pain in or around your ear.

Screening and diagnosis

To examine the inside of your ear, your doctor may use a lighted instrument (otoscope). The inside of your ear and your ear canal may appear red and swollen. Your ear canal may also appear scaly, with flaking skin. If you have drainage from your ear, your doctor may culture a sample to determine if the cause of the infection is bacteria or fungi.

Complications

Swimmer’s ear usually isn’t serious, but complications can occur if it isn’t treated. Complications may include:

• Temporary hearing loss. You may experience muffled hearing, but this usually goes away when the infection is gone.
• Recurrent outer ear infections (chronic otitis externa). Swimmer’s ear may not respond to treatment or may keep coming back in some people. This can lead to infection in the surrounding skin (cellulitis).
• Bone and cartilage damage (necrotizing otitis externa). An outer ear infection that spreads can cause inflammation and damage to the bones and cartilage at the base of your skull, often causing increasingly severe pain. Older adults and people with diabetes are at increased risk. An older term for this is malignant otitis externa; however, this condition has nothing to do with cancer (malignancy).
• More widespread infection. If swimmer’s ear develops into necrotizing otitis externa, the infection may spread and affect other parts of your body, such as the brain or cranial nerves. This severe infection can be life-threatening.

Treatment

The goal of treating swimmer’s ear is to clear up the infection. Treatment may include:

• Cleaning. Clearing your outer ear and ear canal of any drainage and flaky skin allows topical medications to work more effectively. Your doctor may perform this procedure with a suction device or a cotton-tipped probe. To prevent further irritation or injury, don’t clean inside your own ear unless your doctor instructs you to do so.
• Topical medications. Your doctor may prescribe eardrops containing antibiotics to fight infection and corticosteroids to reduce itching and inflammation. Use eardrops liberally (four to five drops at a time) to penetrate the end of your ear canal. If your ear canal is swollen, your doctor may insert a special wick into your ear to allow the drops to reach the end of your ear canal.
• Oral medications. In some cases, doctors suggest using oral medications in addition to topical treatments. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen (Advil, Motrin, others), may help ease severe ear pain. Ask your doctor which over-the-counter pain medication is best for you. Always take NSAIDS with food.
• Lifestyle modifications. Don’t swim, fly or scuba dive during treatment for swimmer’s ear. For the most effective treatment results, water should be kept out of the ear. Talk to your doctor about your bathing habits.

Prevention

Follow these tips to avoid swimmer’s ear:

• Keep your ears dry. Dry your ears thoroughly after exposure to moisture from swimming or bathing. Dry only your outer ear slowly and gently with a soft towel or cloth. Never insert your finger or any other object into your ear.
• Swim wisely. Avoid swimming in polluted water.
• Use earplugs. Some earplugs are designed specifically to keep water out of your ears when swimming.
• Practice self-care. Mix 1 part white vinegar with 1 part alcohol to make an effective eardrop to use before and after swimming. Pour 1 teaspoon of the solution into each ear and let it drain back out. This mixture may help prevent the growth of bacteria and fungi that can cause swimmer’s ear.
• Avoid putting foreign objects in your ear. Never attempt to dig out excess or hardened earwax with items such as a cotton swab, paper clip or hairpin. Using these items can pack material deeper into your ear canal and irritate the thin skin inside your ear.
• Protect your ears. Avoid substances that may irritate your ear, such as hair sprays and hair dyes. Or put cotton balls in your ears when applying these products.
• Use caution after ear infection or surgery. If you already have an ear infection or have recently had ear surgery, talk to your doctor before you swim.

Self-care

If the aching is mild and there’s no drainage from your ear, try these steps:

• Heat therapy. Place a warm (not hot) heating pad over or against your ear to help reduce pain.
• Pain relievers. Try over-the-counter anti-inflammatory drugs to ease your discomfort.
• Ear protection. Keep your ear dry while it’s healing. Use earplugs when showering or bathing. Don’t swim or clean your ears until the infection is gone.

Introduction

If you’re an older adult, you may have dismissed trembling hands or a shaking head as a normal part of the aging process. But it’s more likely your shakiness is a sign of a movement disorder called essential tremor.

Although essential tremor can affect almost any part of your body, trembling occurs most often in your hands, especially when you try to do simple tasks such as drinking a glass of water, tying your shoelaces, writing or shaving. Sometimes, you may also have trembling of your head, voice or arms.

Essential tremor is the most common of the many movement disorders. It’s far more common than Parkinson’s disease, with which it may sometimes be confused. Unlike Parkinson’s disease, however, essential tremor doesn’t lead to serious complications. In fact, the word “essential” in essential tremor means the disorder isn’t linked to other diseases.

For some people, essential tremor may be distressing but not debilitating. Others may find that their tremors make it difficult to work, perform everyday tasks that require fine-motor skills or do the things they enjoy. Severe tremors can lead to social withdrawal and isolation. Fortunately, a variety of treatments exist that may help bring your tremors under control.

Signs and symptoms

Essential tremor often begins gradually. Sometimes it appears during adolescence. More often, though, tremors begin in mid- to late life.

The most common sign is a trembling, up-and-down movement of your hands, although your arms, legs, head and even your tongue and voice box (larynx) also may be affected. Most people have tremors in both hands. Some people have tremors in only one hand, though the tremors often progress to include both hands.

Tremors usually occur only when you engage in a voluntary movement, such as drinking a glass of water, writing or threading a needle. Actions requiring fine-motor skills — using utensils or small tools, for example — may be especially difficult. Fatigue, anxiety and temperature extremes make the signs worse, but tremors usually disappear when you’re asleep or at rest.

Some people have relatively mild tremors throughout their lives, while others develop more severe tremors and increased disability over time. Effects of worsening tremors may include:

• Difficulty holding a cup or glass without spilling
• Difficulty eating normally
• Difficulty putting on makeup or shaving
• Difficulty talking, if your voice box or tongue is affected
• Difficulty writing — handwriting may become increasingly large, shaky and illegible
• The inability to perform actions requiring fine-motor skills, such as playing an instrument or drawing

Essential tremor vs. Parkinson’s disease
Many people associate tremors with Parkinson’s disease, a serious movement disorder. But essential tremor and Parkinson’s disease aren’t related, and the two conditions differ in key ways:

• When tremors occur. Essential tremor of the hands typically occurs when your hands are in use. Tremors from Parkinson’s are most prominent when your hands are at your sides or resting in your lap. This type of tremor usually decreases with movement of the hands.
• Associated conditions. Essential tremor doesn’t cause other health problems, whereas Parkinson’s is associated with a stooped posture, slow movement, a shuffling gait, speech problems other than tremor and sometimes memory loss.
• Parts of body affected. Essential tremor can involve your hands, legs, head and voice. Tremors from Parkinson’s typically affect your hands, but not your head or voice.

Causes

About half of all cases of essential tremor appear to occur because of a genetic mutation. This is referred to as benign familial tremor. Genes are information centers in your cells that control your body’s growth, development and function. A mutation in just one gene can greatly alter the way your body works. Researchers have identified two genes that appear to be involved in essential tremor. It’s possible that mutations in other genes may also lead to the condition.

Exactly what causes essential tremor in people without a known genetic mutation isn’t clear. Doctors do know that the problem occurs in the brain circuits that control your movements. Studies using an imaging technique called positron emission tomography (PET) scanning show that certain parts of the brain — including the thalamus — have increased activity in people with essential tremor. More research is needed to understand the precise mechanism behind the disease.

Risk factors

Benign familial tremors are an autosomal dominant disorder, which means that a defective gene from just one parent is needed to pass on the condition. If you have a parent with a genetic mutation for essential tremor, you have a 50 percent chance of developing the disorder yourself. The only other known risk factor is older age. Although essential tremor can affect people of all ages, it usually appears in late middle age or later.

When to seek medical advice

See your doctor if tremors make it hard to perform daily activities or prevent you from living your life as fully as you’d like. Your doctor can determine whether essential tremor is causing your problem and may be able to suggest treatments that will ease your symptoms.

Screening and diagnosis

You’ll receive a diagnosis of essential tremor only after your doctor has ruled out other possible causes for your symptoms. For that reason, you may undergo blood, urine and neurological tests to check for problems such as thyroid disease, heavy metal poisoning, drug side effects and Parkinson’s disease.

In addition, your doctor will take a complete medical history and perform a thorough physical and neurological exam that may include checking your tendon reflexes, your muscle strength and tone, your ability to feel certain sensations, and your posture and coordination.

The tremor itself may be evaluated in several ways, including performance tests in which you’re asked to write, drink from a glass or hold a piece of paper.

Treatment

Most people with essential tremor don’t need treatment beyond reassurance that the condition isn’t a sign of a more serious disease. Lifestyle changes — which include getting plenty of rest and avoiding stressful situations and stimulants such as caffeine — may help ease the tremors. Most people with essential tremor find that fatigue, anxiety, sleep deprivation and even temperature extremes make their tremors worse.

If lifestyle changes don’t help and tremors are keeping you from doing the things you enjoy, your doctor may recommend these options:

Medications
Medications provide relief from tremors roughly half the time. They include:

• Beta blockers. Normally used to treat high blood pressure, beta blockers, such as propranolol (Inderal), help relieve tremors in some people. Because beta blockers are especially likely to cause dizziness, confusion and memory loss in older adults, they may be a better choice for younger people. They may not be an option if you also have asthma, diabetes or certain heart problems.
• Anti-seizure medications. These drugs, especially primidone (Mysoline), may be effective in people who don’t respond to beta blockers. The main side effects are drowsiness and flu-like symptoms, which usually disappear within a short time.
• Tranquilizers. Doctors sometimes use drugs such as diazepam (Valium) and alprazolam (Xanax) to treat people whose tremors are made much worse by tension or anxiety. Side effects can include confusion and memory loss. Additionally, these medications should be used with caution because they can be habit-forming.
• Botulinum toxin type A (Botox) injections. You’re probably familiar with Botox as a treatment for facial wrinkles, but it can also be useful in treating some types of tremors, especially of the head and voice. Botox injections can improve problems for up to three months at a time. When used to treat hand tremors, Botox can sometimes cause weakness in your fingers.

Surgery
Surgery may be an option for people whose tremors are severely disabling and who don’t respond to medications. Deep brain stimulation (DBS) is a treatment involving a brain implant device called a thalamic stimulator may be appropriate if you have severe tremors and if medications aren’t effective. A pacemaker-like chest unit transmits electrical pulses through a wire to a lead implanted in your thalamus. The pulses, which are painless, may interrupt signals from your thalamus that help cause tremors. You turn the pulse generator on and off by passing a magnet over your chest.

Self-care

The following suggestions can sometimes help reduce or relieve tremors:

• Avoid caffeine. Caffeine can cause your body to produce more adrenaline, which may make your tremors worse. Avoid other stimulants as well.
• Use alcohol sparingly. Some people notice that their tremors improve for up to an hour after they drink alcohol, but drinking isn’t a good solution for people with essential tremor. That’s because tremors tend to worsen once the effects of alcohol wear off. What’s more, larger amounts of alcohol eventually are needed to relieve tremors, which can lead to chronic alcoholism. If you have essential tremor, it’s best to drink sparingly or not at all.
• Learn to relax. Stress tends to make tremors worse, and a relaxed state often improves them. Although it’s not possible to eliminate all stress from your life, you can change how you react to stressful situations using a range of relaxation techniques. These include deep breathing, progressive muscle relaxation, guided imagery and massage as well as disciplines such as yoga and tai chi. Many people also find that physical exercise — walking, jogging, swimming or biking — is a great stress reliever.
• Rest well. Fatigue can exacerbate tremors. Try to get at least seven hours of sound sleep every night. If you have trouble falling asleep, wake up repeatedly or awaken early and can’t go back to sleep, talk to your doctor.
• Strengthen your hands. Your doctor may recommend working with a specialist to learn exercises to promote more stability in your hands and wrists. These usually involve using 1- to 2-pound weights strapped to your wrists. You can continue doing these exercises at home.
• Consider joining a support group. For many people, essential tremor can have serious social and psychological consequences. If the effects of essential tremor are making it hard to live your life as fully as you once did, consider joining a support group for people with the disorder. Support groups aren’t for everyone, but you may find it helpful to have the encouragement of people who understand what you’re going through. Or you might want to consider seeing a counselor or social worker who can help you meet the challenges of living with essential tremor.

Introduction

Serious liver diseases such as cirrhosis can cause a number of complications, including esophageal varices — abnormally enlarged veins in the lower part of the esophagus, the tube that connects your throat and stomach. Esophageal varices develop when normal blood flow to the liver is blocked. The blood then backs up into smaller, more fragile blood vessels in the esophagus, and sometimes in the stomach or rectum, causing the vessels to swell.

Esophageal varices don’t produce symptoms unless they rupture and bleed — a life-threatening condition that requires immediate medical care. When not controlled, esophageal bleeding can be fatal.

To help prevent esophageal varices from bleeding, doctors usually prescribe medications that lower blood pressure. In cases where drugs aren’t effective, esophageal varices may be injected with a clotting solution or tied with elastic bands to prevent bleeding. These same procedures are often used to stop acute bleeding.

Signs and symptoms

About one-third of people with esophageal varices have bleeding. The signs and symptoms of esophageal bleeding range from mild to severe and include:

• Vomiting blood
• Black, tarry or bloody stools
• Decreased urination from unusually low blood pressure
• Excessive thirst
• Lightheadedness
• Shock, in severe cases

Causes

Normally, blood from your intestine, spleen and pancreas enters your liver through a large blood vessel called the portal vein. But if scar tissue blocks circulation through the liver, the blood backs up, leading to increased pressure within the portal vein (portal hypertension). This forces blood into smaller veins in your esophagus, stomach and occasionally your rectum. The excess blood causes these fragile, thin-walled veins to balloon outward and sometimes to rupture and bleed. Once varices develop, they continue to grow larger.

Cirrhosis: A leading cause of esophageal varices
Esophageal varices are usually a complication of cirrhosis. This serious liver disorder, which is irreversible scarring of liver tissue, often results from alcoholic liver disease or hepatitis B or C infection. Another liver disorder, primary biliary cirrhosis, which destroys the small ducts that carry bile, can also cause scarring of liver tissue and lead to esophageal varices.

Sometimes chronic conditions other than cirrhosis lead to enlarged veins in the esophagus . These conditions include:

• Severe congestive heart failure. This occurs when your heart can’t pump enough blood to meet your body’s needs. In congestive heart failure, blood backs up into the vein between the liver and the right side of the heart, increasing blood pressure in the portal vein.
• Blood clot (thrombosis). A blood clot in the portal vein or in the splenic vein, which feeds into the portal vein, can cause esophageal varices.
• Sarcoidosis. This inflammatory disease starts in the lungs but can affect almost any organ in the body, including the liver.
• Schistosomiasis. This parasitic infection affects millions of people in the developing world, especially parts of Africa, South America, the Caribbean, the Middle East and Southeast Asia. It can damage the liver as well as the lungs, intestine and bladder.
• Budd-Chiari syndrome. In this rare condition, blood clots obstruct the veins that carry blood out of the liver.

Risk factors

Although many people with advanced liver disease develop esophageal varices, only about one-third of them have varices that bleed. Bleeding varices are more likely if you have:

• High portal vein pressure. The risk of bleeding increases with the amount of pressure in the portal vein.
• Large varices. The larger the varices, the more likely they are to bleed.
• Red marks on the varices. When viewed through an endoscope — a lighted, fiber-optic instrument — some varices show long, red streaks or red spots. These marks indicate a high risk of bleeding.
• Severe cirrhosis or liver failure. Most often, the more severe your liver disease, the more likely varices are to bleed.
• Fluid buildup. Liver disease can cause large amounts of fluid to accumulate in your abdominal cavity (ascites). Several factors play a role in fluid buildup, including portal hypertension and changes in the hormones and chemicals that regulate fluids in your body. Having this excess fluid increases your risk of variceal bleeding.
• Continued alcohol use. If your liver disease is alcohol-related, your risk of variceal bleeding is far greater if you continue to drink than if you stop.
• Acid reflux. Stomach or bile acids that back up (reflux) into the esophagus erode the esophageal lining, which can trigger bleeding.

When to seek medical advice

See your doctor if you develop signs and symptoms of liver disease, such as:

• Weight loss
• Small, red spider veins under your skin or easy bruising
• Weakness
• Fatigue
• Yellowing of your skin and eyes and dark, cola-colored urine
• The buildup of fluid in your abdominal cavity, which causes it to swell (ascites)
• Itching on your hands and feet and eventually on your entire body
• Swelling of your legs and feet from retained fluid (edema)
• Mental confusion, such as forgetfulness or trouble concentrating (encephalopathy)

If you’ve been diagnosed with esophageal varices and experience bloody vomit or stools, call 911 or your local emergency services right away.

Screening and diagnosis

If you have cirrhosis or other serious liver disease, your doctor may screen you for esophageal varices, sometimes as often as every year or two. These tests are usually used to look for varices:

• Endoscopy. For this test, your doctor inserts a thin, flexible, lighted tube (endoscope) through your mouth and into your esophagus. If any dilated veins are found, they’re graded according to their size and checked for red streaks, which usually indicate a significant risk of bleeding. An esophageal endoscopy takes about 20 to 30 minutes, and the risks are generally minor. The most common side effect is a sore throat from swallowing the endoscope.
• Imaging tests. Both computerized tomography (CT) scans and magnetic resonance imaging (MRI) may be used to diagnose esophageal varices. Unlike an endoscopy, these noninvasive tests also allow your doctor to examine your liver and circulation in the portal vein. But imaging tests aren’t as effective at finding varices as endoscopy is, and they’re not as useful for determining which varices are likely to bleed. For that reason, they’re most often used in addition to endoscopy or when endoscopy can’t be performed.

Complications

The most serious complication of esophageal varices is bleeding. Once you have had a bleeding episode, you’re at greatly increased risk of another, especially during the first 48 hours. Recurrent bleeding is common in people with esophageal varices, and the likelihood of death increases with each episode. You’re at greater risk of repeat bleeding if you are older, have liver or kidney failure, or drink alcohol.

Other complications of bleeding esophageal varices include:

• Hypovolemic shock. This occurs when your body loses at least one-fifth of its blood volume. Symptoms include low blood pressure, a rapid pulse, weakness, sweating, anxiety, mental confusion and possibly unconsciousness.
• Encephalopathy. A damaged liver is less effective at removing toxins from your body — normally one of the liver’s key tasks. The buildup of toxins can damage your brain, leading to changes in your mental state, behavior and personality (hepatic encephalopathy). Signs and symptoms include forgetfulness, confusion and mood changes, and in the most severe cases, delirium and coma.
• Infection. Aspiration pneumonia, which occurs when you inadvertently inhale vomit or other substance into your lungs, can be a life-threatening complication of bleeding varices or of certain treatments to control them.

Treatment

The primary aim in treating esophageal varices is to prevent bleeding. To help achieve this goal, doctors usually prescribe high blood pressure drugs (beta blockers) to reduce pressure in the portal vein. Other drugs may be used for people who don’t respond to beta blockers or who have severe side effects. Sometimes the varices may be injected directly with a solution that causes them to dissolve. Or they may be tied with elastic bands before they have a chance to bleed.

Treating bleeding
Bleeding varices are life-threatening, and immediate treatment is essential. To stop bleeding, you’re likely to have one of the following procedures:

• Variceal ligation. This is the preferred treatment for bleeding esophageal varices. During the procedure, your doctor uses an endoscope to snare the varices with an elastic band, which essentially “strangles” the veins. Variceal ligation usually causes fewer serious complications than do other treatments. It’s also less likely to lead to episodes of repeat bleeding.
• Endoscopic injection therapy. In this procedure, the bleeding varices are injected with a solution that dissolves them. Bleeding is usually controlled after one or two treatments, but complications can occur, including perforation of the esophagus and trouble swallowing (dysphagia).
• Medications. When other therapies aren’t available, your doctor may initially prescribe medications to control bleeding.
• Shunt. In this procedure, called a transjugular intrahepatic portosystemic shunt (TIPS), a small tube called a shunt is placed between the portal vein and the hepatic vein, which carries blood from the liver back to your heart. The tube is kept open with a metal stent. By providing an artificial path for blood through the liver, the shunt often can control bleeding from esophageal varices. But TIPS can cause a number of serious complications, including liver failure and encephalopathy, which may develop when toxins that would normally be filtered by the liver are passed through the shunt directly into the bloodstream. TIPS is mainly used when all other treatments have failed or as a temporary measure in people awaiting a liver transplant.
• Liver transplant. Because no treatment is entirely successful at preventing repeat bleeding episodes and because treatments themselves pose significant risks, liver transplant is an option for people with severe or recurrent bleeding of esophageal varices. Although liver transplantation is often successful, the number of people awaiting transplants far outnumbers the available organs. You may face additional hurdles if your liver disease is the result of alcoholic hepatitis. Some medical centers won’t perform liver transplants on people with alcoholic liver disease or require that you abstain from alcohol for at least six months before you’re eligible for transplant surgery.

Prevention

It’s not always possible to prevent esophageal varices in people with liver disease or portal hypertension. But treating the underlying problem — alcohol abuse, iron overload, or exposure to toxic chemicals, for instance — is of primary importance. Equally important is the use of beta blockers or other medications to prevent increased blood pressure in the portal vein.

Introduction

“Cerebral palsy” is a general term that describes a group of disorders that appear during the first few years of life and affect a child’s ability to coordinate body movements. These disorders are caused by damage to a child’s brain early in the course of development. The damage can occur during fetal development, during the birth process or during the first few months after birth.

Cerebral palsy ranges from mild to severe. Physical signs of cerebral palsy include weakness and floppiness of muscles or spasticity and rigidity. In some cases, neurological disorders — such as mental retardation or seizures — also occur in children with cerebral palsy.

Cerebral palsy isn’t curable. However, getting the right therapy for your child can make a big difference. Today, children with cerebral palsy benefit from a wide range of treatment options and innovations.

Signs and symptoms

There are three major types of cerebral palsy:

• Spastic cerebral palsy. Most children with cerebral palsy have spastic cerebral palsy. This form of the condition causes muscles to stiffen, which makes movement difficult. It can affect both legs (spastic diplegia), or it can affect one side of the body (spastic hemiplegia). In the most severe cases, all four limbs and the trunk are affected (spastic quadriplegia).
• Athetotic cerebral palsy. About one in five people with cerebral palsy have this form, which is also referred to as extrapyramidal cerebral palsy. It affects the entire body and often causes uncontrolled, slow movements.
• Ataxic cerebral palsy. This is the least common of the major types of cerebral palsy. It affects balance and coordination.

Some children have signs and symptoms of more than one type of cerebral palsy, which may be referred to as a mixed form of the condition.

In general, children with cerebral palsy exhibit a wide variety of signs and symptoms, ranging from mild to severe. Cerebral palsy symptoms don’t worsen with age. They may include:

• Lack of muscle coordination when performing voluntary movements (ataxia)
• Stiff muscles and exaggerated reflexes (spasticity)
• Asymmetrical walking gait, with one foot or leg dragging
• Variations in muscle tone, from too stiff to too floppy
• Excessive drooling or difficulties swallowing, sucking or speaking
• Tremors
• Difficulty with precise motions, such as writing or buttoning a shirt

Some children with cerebral palsy have severe mental retardation, but others are extremely bright. Many need a wheelchair and extensive, lifelong care, but some require little or no special assistance.

Causes

Cerebral palsy results from an abnormality in or injury to the cerebrum — the largest area of the brain, which controls sensation and voluntary motor function. Although cerebral palsy affects movement, the underlying problem originates in the brain, not in the muscles themselves.

A small number of children with cerebral palsy acquire the disorder after birth. In these cases, doctors can sometimes pinpoint a specific reason for the neurological problem. For example, cerebral palsy can develop after an illness during early infancy, such as bacterial meningitis — an infection and inflammation of the membranes and fluid surrounding the brain and spinal cord. It can also be the result of a head injury.

However, doctors don’t completely understand the cause of most cases of cerebral palsy, which are present at birth (congenital). For many years, doctors and researchers believed that cerebral palsy was caused by a lack of oxygen during birth. Now they believe that only a small number of cases are caused by problems during labor and delivery.

Some possible causes
Doctors and researchers have now identified many possible causes of congenital cerebral palsy, including:

• Maternal infection during pregnancy, such as rubella or other viral infections
• Severe jaundice in newborns, which may be caused by infection, severe bruising or problems with red blood cells due to ABO or Rh incompatibility — two incompatibilities between the blood of the mother and her fetus
• Abnormal brain development before birth, resulting from genetic causes or metabolic disorders
• Disturbance to brain circulation before birth, caused by an artery spasm or blood clot, similar to a stroke in adults

Risk factors

Most children with cerebral palsy don’t have any apparent problems during development in the womb and birth. But some factors may increase the risk of cerebral palsy:

• Babies that are premature or have a low birth weight 
• Fetuses in a feet-first position (breech presentation) at the beginning of labor
• Complicated labor and delivery
• Maternal infection during pregnancy
• Health problems in the mother during pregnancy that impair normal blood circulation to the uterus and placenta

Meconium staining of amniotic fluid, caused by stool passed by the fetus in utero, also may indicate prenatal difficulties. However, most children with one or more of these risk factors don’t develop cerebral palsy.

When to seek medical advice

If your baby seems to display weakness or paralysis in a limb or isn’t developing motor skills at the expected times, talk to your family doctor or pediatrician. Every baby develops at his or her own pace, so there’s no need to panic if your baby doesn’t meet one of the monthly milestones described in a parenting book. But it’s important to share any concerns about your baby’s development with your doctor.

For example, children usually become right-handed or left-handed by age 2. Infants who appear right-handed or left-handed at younger ages may actually have impaired movement of one hand.

Screening and diagnosis

Early signs of cerebral palsy may be present from birth, but it’s often difficult to make a definite diagnosis during the first six months. Cerebral palsy is generally diagnosed by age 1 or 2.

If your child shows some signs of cerebral palsy, your doctor will likely schedule an appointment to observe your child and to talk to you about your child’s physical and behavioral development. In this evaluation, your doctor will check your child’s reflexes, muscle tone and movements. Additional tests may rule out other disorders that can cause movement problems. Your doctor may have your child undergo one or more of these procedures:

• Computerized tomography (CT) scan. Images created with a CT scanner show the structure of your child’s brain, as well as the presence and extent of any damage.
• Magnetic resonance imaging (MRI) scan. The cylinder-shaped MRI scanner uses no X-rays. Instead, a computer creates tissue-slice images of the brain from data generated by a powerful magnetic field and radio waves. These images can be viewed from any direction or plane.
• Other tests. Some children may need genetic or metabolic tests to help rule out other conditions.

You may be referred to a specialist to help determine if your child has cerebral palsy or some other condition. Your doctor may recommend a visit to a doctor with specialized training in the development of the brain and nervous system in children (pediatric neurologist), a doctor who specializes in childhood development (developmental pediatrician), or a doctor who specializes in physical medicine and rehabilitation (physiatrist).

Complications

Besides difficulty with movement and posture, cerebral palsy may result in these health problems:

• Development of joint deformities or dislocation, if there’s considerable spasticity
• Nutrition problems, if there are swallowing or feeding difficulties

Some children with cerebral palsy will have multiple handicaps and may require long term care. Some of the associated problems may include:

• Difficulty with vision, hearing and speech
• Dental problems
• Mental retardation
• Seizures
• Abnormal sensation or perception
• Urinary incontinence

Treatment

The brain abnormality or damage that underlies cerebral palsy doesn’t worsen with time, but children with cerebral palsy often require long-term care. The type and amount of treatment depend on how many problems your child has and how severe they are.

The goal of cerebral palsy treatment is to help your child reach his or her maximum potential. Reaching this goal typically requires a multidisciplinary team of professionals, including physicians, therapists, psychologists, educators, nurses, special education teachers and social workers. These professionals work together to address issues of social and emotional development, communication, education, nutrition and mobility. Cerebral palsy treatments may include:

• Physical therapy. Physical therapists work to help your child reach his or her maximum potential for functional independence through a variety of approaches including exercise, mobility training, orthotics or braces, and use of other equipment. Muscle training and exercises may help your child’s strength, flexibility, balance, motor development and mobility, as well as ease caregiving.
• Occupational therapy. Therapists in this field focus on the development of fine motor skills and self-care skills. Using exercises, facilitated practice, alternative strategies and adaptive equipment, they work to promote your child’s independent participation in daily activities and routines in the home, school and community. They may also address difficulties with feeding and swallowing.
• Speech therapy. A speech therapist works with your child on both the receptive (understanding) part of speech and language as well as the expressive part (talking). Speech therapists help improve your child’s ability to speak clearly or communicate using alternative means such as an augmentative communication device or sign language. Speech therapists may also help with difficulties related to feeding and swallowing.
• Vision and hearing aids. Depending on how severely your child’s eyes are affected, he or she may need eyeglasses or surgery to correct a condition, such as cross-eye or other inability of the eyes to focus together properly (strabismus). Hearing aids may help correct any hearing problems.
• Orthotics. A variety of orthotics or “braces” or “splints” may be recommended for your child. These may be used on your child’s legs, arms or trunk. Some of these supports are used to help with function, such as improved walking. The purpose of others is for additional stretching or optimal positioning of a joint. You’ll need to pay careful attention to your child’s skin under the orthotics to make sure that the skin isn’t becoming irritated. Just like your child needs new shoes as they grow, they may also need new orthotics over time. Your rehabilitation team can help you decide which type of orthotic is most useful at what time of your child’s life.
• Medications. These may include muscle relaxants to ease muscle spasticity and anticonvulsants to reduce seizures. Injections of botulinum toxin (Botox) directly into spastic muscles also may be helpful.
• Surgery. Children with severe contractures or deformities may need surgery on tendons, bones or joints to place their arms and legs in their correct positions. This can make it easier to use a walker, braces or crutches. Children with severe spasticity who haven’t responded to oral medications may also benefit from surgical procedures.One option is dorsal rhizotomy, a procedure in which surgeons identify and cut a portion of the spinal sensory roots that provide input to spastic leg muscles. Another option is intrathecal baclofen. In this procedure, an intraspinal catheter is placed and connected to a reservoir under the skin of the abdomen. This mechanism continuously pumps small amounts of an antispastic medication called baclofen into the fluid around the spinal cord.

  These surgeries require careful screening and an expert team of health professionals, including pediatric neurosurgeons, orthopedic surgeons, pediatric neurologists, pediatric physiatrists and physical therapists.

• Assistive technology. A range of devices and gadgets can help with communication, mobility and daily tasks. Assistive technology includes such small things as rails, grab bars, magnifiers, and Velcro grips attached to forks and pens to make them easier to grasp. It also includes more expensive, high-tech tools, such as customized wheelchairs, voice communication devices, computer software programs, and positioning equipment that puts a child in the correct posture to sit or stand with other kids or family members. These devices and gadgets for school and home can make a big difference in the lives of children with cerebral palsy.

Prevention

For more than a century, doctors have hoped that by somehow improving labor and birth practices, they could reduce the incidence of cerebral palsy. But these rates have remained fairly constant, despite increased prenatal care, electronic fetal monitoring, prenatal ultrasound and increased use of Caesarean section delivery over the past 25 years.

Fewer babies now develop cerebral palsy as a consequence of birth injury. However, larger numbers of extremely premature babies survive, and some will develop cerebral palsy.

Most cases of cerebral palsy can’t be prevented, despite the best efforts of parents and doctors. But, if you’re pregnant, you can take these steps to keep healthy to minimize the possibility of pregnancy complications:

• Make sure you’re immunized. Immunization against diseases such as rubella may prevent an infection that could cause fetal brain damage.
• Take care of yourself. The healthier you are heading into a pregnancy, the less likely you’ll be to develop an infection that may result in cerebral palsy.
• Seek early and continuous prenatal care. Regular visits to your doctor during your pregnancy are a good way to reduce health risks to you and your unborn baby. Seeing your doctor regularly can help prevent premature birth, low birth weight and infections.

Coping skills

When a child is diagnosed with a disability, it forces the whole family to face a range of new challenges. Here are a few tips for caring for yourself and your child:

• Foster your child’s independence. Encourage any effort at independence, no matter how small. Just because you can do something faster and quicker doesn’t mean you should.
• Be an advocate for your child. You are an important part of your child’s health care team. Don’t be afraid to speak out on your child’s behalf or to ask tough questions of your physicians, therapists and teachers.
• Find support. A circle of support can make a big difference in helping you cope with cerebral palsy and its effects. As a parent, you may feel grief and guilt over your child’s disability. Your doctor can help you locate support groups, organizations and counseling services in your community. Your child may benefit from family support programs, school programs and counseling.

Introduction

Chiari malformation is a condition in which brain tissue protrudes into your spinal canal. It occurs when a portion of your skull is abnormally small or misshapen, pressing on your brain and forcing it downward. Although Chiari malformation is uncommon, it’s now diagnosed more frequently, largely due to improved imaging tests.

Chiari malformation is usually present at birth (congenital), but it can develop in some children after they are born. Signs and symptoms may not occur until adulthood.

Doctors categorize Chiari malformation into several types, depending on the amount of brain tissue that is pushed down into the spinal canal, and whether developmental abnormalities of the brain or spine are present. The more common types are less severe and involve less displaced tissue. Other types are rare and more severe.

Treatment for Chiari malformation depends on its severity and the characteristics of your condition. Regular monitoring, medications and surgery are all treatment options.

Signs and symptoms

Some people with Chiari malformation have no signs or symptoms. Their condition is detected only when tests are performed for unrelated disorders. However, depending on the type and severity, Chiari malformation can cause a number of signs and symptoms.

Signs and symptoms usually start during infancy, although they can begin in adolescence or adulthood. Even when they’re less serious, as in the more common types I and II, signs and symptoms still can be problematic and life disrupting.

Headaches, often severe, are the classic symptom of Chiari malformation. They are typically precipitated with sudden coughing, sneezing or straining. People with Chiari malformation type I also can experience:

• Neck pain (running down the shoulders at times)
• Unsteady gait (problems with balance)
• Poor hand coordination (fine-motor skills)
• Numbness and tingling of the hands and feet
• Dizziness
• Difficulty swallowing (sometimes accompanied by gagging, choking and vomiting)
• Vision problems (blurred or double vision)
• Slurred speech

Less often, people with Chiari malformation may experience:

• Ringing or buzzing in the ears (tinnitus)
• Poor bladder control
• Chest pain, in a band-like pattern around the chest
• Curvature of the spine (scoliosis) related to spinal cord impairment
• Abnormal breathing — specifically, sleep apnea characterized by periods of breathing cessation during sleep

Some people have occasional “dropping” episodes — feeling faint and unexpectedly collapsing to the floor, losing consciousness for a few seconds.

In Chiari malformation type II, in which a greater amount of tissue protrudes into the spinal canal compared with type I, the signs and symptoms can include not only those above, but also myelomeningocele, a form of spina bifida in which the backbone and the spinal canal have not closed properly before birth. This type is sometimes called Arnold-Chiari malformation.

In one of the most severe types of the condition, Chiari malformation type III, a portion of the lower back part of the brain (cerebellum) or the brainstem extends through an abnormal opening in the back of the skull.

In people with the even more severe Chiari malformation type IV, the brain itself has never developed normally.

Causes

Chiari malformation occurs when the section of the skull containing the cerebellum is too small or is deformed, thus putting pressure on and crowding the brain. There’s no clear cause of this misshapen skull.

When the cerebellum is pushed into the upper spinal canal, it can interfere with the normal flow of cerebrospinal fluid (CSF) that protects your brain and spinal cord. This impaired circulation of CSF can lead to the blockage of signals transmitted from your brain to your body, or to a buildup of spinal fluid in the brain or spinal cord. Alternatively, the pressure from the cerebellum upon the spinal cord or lower brainstem can cause neurological signs or symptoms.

Risk factors

Chiari malformation occurs about three times more often in females than in males.

There’s some evidence that Chiari malformation runs in some families. However, research into a possible hereditary component is still in its early phase.

When to seek medical advice

If you have any of the signs and symptoms that may be associated with Chiari malformation, see your doctor for an evaluation.

Because many symptoms of Chiari malformation can also be associated with other disorders, a thorough medical evaluation is important. Head pain, for example, can be caused by migraines, sinus disease or a brain tumor, as well as Chiari malformation. Other signs and symptoms overlap with conditions such as multiple sclerosis.

For a thorough examination, your primary care doctor may refer you to a specialist in the brain and nervous system (neurologist) and to a specialist in interpreting X-rays and other imaging (radiologist) to conduct the most appropriate tests.

Screening and diagnosis

The diagnostic process begins with your doctor taking your medical history and with a complete physical examination. Your doctor will ask whether you’re having symptoms such as head and neck pain, and will ask you to describe them. He or she will also check your fine-motor skills and swallowing ability.

If you have symptoms such as head pain, and the exact cause isn’t apparent to your doctor, you’ll likely undergo a magnetic resonance imaging (MRI) scan of your skull, which is the definitive diagnostic tool for Chiari malformation.

Using magnetic fields and radio waves, this test produces three-dimensional, high-resolution images of structural abnormalities that may be contributing to your symptoms. It can also provide pictures of the cerebellum and determine whether it extends into the spinal canal. A dye or contrast medium can be injected, and once it travels to your brain, it can enhance the MRI images. An MRI is a safe and painless test. Over time, repeat MRIs can be used to monitor the progression of this disorder.

Your doctor may use other imaging techniques as well. For example, your doctor may recommend a computerized tomography (CT) scan, which uses X-rays in conjunction with a computer to produce precise, sectional images of the bone tissue that surrounds the spinal column.

Complications

In some people, Chiari malformation can become a progressive disorder and lead to serious complications. In others, there may be no associated symptoms and no intervention is necessary. The complications associated with this condition include:

• Hydrocephalus. This accumulation of excess fluid within the brain may require placement of a flexible tube (shunt) to divert and drain the cerebrospinal fluid to another area of the body.
• Paralysis. This may occur due to the crowding and pressure on the spinal column. Paralysis tends to be permanent, even after treatment with surgery.
• Syringomyelia. Some people with Chiari malformation also develop a condition called syringomyelia, in which a cavity or cyst (cyrinx) forms within the spinal column. Although the mechanism connecting Chiari malformation with syringomyelia is unclear, it may be associated with injury or displacement of nerve fibers in the spinal cord. When a cavity forms, it tends to be filled with fluid and can additionally impair the function of the spinal cord.
• Death. When a child is born with Chiari malformation type IV, death is common, usually early in infancy.

Treatment

Treatment for Chiari malformation depends on the severity and the characteristics of your condition. If you have no symptoms, your doctor likely will recommend no treatment other than monitoring with regular examinations.

When headaches or other types of pain are the primary symptom, your doctor may recommend pain medication. Some people experience symptom relief with anti-inflammatory or pain-relieving agents such as indomethacin (Indocin). This approach may prevent or delay the need for an operation.

Reducing pressure by surgery
Surgery is the approach doctors use most often to treat symptomatic Chiari malformation. The goal is to stop the progression of changes in the anatomy of the brain and spinal canal, as well as ease or stabilize symptoms. When successful, surgery can reduce pressure on the cerebellum and the spinal cord, and restore the normal flow of spinal fluid.

In the most common operation for Chiari malformation — called posterior fossa craniectomy or posterior fossa decompression — your surgeon removes a small section of bone in the back of the skull, relieving pressure by giving the brain more room. The covering of the brain, called the dura, is then opened, and a patch is sewn in place to enlarge the covering and provide more room for the brain; this patch may be an artificial material, or it could be tissue harvested from your own leg or neck. The exact technique may vary, depending on whether a fluid-filled cavity is present, or if you have hydrocephalus. The operation takes about two to three hours, and recovery in the hospital usually requires two to four days.

Risks and follow-up
The use of surgery carries risks — the possibility of infection or problems with wound healing. Discuss the pros and cons with your doctor when deciding whether surgery is the best alternative for you. The operation is successful in most people, but if nerve injury in the spinal canal has already occurred prior to surgery, this procedure won’t reverse the damage.

After the operation, you’ll need regular follow-up examinations with your doctor, including periodic imaging tests to assess the outcome of surgery and the flow of cerebrospinal fluid.

Introduction

Cavities are decayed areas of your teeth that develop into tiny openings or holes. Cavities, also called tooth decay, are caused by a combination of factors, including not cleaning your teeth well, frequent snacking and sipping sugary drinks.

Cavities and tooth decay are one of the most common health problems around the world. They’re especially common in children and young adults. But anyone who has teeth can get cavities, including infants and older adults.

If cavities aren’t treated, they get larger and the decay can become severe enough to cause serious toothache pain, infection, tooth loss and other complications. You probably know that regular dental visits and good brushing and flossing habits go a long way toward preventing cavities and tooth decay. But you may be surprised to learn that cheese may also help prevent cavities, and that potato chips may be more harmful than a candy bar. Detecting and treating cavities and tooth decay early can save you pain and expense later — as well as your teeth.

Signs and symptoms

The signs and symptoms of cavities and tooth decay vary depending on the severity and location of the cavity. When a cavity or decay is just beginning, you may not have any symptoms at all.

But as decay gets worse, it may cause such symptoms as:

• Toothache or tooth pain
• Tooth sensitivity
• Mild to sharp pain when eating or drinking something sweet, hot or cold
• Pain that lasts even after you stop eating or drinking
• Visible holes or pits in your teeth
• Pain when you bite down
• Pus around a tooth

Causes

Your mouth, like many other parts of your body, naturally contains many types of bacteria. Some of these bacteria thrive on food and drinks that contain sugars and cooked starches, also known as fermenting carbohydrates. When these carbohydrates aren’t cleaned off your teeth, the bacteria can convert them into acids starting within just 20 minutes. The bacteria, acids, food particles and saliva then form into dental plaque — a sticky film that coats your teeth. If you run your tongue along your teeth, you can feel this plaque several hours after you’ve brushed. The plaque is slightly rough and is more noticeable on your back teeth, especially along the gumline.

The acids in plaque attack minerals in the tooth’s hard, outer surface, called the enamel. This erosion causes tiny openings or holes in the enamel — cavities. Once spots of enamel are worn away, the bacteria and acid can reach the next layer of your teeth, called dentin. This layer is softer and less resistant to acid than enamel is, so once tooth decay reaches this point, the decay process often speeds up.

As tooth decay continues, the bacteria and acid continue their march through the layers of your teeth, moving next to the pulp, or the inner material of the tooth. The pulp contains nerves and blood vessels. The pulp becomes swollen and irritated from the bacteria. The bone supporting the tooth also may become involved. When a cavity and decay is this advanced, you may have severe toothache pain, sensitivity, pain when biting or other symptoms. Your body also may respond to these bacterial invaders by sending white blood cells to fight the infection. This may result in a tooth abscess.

This process of tooth decay takes time. Permanent teeth are stronger than primary teeth and may hold off decay for a year or two. Saliva also helps wash away some of the bacteria and acid. But as the decay erodes each layer of your tooth, the process speeds up.

Tooth decay most frequently occurs in the back teeth — the molars and premolars. These teeth have lots of grooves, pits and crannies. Although these grooves are great for helping chew food, they can also collect food particles. These back teeth are also harder to keep clean than your smoother and more accessible front teeth. As a result, plaque can build up between these back teeth and bacteria can thrive, producing acid that destroys the enamel.

Risk factors

Cavities are one of the most common worldwide health problems, and everyone who has teeth is at risk of getting them. But some factors increase the risk that you’ll get a cavity or develop tooth decay. These risk factors include:

• Certain foods and drinks. Some foods and drinks are more likely than others to cause decay. Fermentable carbohydrates are the biggest problem. These foods cling to your teeth for a long time. Fermentable carbohydrates include all sugars and most cooked starches. Examples include milk, honey, table sugar, soda, raisins, cake, hard candy, breath mints, dried fruit, cookies, dry cereal, bread and potato chips. Some food that may seem like obvious culprits may not be after all. For instance, although candy bars, jelly beans and caramels are sticky and sugary, they’re easily washed away by saliva, making them less of a threat than are potato chips, which stubbornly stick to your teeth.
• Frequent snacking or sipping. When it comes to your teeth, the amount of sugary snacks you eat is less important than when you eat them. If you frequently snack or sip sodas, acid has more time to attack your teeth and wear them down. This is also why parents are encouraged not to give babies bottles filled with milk, formula, juice or other sugar-containing liquids at bedtime. The beverage will remain on their teeth for hours and cause erosion — often called baby bottle tooth decay. If you’re nursing or feeding an infant formula, talk to your health care providers about how to prevent early tooth decay. They may suggest having your baby drink some water after eating to help rinse away the sugary milk or formula.
• Not brushing. If you don’t clean your teeth after eating and drinking, plaque builds up, eroding your teeth.
• Bottled water. Adding fluoride to public water supplies has helped decrease tooth decay by offering protective minerals for tooth enamel. But today, many people drink bottled or filtered water that doesn’t contain fluoride, and they may miss out on the protective benefits of fluoride. On the other hand, some bottled water may contain added fluoride, and if your drinking water also contains fluoride, babies and children could then get too much fluoride. Talk to your child’s dentist about the amount of fluoride he or she may be getting and check ingredient labels on your bottled water.
• Older age. An increasing number of older adults still have their natural teeth. However, over time, these teeth can wear down and become more vulnerable to tooth decay and cavities. Older adults also have more decay on root surfaces.
• Receding gums. When your gums pull away from your teeth, plaque can form on the roots of your teeth. Tooth roots are naturally covered with a coating called cementum, but the cementum is quickly lost when the root surface is exposed. The underlying dentin is softer than enamel and can become decayed more easily, leading to root decay.
• Dry mouth. Dry mouth is a lack of saliva. Saliva has an important role in preventing tooth decay. It washes away food and plaque from your teeth. Minerals found in saliva help repair early tooth decay. Saliva also limits bacterial growth that can dissolve tooth enamel or lead to mouth infections. And saliva neutralizes damaging acids in your mouth.
• Weak or rough dental fillings. Over the years, dental fillings can become weak and begin to breakdown, or the edges can become rough. Either of these situations can allow plaque to build up more easily and make it harder to completely remove plaque.
• Eating disorders. Anorexia and bulimia can lead to significant tooth erosion and cavities. Stomach acid from vomiting, for instance, washes over the teeth and erodes the enamel. Eating disorders can also interfere with saliva production. In addition, some people with eating disorders sip soda or other acidic drinks throughout the day, which creates a continual acid bath over the teeth.
• Heartburn. Gastroesophageal reflux disorder (GERD), acid reflux and heartburn can cause stomach acid to flow into your mouth, wearing away the enamel of your teeth.
• Close contact. Some harmful, decay-causing bacteria in the mouth can be passed from one person to another by kissing or sharing eating utensils. Parents or even child care providers may pass along harmful bacteria to infants and children, for example.
• Certain cancer treatments. Having radiation to your head or neck areas can increase the risk of getting cavities by changing the saliva produced in the mouth, which allows more cavity-producing bacteria to thrive.

When to seek medical advice

You may not be aware that a cavity is starting, so visiting your dentist regularly is your best protection against cavities and tooth decay. However, a toothache or tooth pain is commonly a telltale sign of a cavity. If your teeth or mouth hurt, visit your dentist as soon as possible.

In addition to pain, contact your dentist if you develop any of these signs or symptoms:

• Red, tender or swollen gums
• Bleeding gums
• Gums that are pulling away from your teeth, which may make your teeth seem longer
• Pus around your teeth and gums when you press on the gums
• A bad taste in your mouth
• Unexplained bad breath
• Loose teeth
• Changes in the way your top and bottom teeth touch
• Changes in the feel of your dentures
• Sensitivity to sweet, hot or cold foods or beverages
• You avoid brushing or cleaning certain teeth or areas because of pain

If a cavity is treated before it starts causing pain, there’s a smaller chance of significant damage requiring more involved treatment. That’s why it’s important to have regular dental checkups and cleanings even when your mouth feels fine. By the time you notice symptoms, the damage is getting worse.

Screening and diagnosis

Your dentist can detect a cavity and tooth decay pretty easily. Your dentist will ask about tooth pain and sensitivity. Your dentist will examine your mouth and teeth and may probe your teeth with dental instruments to check for soft areas. You may also have dental X-rays, which can show cavities and decay.

Your dentist will also be able to tell you specifically which of the three types of cavities you have:

• Smooth surface decay. This is decay on a flat surface of a tooth, where bacteria can remain for a long time and acid can dissolve the tooth enamel. It most commonly involves the cheek side of teeth at the gumline. This is also the type of decay that’s generally easiest to prevent and treat, unless it occurs on the smooth contacting surfaces between the teeth.
• Pit and fissure decay. This is decay that affects the pits and grooves on the chewing surface of your back teeth. This decay can progress quickly if you don’t practice good oral hygiene or get prompt treatment.
• Root decay. This type of decay occurs on the surface over tooth roots. It’s most common among older adults with receding gums.

Complications

Cavities and tooth decay are so common that you may not take them seriously. And you may think that it doesn’t matter if children get cavities in their baby teeth. However, cavities and tooth decay can have serious and lasting complications, even for children who haven’t yet gotten their permanent teeth.

Complications may include:

• Pain
• Tooth abscess
• Tooth loss
• Broken teeth
• Chewing problems
• Serious infections

In addition, when cavities and decay become very painful and severe, they can interfere with daily living. The pain may prevent you from going to school or work, for instance. If it’s too painful or difficult to chew or eat, you may lose weight or have nutrition problems. If cavities result in tooth loss, it may affect your self-esteem. In rare cases, an abscess from a cavity can cause serious or even life-threatening infections when not properly treated.

Treatment

Treatment of cavities and decay depends on how severe they are and your particular situation. Treatment options include:

• Fluoride treatments. Fluoride is a mineral that helps prevent cavities and helps teeth repair themselves. If your cavity is just getting started, a fluoride treatment may be able to help restore enamel. Professional fluoride treatments contain more fluoride than what’s found in over-the-counter toothpaste and mouth rinses. Fluoride treatments may be in a liquid solution, a gel, foam or varnish that is brushed onto your teeth or placed in a tray that fits over your teeth. Each treatment takes a few minutes. Your dentist may suggest having periodic fluoride treatments.
• Fillings. A filling is material that replaces decayed areas of your teeth. Fillings, sometimes called restorations, are the main treatment option when the decay has progressed beyond the initial enamel-erosion process. Your dentist drills away the decayed material inside your tooth. The gap is then filled to restore the tooth shape. Fillings are made of various materials, such as tooth-colored composite resins, porcelain, or combinations of several materials. Silver amalgam fillings contain a variety of materials including small amounts of mercury. Some people don’t like using mercury fillings because they fear possible health effects. While some medical studies have shown these fillings to be safe, they remain controversial.
• Crowns. If you have extensive decay or weakened teeth, you may need a crown rather than a filling to treat your cavity. The decayed area is drilled away. A crown is then fit over the remaining portion of tooth. Crowns are made of gold, porcelain or porcelain fused to metal.
• Root canal. When decay is severe and reaches the inner material of the tooth, you may need a root canal. In this procedure, the pulp of the tooth is removed and then replaced with a filling.
• Tooth extractions. A severely decayed tooth may need to be removed entirely. Having a tooth extracted can cause the other teeth in your mouth to move, so if possible, consider getting a dental implant to replace the missing tooth.

Prevention

Good oral and dental hygiene can help prevent cavities and tooth decay. Follow these tips to help prevent cavities:

• Brush after eating or drinking. Brush your teeth at least twice a day and ideally after every meal, using fluoride-containing toothpaste. To clean between your teeth, floss or use an interdental cleaner. If you can’t brush after eating, at least try to rinse your mouth with water.
• Rinse your mouth. If your dentist feels you are at higher risk of developing a cavity, using a fluoridated mouth rinse can help reduce your risk.
• Visit your dentist regularly. Get professional tooth cleanings and regular oral exams, which can help prevent problems or spot them early. Your dentist can recommend a schedule for your situation.
• Consider dental sealants. A sealant is a protective plastic coating that’s applied to the chewing surface of back teeth — sealing the grooves in the teeth most likely to get cavities. The sealant protects tooth enamel from plaque and acid. Sealants can help both children and adults. The Centers for Disease Control and Prevention strongly recommends sealants for all school-age children. Sealants last for several years before they need to be replaced.
• Drink some tap water. Adding fluoride to public water supplies has helped decrease tooth decay significantly. But today, many people drink bottled water that doesn’t contain fluoride.
• Avoid frequent snacking and sipping. Whenever you eat or drink something, you help your mouth create acids that destroy your tooth enamel. If you snack or drink throughout the day, your teeth are under constant attack.
• Eat tooth-healthy foods. Some foods and beverages are better for your teeth than others. Avoid foods that get stuck in grooves and pits of your teeth for long periods, such as chips, candy or cookies. Instead, eat food that protects your teeth, such as cheese, which some research shows may help prevent cavities, as well as fresh fruits and vegetables, which increase saliva flow, and unsweetened coffee, teas and sugar-free gum, which wash away food particles.
• Consider fluoride treatments. Your dentist may recommend a fluoride treatment, especially if you aren’t getting enough fluoride naturally, such as through fluoridated drinking water. In a fluoride treatment, your dentist applies concentrated fluoride to your teeth for several minutes. You can also use fluoridated toothpaste or mouthwash.
• Ask about antibacterial treatments. Some people are especially vulnerable to tooth decay, perhaps because of medical conditions, for instance. In these cases, your dentist may recommend special mouth rinses or other antibacterial treatments to cut down on harmful bacteria in your mouth.

Check with your dentist to see which methods are best for you.

Self-care

If cavities and tooth decay are causing pain, sensitivity or discomfort, the first thing to do is visit your dentist. Some steps you can also take at home to control your pain include:

• Thoroughly cleaning all parts of your mouth and teeth; don’t avoid painful areas
• Using warm water to brush your teeth
• Using a toothpaste designed for sensitive teeth
• Avoiding foods or beverages that are hot, cold or sweet enough to trigger pain
• Taking over-the-counter pain relievers, if your health care professional has said it’s OK for you
• Using an over-the-counter anesthetic specifically designed to soothe painful teeth

Introduction

Salmonella infection (salmonellosis) is a common bacterial infection of the intestinal tract. Salmonella typically live in the intestines of animals and humans and are shed through feces, where the bacteria remain highly contagious. Humans become infected most frequently through contaminated food sources, such as poultry, meat and eggs.

Typically, people with salmonella infection develop diarrhea, fever and abdominal cramps within 12 to 72 hours. Signs and symptoms of salmonella infection generally last four to seven days. Most healthy people recover without specific treatment.

In some cases, diarrhea can be extremely dehydrating and require prompt medical attention. Life-threatening complications may also develop should the infection spread beyond your intestines.

Your risk of salmonella infection is higher if you travel to countries with poor sanitation. Preventive measures include proper cooking, good hygiene such as hand washing, and avoiding raw or undercooked eggs and meat.

Signs and symptoms

In general, salmonella symptoms begin with nausea and vomiting and progress to abdominal pains and diarrhea. Additional signs and symptoms include fever, chills and muscle pains, and can last anywhere from several days to two weeks.

There are more than 2,000 types of salmonella bacteria, although fewer than a dozen types are responsible for most illness in humans. Other symptoms may be present depending on the type of salmonella germ causing your infection. The most prevalent salmonella-related illnesses are:

• Gastroenteritis. This increasingly common salmonella-induced illness is caused by the S. enteritidis bacterium, which is most often ingested through raw or undercooked meat, poultry, eggs or egg products. The incubation period ranges from several hours to two days, and additional signs include blood in the stool.
• Enteric fever. Also known as typhoid fever, this illness is caused by the S. typhi bacterium and is most commonly contracted by drinking salmonella-contaminated water. The incubation period ranges from five to 21 days following infection. Additional signs and symptoms may include constipation, cough, sore throat, headache and mental confusion. Slightly raised, rose-colored spots on your upper chest also may appear. In addition, a slowing of your heartbeat (bradycardia) and enlargement of your liver and spleen (hepatosplenomegaly) may be present.
• Bacteremia. This condition results when salmonella bacteria enter and circulate throughout your bloodstream. Infants and people with compromised immune systems are at special risk of developing serious complications, including infection of tissues surrounding the brain and spinal cord (meningitis) and infection within the bloodstream (sepsis). People with salmonella-induced bacteremia may show few symptoms; however, fever can be present.

If you have intestinal salmonella and you have a healthy immune system, you may not seem ill or show signs or symptoms. However, you may continue to shed the bacteria in your feces and remain contagious for up to a year.

Causes

Salmonella infection begins when you ingest one of the various types of salmonella bacteria — with S. enteritidis, S. typhi and S. choleraesuis responsible for most salmonella-related illnesses. Those bacteria that survive the acidic environment of your stomach then travel to your small intestine and adhere to its lining, where they begin their life cycle. Fresh bacteria are shed in your feces, where they remain highly contagious.

You can contract salmonella infection by touching or ingesting anything contaminated with salmonella bacteria. Reservoirs for the microorganism include pet reptiles, dogs and cats, pigs and cattle, infected humans, contaminated water, raw dairy products and chicken eggs. Salmonella can survive for months in water, ice, sewage and frozen meat.

Most frequently, humans come in contact with salmonella through food sources such as contaminated poultry, meat, eggs and egg products.

Methods of salmonella infection include:

• Swallowing or putting something contaminated with salmonella into your mouth
• Drinking water contaminated with salmonella
• Touching contaminated reptiles, including iguanas, turtles or snakes — about 90 percent of reptiles carry salmonella
• Touching contaminated pet rodents
• Eating raw or undercooked food contaminated with salmonella
• Touching your hand to your mouth if your hand has been in contact with a contaminated surface or object
• Having close contact with other infected people or animals — especially their feces — allowing bacteria to be transmitted from your hands to your mouth

Risk factors

The risk factors for becoming infected with salmonella include:

• Being exposed to contaminated food or water
• Ingesting improperly cooked or stored food, especially poultry, meat or eggs
• Traveling internationally, especially to countries with poor sanitation
• Having infected family members
• Owning a pet reptile, such as an iguana, lizard or turtle
• Having an impaired immune system, such as people with AIDS and transplant recipients
• Having inflammatory bowel disease, in which damage to the lining of your gastrointestinal tract reduces barriers to salmonella entering your small intestine
• Having sickle cell disease, which lowers your immunity to infection
• Having a disease such as malaria or sickle cell anemia, which impairs phagocytes — cells in your body that attack pathogens
• Using corticosteroids, which suppress your immune system
• Using antacids, which lowers stomach acidity and reduces barriers to salmonella entering your small intestine

When to seek medical advice

Seek medical attention if you develop diarrhea that doesn’t clear within several days or is accompanied by blood in your stool. Also call a health care provider if you experience severe vomiting, abdominal pain or dehydration.

Screening and diagnosis

The simplest way to diagnose salmonella infection is to isolate the bacteria in a stool or other culture. Typically, your doctor will ask for a stool sample and send it to a laboratory, where a technician will try to grow and identify the infectious organism under a microscope.

Although salmonella infection elsewhere in your body isn’t always present in your bloodstream, a blood culture might help identify certain types of bacteria and rule out other pathogens.

Complications

Salmonella infection itself isn’t life-threatening. However, in certain people — especially children, older adults, transplant recipients and people with a weakened immune system — the development of complications can be dangerous.

Complications of salmonella infection may include:

• Reiter’s syndrome — an inflammatory condition characterized by eye irritation, painful urination and painful joints — which can lead to chronic arthritis
• Severe dehydration
• Infection of the tissues surrounding your brain and spinal cord (meningitis)
• Infection of your bloodstream (blood poisoning or septicemia)
• Inflammation of the lining of your heart or valves (endocarditis)
• Infection of your bones or bone marrow (osteomyelitis)
• Spread of infection to other parts of your body

Treatment

There’s no reliable treatment for salmonella intestinal infection, and recovery usually depends on the health of your immune system. In most otherwise healthy people, diarrhea and abdominal pains subside within several days to two weeks without specific treatment.

For people with weakened immune systems, the illness can endure and lead to severe diarrhea, fever and significant dehydration and malnutrition. The goal of salmonella treatment is to replace lost fluids, alleviate signs and symptoms, improve your immune response and destroy the invading pathogens. These options include:

• Fluid replacement. You’ll need to replace fluids and electrolytes — minerals such as sodium, potassium and calcium that maintain the balance of fluids in your body — lost to persistent diarrhea. This can be done either by drinking lots of liquids, or in cases of serious fluid loss, receiving fluids intravenously. These precautions will help keep your body hydrated and functioning properly.
• Dietary modifications. Avoid milk products to help alleviate abdominal pains. Substitute stomach-soothing foods, including bananas, rice, apples and toast.
• Antibiotics. If infection has traveled outside your intestine, antibiotic medications can help destroy or inhibit the growth of salmonella bacteria. These drugs include ciprofloxacin (Cipro), a sulfamethoxazole and trimethoprim combination (Bactrim), ceftriaxone (Rocephin) and amoxicillin (Amoxil). Duration of treatment may vary depending on your illness, and range from 14 days for enteric fever to six weeks for bacteremia. Resistance to antibiotics is increasingly reported in various strains of salmonella.
• Antidiarrheals. These medications relieve diarrhea by slowing down intestinal movements and increasing fluid absorption. These drugs include loperamide (Anti-Diarrheal Formula, Imodium).

Prevention

Salmonella infection is contagious, so take precautions to avoid spreading bacteria to others.

Preventive methods are especially important when preparing food or providing care for infants, older adults and people with compromised immune systems.

Follow these suggestions:

• Keep eggs adequately refrigerated (lower than 41 F), and discard cracked or dirty eggs. Avoid keeping eggs unrefrigerated for more than two hours.
• Cook eggs for 15 seconds or more at 145 F. Eat eggs promptly after cooking.
• Avoid eating raw eggs, as in cookie dough, homemade ice cream or eggnog. If you must consume raw eggs, ensure that they have been pasteurized. Check the egg carton or package for labeling. 
• Separate uncooked meats from produce and cooked foods to prevent transfer of any bacteria.
• Wash your hands after handling uncooked foods. Also be sure to thoroughly wash cutting boards and utensils.
• Wash your hands after contact with animals, including reptiles, rodents and other pets.
• Wash your hands after handling human and animal feces, including those of household pets.

Introduction

Almost everyone has had hiccups. Some people even have them before they’re born. “Singultus” is the medical term for hiccups, derived from the Latin word “singult,” which means the act of catching your breath while sobbing, an apt description of the way hiccups sound. Although they can be embarrassing — especially if the “hic” pops out of your mouth in a quiet room or during a meeting — hiccups are rarely cause for concern.

Often, there’s no obvious cause for hiccups. Sometimes they may be the result of eating a large meal, drinking a carbonated beverage or sudden excitement. Rarely, hiccups may be a sign of an underlying medical condition.

Hiccups usually disappear on their own. If your hiccups don’t go away after a few minutes, home remedies may help. If hiccups persist for more than 48 hours or if they are so severe that they interfere with eating or breathing, see your doctor.

Signs and symptoms

The characteristic sound of a hiccup, sometimes preceded by a small tightening sensation in your chest, abdomen or throat, are the only signs and symptoms associated with hiccups. People may have as few as four hiccups a minute or, rarely, as many as 60 hiccups a minute.

How long your hiccup episode lasts determines the type of hiccups you have:

• Transient or acute hiccups. This is the most common form of hiccups. Transient hiccups include hiccup episodes that last less than 48 hours. Most bouts of transient hiccups last only a few minutes.
• Persistent hiccups. These hiccups last longer than 48 hours, but less than a month.
• Intractable hiccups. Hiccups fall into this category when they last more than two months.

Causes

A hiccup is an unintentional contraction of your diaphragm — the muscle that separates your chest from your abdomen and plays an important role in breathing. This contraction makes your vocal cords close very briefly, which produces the sound of a hiccup.

Acute or transient hiccups
Although there’s often no clear cause for a bout of hiccups, some factors that can trigger acute or transient hiccups include:

• Eating spicy food. Spicy food may cause irritation to the nerves that control normal contractions of your diaphragm.
• Eating a large meal, drinking carbonated beverages or swallowing air. These can cause your stomach to expand (distend), which pushes up your diaphragm, making hiccups more likely.
• Drinking alcohol. Alcohol can relax your diaphragm and vocal cords, making it easier for other factors to trigger hiccups.
• Sudden temperature changes. A quick change in temperature, either inside or outside your body, such as drinking hot liquids and then cold liquids or your shower water switching suddenly from hot to cold, can set off hiccups.
• Tobacco use. Tobacco use may irritate the nerves that controls the diaphragm (phrenic nerves), causing hiccups.
• Sudden excitement or emotional stress. Although it’s not clear why stress or sudden excitement causes hiccups, it may be due to the effect being startled has on one of the nerves involved in the hiccup reflex (vagus nerves).

Persistent and intractable hiccups
Rarely, hiccups may be the result of an underlying medical condition. When this is the case, the hiccups usually last longer than 48 hours. More than 100 causes of persistent and intractable hiccups have been identified. They are generally grouped into the following categories:

• Nerve damage or irritation. Damage or irritation of one of your vagus nerves or phrenic nerves is the most common cause of persistent or intractable hiccups.The vagus nerve serves as a communication pathway between your brain and organs, such as your heart, lungs and intestines. There’s one vagus nerve on each side of your body. These nerves run from your brainstem through your neck and down to your chest and abdomen. The phrenic nerve controls movement of your diaphragm. There’s one phrenic nerve on each side of your body. The phrenic nerves run from your brainstem through your neck and down to your diaphragm.Examples of conditions that may damage or irritate these nerves include a foreign body (often a hair) in your ear, a tumor, cyst or goiter in your neck or chest, gastroesophageal reflux, or an abscess on your diaphragm.
• Central nervous system disorders. A tumor or infection in your central nervous system, or damage to your central nervous system as a result of trauma, can release your body’s normal control of the hiccup reflex.
• Metabolic disorders. Metabolic disorders that may cause hiccups include a condition that interferes with the ability of your kidneys to keep wastes from building to toxic levels (uremia) and a condition that results in less than the normal levels of carbon dioxide in your blood (hypocapnia).
• Surgery. General anesthesia and complications following surgery can cause intractable hiccups.
• Mental or emotional triggers. Anxiety, stress and excitement have been associated with some cases of persistent or intractable hiccups.

Risk factors

If you use tobacco or drink alcohol regularly, you may get transient hiccups more often than people who don’t. Men are more likely to have persistent or intractable hiccups.

When to seek medical advice

Make an appointment to see your doctor if your hiccups last more than 48 hours or if they are so severe that they cause problems with eating or breathing.

Screening and diagnosis

For hiccups lasting longer than 48 hours, your doctor will perform a physical exam and talk with you about your medical history. If your doctor suspects an underlying medical condition may be causing your hiccups, he or she may recommend one or more of the following tests:

• Blood tests. A laboratory exam of a blood sample may help reveal an infection, metabolic disorder or tumor.
• Chest X-ray. A chest X-ray may detect abnormalities affecting the vagus nerve, phrenic nerve or diaphragm.
• Ear exam. Examination of the external ear canal may reveal a foreign substance in your ear that could be causing your hiccups.
• Fluoroscopy. This exam is a type of X-ray that uses low-dose radiation to produce images of a body part in motion. Fluoroscopy can show if one side (unilateral) or both sides (bilateral) of your diaphragm are being affected by hiccup contractions. The results of fluoroscopy can help rule out some underlying medical conditions.

If the cause of your hiccups remains unclear after these tests, additional tests may be necessary, depending on your condition.

Treatment

Most cases of hiccups go away on their own, without medical treatment. If an underlying medical condition is causing your hiccups, treatment of that illness may eliminate the hiccups. If your hiccups are persistent or intractable, your doctor may recommend the following treatment:

• Medication. Several forms of medication may be effective for treating hiccups. The most commonly used is chlorpromazine (Thorazine). Other medications that may be helpful include metoclopramide (Reglan), anticonvulsants, benzodiazepines and baclofen (Lioresal).
• Carotid sinus massage. Your carotid sinus is located in your neck, just below your jaw and just above the point where your carotid artery — a blood vessel that supplies blood to your brain — divides into its two main branches. Massage of your carotid sinus may help eliminate hiccups. This hiccups treatment should be performed only by your health care provider. Don’t try carotid massage at home: It can be dangerous.
• Nasogastric (NG) tube. If your stomach is distended, a thin, flexible tube inserted through your nose and into your stomach (nasogastric tube) may stop hiccups by providing relief from stomach distention. The tube usually is removed as soon as the hiccups stop.
• Nerve block. Rarely, if other treatments aren’t effective, your doctor may recommend an injection of an anesthetic to block your phrenic nerve to stop hiccups.

Prevention

You may be able to decrease your frequency of transient or acute hiccups by avoiding common hiccup triggers, such as eating quickly, eating large meals or spicy foods, drinking carbonated beverages or alcohol, sudden changes in temperature, and using tobacco.

Self-care

Although there’s no surefire way to stop hiccups, if you have a bout of hiccups that lasts longer than a few minutes, the following home remedies may provide relief:

• Swallow a teaspoon of sugar
• Breathe temporarily into a paper bag
• Drink a glass of cold water
• Hold your breath for a count of 10
• Have someone startle you

Complementary and alternative medicine

When persistent or intractable hiccups don’t respond to other remedies, alternative treatments such as hypnosis and acupuncture may be helpful.

Introduction

Doctors today refer to it as parvovirus infection or erythema infectiosum. Some people may call it slapped-cheek disease because of the face rash that develops resembling slap marks. Parvovirus infection is also commonly called fifth disease because it was fifth of a group of once-common childhood diseases with similar rashes. The other four are measles, rubella, scarlet fever and Dukes’ disease.

Whatever the name, parvovirus infection is still a common but mild infection in children that generally requires little treatment. However, parvovirus infection in some pregnant women can lead to serious health problems for the fetus. Parvovirus infection is also more serious for people with certain anemias or with a compromised immune system.

Signs and symptoms

Early phase of parvovirus infection
Most children with parvovirus infection feel well. Some develop mild, cold-like signs and symptoms early in the illness, and these initial parvovirus symptoms typically last five to 10 days. They may include:

• Sore throat
• Slight fever
• Upset stomach
• Headache
• Fatigue
• Itching

Following phases

• Several days later, a distinctive bright red facial rash usually appears on both cheeks.
• Eventually, the rash may extend to the arms, trunk, thighs and buttocks, where the rash has a pink, lacy, slightly raised appearance.

Generally, the rash occurs near the end of the illness. It’s possible to mistake the rash for other viral rashes or a medicine-related rash. Infants and toddlers develop the same signs and symptoms as do school-age children. The rash may come and go for up to three weeks, becoming more visible when a child is exposed to extreme temperatures or spends time in the sun.

In adults
In adults, the most prominent symptom of parvovirus infection is joint soreness (arthralgia), lasting days to weeks. Joints most commonly affected are the hands, wrists, knees and ankles.

Asymptomatic parvovirus infection
Parvovirus infection can also occur without any signs or symptoms in either children or adults.

Causes

The human parvovirus B19 causes parvovirus infection. This isn’t the same as the parvovirus seen in dogs and cats, so you can’t get the infection from a pet or vice versa.

Parvovirus spreads from person to person, just like a cold, often through respiratory secretions and hand-to-hand contact. The illness is contagious in the week before the rash appears. Once the rash appears, the person with the illness is no longer considered contagious and doesn’t need to be isolated.

Parvovirus B19 is most common among elementary school-age children during outbreaks in the winter and spring months, but anyone can become ill with it anytime of the year.

When to seek medical advice

For your child
If your child develops what appear to be signs and symptoms of parvovirus infection, but you’re not sure, contact your doctor to see if there may be some other cause for the signs and symptoms. Also contact your doctor if your child has a temperature greater than 102 F (38.9 C) or if you have other concerns.

If you have anemia
If you have sickle cell disease or a similar type of chronic anemia, parvovirus infection can lead to severe anemia. See your doctor for treatment. Once the infection is under control, the anemia will get better.

If you’re pregnant
If you’re pregnant and you suspect you’ve been exposed to parvovirus, see your doctor. A pregnant woman with parvovirus infection may pass the illness along to her baby. Although the great majority of pregnant women who have parvovirus infection will deliver normal, healthy children, there’s a small risk to the unborn baby of severe and even life-threatening health conditions.

If your immune system is weak
Also, see your doctor for help with treatment if you have a weakened immune system, perhaps because of another preexisting disease, cancer treatment or an organ transplant.

Screening and diagnosis

If a rash is present, your doctor may be able to make a diagnosis by examination. About half of adults are immune to parvovirus infection, most likely because of a previous, unnoticed, childhood infection.

If you’re pregnant or if you’re an adult with a compromised immune system, blood tests can help determine if you’re immune to the infection or if you’ve recently become infected. The blood tests commonly used are tests for antibodies that are specific for parvovirus infection. Subsequent action depends on test results:

• If the blood tests indicate immunity, you don’t need to be concerned. You can’t be reinfected.
• If the tests confirm evidence of recent parvovirus infection, you may need additional testing to determine what, if any, complications — such as anemia — need treatment.
• If you’re pregnant and you have parvovirus infection, your doctor may perform additional tests, such as ultrasound and possibly additional blood tests, to watch for potential fetal complications.

Complications

Complications related to pregnancy
If you’re pregnant and you become infected with parvovirus B19, particularly during the first half of your pregnancy, there’s a chance your baby may develop serious complications, such as severe anemia. But this occurs in only a small percentage of infected pregnant women.

Fetal anemia can cause congestive heart failure in your baby, manifested by a severe form of edema — swelling of body tissues due to excessive fluid — called fetal hydrops, which may lead to miscarriage. If you have parvovirus infection, your doctor may monitor your pregnancy with ultrasound examinations for the possible development of fetal complications.

The fetal anemia, congestive heart failure and edema can improve over several weeks. Your doctor may suggest steps to try to correct these problems. Possible approaches include a blood transfusion directly to your fetus or giving you medications that pass through your placenta to your fetus.

Most pregnant women with parvovirus infection have normal, healthy babies. Parvovirus infection doesn’t increase the risk of birth defects or mental retardation.

Other complications in adults
Other complications in adults include the following:

• If you have sickle cell anemia or other types of anemia in which red blood cells are used up faster than your bone marrow can replace them, parvovirus infection can lead to severe anemia.
• If you have a weakened immune system, particularly if you’ve undergone chemotherapy, signs and symptoms of the infection can be severe, requiring medical care.

Treatment

For a noncomplicated parvovirus infection, sufficient parvovirus treatment generally consists of self-care steps at home. The rash itself doesn’t need treatment.

If you have severe anemia you may need to be hospitalized and receive blood transfusions. If you have a weakened immune system you may receive antibodies (via immune globulin) to treat your infection.

If you’re pregnant and develop parvovirus infection, your doctor may monitor possible effects on your baby. Treatments may include blood transfusions and medications if your baby has anemia, congestive heart failure or edema.

Prevention

There’s no vaccine to prevent parvovirus infection. Once you’ve become infected with parvovirus, you acquire lifelong immunity. Washing your hands and your child’s hands frequently may help diminish the chances of getting an infection. Throw away used tissues immediately after use — and wash your hands after handling them.

Self-care

Self-care treatment is aimed primarily at relieving signs and symptoms and easing any discomfort. Make sure you or your child gets plenty of rest and drinks lots of fluids. You can use acetaminophen (Tylenol, others) to relieve temperatures of more than 102 F (38.9 C) or minor aches and pains. Avoid giving aspirin to children. Aspirin may trigger a rare but potentially fatal disorder known as Reye’s syndrome.

It’s impractical and unnecessary to isolate your sick child. You won’t know your child has parvovirus infection until the rash appears, and by that time, your child is no longer contagious.

Introduction

A broken rib, or fractured rib, is a common injury that occurs when one of the bones in your rib cage breaks or cracks. The most common cause of broken ribs is trauma to the chest, such as from a fall, motor vehicle accident or impact during contact sports.

Signs and symptoms of a broken rib include pain, especially when taking a deep breath or pressing on the injured area.

In most cases, treatment of broken ribs is directed at controlling the pain until the fracture heals. Broken ribs usually heal in about one to two months.

Signs and symptoms

Signs and symptoms of a broken rib may include:

• Pain when you take a deep breath
• Pain that gets worse when you press on the injured area, or when you bend or twist your body

Causes

Broken ribs are a common injury, usually caused by trauma to the chest as during a fall, motor vehicle accident or impact during contact sports.

If you have a condition that weakens your bones — such as osteoporosis, a disease that causes you to lose bone density — it’s possible to break a rib with a milder strain, such as a strong coughing spell.

Risk factors

The following factors can increase your risk of breaking a rib:

• Osteoporosis. Having osteoporosis, a disease in which your bones lose their density, makes you more susceptible to a bone fracture.
• Age. Because older adults are more prone to osteoporosis and have less elastic ribs, they are at an increased risk of rib fracture.
• Sports participation. Participating in contact sports, such as hockey or football, increases your risk of trauma to your chest, which can result in a rib fracture.
• Cancerous lesion in a rib. A cancerous lesion can weaken the bone, making it more susceptible to breaks.

When to seek medical advice

See your doctor if you have pain in your rib area that occurs after trauma or is present with deep breaths or hinders your breathing.

If you experience pressure, fullness or a squeezing pain in the center of your chest that lasts for more than a few minutes, pain that extends beyond your chest to your shoulder or arm, and increasing episodes of chest pain, get medical attention immediately. These signs and symptoms may indicate a heart attack.

Screening and diagnosis

Your doctor may be able to diagnose a broken rib based on a medical history and physical examination. During the exam, your doctor will ask about your signs and symptoms and may press gently on your chest.

To confirm the diagnosis, you likely will undergo imaging tests, usually a chest X-ray or, on occasion, a computerized tomography (CT) scan.

Complications

When ribs break, the sharp edges can occasionally puncture your lung or surrounding tissue. This can cause blood (hemothorax) or air (pneumothorax) to accumulate in the space between your lungs and the walls of your chest. These conditions require immediate medical attention.

Treatment

Self-care measures, including rest and the use of ice for pain and swelling, are the best treatments for a broken rib.

Over-the-counter pain medications, including acetaminophen (Tylenol, others) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin, others), can help relieve discomfort as you wait for the fracture to heal. If the pain is severe, injections around the nerves that supply the ribs (nerve blocks) can be used.

Doctors rarely use compression wraps — elastic bandages that you can wrap around your chest — anymore to help “splint” and immobilize the area. Doctors typically don’t recommend compression wraps for broken ribs because compression wraps can keep you from taking deep breaths, which can increase the risk of lung infections (pneumonia).

Broken ribs usually heal completely in about one to two months.

Prevention

The following measures may help you prevent a broken rib:

• Protect yourself from athletic injuries. Wear protective equipment when playing contact sports.
• Take steps to decrease your risk of household falls. Remove clutter from your floors and clean spills promptly, use a rubber mat in the shower, keep your home well lit, and put skid-proof backing on carpets and area rugs.
• Decrease your chance of getting osteoporosis. Getting enough calcium in your diet is important for maintaining strong bones. Aim for about 1,200 milligrams of calcium daily from food and supplements.

Self-care

Self-care measures — including rest, over-the-counter pain medications and use of ice — are the best treatment for a broken rib. Avoid activities that aggravate the injury or cause more pain, such as:

• Vigorous coughing
• Pressing or putting pressure on your chest
• Bending or twisting your body, such as in sports like golf or bowling
• Contact sports, such as football or basketball