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Type 2 diabetes, once known as adult-onset or noninsulin-dependent diabetes, is a chronic condition that affects the way your body metabolizes sugar (glucose), your body’s important source of fuel.

With type 2 diabetes, your body either resists the effects of insulin — a hormone that regulates the movement of sugar into your cells — or doesn’t produce enough insulin to maintain a normal glucose level.

More common in adults, type 2 diabetes increasingly affects children as childhood obesity increases. There’s no cure for type 2 diabetes, but you may be able to manage the condition by eating well, exercising and maintaining a healthy weight. If diet and exercise aren’t enough to manage your blood sugar well, you also may need diabetes medications or insulin therapy.

Symptoms

Type 2 diabetes symptoms often develop slowly. In fact, you can have type 2 diabetes for years and not know it. Look for:

• Increased thirst and frequent urination. Excess sugar building up in your bloodstream causes fluid to be pulled from the tissues. This may leave you thirsty. As a result, you may drink — and urinate — more than usual.
• Increased hunger. Without enough insulin to move sugar into your cells, your muscles and organs become depleted of energy. This triggers intense hunger.
• Weight loss. Despite eating more than usual to relieve hunger, you may lose weight. Without the ability to metabolize glucose, the body uses alternative fuels stored in muscle and fat. Calories are lost as excess glucose is released in the urine.
• Fatigue. If your cells are deprived of sugar, you may become tired and irritable.
• Blurred vision. If your blood sugar is too high, fluid may be pulled from the lenses of your eyes. This may affect your ability to focus.
• Slow-healing sores or frequent infections. Type 2 diabetes affects your ability to heal and resist infections.
• Areas of darkened skin. Some people with type 2 diabetes have patches of dark, velvety skin in the folds and creases of their bodies — usually in the armpits and neck. This condition, called acanthosis nigricans, may be a sign of insulin resistance.

Causes

Type 2 diabetes develops when the body becomes resistant to insulin or when the pancreas stops producing enough insulin. Exactly why this happens is unknown, although genetics and environmental factors, such as excess weight and inactivity, seem to be contributing factors.

How insulin works

Insulin is a hormone that comes from the gland situated behind and below the stomach (pancreas).

• The pancreas secretes insulin into the bloodstream.
• The insulin circulates, enabling sugar to enter your cells.
• Insulin lowers the amount of sugar in your bloodstream.
• As your blood sugar level drops, so does the secretion of insulin from your pancreas.
  

  The role of glucose

  Glucose — a sugar — is a main source of energy for the cells that make up muscles and other tissues.

• Glucose comes from two major sources: food and your liver.
• Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin.
• Your liver stores and makes glucose.
• When your glucose levels are low, such as when you haven’t eaten in a while, the liver breaks down stored glycogen into glucose to keep your glucose level within a normal range.

In type 2 diabetes, this process doesn’t work well. Instead of moving into your cells, sugar builds up in your bloodstream. As blood sugar levels increase, the insulinproducing beta cells in the pancreas produce more insulin, but eventually these cells become impaired and can’t make enough insulin to meet the body’s demands.

In the much less common type 1 diabetes, the immune system destroys the beta cells, leaving the body with little to no insulin.

Treatments and drugs

Management of type 2 diabetes includes:

• Healthy eating
• Regular exercise
• Possibly, diabetes medication or insulin therapy
• Blood sugar monitoring

These steps will help keep your blood sugar level closer to normal, which can delay or prevent complications.

Healthy eating

Contrary to popular perception, there’s no specific diabetes diet. However, it’s important to center your diet on these high-fiber, low-fat foods:

• Fruits
• Vegetables
• Whole grains

You’ll also need to eat fewer animal products, refined carbohydrates and sweets.

Low glycemic index foods also may be helpful. The glycemic index is a measure of how quickly a food causes a rise in your blood sugar. Foods with a high glycemic index raise your blood sugar quickly. Low glycemic foods may help you achieve a more stable blood sugar. Foods with a low glycemic index typically are foods that are higher in fiber.

A registered dietitian can help you put together a meal plan that fits your health goals, food preferences and lifestyle. He or she can also teach you how to monitor your carbohydrate intake and let you know about how many carbohydrates you need to eat with your meals and snacks to keep your blood sugar levels more stable.

Physical activity

Everyone needs regular aerobic exercise, and people who have type 2 diabetes are no exception. Get your doctor’s OK before you start an exercise program. Then choose activities you enjoy, such as walking, swimming and biking. What’s most important is making physical activity part of your daily routine.

Aim for at least 30 minutes of aerobic exercise most days of the week. Stretching and strength training exercises are important, too. If you haven’t been active for a while, start slowly and build up gradually.

A combination of exercises — aerobic exercises, such as walking or dancing on most days, combined with resistance training, such as weightlifting or yoga twice a week — often helps control blood sugar more effectively than either type of exercise alone.

Remember that physical activity lowers blood sugar. Check your blood sugar level before any activity. You might need to eat a snack before exercising to help prevent low blood sugar if you take diabetes medications that lower your blood sugar.

Monitoring your blood sugar

Depending on your treatment plan, you may check and record your blood sugar level every now and then or, if you’re on insulin, multiple times a day. Ask your doctor how often he or she wants you to check your blood sugar. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range.

Sometimes, blood sugar levels can be unpredictable. With help from your diabetes treatment team, you’ll learn how your blood sugar level changes in response to food, exercise, alcohol, illness and medication.

Diabetes medications and insulin therapy

Some people who have type 2 diabetes can achieve their target blood sugar levels with diet and exercise alone, but many also need diabetes medications or insulin therapy. The decision about which medications are best depends on many factors, including your blood sugar level and any other health problems you have. Your doctor might even combine drugs from different classes to help you control your blood sugar in several different ways.

Examples of possible treatments for type 2 diabetes include:

• Metformin (Glucophage, Glumetza, others). Generally, metformin is the first medication prescribed for type 2 diabetes. It works by improving the sensitivity of your body tissues to insulin so that your body uses insulin more effectively. Metformin also lowers glucose production in the liver. Metformin usually won’t lower blood sugar enough on its own. Your doctor will also recommend lifestyle changes, such as losing weight and becoming more active. Nausea and diarrhea are possible side effects of metformin. These side effects usually go away as your body gets used to the medicine. If metformin and lifestyles changes aren’t enough to control your blood sugar level, other oral or injected medications can be added.
• Sulfonylureas. These medications help your body secrete more insulin. Examples of medications in this class include glyburide (DiaBeta, Glynase), glipizide (Glucotrol) and glimepiride (Amaryl). Possible side effects include low blood sugar and weight gain.
• Meglitinides. These medications work like sulfonylureas by encouraging the body to secrete more insulin, but they’re faster acting, and they don’t stay active in the body for as long. They also have a risk of causing low blood sugar, but not as much risk as sulfonylureas do. Weight gain is a possibility with this class of medications as well. Examples include repaglinide (Prandin) and nateglinide (Starlix).
• Thiazolidinediones. Like metformin, these medications make the body’s tissues more sensitive to insulin. This class of medications has been linked to weight gain and other more serious side effects, such as an increased risk of heart failure and fractures. Because of these risks, these medications generally aren’t a first-choice treatment.Rosiglitazone (Avandia) and pioglitazone (Actos) are examples of thiazolidinediones
• DPP-4 inhibitors. These medications help reduce blood sugar levels, but tend to have a modest effect. They don’t seem to cause weight gain. Examples of these medications are sitagliptin (Januvia), saxagliptin (Onglyza) and linagliptin (Tradjenta).
• GLP-1 receptor agonists. These medications slow digestion and help lower blood sugar levels, though not as much as sulfonylureas. This class of medications isn’t recommended for use alone. Exenatide (Byetta) and liraglutide (Victoza) are examples of GLP-1 receptor agonists. Possible side effects include nausea and an increased risk of pancreatitis.
• SGLT2 inhibitors. These are the newest diabetes drugs on the market. They work by preventing the kidneys from reabsorbing sugar in the blood. Instead, the sugar is excreted in the urine. Examples include canagliflozin (Invokana) and dapagliflozin (Farxiga). Side effects may include yeast infections and urinary tract infections.
• Insulin therapy. Some people who have type 2 diabetes need insulin therapy as well. In the past, insulin therapy was used as last resort, but today it’s often prescribed sooner because of its benefits. Because normal digestion interferes with insulin taken by mouth, insulin must be injected. Depending on your needs, your doctor may prescribe a mixture of insulin types to use throughout the day and night. Often, people with type 2 diabetes start insulin use with one long-acting shot at night. Insulin injections involve using a fine needle and syringe or an insulin pen injector — a device that looks similar to an ink pen, except the cartridge is filled with
  insulin.There are many types of insulin, and they each work in a different way. Options include:
  • Insulin glulisine (Apidra)
  • Insulin lispr
  • (Humalog)
  • Insulin aspart (Novolog)
  • Insulin glargine (Lantus)
  • Insulin detemir (Levemir)
  • Insulin isophane (Humulin N, Novolin N)

Discuss the pros and cons of different drugs with your doctor. Together you can decide which medication is best for you after considering many factors, including costs and other aspects of your health. In addition to diabetes medications, your doctor might prescribe low-dose aspirin therapy as well as blood pressure and cholesterol-lowering medications to help prevent heart and blood vessel disease.

Bariatric surgery

If you have type 2 diabetes and your body mass index (BMI) is greater than 35, you may be a candidate for weight-loss surgery (bariatric surgery). Blood sugar levels return to normal in 55 to 95 percent of people with diabetes, depending on the procedure performed. Surgeries that bypass a portion of the small intestine have more of an effect on blood sugar levels than do other weight-loss surgeries.

Drawbacks to the surgery include cost, and there are risks involved, including a risk of death. Additionally, drastic lifestyle changes are required and long-term complications may include nutritional deficiencies and osteoporosis.

Pregnancy

Women with type 2 diabetes may need to alter their treatment during pregnancy. Many women use insulin therapy during pregnancy. Cholesterol-lowering medications and some blood pressure drugs can’t be used during pregnancy.

If you have signs of diabetic retinopathy, it may worsen during pregnancy. Visit your ophthalmologist during the first trimester of your pregnancy and at one year postpartum.

Signs of trouble

Because so many factors can affect your blood sugar, problems sometimes arise that require immediate care, such as:

• High blood sugar (hyperglycemia). Your blood sugar level can rise for many reasons, including eating too much, being sick or not taking enough glucoselowering medication. Check your blood sugar level often, and watch for signs and symptoms of high blood sugar — frequent urination, increased thirst, dry mouth, blurred vision, fatigue and nausea. If you have hyperglycemia, you’ll need to adjust your meal plan, medications or both.
• Hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Signs and symptoms of this life-threatening condition include a blood sugar reading higher than 600 mg/dL (33.3 mmol/L), dry mouth, extreme thirst, fever greater than 101 F (38 C), drowsiness, confusion, vision loss, hallucinations and dark urine. Your blood sugar monitor may not be able to give you an exact reading at such high levels and may instead just read “high.”HHNS is caused by sky-high blood sugar that turns blood thick and syrupy. It tends to be more common in older people with type 2 diabetes, and it’s often preceded by an illness or infection. HHNS usually develops over days or weeks. Call your doctor or seek immediate medical care if you have signs or symptoms of this condition.
• Increased ketones in your urine (diabetic ketoacidosis). If your cells are starved for energy, your body may begin to break down fat. This produces toxic acids known as ketones. Watch for loss of appetite, weakness, vomiting, fever, stomach pain and fruitysmelling breath. You can check your urine for excess ketones with an over-thecounter ketones test kit. If you have excess ketones in your urine, consult your doctor right away or seek emergency care. This condition is more common in people with type 1 diabetes but can sometimes occur in people with type 2 diabetes.
• Low blood sugar (hypoglycemia). If your blood sugar level drops below your target range, it’s known as low blood sugar (hypoglycemia). Your blood sugar level can drop for many reasons, including skipping a meal or getting more physical activity than normal. Low blood sugar is most likely if you take glucose-lowering medications that promote the secretion of insulin or if you’re taking insulin.Check your blood sugar level regularly, and watch for signs and symptoms of low blood sugar — sweating, shakiness, weakness, hunger, dizziness, headache, blurred vision, heart palpitations, slurred speech, drowsiness, confusion and seizures.If you develop hypoglycemia during the night, you might wake with sweat-soaked pajamas or a headache. Due to a natural rebound effect, nighttime hypoglycemia might cause an unusually high blood sugar reading first thing in the morning.

  If you have signs or symptoms of low blood sugar, drink or eat something that will quickly raise your blood sugar level — fruit juice, glucose tablets, hard candy, regular (not diet) soda or another source of sugar. Retest in 15 minutes to be sure your blood glucose levels are normal.

  If they’re not, treat again and retest in another 15 minutes. If you lose consciousness, a family member or close contact may need to give you an emergency injection of a hormone that stimulates the release of sugar into the blood (glucagon).

Prevention

Healthy lifestyle choices can help you prevent type 2 diabetes. Even if you have diabetes in your family, diet and exercise can help you prevent the disease. If you’ve already received a diagnosis of diabetes, you can use healthy lifestyle choices to help prevent complications. And if you have prediabetes, lifestyle changes can slow or halt the progression from prediabetes to diabetes.

• Eat healthy foods. Choose foods lower in fat and calories and higher in fiber. Focus on fruits, vegetables and whole grains.
• Get physical. Aim for 30 minutes of moderate physical activity a day. Take a brisk daily walk. Ride a bike. Swim laps. If you can’t fit in a long workout, spread 10- minute or longer sessions throughout the day.
• Lose excess pounds. If you’re overweight, losing 7 percent of your body weight can reduce the risk of diabetes. To keep your weight in a healthy range, focus on permanent changes to your eating and exercise habits. Motivate yourself by remembering the benefits of losing weight, such as a healthier heart, more energy and improved self-esteem.

Sometimes medication is an option as well. Metformin (Glucophage, Glumetza, others), an oral diabetes medication, may reduce the risk of type 2 diabetes — but healthy lifestyle choices remain essential.

A stroke occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients. Within minutes, brain cells begin to die.

A stroke is a medical emergency. Prompt treatment is crucial. Early action can minimize brain damage and potential complications.

The good news is that strokes can be treated and prevented, and many fewer Americans die of stroke now than even 15 years ago.

Symptoms and causes

Symptoms

Watch for these signs and symptoms if you think you or someone else may be having a stroke. Note when your signs and symptoms begin, because the length of time they have been present may guide your treatment decisions:

• Trouble with speaking and understanding. You may experience confusion. You may slur your words or have difficulty understanding speech.
• Paralysis or numbness of the face, arm or leg. You may develop sudden numbness, weakness or paralysis in your face, arm or leg, especially on one side of your body. Try to raise both your arms over your head at the same time. If one arm begins to fall, you may be having a stroke. Similarly, one side of your mouth may droop when you try to smile.
• Trouble with seeing in one or both eyes. You may suddenly have blurred or blackened vision in one or both eyes, or you may see double.
• Headache. A sudden, severe headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you’re having a stroke.
• Trouble with walking. You may stumble or experience sudden dizziness, loss of balance or loss of coordination.

When to see a doctor Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem to fluctuate or disappear. Think “FAST” and do the following:

• Face. Ask the person to smile. Does one side of the face droop?
• Arms. Ask the person to raise both arms. Does one arm drift downward? Or is one arm unable to raise up?
• Speech. Ask the person to repeat a simple phrase. Is his or her speech slurred or strange?
• Time. If you observe any of these signs, call 911 immediately. Call 911 or your local emergency number right away. Don’t wait to see if symptoms go away. Every minute counts. The longer a stroke goes untreated, the greater the potential for brain damage and disability. If you’re with someone you suspect is having a stroke, watch the person carefully while waiting for emergency assistance.

Causes

A stroke occurs when the blood supply to your brain is interrupted or reduced. This deprives your brain of oxygen and nutrients, which can cause your brain cells to die.

A stroke may be caused by a blocked artery (ischemic stroke) or the leaking or bursting of a blood vessel (hemorrhagic stroke). Some people may experience only a temporary disruption of blood flow to their brain (transient ischemic attack, or TIA).

Ischemic stroke

About 85 percent of strokes are ischemic strokes. Ischemic strokes occur when the arteries to your brain become narrowed or blocked, causing severely reduced blood flow (ischemia). The most common ischemic strokes include:

• Thrombotic stroke. A thrombotic stroke occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to your brain. A clot may be caused by fatty deposits (plaque) that build up in arteries and cause reduced blood flow (atherosclerosis) or other artery conditions.
• Embolic stroke. An embolic stroke occurs when a blood clot or other debris forms away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of blood clot is called an embolus.

Hemorrhagic stroke

Hemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures. Brain hemorrhages can result from many conditions that affect your blood vessels, including uncontrolled high blood pressure (hypertension), overtreatment with anticoagulants and weak spots in your blood vessel walls (aneurysms). A less common cause of hemorrhage is the rupture of an abnormal tangle of thin-walled blood vessels (arteriovenous malformation) present at birth. Types of hemorrhagic stroke include:

• Intracerebral hemorrhage. In an intracerebral hemorrhage, a blood vessel in the brain bursts and spills into the surrounding brain tissue, damaging brain cells. Brain cells beyond the leak are deprived of blood and also damaged. High blood pressure, trauma, vascular malformations, use of blood-thinning medications and other conditions may cause an intracerebral hemorrhage.
• Subarachnoid hemorrhage. In a subarachnoid hemorrhage, an artery on or near the surface of your brain bursts and spills into the space between the surface of your brain and your skull. This bleeding is often signaled by a sudden, severe headache.A subarachnoid hemorrhage is commonly caused by the bursting of a small sack-shaped or berry-shaped outpouching on an artery known as an aneurysm. After the hemorrhage, the blood vessels in your brain may widen and narrow erratically (vasospasm), causing brain cell damage by further limiting blood flow.

Ischemic stroke

Ischemic stroke occurs when a blood clot blocks or plugs an artery leading to the brain. A blood clot often forms in arteries damaged by the buildup of plaques (atherosclerosis). It can occur in the carotid artery of the neck as well as other arteries.

Transient ischemic attack (TIA)

A transient ischemic attack (TIA) — also known as a ministroke — is a brief period of symptoms similar to those you’d have in a stroke. A temporary decrease in blood supply to part of your brain causes TIAs, which often last less than five minutes.

Like an ischemic stroke, a TIA occurs when a clot or debris blocks blood flow to part of your brain. A TIA doesn’t leave lasting symptoms because the blockage is temporary.

Seek emergency care even if your symptoms seem to clear up. Having a TIA puts you at greater risk of having a full-blown stroke, causing permanent damage later. If you’ve had a TIA, it means there’s likely a partially blocked or narrowed artery leading to your brain or a clot source in the heart.

It’s not possible to tell if you’re having a stroke or a TIA based only on your symptoms. Up to half of people whose symptoms appear to go away actually have had a stroke causing brain damage.

Complications

A stroke can sometimes cause temporary or permanent disabilities, depending on how long the brain lacks blood flow and which part was affected. Complications may include:

• Paralysis or loss of muscle movement. You may become paralyzed on one side of your body, or lose control of certain muscles, such as those on one side of your face or one arm. Physical therapy may help you return to activities hampered by paralysis, such as walking, eating and dressing.
• Difficulty talking or swallowing. A stroke may cause you to have less control over the way the muscles in your mouth and throat move, making it difficult for you to talk clearly (dysarthria), swallow or eat (dysphagia). You also may have difficulty with language (aphasia), including speaking or understanding speech, reading or writing. Therapy with a speech and language pathologist may help.
• Memory loss or thinking difficulties. Many people who have had strokes experience some memory loss. Others may have difficulty thinking, making judgments, reasoning and understanding concepts.
• Emotional problems. People who have had strokes may have more difficulty controlling their emotions, or they may develop depression.
• Pain. People who have had strokes may have pain, numbness or other strange sensations in parts of their bodies affected by stroke. For example, if a stroke causes you to lose feeling in your left arm, you may develop an uncomfortable tingling sensation in that arm. People also may be sensitive to temperature changes, especially extreme cold after a stroke. This complication is known as central stroke pain or central pain syndrome. This condition generally develops several weeks after a stroke, and it may improve over time. But because the pain is caused by a problem in your brain, rather than a physical injury, there are few treatments.
• Changes in behavior and self-care ability. People who have had strokes may become more withdrawn and less social or more impulsive. They may need help with grooming and daily chores.

As with any brain injury, the success of treating these complications will vary from person to person.

Treatment

Emergency treatment for stroke depends on whether you’re having an ischemic stroke blocking an artery — the most common kind — or a hemorrhagic stroke that involves bleeding into the brain.

Ischemic stroke

To treat an ischemic stroke, doctors must quickly restore blood flow to your brain. Emergency treatment with medications. Therapy with clot-busting drugs must start with
Emergency treatment with medications. Therapy with clot-busting drugs must start within 3 hours if they are given into the vein — and the sooner, the better. Quick treatment not only improves your chances of survival but also may reduce complications. You may be given:

• Aspirin. Aspirin is an immediate treatment given in the emergency room to reduce the likelihood of having another stroke. Aspirin prevents blood clots from forming.
• Intravenous injection of tissue plasminogen activator (TPA). Some people can benefit from an injection of a recombinant tissue plasminogen activator (TPA), also called alteplase. An injection of TPA is usually given through a vein in the arm. This potent clot-busting drug needs to be given within 4.5 hours after stroke symptoms begin if it’s given in the vein. TPA restores blood flow by dissolving the blood clot causing your stroke, and it may help people who have had strokes recover more fully. Your doctor will consider certain risks, such as potential bleeding in the brain, to determine if TPA is appropriate for you.

Emergency procedures. Doctors sometimes treat ischemic strokes with procedures that must be performed as soon as possible, depending on features of the blood clot:

• Medications delivered directly to the brain. Doctors may insert a long, thin tube (catheter) through an artery in your groin and thread it to your brain to deliver TPA directly into the area where the stroke is occurring. The time window for this treatment is somewhat longer than for intravenous TPA but is still limited.
• Mechanical clot removal. Doctors may use a catheter to maneuver a tiny device into your brain to physically break up or grab and remove the clot.

However, recent studies suggest that for most people, delivering medication directly to the brain (intra-arterial thrombolysis) or using a device to break up or remove clots (mechanical thrombectomy) may not be beneficial. Researchers are working to determine who might benefit from this procedure.

Other procedures. To decrease your risk of having another stroke or transient ischemic attack, your doctor may recommend a procedure to open up an artery that’s narrowed by fatty deposits (plaques). Doctors sometimes recommend the following procedures to prevent a stroke. Options will vary depending on your situation:

• Carotid endarterectomy. In a carotid endarterectomy, a surgeon removes plaques from arteries that run along each side of your neck to your brain (carotid arteries). In this procedure, your surgeon makes an incision along the front of your neck, opens your carotid artery and removes plaques that block the carotid artery. Your surgeon then repairs the artery with stitches or a patch made from a vein or artificial material (graft). The procedure may reduce your risk of ischemic stroke. However, a carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.
• Angioplasty and stents. In an angioplasty, a surgeon gains access to your carotid arteries most often through an artery in your groin. Here, he or she can gently and safely navigate to the carotid arteries in your neck. A balloon is then used to expand the narrowed artery. Then a stent can be inserted to support the opened artery.

Hemorrhagic stroke

Emergency treatment of hemorrhagic stroke focuses on controlling your bleeding and reducing pressure in your brain. Surgery also may be performed to help reduce future risk.
Emergency measures. If you take warfarin (Coumadin) or anti-platelet drugs such as clopidogrel (Plavix) to prevent blood clots, you may be given drugs or transfusions of blood products to counteract the blood thinners’ effects. You may also be given drugs to lower pressure in your brain (intracranial pressure), lower your blood pressure, prevent vasospasm or prevent seizures.

Once the bleeding in your brain stops, treatment usually involves supportive medical care while your body absorbs the blood. Healing is similar to what happens while a bad bruise goes away. If the area of bleeding is large, your doctor may perform surgery to remove the blood and relieve pressure on your brain.

Surgical blood vessel repair. Surgery may be used to repair blood vessel abnormalities associated with hemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if an aneurysm or arteriovenous malformation (AVM) or other type of vascular malformation caused your hemorrhagic stroke:

• Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm, to stop blood flow to it. This clamp can keep the aneurysm from bursting, or it can prevent rebleeding of an aneurysm that has recently hemorrhaged.
• Coiling (endovascular embolization). In this procedure, a surgeon inserts a catheter into an artery in your groin and guides it to your brain using X-ray imaging. Your surgeon then guides tiny detachable coils into the aneurysm (aneurysm coiling). The coils fill the aneurysm, which blocks blood flow into the aneurysm and causes the blood to clot.
• Surgical AVM removal. Surgeons may remove a smaller AVM if it’s located in an accessible area of your brain, to eliminate the risk of rupture and lower the risk of hemorrhagic stroke. However, it’s not always possible to remove an AVM if its removal would cause too large a reduction in brain function, or if it’s large or located deep within your brain.
• Intracranial bypass. In some unique circumstances, surgical bypass of intracranial blood vessels may be an option to treat poor blood flow to a region of the brain or complex vascular lesions, such as aneurysm repair.
• Stereotactic radiosurgery. Using multiple beams of highly focused radiation, stereotactic radiosurgery is an advanced minimally invasive treatment used to repair vascular malformations.

Stroke recovery and rehabilitation

Brain hemisphere connections

Following emergency treatment, stroke care focuses on helping you regain your strength, recover as much function as possible and return to independent living. The impact of your stroke depends on the area of the brain involved and the amount of tissue damaged.

If your stroke affected the right side of your brain, your movement and sensation on the left side of your body may be affected. If your stroke damaged the brain tissue on the left side of your brain, your movement and sensation on the right side of your body may be affected. Brain damage to the left side of your brain may cause speech and language disorders.

In addition, if you’ve had a stroke, you may have problems with breathing, swallowing, balancing and vision.

Most stroke survivors receive treatment in a rehabilitation program. Your doctor will recommend the most rigorous therapy program you can handle based on your age, overall health and your degree of disability from your stroke. Your doctor will take into consideration your lifestyle, interests and priorities, and the availability of family members or other caregivers.

Your rehabilitation program may begin before you leave the hospital. It may continue in a rehabilitation unit of the same hospital, another rehabilitation unit or skilled nursing facility, an outpatient unit, or your home.

Every person’s stroke recovery is different. Depending on your condition, your treatment team may include:

Speech therapy session

• Doctor trained in brain conditions (neurologist)
• Rehabilitation doctor (physiatrist)
• Nurse
• Dietitian
• Physical therapist
• Occupational therapist
• Recreational therapist
• Speech therapist
• Social worker
• Case manager
• Psychologist or psychiatrist
• Chaplain

Prevention

Knowing your stroke risk factors, following your doctor’s recommendations and adopting a healthy lifestyle are the best steps you can take to prevent a stroke. If you’ve had a stroke or a transient ischemic attack (TIA), these measures may help you avoid having another stroke. The follow-up care you receive in the hospital and afterward may play a role as well. Many stroke prevention strategies are the same as strategies to prevent heart disease. In general, healthy lifestyle recommendations include:

• Controlling high blood pressure (hypertension). One of the most important things you can do to reduce your stroke risk is to keep your blood pressure under control. If you’ve had a stroke, lowering your blood pressure can help prevent a subsequent transient ischemic attack or stroke. Exercising, managing stress, maintaining a healthy weight, and limiting the amount of sodium and alcohol you eat and drink are all ways to keep high blood pressure in check.. In addition to recommending lifestyle changes, your doctor may prescribe medications to treat high blood pressure.
  Lowering the amount of cholesterol and saturated fat in your diet. Eating less cholesterol and fat, especially saturated fat and trans fats, may reduce the fatty deposits (plaques) in your arteries. If you can’t control your cholesterol through dietary changes alone, your doctor may prescribe a cholesterol-lowering medication.
• Quitting tobacco use. Smoking raises the risk of stroke for smokers and nonsmokers exposed to secondhand smoke. Quitting tobacco use reduces your risk of stroke.
• Controlling diabetes. You can manage diabetes with diet, exercise, weight control and medication.
• Maintaining a healthy weight. Being overweight contributes to other stroke risk factors, such as high blood pressure, cardiovascular disease and diabetes. Weight loss of as little as 10 pounds may lower your blood pressure and improve your cholesterol levels.
• Eating a diet rich in fruits and vegetables. A diet containing five or more daily servings of fruits or vegetables may reduce your risk of stroke. Following the Mediterranean diet, which emphasizes olive oil, fruit, nuts, vegetables and whole grains, may be helpful.
• Exercising regularly. Aerobic or “cardio” exercise reduces your risk of stroke in many ways. Exercise can lower your blood pressure, increase your level of high-density lipoprotein cholesterol, and improve the overall health of your blood vessels and heart. It also helps you lose weight, control diabetes and reduce stress. Gradually work up to 30 minutes of activity — such as walking, jogging, swimming or bicycling — on most, if not all, days of the week.
• Drinking alcohol in moderation, if at all. Alcohol can be both a risk factor and a protective measure for stroke. Heavy alcohol consumption increases your risk of high blood pressure, ischemic strokes and hemorrhagic strokes. However, drinking small to moderate amounts of alcohol, such as one drink a day, may help prevent ischemic stroke and decrease your blood’s clotting tendency. Alcohol may also interact with other drugs you’re taking. Talk to your doctor about what’s appropriate for you.
• Treating obstructive sleep apnea, if present. Your doctor may recommend an overnight oxygen assessment to screen for obstructive sleep apnea (OSA). If OSA is detected, it may be treated by giving you oxygen at night or having you wear a small device in your mouth.
• Avoiding illicit drugs. Certain street drugs, such as cocaine and methamphetamines, are established risk factors for a TIA or a stroke. Cocaine reduces blood flow and can cause narrowing of arteries

Preventive medications
If you’ve had an ischemic stroke or TIA, your doctor may recommend medications to help reduce your risk of having another stroke. These include:

• Anti-platelet drugs. Platelets are cells in your blood that initiate clots. Anti-platelet drugs make these cells less sticky and less likely to clot. The most commonly used antiplatelet medication is aspirin. Your doctor can help you determine the right dose of aspirin for you. Your doctor may also consider prescribing Aggrenox, a combination of low-dose aspirin and the anti-platelet drug dipyridamole, to reduce the risk of blood clotting. If aspirin doesn’t prevent your TIA or stroke, or if you can’t take aspirin, your doctor may instead prescribe an anti-platelet drug such as clopidogrel (Plavix).
• Anticoagulants. These drugs, which include heparin and warfarin (Coumadin), reduce blood clotting. Heparin is fast-acting and may be used over a short period of time in the hospital. Slower acting warfarin may be used over a longer term. Warfarin is a powerful blood-thinning drug, so you’ll need to take it exactly as directed and watch for side effects. Your doctor may prescribe these drugs if you have certain blood-clotting disorders, certain arterial abnormalities, an abnormal heart rhythm or other heart problems. Other newer blood thinners may be used if your TIA or stroke was caused by an abnormal heart rhythm.

Osteoporosis causes bones to become weak and brittle — so brittle that a fall or even mild stresses like bending over or coughing can cause a fracture. Osteoporosis-related fractures most commonly occur in the hip, wrist or spine.

Bone is living tissue that is constantly being broken down and replaced. Osteoporosis occurs when the creation of new bone doesn’t keep up with the removal of old bone.

Osteoporosis affects men and women of all races. But white and Asian women — especially older women who are past menopause — are at highest risk. Medications, healthy diet and weight-bearing exercise can help prevent bone loss or strengthen already weak bones.

Symptoms

There typically are no symptoms in the early stages of bone loss. But once bones have been weakened by osteoporosis, you may have signs and symptoms that include:

• Back pain, caused by a fractured or collapsed vertebra
• Loss of height over time
• A stooped posture
• A bone fracture that occurs much more easily than expected

Causes

Your bones are in a constant state of renewal — new bone is made and old bone is broken down. When you’re young, your body makes new bone faster than it breaks down old bone and your bone mass increases. Most people reach their peak bone mass by their early 20s. As people age, bone mass is lost faster than it’s created.

How likely you are to develop osteoporosis depends partly on how much bone mass you attained in your youth. The higher your peak bone mass, the more bone you have “in the bank” and the less likely you are to develop osteoporosis as you age.

Treatments and drugs

For both men and women at increased risk of fracture, the most widely prescribed osteoporosis medications are bisphosphonates. Examples include:

• Alendronate (Fosamax)
• Risedronate (Actonel, Atelvia)
• Ibandronate (Boniva)
• Zoledronic acid (Reclast)

Side effects include nausea, abdominal pain, difficulty swallowing, and the risk of an inflamed esophagus or esophageal ulcers. These are less likely to occur if the medicine is taken properly. Intravenous forms of bisphosphonates don’t cause stomach upset. And it may be easier to schedule a quarterly or yearly injection than to remember to take a weekly or monthly pill, but it can be more costly to do so.

Using bisphosphonate therapy for more than five years has been linked to a rare problem in which the middle of the thighbone cracks and might even break completely. Bisphosphonates also have the potential to affect the jawbone. Osteonecrosis of the jaw is a rare condition that can occur after a tooth extraction in which a section of jawbone dies and deteriorates. You should have a recent dental examination before starting bisphosphonates.

Hormone-related therapy

Estrogen, especially when started soon after menopause, can help maintain bone density. However, estrogen therapy can increase a woman’s risk of blood clots, endometrial cancer, breast cancer and possibly heart disease. Therefore, estrogen is typically used for bone health only if menopausal symptoms also require treatment.

Raloxifene (Evista) mimics estrogen’s beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen. Taking this drug may also reduce the risk of some types of breast cancer. Hot flashes are a common side effect. Raloxifene also may increase your risk of blood clots.

In men, osteoporosis may be linked with a gradual age-related decline in testosterone levels. Testosterone replacement therapy can help increase bone density, but osteoporosis medications have been better studied in men with osteoporosis and are recommended alone or in addition to testosterone.

Other osteoporosis medications

If you can’t tolerate the more common treatments for osteoporosis — or if they don’t work well enough — your doctor might suggest trying:

• Denosumab (Prolia). Compared with bisphosphonates, denosumab produces similar or better bone density results and reduces the chance of all types of fractures. Denosumab is delivered via a shot under the skin every six months. The most common side effects are back and muscle pain.
• Teriparatide (Forteo). This powerful drug is similar to parathyroid hormone and stimulates new bone growth. It’s given by injection under the skin. After two years of treatment with teriparatide, another osteoporosis drug is taken to maintain the new bone growth. This drug is reserved for patients with severe osteoporosis.

Prevention

Three factors essential for keeping your bones healthy throughout your life are:

• Adequate amounts of calcium
• Adequate amounts of vitamin D
• Regular exercise
  

  Calcium

  Men and women between the ages of 18 and 50 need 1,000 milligrams of calcium a day. This daily amount increases to 1,200 milligrams when women turn 50 and men turn 70. Good sources of calcium include:

• Low-fat dairy products (200 to 300 milligrams per serving)
• Dark green leafy vegetables
• Canned salmon or sardines with bones
• Soy products, such as tofu
• Calcium-fortified cereals and orange juice If you find it difficult to get enough calcium from your diet, consider taking calcium supplements. However, too much calcium has been linked to heart problems and kidney stones. The Institute of Medicine recommends that total calcium intake, from supplements and diet combined, should be no more than 2,000 milligrams daily for people older than 50.

Vitamin D

Vitamin D improves your body’s ability to absorb calcium. Many people get adequate amounts of vitamin D from sunlight, but this may not be a good source if you live in high latitudes, if you’re housebound, or if you regularly use sunscreen or avoid the sun entirely because of the risk of skin cancer.

Scientists don’t yet know the optimal daily dose of vitamin D. A good starting point for adults is 600 to 800 international units (IU) a day, through food or supplements. If your blood levels of vitamin D are low, your doctor may suggest higher doses. Teens and adults can safely take up to 4,000 international units (IU) a day.

Exercise

Exercise can help you build strong bones and slow bone loss. Exercise will benefit your bones no matter when you start, but you’ll gain the most benefits if you start exercising regularly when you’re young and continue to exercise throughout your life.

Combine strength training exercises with weight-bearing exercises. Strength training helps strengthen muscles and bones in your arms and upper spine, and weight-bearing exercises — such as walking, jogging, running, stair climbing, skipping rope, skiing and impact-producing sports — affect mainly the bones in your legs, hips and lower spine.

Swimming, cycling and exercising on machines such as elliptical trainers can provide a good cardiovascular workout, but because such exercises are low impact, they’re not as helpful for improving bone health as weight-bearing exercises are. There is evidence that competitive cyclists have reduced bone mineral density. They should combine strength training and weight-bearing exercises and consider a test for osteoporosis.

Osteoarthritis is the most common form of arthritis, affecting millions of people worldwide. It occurs when the protective cartilage on the ends of your bones wears down over time.

Although osteoarthritis can damage any joint in your body, the disorder most commonly affects joints in your hands, knees, hips and spine.

Osteoarthritis often gradually worsens, and no cure exists. But staying active, maintaining a healthy weight and other treatments may slow progression of the disease and help improve pain and joint function.

Symptoms

Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of osteoarthritis include:

• Pain. Your joint may hurt during or after movement.
• Tenderness. Your joint may feel tender when you apply light pressure to it.
• Stiffness. Joint stiffness may be most noticeable when you wake up in the morning or after a period of inactivity.
• Loss of flexibility. You may not be able to move your joint through its full range of motion.
• Grating sensation. You may hear or feel a grating sensation when you use the joint.
• Bone spurs. These extra bits of bone, which feel like hard lumps, may form around the affected joint.

Causes

Osteoarthritis occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates. Cartilage is a firm, slippery tissue that permits nearly frictionless joint motion. In osteoarthritis, the slick surface of the cartilage becomes rough. Eventually, if the cartilage wears down completely, you may be left with bone rubbing on bone.

Treatments and drugs

There’s no known cure for osteoarthritis, but treatments can help reduce pain and maintain joint movement.

Medications

Osteoarthritis symptoms may be helped by certain medications, including:

• Acetaminophen. Acetaminophen (Tylenol, others) can relieve pain, but it doesn’t reduce inflammation. It has been shown to be effective for people with osteoarthritis who have mild to moderate pain. Taking more than the recommended dosage of acetaminophen can cause liver damage.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs may reduce inflammation and relieve pain. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve, others). Stronger NSAIDs are available by prescription. NSAIDs can cause stomach upset, ringing in your ears, cardiovascular problems, bleeding problems, and liver and kidney damage. They should not be used by people over 65 years of age and those who have stomach bleeding. Topical NSAIDS have fewer side effects and may relieve pain just as well.

Therapy

Exercising and achieving a healthy weight are the best and most important ways to treat osteoarthritis. Your doctor also may suggest:

• Physical therapy. A physical therapist can work with you to create an individualized exercise program that will strengthen the muscles around your joint, increase your range of motion and reduce pain.
• Occupational therapy. An occupational therapist can help you discover ways to do everyday tasks or do your job without putting extra stress on your already painful joint. For instance, a toothbrush with a large grip could make brushing your teeth easier if you have finger osteoarthritis. A bench in your shower could help relieve the pain of standing if you have knee osteoarthritis.
• Braces or shoe inserts. Your doctor may recommend shoe inserts or other devices that can help reduce pain when you stand or walk. These devices can immobilize or support your joint to help take pressure off it.
• A chronic pain class. The Arthritis Foundation and some medical centers have classes for people with osteoarthritis and chronic pain. Ask your doctor about classes in your area or check with the Arthritis Foundation. These classes teach skills that help you manage your osteoarthritis pain. And you’ll meet other people with osteoarthritis and learn their tips and tricks for reducing and coping with joint pain.

Surgical and other procedures

If conservative treatments don’t help, you may want to consider procedures such as:

• Cortisone shots. Injections of corticosteroid medications may relieve pain in your joint. During this procedure your doctor numbs the area around your joint, then places a needle into the space within your joint and injects medication. The number of cortisone shots you can receive each year is limited, because the medication can worsen joint damage over time.
• Lubrication injections. Injections of hyaluronic acid may offer pain relief by providing some cushioning in your knee. Hyaluronic acid is similar to a component normally found in your joint fluid.
• Realigning bones. During a surgical procedure called an osteotomy, the surgeon cuts across the bone either above or below the knee to realign the leg. Osteotomy can reduce knee pain by shifting your body weight away from the worn-out part of your knee.
• Joint replacement. In joint replacement surgery (arthroplasty), your surgeon removes your damaged joint surfaces and replaces them with plastic and metal parts. The hip and knee joints are those most commonly replaced. Surgical risks include infections and blood clots. Artificial joints can wear out or come loose and may need to eventually be replaced. Repeat joint replacements are more challenging and less successful than the original surgery.

Nicotine dependence — also called tobacco dependence — is an addiction to tobacco products caused by the drug nicotine. Nicotine dependence means you can’t stop using the substance, even though it’s causing you harm.

Nicotine produces physical and mood-altering effects in your brain that are temporarily pleasing. These effects make you want to use tobacco and lead to dependence. At the same time, stopping tobacco use causes withdrawal symptoms, including irritability and anxiety.

While it’s the nicotine in tobacco that causes nicotine dependence, the toxic effects of tobacco result from other substances in tobacco. Smokers have much higher rates of heart disease, stroke and cancer than nonsmokers do.

Regardless of how long you’ve smoked, stopping smoking can improve your health. Many effective treatments for nicotine dependence are available to help you manage withdrawal and stop smoking for good. Ask your doctor for help

Symptoms

In some people, using any amount of tobacco can quickly lead to nicotine dependence. Signs that you may be addicted include:

• You can’t stop smoking. You’ve made one or more serious, but unsuccessful, attempts to stop.
• You experience withdrawal symptoms when you try to stop. Your attempts at stopping have caused physical and mood-related signs and symptoms, such as strong cravings, anxiety, irritability, restlessness, difficulty concentrating, depressed mood, frustration, anger, increased hunger, insomnia, constipation or diarrhea.
• You keep smoking despite health problems. Even though you’ve developed problems with your lungs or your heart, you haven’t been able to stop.
• You give up social or recreational activities in order to smoke. You may stop going to smoke-free restaurants or stop socializing with certain family members or friends because you can’t smoke in these locations or situations.

Causes

Nicotine is the chemical in tobacco that keeps you smoking. Nicotine is very addictive when delivered to the lungs by inhaling tobacco smoke. It increases the release of brain chemicals called neurotransmitters, which help regulate mood and behavior. One of these neurotransmitters is dopamine, which may improve your mood and activate feelings of pleasure. Experiencing these effects from nicotine in tobacco is what makes tobacco so addictive. Nicotine dependence involves behavioral as well as physical factors. Behaviors and cues that you may associate with smoking include:

• Certain times of the day, such as first thing in the morning, with morning coffee or during breaks at work
• After a meal
• Drinking alcohol
• Certain places or friends
• Talking on the phone
• Stressful situations or when you’re feeling down
• Sight or smell of a burning cigarette
• Driving your car

To overcome your dependence on tobacco, you need to deal with the behaviors and routines that you associate with smoking.

Treatments and drugs

Smoking is the single most preventable cause of death in the U.S. Your health will benefit almost immediately if you stop smoking. Younger smokers who stop can have a normal life expectancy, and even older smokers who stop add years and quality to their life expectancy.

According to a report of the Surgeon General, a year after quitting, your risk of a heart attack drops sharply. After two to five years, your stroke risk may be reduced to that of a nonsmoker. And at 10 years, your risk of cancer may be reduced to about half that of a smoker.

Like most smokers, you’ve probably made at least one serious attempt to stop. But it’s rare to stop smoking on your first attempt — especially if you try to do it without help. You’re much more likely to stop if you use medications and counseling, which have both been proved effective, especially in combination.

Medications

Many treatments, including nicotine replacement therapy and non-nicotine medications, have been approved as safe and effective in treating nicotine dependence. Using more than one medication may help you get better results. For example, combining a longer acting medication with a short-acting nicotine replacement product may be beneficial. Talk to your health care provider about the right treatment for you.

If you’re pregnant or breast-feeding, you smoke fewer than 10 cigarettes a day, or you’re under age 18, talk to your doctor before taking any over-the-counter nicotine replacement products.

Nicotine replacement therapy

Nicotine replacement therapy gives you nicotine without the other harmful chemicals in tobacco smoke. Many people mistakenly believe that nicotine causes cancer, but that’s not the case.

Nicotine replacement medications, including patches, gum, lozenges, nasal spray and inhaler, can help relieve difficult withdrawal symptoms and cravings. The best time to start using nicotine replacement medication is on the date you’ve set to stop smoking. Some smokers start earlier in order to reduce smoking on their way to stopping altogether.

Most nicotine replacement products are available over-the-counter:

• Nicotine patch (NicoDerm CQ, Habitrol, others). The patch delivers nicotine through your skin and into your bloodstream. You wear a new patch each day. The treatment period usually lasts for eight weeks or longer. If you haven’t been able to stop smoking completely after two weeks or so of treatment, ask your doctor for help in adjusting the dose of the patch or adding another medication.
• Nicotine gum (Nicorette, others). This gum delivers nicotine to your blood through the lining of your mouth. It’s available in a 2-milligram (mg) dose for regular smokers and a 4-mg dose for heavy smokers. Nicotine gum is often recommended to curb cravings. Chew the gum for a few times until you feel a mild tingling or peppery taste, then park the gum between your cheek and gumline for several minutes. This chewing and parking allows nicotine to be gradually absorbed in your bloodstream. Avoid drinking or eating right before, while using, or right after nicotine gum. The goal is to reduce the amount and eliminate the need for the gum in about three months.
• Nicotine lozenge (Commit, Nicorette mini lozenge). This lozenge dissolves in your mouth and, like nicotine gum, delivers nicotine through the lining of your mouth. The lozenges are available in a 2-mg dose for regular smokers and a 4-mg dose for heavy smokers. Place the lozenge in your mouth between your gumline and cheek or under your tongue and allow it to dissolve. You’ll start with one lozenge every one to two hours and gradually increase the time between lozenges. Avoid drinking anything right before, while using or right after the lozenge.

These nicotine replacement products are available by prescription:

• Nicotine nasal spray (Nicotrol NS). The nicotine in this product, sprayed directly into each nostril, is absorbed through your nasal membranes into your blood vessels. The nasal spray delivers nicotine a bit quicker than gum, lozenges or the patch, but not as rapidly as smoking a cigarette. It’s usually prescribed for threemonth periods for up to six months. Side effects may include nasal irritation.
• Nicotine inhaler (Nicotrol). This device is shaped something like a cigarette holder. You puff on it, and it delivers nicotine vapor into your mouth. You absorb the nicotine through the lining in your mouth, where it then enters your bloodstream. Common side effects are mouth or throat irritation and occasional coughing.

Non-nicotine medications

Medications that don’t contain nicotine include:

• Bupropion (Zyban, Wellbutrin). The antidepressant drug bupropion increases levels of dopamine and norepinephrine, brain chemicals that are also boosted by nicotine. Bupropion may be prescribed along with a nicotine patch. Typically your doctor will advise you to start bupropion one week before you stop smoking. Bupropion has the advantage of helping to minimize weight gain after you quit smoking. Side effects may include sleep disturbance and dry mouth. If you have a history of seizures or serious head trauma, such as a skull fracture, you shouldn’t take this drug.
• Varenicline (Chantix). This medication acts on the brain’s nicotine receptors, decreasing withdrawal symptoms and reducing the feelings of pleasure you get from smoking. Typically your doctor will advise you to start varenicline one week before you stop smoking. Potential side effects include nausea, headache, insomnia and vivid dreams. Rarely, varenicline has been associated with serious psychiatric symptoms, such as depressed mood, agitation and suicidal thoughts.
• Nortriptyline (Pamelor). This tricyclic antidepressant has been shown to help smokers stop. It acts by increasing the levels of the brain neurotransmitter norepinephrine. It may be prescribed if other medications for stopping tobacco use don’t help. Side effects may include dry mouth.

Counseling, support groups and other programs

Combining medications with behavioral counseling provides the best chance for establishing long-term smoking abstinence. Medications help you cope with withdrawal symptoms, while behavioral treatments help you develop the skills you need to avoid tobacco over the long run. The more time you spend with a counselor, the better your treatment results will be.

Several types of counseling and support can help with stopping smoking:

• Telephone counseling. No matter where you live, you can take advantage of phone counseling to help you give up tobacco. Every state in the U.S. has a telephone quit line, and some have more than one. To find the options in your state, call 800-QUIT-NOW (800-784-8669).
• Individual or group counseling program. Your doctor may recommend local support groups or a treatment program where counseling is provided by a tobacco treatment specialist. Counseling helps you learn techniques for preparing to stop smoking and provides support for you during the process. Many hospitals, health care plans, health care providers and employers offer treatment programs or have tobacco treatment specialists who are certified to provide treatment for nicotine dependence. Nicotine Anonymous groups are available in many locations to provide support for smokers trying to quit. Some medical centers provide residential treatment programs — the most intensive treatment available.
• Internet-based programs. Several websites offer support and strategies for people who want to stop smoking. BecomeAnEX is free and provides information and techniques as well as blogs, community forums, ask the expert and many other features. Text messaging services, including personalized reminders about a quitsmoking plan, also may prove helpful.

Methods to avoid

There is no scientific evidence that these products work to help stop smoking and little is known about their safety.

• Products claiming to deter smoking. This includes products that change the taste of tobacco, special diets to curb nicotine cravings and vitamin combinations marketed as smoking cessation aids.
• Herbs and supplements. Homeopathic aids and herbal supplements are not regulated by the Food and Drug Administration (FDA), so they don’t need to prove their effectiveness or safety.
• Nicotine lollipops and balms. Products containing nicotine salicylate are not approved by the FDA, and these products pose a risk for accidental use by children.
• Electronic cigarettes (e-cigarettes). Flavored mist containing nicotine that looks like smoke is puffed through a system that looks like a cigarette. Questions exist about the safety of e-cigarette vapor and the amount of nicotine provided.
• Hypnosis. Although no evidence supports the use of hypnosis in smoking cessation, some people say they find it helpful. If you choose to pursue hypnosis, talk to your doctor about finding a reputable hypnotherapist.

Tobacco in any form is not safe. This includes the use of:

• Dissolvable tobacco products. Tobacco pouches, lozenges, strips or other products contain small amounts of tobacco and nicotine you hold or dissolve in your mouth. These tobacco products are used by smokers in places where smoking is not allowed. There is no evidence they will help you stop smoking and little is known about their health effects.
• Smokeless tobacco and snuff (snus). These products contain nicotine in amounts similar to cigarettes and increase your risk of mouth and throat cancer, tooth and gum diseases, and other health problems.
• Pipes and cigars. These products have similar, though less frequent, health risks as cigarettes, and they are not a safe alternative.
• Hookahs (narghiles). These are water pipes that burn tobacco, and the smoke is inhaled through a hose. They are not safer than cigarettes. The water does not filter out toxins in the smoke, and the water and pipe have a risk of transmitting infections.
• Flavored cigarettes. Clove cigarettes (kreteks) and flavored cigarettes (bidis) carry the same health risks as smoking regular cigarettes and can cause additional health problems. Although they’re not legal in the United States, they’re still available in some countries.

Prevention

The best way to prevent tobacco dependence is to not smoke in the first place. The best way to prevent your children from smoking is to not smoke yourself. If you’re a parent who smokes, the younger your children are when you quit, the less likely they are to become smokers themselves.

Even if you don’t smoke, here are some things you might try as a parent:

• Promote smoke-free environments. Support legislation to make all workplaces smoke-free. Encourage smoke-free public places, including restaurants or other places where your teen may work.
• Support legislation to increase taxes on tobacco products. Higher prices discourage teens from starting to smoke. Higher prices on tobacco products, coupled with smoke-free workplace laws, are the most effective public health policies to reduce smoking in adults and prevent young people from ever starting.
• Talk with your teenagers. Ask whether their friends smoke. Most teenagers smoke their first cigarette with a friend who already smokes. Let your child know that other forms of tobacco, including cigars and smokeless tobacco, also carry significant health risks.
• Learn what your children think about smoking. Ask them to read this article so that you can discuss it together. You can be a great influence on whether your children smoke, despite what they see in movies and on the Internet.
• Help your children explore personal feelings. Use nonjudgmental questions and rehearse with them how they could handle tough situations regarding peer pressure and smoking.
• Note the social repercussions. Remind your teenager that smoking gives you bad breath and makes your hair and clothes smell.
• Work with your schools. Become active in community and school stop-smoking programs.

A migraine headache can cause intense throbbing or a pulsing sensation in one area of the head and is commonly accompanied by nausea, vomiting, and extreme sensitivity to light and sound.

Migraine attacks can cause significant pain for hours to days and be so severe that all you can think about is finding a dark, quiet place to lie down.

Some migraines are preceded or accompanied by sensory warning symptoms (aura), such as flashes of light, blind spots, or tingling in your arm or leg.

Medications can help reduce the frequency and severity of migraines. If treatment hasn’t worked for you in the past, talk to your doctor about trying a different migraine headache medication. The right medicines, combined with self-help remedies and lifestyle changes, may make a big difference.

Symptoms

Migraine headaches often begin in childhood, adolescence or early adulthood. Migraines may progress through four stages, including prodrome, aura, headache and postdrome, though you may not experience all the stages.

Prodrome

One or two days before a migraine, you may notice subtle changes that signify an oncoming migraine, including:

• Constipation
• Depression
• Food cravings
• Hyperactivity
• Irritability
• Neck stiffness
• Uncontrollable yawning

Aura

Aura may occur before or during migraine headaches. Auras are nervous system symptoms that are usually visual disturbances, such as flashes of light. Sometimes auras can also be touching sensations (sensory), movement (motor) or speech (verbal) disturbances. Most people experience migraine headaches without aura. Each of these symptoms usually begins gradually, builds up over several minutes, and then commonly lasts for 20 to 60 minutes. Examples of aura include:

• Visual phenomena, such as seeing various shapes, bright spots or flashes of light
• Vision loss
• Pins and needles sensations in an arm or leg
• Speech or language problems (aphasia)

Less commonly, an aura may be associated with limb weakness (hemiplegic migraine).

Attack

When untreated, a migraine usually lasts from four to 72 hours, but the frequency with which headaches occur varies from person to person. You may have migraines several times a month or much less often. During a migraine, you may experience the following symptoms:

• Pain on one side or both sides of your head
• Pain that has a pulsating, throbbing quality
• Sensitivity to light, sounds and sometimes smells
• Nausea and vomiting
• Blurred vision
• Lightheadedness, sometimes followed by fainting

Postdrome

The final phase, known as postdrome, occurs after a migraine attack. During this time you may feel drained and washed out, though some people report feeling mildly euphoric.

Causes

Although much about the cause of migraines isn’t understood, genetics and environmental factors appear to play a role.

Migraines may be caused by changes in the brainstem and its interactions with the trigeminal nerve, a major pain pathway.

Imbalances in brain chemicals — including serotonin, which helps regulate pain in your nervous system — also may be involved. Researchers continue to study the role of serotonin in migraines.

Serotonin levels drop during migraine attacks. This may cause your trigeminal system to release substances called neuropeptides, which travel to your brain’s outer covering (meninges). The result is headache pain.

Migraine headache triggers

Whatever the exact mechanism of the headaches, a number of things may trigger them. Common migraine triggers include:

• Hormonal changes in women. Fluctuations in estrogen seem to trigger headaches in many women with known migraines. Women with a history of migraines often report headaches immediately before or during their periods, when they have a major drop in estrogen. Others have an increased tendency to develop migraines during pregnancy or menopause. Hormonal medications, such as oral contraceptives and hormone replacement therapy, also may worsen migraines. Some women, however, may find their migraines occur less often when taking these medications.
• Foods. Aged cheeses, salty foods and processed foods may trigger migraines. Skipping meals or fasting also can trigger attacks.
• Food additives. The sweetener aspartame and the preservative monosodium glutamate, found in many foods, may trigger migraines.
• Drinks. Alcohol, especially wine, and highly caffeinated beverages may trigger migraines.
• Stress. Stress at work or home can cause migraines.
• Sensory stimuli. Bright lights and sun glare can induce migraines, as can loud sounds. Unusual smells — including perfume, paint thinner, secondhand smoke and others — can trigger migraines in some people.
• Changes in wake-sleep pattern. Missing sleep or getting too much sleep may trigger migraines in some people, as can jet lag.
• Physical factors. Intense physical exertion, including sexual activity, may provoke migraines.
• Changes in the environment. A change of weather or barometric pressure can prompt a migraine.
• Medications. Oral contraceptives and vasodilators, such as nitroglycerin, can aggravate migraines.

Treatments and drugs

Migraines can’t be cured, but doctors will work with you to help you manage your condition.

A variety of medications have been specifically designed to treat migraines. In addition, some drugs commonly used to treat other conditions also may help relieve or prevent migraines. Medications used to combat migraines fall into two broad categories:

• Pain-relieving medications. Also known as acute or abortive treatment, these types of drugs are taken during migraine attacks and are designed to stop symptoms that have already begun.
• Preventive medications. These types of drugs are taken regularly, often on a daily basis, to reduce the severity or frequency of migraines.

Choosing a strategy to manage your migraines depends on the frequency and severity of your headaches, the degree of disability your headaches cause, and your other medical conditions.

Some medications aren’t recommended if you’re pregnant or breast-feeding. Some medications aren’t given to children. Your doctor can help find the right medication for you.

Pain-relieving medications

For the most effective results, take pain-relieving drugs as soon as you experience signs or symptoms of a migraine. It may help if you rest or sleep in a dark room after taking them. Medications include:

• Pain relievers. Aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin IB, others), may help relieve mild migraines. Pain relievers, such as acetaminophen (Tylenol, others), also may help relieve mild migraines in some people. Drugs marketed specifically for migraines, such as the combination of acetaminophen, aspirin and caffeine (Excedrin Migraine), also may ease moderate migraine pain, but aren’t effective alone for severe migraines. If taken too often or for long periods of time, these medications can lead to ulcers, gastrointestinal bleeding and medication-overuse headaches. The prescription pain reliever indomethacin may help thwart a migraine headache and is available in suppository form, which may be helpful if you’re nauseated.
• Triptans. Many people with migraine attacks use triptans to treat their migraines. Triptans work by promoting constriction of blood vessels and blocking pain pathways in the brain. Triptans effectively relieve the pain and other symptoms that are associated with migraines. Medications include sumatriptan (Imitrex), rizatriptan (Maxalt), almotriptan (Axert), naratriptan (Amerge), zolmitriptan (Zomig), frovatriptan (Frova) and eletriptan (Relpax). Some triptans are available as nasal sprays and injections, in addition to tablets.
  Side effects of triptans include nausea, dizziness, drowsiness and muscle weakness. They aren’t recommended for people at risk of strokes and heart attacks. A single-tablet combination of sumatriptan and naproxen sodium (Treximet) has proved to be more effective in relieving migraine symptoms than either medication on its own.
• Ergots. Ergotamine and caffeine combination drugs (Migergot, Cafergot) are less effective than triptans. Ergots seem most effective in those whose pain lasts for more than 48 hours. Ergotamine may cause worsened nausea and vomiting related to your migraines and other side effects, and it may also lead to medication-overuse headaches. Dihydroergotamine (D.H.E. 45, Migranal) is an ergot derivative that is more effective and has fewer side effects than ergotamine. It’s available as a nasal spray and in injection form. This medication may cause fewer side effects than ergotamine and is less likely to lead to medication-overuse headaches.
• Anti-nausea medications. Because migraines are often accompanied by nausea, with or without vomiting, medication for nausea is appropriate and is usually combined with other medications. Frequently prescribed medications are chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro).
• Opioid medications. Opioid medications containing narcotics, particularly codeine, are sometimes used to treat migraine headache pain for people who can’t take triptans or ergot. Narcotics are habit-forming and are usually used only as a last resort.
• Glucocorticoids (prednisone, dexamethasone). A glucocorticoid may be used in conjunction with other medications to improve pain relief. Because of the risk of steroid toxicity, glucocorticoids shouldn’t be used frequently.

Preventive medications

You may be a candidate for preventive therapy if you have four or more debilitating attacks a month, if attacks last more than 12 hours, if pain-relieving medications aren’t helping, or if your migraine signs and symptoms include a prolonged aura or numbness and weakness.

Preventive medications can reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks.

Your doctor may recommend that you take preventive medications daily, or only when a predictable trigger, such as menstruation, is approaching.

In most cases, preventive medications don’t stop headaches completely, and some drugs cause serious side effects. If you have had good results from preventive medicine and your migraines are well controlled, your doctor may recommend tapering off the medication to see if your migraines return without it.

To prevent or reduce the frequency of your migraines, take these medications as your doctor recommends:

• Cardiovascular drugs. Beta blockers, which are commonly used to treat high blood pressure and coronary artery disease, may reduce the frequency and severity of migraines. The beta blockers propranolol (Inderal La, Innopran XL, others), metoprolol tartrate (Lopressor) and timolol (Betimol) have proved effective for preventing migraines. Other beta blockers are also sometimes used for treatment of migraine. You may not notice improvement in symptoms for several weeks after taking these medications. If you’re older than age 60, use tobacco, or have certain heart or blood vessel conditions, doctors may recommend you take alternate medications instead of beta blockers. Another class of cardiovascular medications (calcium channel blockers) used to treat high blood pressure and keep blood vessels from becoming narrow or wide, also may be helpful in preventing migraines and relieving symptoms from migraines. Verapamil (Calan, Verelan, others) is a calcium channel blocker that may help you. In addition, the angiotensin-converting enzyme inhibitor lisinopril (Zestril) may be useful in reducing the length and severity of migraines. Researchers don’t understand exactly why these cardiovascular medications prevent migraine attacks.
• Antidepressants. Certain antidepressants help to prevent some types of headaches, including migraines. Tricyclic antidepressants may be effective in preventing migraines. You don’t have to have depression to benefit from these drugs.Tricyclic antidepressants may reduce the frequency of migraine headaches by affecting the level of serotonin and other brain chemicals. Amitriptyline is the only tricyclic antidepressant proved to effectively prevent migraine headaches. Other tricyclic antidepressants are sometimes used because they may have fewer side effects than amitriptyline. These medications can cause dryness of mouth, constipation, weight gain and other side effects. Another class of antidepressants called selective serotonin reuptake inhibitors hasn’t been proved to be effective for migraine headache prevention. However, research suggests that one serotonin and norepinephrine reuptake inhibitor, venlafaxine (Effexor XR), may be helpful in preventing migraines.
• Anti-seizure drugs. Some anti-seizure drugs, such as valproate sodium (Depacon) and topiramate (Topamax), seem to reduce the frequency of migraine headaches. In high doses, however, these anti-seizure drugs may cause side effects. Valproate sodium may cause nausea, tremor, weight gain, hair loss and dizziness. Valproate products should not be used in pregnant women for prevention of migraine headaches. Topiramate may cause diarrhea, nausea, weight loss, memory difficulties and concentration problems.
• OnabotulinumtoxinA (Botox). OnabotulinumtoxinA (Botox) has been shown to be helpful in treating chronic migraine headaches in adults. During this procedure, injections are made in muscles of the forehead and neck. When this is effective, the treatment usually needs to be repeated every 12 weeks.
• Pain relievers. Taking nonsteroidal anti-inflammatory drugs, especially naproxen (Naprosyn), may help prevent migraines and reduce symptoms.

Prevention

Whether or not you take preventive medications, you may benefit from lifestyle changes that can help reduce the number and severity of migraines. One or more of these suggestions may be helpful for you:

• Avoid triggers. If certain foods or odors seem to have triggered your migraines in the past, avoid them. Your doctor may recommend you reduce your caffeine and alcohol intake and avoid tobacco. In general, establish a daily routine with regular sleep patterns and regular meals. In addition, try to control stress.
• Exercise regularly. Regular aerobic exercise reduces tension and can help prevent migraines. If your doctor agrees, choose any aerobic exercise you enjoy, including walking, swimming and cycling. Warm up slowly, however, because sudden, intense exercise can cause headaches. Obesity is also thought to be a factor in migraine headaches, and regular exercise can help you maintain a healthy weight or lose weight.
• Reduce the effects of estrogen. If you’re a woman who has migraines and estrogen seems to trigger or make your headaches worse, you may want to avoid or reduce the medications you take that contain estrogen.

  These medications include birth control pills and hormone replacement therapy. Talk with your doctor about the appropriate alternatives or dosages for you.

Kidney stones (renal lithiasis, nephrolithiasis) are small, hard mineral deposits that form inside your kidneys. The stones are made of mineral and acid salts.

Kidney stones have many causes and can affect any part of your urinary tract — from your kidneys to your bladder. Often, stones form when the urine becomes concentrated, allowing minerals to crystallize and stick together.

Passing kidney stones can be quite painful, but the stones usually cause no permanent damage. Depending on your situation, you may need nothing more than to take pain medication and drink lots of water to pass a kidney stone. In other instances — for example, if stones become lodged in the urinary tract or cause complications — surgery may be needed.

Your doctor may recommend preventive treatment to reduce your risk of recurrent kidney stones if you’re at increased risk of developing them again.

Symptoms

A kidney stone may not cause symptoms until it moves around within your kidney or passes into your ureter — the tube connecting the kidney and bladder. At that point, you may experience these signs and symptoms:

• Severe pain in the side and back, below the ribs
• Pain that spreads to the lower abdomen and groin
• Pain that comes in waves and fluctuates in intensity
• Pain on urination
• Pink, red or brown urine
• Cloudy or foul-smelling urine
• Nausea and vomiting
• Persistent need to urinate
• Urinating more often than usual
• Fever and chills if an infection is present
• Urinating small amounts of urine Pain caused by a kidney stone may change — for instance, shifting to a different location or increasing in intensity — as the stone moves through your urinary tract.

Causes

Kidney stones often have no definite, single cause, although several factors may increase your risk.

Kidney stones form when your urine contains more crystal-forming substances — such as calcium, oxalate and uric acid — than the fluid in your urine can dilute. At the same time, your urine may lack substances that prevent crystals from sticking together, creating an ideal environment for kidney stones to form.

Types of kidney stones

Knowing the type of kidney stone helps determine the cause and may give clues on how to reduce your risk of getting more kidney stones. Types of kidney stones include:

• Calcium stones. Most kidney stones are calcium stones, usually in the form of calcium oxalate. Oxalate is a naturally occurring substance found in food. Some fruits and vegetables, as well as nuts and chocolate, have high oxalate levels. Your liver also produces oxalate. Dietary factors, high doses of vitamin D, intestinal bypass surgery and several metabolic disorders can increase the concentration of calcium or oxalate in urine. Calcium stones may also occur in the form of calcium phosphate.
• Struvite stones. Struvite stones form in response to an infection, such as a urinary tract infection. These stones can grow quickly and become quite large, sometimes with few symptoms or little warning.
• Uric acid stones. Uric acid stones can form in people who don’t drink enough fluids or who lose too much fluid, those who eat a high-protein diet, and those who have gout. Certain genetic factors also may increase your risk of uric acid stones.
• Cystine stones. These stones form in people with a hereditary disorder that causes the kidneys to excrete too much of certain amino acids (cystinuria).
• Other stones. Other, rarer types of kidney stones also can occur.

Treatments and drugs

Small stones with minimal symptoms

Most kidney stones won’t require invasive treatment. You may be able to pass a small stone by:

• Drinking water. Drinking as much as 2 to 3 quarts (1.9 to 2.8 liters) a day may help flush out your urinary system. Unless your doctor tells you otherwise, drink enough fluid — mostly water — to produce clear or nearly clear urine.
• Pain relievers. Passing a small stone can cause some discomfort. To relieve mild pain, your doctor may recommend pain relievers such as ibuprofen (Advil, Motrin IB, others), acetaminophen (Tylenol, others) or naproxen sodium (Aleve).
• Medical therapy. Your doctor may give you a medication to help pass your kidney stone. This type of medication, known as an alpha blocker, relaxes the muscles in your ureter, helping you pass the kidney stone more quickly and with less pain.

Large stones and those that cause symptoms

Kidney stones that can’t be treated with conservative measures — either because they’re too large to pass on their own or because they cause bleeding, kidney damage or ongoing urinary tract infections — may require more extensive treatment. Procedures may include:

• Using sound waves to break up stones. For certain kidney stones — depending on size and location — your doctor may recommend a procedure called extracorporeal shock wave lithotripsy (ESWL). ESWL uses sound waves to create strong vibrations (shock waves) that break the stones into tiny pieces that can be passed in your urine. The procedure lasts about 45 to 60 minutes and can cause moderate pain, so you may be under sedation or light anesthesia to make you comfortable. ESWL can cause blood in the urine, bruising on the back or abdomen, bleeding around the kidney and other adjacent organs, and discomfort as the stone fragments pass through the urinary tract.
• Surgery to remove very large stones in the kidney. A procedure called percutaneous nephrolithotomy (nef-row-lih-THOT-uh-me) involves surgically removing a kidney stone using small telescopes and instruments inserted through a small incision in your back. You will receive general anesthesia during the surgery and be in the hospital for one to two days while you recover. Your doctor may recommend this surgery if ESWL was unsuccessful.
• Using a scope to remove stones. To remove a smaller stone in your ureter or kidney, your doctor may pass a thin lighted tube (ureteroscope) equipped with a camera through your urethra and bladder to your ureter. Once the stone is located, special tools can snare the stone or break it into pieces that will pass in your urine. Your doctor may then place a small tube (stent) in the ureter to relieve swelling and promote healing. You may need general or local anesthesia during this procedure.
• Parathyroid gland surgery. Some calcium phosphate stones are caused by overactive parathyroid glands, which are located on the four corners of your thyroid gland, just below your Adam’s apple. When these glands produce too much parathyroid hormone (hyperparathyroidism), your calcium levels can become too high and kidney stones may form as a result. Hyperparathyroidism sometimes occurs when a small, benign tumor forms in one of your parathyroid glands or you develop another condition that leads these glands to produce more parathyroid hormone. Removing the growth from the gland stops the formation of kidney stones. Or your doctor may recommend treatment of the condition that’s causing your parathyroid gland to overproduce the hormone.

Prevention

Prevention of kidney stones may include a combination of lifestyle changes and medications.

Lifestyle changes

You may reduce your risk of kidney stones if you:

• Drink water throughout the day. For people with a history of kidney stones, doctors usually recommend passing about 2.6 quarts (2.5 liters) of urine a day. Your doctor may ask that you measure your urine output to make sure that you’re drinking enough water. If you live in a hot, dry climate or you exercise frequently, you may need to drink even more water to produce enough urine. If your urine is light and clear, you’re likely drinking enough water.
• Eat fewer oxalate-rich foods. If you tend to form calcium oxalate stones, your doctor may recommend restricting foods rich in oxalates. These include rhubarb, beets, okra, spinach, Swiss chard, sweet potatoes, nuts, tea, chocolate and soy products.
• Choose a diet low in salt and animal protein. Reduce the amount of salt you eat and choose nonanimal protein sources, such as legumes. Consider using a salt substitute.
• Continue eating calcium-rich foods, but use caution with calcium supplements. Calcium in food doesn’t have an effect on your risk of kidney stones. Continue eating calcium-rich foods unless your doctor advises otherwise. Ask your doctor before taking calcium supplements, as these have been linked to increased risk of kidney stones. You may reduce the risk by taking supplements with meals. Diets low in calcium can increase kidney stone formation in some people.

Ask your doctor for a referral to a dietitian who can help you develop an eating plan that reduces your risk of kidney stones.

Medications

Medications can control the amount of minerals and acid in your urine and may be helpful in people who form certain kinds of stones. The type of medication your doctor prescribes will depend on the kind of kidney stones you have. Here are some examples:

• Calcium stones. To help prevent calcium stones from forming, your doctor may prescribe a thiazide diuretic or a phosphate-containing preparation.
• Uric acid stones. Your doctor may prescribe allopurinol (Zyloprim, Aloprim) to reduce uric acid levels in your blood and urine and a medicine to keep your urine alkaline. In some cases, allopurinol and an alkalizing agent may dissolve the uric acid stones.
• Struvite stones. To prevent struvite stones, your doctor may recommend strategies to keep your urine free of bacteria that cause infection. Long-term use of antibiotics in small doses may help achieve this goal. For instance, your doctor may recommend an antibiotic before and for a while after surgery to treat your kidney stones.
• Cystine stones. Cystine stones can be difficult to treat. Your doctor may recommend that you drink more fluids so that you produce a lot more urine. If that alone doesn’t help, your doctor may also prescribe a medication that decreases the amount of cystine in your urine.

Influenza is a viral infection that attacks your respiratory system — your nose, throat and lungs. Influenza, commonly called the flu, is not the same as stomach “flu” viruses that cause diarrhea and vomiting.

For most people, influenza resolves on its own, but sometimes, influenza and its complications can be deadly. People at higher risk of developing flu complications include:

• Young children under 5, and especially those under 2 years
• Adults older than 65
• Residents of nursing homes and other long-term care facilities
• Pregnant women
• People with weakened immune systems
• People who have chronic illnesses, such as asthma, heart disease, kidney disease and diabetes
• People who are very obese, with a body mass index (BMI) of 40 or higher Your best defense against influenza is to receive an annual vaccination.

Symptoms

Initially, the flu may seem like a common cold with a runny nose, sneezing and sore throat. But colds usually develop slowly, whereas the flu tends to come on suddenly. And although a cold can be a nuisance, you usually feel much worse with the flu.

Common signs and symptoms of the flu include:

• Fever over 100 F (38 C)
• Aching muscles, especially in your back, arms and legs
• Chills and sweats
• Headache
• Dry, persistent cough
• Fatigue and weakness
• Nasal congestion
• Sore throat

Causes

• Flu viruses travel through the air in droplets when someone with the infection coughs, sneezes or talks. You can inhale the droplets directly, or you can pick up the germs from an object — such as a telephone or computer keyboard — and then transfer them to your eyes, nose or mouth.
• People with the virus are likely contagious from the day or so before symptoms first appear until about five days after symptoms begin, though sometimes people are contagious for as long as 10 days after symptoms appear. Children and people with weakened immune systems may be contagious for a slightly longer time.
• Influenza viruses are constantly changing, with new strains appearing regularly. If you’ve had influenza in the past, your body has already made antibodies to fight that particular strain of the virus. If future influenza viruses are similar to those you’ve encountered before, either by having the disease or by vaccination, those antibodies may prevent infection or lessen its severity.
• But antibodies against flu viruses you’ve encountered in the past can’t protect you from new influenza subtypes that can be very different immunologically from what you had before.

Treatments and drugs

• Usually, you’ll need nothing more than bed rest and plenty of fluids to treat the flu. But in some cases, your doctor may prescribe an antiviral medication, such as oseltamivir (Tamiflu) or zanamivir (Relenza). If taken soon after you notice symptoms, these drugs may shorten your illness by a day or so and help prevent serious complications.
• Oseltamivir is an oral medication. Zanamivir is inhaled through a device similar to an asthma inhaler and shouldn’t be used by anyone with respiratory problems, such as asthma and lung disease.
• Antiviral medication side effects may include nausea and vomiting. These side effects may be lessened if the drug is taken with food. Oseltamivir has also been associated with delirium and self-harm behaviors in teenagers.
• Some researchers recommend further study on both of these drugs because of uncertainty about their effects beyond a slight reduction in the time of illness. Some studies have suggested that these medications can also help reduce the severity of complications. The Centers for Disease Control and Prevention still recommends their use for some people, however.
• An additional concern is that some strains of influenza have become resistant to oseltamivir, amantadine and rimantadine (Flumadine), which are older antiviral drugs.

Prevention

The Centers for Disease Control and Prevention recommends annual flu vaccination for everyone over the age of 6 months.

Each year’s seasonal flu vaccine contains protection from the three or four influenza viruses that are expected to be the most common during that year’s flu season. The vaccine is typically available as an injection or as a nasal spray.

Controlling the spread of infection

The influenza vaccine isn’t 100 percent effective, so it’s also important to take measures such as these to reduce the spread of infection:

• Wash your hands. Thorough and frequent hand-washing is an effective way to prevent many common infections. Or use alcohol-based hand sanitizers if soap and water aren’t readily available.
• Contain your coughs and sneezes. Cover your mouth and nose when you sneeze or cough. To avoid contaminating your hands, cough or sneeze into a tissue or into the inner crook of your elbow.
• Avoid crowds. Flu spreads easily wherever people congregate — in child care centers, schools, office buildings, auditoriums and public transportation. By avoiding crowds during peak flu season, you reduce your chances of infection. And, if you’re sick, stay home for at least 24 hours after your fever subsides so that you lessen your chance of infecting others.

A hip fracture is a serious injury, with complications that can be life-threatening. The risk of hip fracture rises with age.

Older people are at a higher risk of hip fracture because bones tend to weaken with age (osteoporosis). Multiple medications, poor vision and balance problems also make older people more likely to trip and fall — one of the most common causes of hip fracture.

A hip fracture almost always requires surgical repair or replacement, followed by months of physical therapy. Taking steps to maintain bone density and avoid falls can help prevent hip fracture.

Symptoms

Signs and symptoms of a hip fracture include:

• Inability to move immediately after a fall
• Severe pain in your hip or groin
• Inability to put weight on your leg on the side of your injured hip
• Stiffness, bruising and swelling in and around your hip area
• Shorter leg on the side of your injured hip
• Turning outward of your leg on the side of your injured hip

Causes

A severe impact — in a car crash, for example — can cause hip fractures in people of all ages. In older adults, a hip fracture is most often a result of a fall from a standing height. In people with very weak bones, a hip fracture can occur simply by standing on the leg and twisting.

Treatments and drugs

Treatment for hip fracture usually involves a combination of surgery, rehabilitation and medication.

Surgery

The type of surgery you have generally depends on the location and severity of the fracture, whether the broken bones aren’t properly aligned (displaced fracture), and your age and underlying health conditions. The options include:

• Internal repair using screws. Metal screws are inserted into the bone to hold it together while the fracture heals. Sometimes screws are attached to a metal plate that runs down the femur.
• Partial hip replacement. If the ends of the broken bone are displaced or damaged, your surgeon may remove the head and neck of the femur and install a metal replacement (prosthesis).
• Total hip replacement. Your upper femur and the socket in your pelvic bone are replaced with prostheses. Total hip replacement may be a good option if arthritis or a prior injury has damaged your joint, affecting its function even before the fracture.

Your doctor may recommend partial or total hip replacement if the blood supply to the ball part of your hip joint was damaged during the fracture. That type of injury, which occurs most often in older people with femoral neck fractures, means the bone is less likely to heal properly.

Rehabilitation

Your care team will probably get you out of bed and moving on the first day after surgery. Physical therapy will initially focus on range of motion and strengthening exercises. Depending on the type of surgery you had and whether you have assistance at home, you may need to go from the hospital to an extended care facility.

In extended care and at home, you may work with an occupational therapist to learn techniques for independence in daily life, such as using the toilet, bathing, dressing and cooking. Your occupational therapist will determine if a walker or wheelchair may help you regain mobility and independence.

Medication

About 20 percent of people who have a hip fracture will have another hip fracture within two years. Bisphosphonates may help reduce the risk of a second hip fracture.

Most of these drugs are taken orally and are associated with side effects that may be difficult to tolerate, including acid reflux and inflammation of the esophagus. To avoid these side effects, your doctor may recommend taking bisphosphonate via intravenous (IV) tubing.

Bisphosphonates generally aren’t recommended for people with kidney problems. Rarely, long-term bisphosphonate therapy might cause pain and swelling in the jaw, vision problems or atypical hip fracture.

Prevention

Healthy lifestyle choices in early adulthood build a higher peak bone mass and reduce your risk of osteoporosis in later years. The same measures may lower your risk of falls and improve your overall health if you adopt them at any age.

To avoid falls and to maintain healthy bone:

• Get enough calcium and vitamin D. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
• Exercise to strengthen bones and improve balance. Weight-bearing exercises, such as walking, help you maintain peak bone density for more years. Exercise also increases your overall strength, making you less likely to fall. Balance training is also important to reducing your risk of falls, since balance tends to deteriorate with age.
• Avoid smoking or excessive drinking. Tobacco and alcohol use can reduce bone density. Drinking too much alcohol also can impair your balance and make you more likely to fall.
• Assess your home for hazards. Remove throw rugs, keep electrical cords against the wall, and clear excess furniture and anything else that could trip you. Make sure every room and passageway is well-lit.
• Check your eyes. Have an eye exam every other year, or more often if you have diabetes or an eye disease.
• Watch your medications. Feeling weak and dizzy, which are possible side effects of many medications, can increase your risk of falling. Talk to your doctor about side effects caused by your medications.
• Stand up slowly. Getting up too quickly can cause your blood pressure to drop and make you feel wobbly.
• Use a walking stick or walker. If you don’t feel steady when you walk, ask your doctor or occupational therapist whether these aids might help.

Hemorrhoids (HEM-uh-roids), also called piles, are swollen and inflamed veins in your anus and lower rectum. Hemorrhoids may result from straining during bowel movements or from the increased pressure on these veins during pregnancy, among other causes. Hemorrhoids may be located inside the rectum (internal hemorrhoids), or they may develop under the skin around the anus (external hemorrhoids).

Hemorrhoids are common ailments. By age 50, about half of adults have had to deal with the itching, discomfort and bleeding that can signal the presence of hemorrhoids.

Fortunately, many effective options are available to treat hemorrhoids. Most people can get relief from symptoms by using home treatments and making lifestyle changes.

Symptoms

Signs and symptoms of hemorrhoids may include:

• Painless bleeding during bowel movements — you might notice small amounts of bright red blood on your toilet tissue or in the toilet bowl
• Itching or irritation in your anal region
• Pain or discomfort
• Swelling around your anus
• A lump near your anus, which may be sensitive or painful
• Leakage of feces

Hemorrhoid symptoms usually depend on the location. Internal hemorrhoids lie inside the rectum. You usually can’t see or feel these hemorrhoids, and they usually don’t cause discomfort.

But straining or irritation when passing stool can damage a hemorrhoid’s delicate surface and cause it to bleed. Occasionally, straining can push an internal hemorrhoid through the anal opening. This is known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.

External hemorrhoids are under the skin around your anus. When irritated, external hemorrhoids can itch or bleed. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus), resulting in severe pain, swelling and inflammation.

When to see a doctor

Bleeding during bowel movements is the most common sign of hemorrhoids. But rectal bleeding can occur with other diseases, including colorectal cancer and anal cancer. Don’t assume that bleeding is coming from hemorrhoids without consulting a doctor.

Your doctor can do a physical examination and perform other tests to diagnose hemorrhoids and rule out more-serious conditions or diseases. Also consider seeking medical advice if your hemorrhoids cause pain, bleed frequently or excessively, or don’t improve with home remedies.

If your hemorrhoid symptoms began along with a marked change in bowel habits or if you’re passing black, tarry or maroon stools, blood clots, or blood mixed in with the stool, consult your doctor immediately. These types of stools can signal more extensive bleeding elsewhere in your digestive tract.

Seek emergency care if you experience large amounts of rectal bleeding, lightheadedness, dizziness or faintness.

Causes

The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins (hemorrhoids) can develop from an increase in pressure in the lower rectum. Factors that might cause increased pressure include:

• Straining during bowel movements
• Sitting for long periods of time on the toilet
• Chronic diarrhea or constipation
• Obesity
• Pregnancy
• Anal intercourse
• Low-fiber diet

Hemorrhoids are more likely as you get older because the tissues that support the veins in your rectum and anus can weaken and stretch with aging.

Treatments and drugs

Most of the time, treatment for hemorrhoids involves steps that you can take on your own, such as lifestyle modifications. But sometimes medications or surgical procedures are necessary.

Medications

If your hemorrhoids produce only mild discomfort, your doctor may suggest over-thecounter creams, ointments, suppositories or pads. These products contain ingredients, such as witch hazel or hydrocortisone, that can relieve pain and itching, at least temporarily.

Don’t use an over-the-counter cream or other product for more than a week unless directed by your doctor. These products can cause side effects, such as skin rash, inflammation and skin thinning.

Minimally invasive procedures

If a blood clot has formed within an external hemorrhoid, your doctor can remove the clot with a simple incision, which may provide prompt relief.

For persistent bleeding or painful hemorrhoids, your doctor may recommend another minimally invasive procedure. These treatments can be done in your doctor’s office or other outpatient setting.

• Rubber band ligation. Your doctor places one or two tiny rubber bands around the base of an internal hemorrhoid to cut off its circulation. The hemorrhoid withers and falls off within a week. This procedure — called rubber band ligation — is effective for many people. Hemorrhoid banding can be uncomfortable and may cause bleeding, which might begin two to four days after the procedure but is rarely severe.
• Injection (sclerotherapy). In this procedure, your doctor injects a chemical solution into the hemorrhoid tissue to shrink it. While the injection causes little or no pain, it may be less effective than rubber band ligation.
• Coagulation (infrared, laser or bipolar). Coagulation techniques use laser or infrared light or heat. They cause small, bleeding, internal hemorrhoids to harden and shrivel.While coagulation has few side effects, it’s associated with a higher rate of hemorrhoids coming back (recurrence) than is the rubber band treatment.

Surgical procedures

If other procedures haven’t been successful or you have large hemorrhoids, your doctor may recommend a surgical procedure. Surgery can be performed on an outpatient basis or you may need to stay in the hospital overnight.

• Hemorrhoid removal. During a hemorrhoidectomy, your surgeon removes excessive tissue that causes bleeding. Various techniques may be used. The surgery may be done with a local anesthetic combined with sedation, a spinal anesthetic or a general anesthetic.Hemorrhoidectomy is the most effective and complete way to treat severe or recurring hemorrhoids. Complications may include temporary difficulty emptying your bladder and urinary tract infections associated with this problem.

  Most people experience some pain after the procedure. Medications can relieve your pain. Soaking in a warm bath also may help.

• Hemorrhoid stapling. This procedure, called stapled hemorrhoidectomy or stapled hemorrhoidopexy, blocks blood flow to hemorrhoidal tissue. Stapling generally involves less pain than hemorrhoidectomy and allows an earlier return to regular activities.Compared with hemorrhoidectomy, however, stapling has been associated with a greater risk of recurrence and rectal prolapse, in which part of the rectum protrudes from the anus. Talk with your doctor about what might be the best option for you.

Prevention

The best way to prevent hemorrhoids is to keep your stools soft, so they pass easily. To prevent hemorrhoids and reduce symptoms of hemorrhoids, follow these tips:

• Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can cause hemorrhoids or worsen symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
• Drink plenty of fluids. Drink six to eight glasses of water and other liquids (not alcohol) each day to help keep stools soft.
• Consider fiber supplements. Most people don’t get enough of the recommended amount of fiber — 25 grams a day for women and 38 grams a day for men — in their diet. Studies have shown that over-the-counter fiber supplements, such as Metamucil and Citrucel, improve overall symptoms and bleeding from hemorrhoids. These products help keep stools soft and regular. If you use fiber supplements, be sure to drink at least eight glasses of water or other fluids every day. Otherwise, the supplements can cause constipation or make constipation worse.
• Don’t strain. Straining and holding your breath when trying to pass a stool creates greater pressure in the veins in the lower rectum.
• Go as soon as you feel the urge. If you wait to pass a bowel movement and the urge goes away, your stool could become dry and be harder to pass.
• Exercise. Stay active to help prevent constipation and to reduce pressure on veins, which can occur with long periods of standing or sitting. Exercise can also help you lose excess weight that may be contributing to your hemorrhoids.
• Avoid long periods of sitting. Sitting too long, particularly on the toilet, can increase the pressure on the veins in the anus.