Osteoarthritis

Definition

Osteoarthritis causes cartilage — the hard, slippery tissue that covers the ends of bones where they form a joint — to break down. Rheumatoid arthritis is an autoimmune disorder that first targets the lining of joints (synovium).Arthritis is inflammation of one or more of your joints. The main symptoms of arthritis are joint pain and stiffness, which typically worsen with age. The most common types of arthritis are osteoarthritis and rheumatoid arthritis.

Uric acid crystals, infections or underlying disease, such as psoriasis or lupus, can cause other types of arthritis.

Treatments vary depending on the type of arthritis. The main goals of arthritis treatments are to reduce symptoms and improve quality of life.

Symptoms

PainThe most common signs and symptoms of arthritis involve the joints. Depending on the type of arthritis you have, your signs and symptoms may include:

• Stiffness
• Swelling
• Redness
• Decreased range of motion

Causes

OsteoarthritisThe two main types of arthritis — osteoarthritis and rheumatoid arthritis — damage joints in different ways.

The most common type of arthritis, osteoarthritis involves wear-and-tear damage to your joint's cartilage — the hard, slick coating on the ends of bones. Enough damage can result in bone grinding directly on bone, which causes pain and restricted movement. This wear and tear can occur over many years, or it can be hastened by a joint injury or infection.

Rheumatoid arthritis

In rheumatoid arthritis, the body's immune system attacks the lining of the joint capsule, a tough membrane that encloses all the joint parts. This lining, known as the synovial membrane, becomes inflamed and swollen. The disease process can eventually destroy cartilage and bone within the joint.

Risk factors

Family history. Some types of arthritis run in families, so you may be more likely to develop arthritis if your parents or siblings have the disorder. Your genes can make you more susceptible to environmental factors that may trigger arthritis.Risk factors for arthritis include:

• Age. The risk of many types of arthritis — including osteoarthritis, rheumatoid arthritis and gout — increases with age.
• Your sex. Women are more likely than are men to develop rheumatoid arthritis, while most of the people who have gout, another type of arthritis, are men.
• Previous joint injury. People who have injured a joint, perhaps while playing a sport, are more likely to eventually develop arthritis in that joint.
• Obesity. Carrying excess pounds puts stress on joints, particularly your knees, hips and spine. Obese people have a higher risk of developing arthritis.

Complications

Severe arthritis, particularly if it affects your hands or arms, can make it difficult for you to do daily tasks. Arthritis of weight-bearing joints can keep you from walking comfortably or sitting up straight. In some cases, joints may become twisted and deformed.

Preparing for your appointment

What you can doWhile you might first discuss your symptoms with your family doctor, he or she may refer you to a doctor who specializes in the treatment of joint problems (rheumatologist) for further evaluation.

Before your appointment, make a list that includes:

• Detailed descriptions of your symptoms
• Information about medical problems you've had in the past
• Information about the medical problems of your parents or siblings
• All the medications and dietary supplements you take
• Questions you want to ask the doctor

What to expect from your doctor

Your doctor may ask some of the following questions:

• When did your symptoms start?
• Does activity make the pain better or worse?
• What joints are painful?
• Do you have a family history of joint pain?

Tests and diagnosis

Laboratory testsDuring the physical exam, your doctor will check your joints for swelling, redness and warmth. He or she will also want to see how well you can move your joints. Depending on the type of arthritis suspected, your doctor may suggest some of the following tests.

The analysis of different types of body fluids can help pinpoint the type of arthritis you may have. Fluids commonly analyzed include blood, urine and joint fluid. To obtain a sample of your joint fluid, your doctor will cleanse and numb the area before inserting a needle in your joint space to withdraw some fluid (aspiration).

Imaging

These types of tests can detect problems within your joint that may be causing your symptoms. Examples include:

• X-rays. Using low levels of radiation to visualize bone, X-rays can show cartilage loss, bone damage and bone spurs. X-rays may not reveal early arthritic damage, but they are often used to track progression of the disease.
• Computerized tomography (CT). CT scanners take X-rays from many different angles and combine the information to create cross-sectional views of internal structures. CTs can visualize both bone and the surrounding soft tissues.
• Magnetic resonance imaging (MRI). Combining radio waves with a strong magnetic field, MRI can produce more-detailed cross-sectional images of soft tissues such as cartilage, tendons and ligaments.
• Ultrasound. This technology uses high-frequency sound waves to image soft tissues, cartilage and fluid-containing structures such as bursae. Ultrasound also is used to guide needle placement for joint aspirations and injections.

Arthroscopy

In some cases, your doctor may look for damage in your joint by inserting a small, flexible tube — called an arthroscope — through an incision near your joint. The arthroscope transmits images from inside the joint to a video screen.

Treatments and drugs

MedicationsArthritis treatment focuses on relieving symptoms and improving joint function. You may need to try several different treatments, or combinations of treatments, before you determine what works best for you.

The medications used to treat arthritis vary depending on the type of arthritis. Commonly used arthritis medications include:

• Analgesics. These types of medications help reduce pain, but have no effect on inflammation. Examples include acetaminophen (Tylenol, others), tramadol (Ultram, others) and narcotics containing oxycodone (Percocet, Oxycontin, others) or hydrocodone (Vicodin, Lortab, others).
• Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs reduce both pain and inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Some types of NSAIDs are available only by prescription. Oral NSAIDs can cause stomach irritation, and some may increase your risk of heart attack or stroke. Some NSAIDs are also available as creams or gels, which can be rubbed on joints.
• Counterirritants. Some varieties of creams and ointments contain menthol or capsaicin, the ingredient that makes hot peppers spicy. Rubbing these preparations on the skin over your aching joint may interfere with the transmission of pain signals from the joint itself.
• Disease-modifying antirheumatic drugs (DMARDs). Often used to treat rheumatoid arthritis, DMARDs slow or stop your immune system from attacking your joints. Examples include methotrexate (Trexall) and hydroxychloroquine (Plaquenil).
• Biologics. Typically used in conjunction with DMARDs, biologic response modifiers are genetically engineered drugs that target various protein molecules that are involved in the immune response. Examples include etanercept (Enbrel) and infliximab (Remicade).
• Corticosteroids. This class of drug, which includes prednisone and cortisone, reduces inflammation and suppresses the immune system. Corticosteroids can be taken orally or be injected directly into the painful joint.

Therapy

Physical therapy can be helpful for some types of arthritis. Exercises can improve range of motion and strengthen the muscles surrounding joints. In some cases, splints or braces may be warranted.

Surgery

If conservative measures don't help, your doctor may suggest surgery, such as:

• Joint replacement. This procedure removes your damaged joint and replaces it with an artificial one. Joints most commonly replaced are hips and knees.
• Joint fusion. This procedure is more often used for smaller joints, such as those in the wrist, ankle and fingers. It removes the ends of the two bones in the joint and then locks those ends together until they heal into one rigid unit.

Lifestyle and home remedies

• Weight loss. If you're obese, losing weight will reduce the stress on your weight-bearing joints. This may increase your mobility and limit future joint injury.
• Exercise. Regular exercise can help keep your joints flexible. Swimming and water aerobics may be good choices because the buoyancy of the water reduces stress on weight-bearing joints.
• Heat and cold. Heating pads or ice packs may help relieve arthritis pain.
• Assistive devices. Using canes, walkers, raised toilet seats and other assistive devices can help protect your joints and improve your ability to perform daily tasks

Alternative medicine

Acupuncture. This therapy uses fine needles inserted at specific points on the skin to reduce many types of pain, including that caused by some types of arthritis.Many people use alternative remedies for arthritis, but there is little reliable evidence to support the use of many of these products. The most promising alternative remedies for arthritis include:

• Glucosamine. Although study results have been mixed, it now appears that glucosamine works no better than placebo. However, glucosamine and the placebo both relieved arthritis pain better than taking nothing, particularly in people who have moderate to severe pain.
• Transcutaneous electrical nerve stimulation (TENS). Using a small device that produces mild electrical pulses, TENS therapy stimulates nerves near the aching joint and may interfere with the transmission of pain signals to the brain.
• Yoga or tai chi. The slow, stretching movements associated with yoga and tai chi may help improve joint flexibility and range of motion in people with some types of arthritis.
• Massage. Light stroking and kneading of muscles may increase blood flow and warm affected joints, temporarily relieving pain. Make sure your massage therapist knows which joints are affected by arthritis.

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Osteoporosis

Osteoporosis is a condition that weakens bones, making them fragile and more likely to break.

It's a fairly common condition that affects around three million people in the UK. More than 300,000 people receive hospital treatment for fragility fractures (fractures that occur from standing height or less) every year as a result of osteoporosis.

Wrist fractures, hip fractures and fractures of the vertebrae (bones in the spine) are the most common type of breaks that affect people with osteoporosis. However, they can also occur in other bones, such as in the arm, ribs or pelvis.

There are usually no warnings you've developed osteoporosis and it's often only diagnosed when a bone is fractured after even minor falls.

Symptoms of osteoporosis 

Osteoporosis develops slowly over several years.

There are often no warning signs or symptoms until a minor fall or a sudden impact causes a bone fracture.

Healthy bones should be able to withstand a fall from standing height, so a bone that breaks in these circumstances is known as a fragility fracture.

The most common injuries in people with osteoporosis are:

• wrist fractures
• hip fractures 
• fractures of the spinal bones (vertebrae)

Sometimes a cough or sneeze can cause a rib fracture or the partial collapse of one of the bones of the spine.

In older people, a fractured bone can be serious and result in long-term disability. For example, a hip fracture may lead to long-term mobility problems.

Although a fracture is the first sign of osteoporosis, some older people develop the characteristic stooping (bent forward). It happens when the bones in the spine have fractured, making it difficult to support the weight of the body.

Is osteoporosis painful?

Osteoporosis isn't usually painful until it causes a fracture.

Although not always painful, spinal fractures are the most common cause of long-term (chronic) pain associated with osteoporosis.

What causes osteoporosis?

During childhood, bones grow and repair very quickly, but this process slows as you get older.

Bones stop growing in length between the ages of 16 and 18, but continue to increase in density until you're in your late 20s.

You gradually start to lose bone density from about 35 years of age. Women lose bone rapidly in the first few years after themenopause (when monthly periods stop and the ovaries stop producing an egg).

Losing bone is a normal part of the ageing process, but for some people it can lead to osteoporosis and an increased risk of fractures.

Other factors that increase your risk of developing osteoporosis include:

• inflammatory conditions, such as rheumatoid arthritis, Crohn's disease and chronic obstructive pulmonary disorder (COPD)
• conditions that affect the hormone-producing glands, such as an overactive thyroid gland (hyperthyroidism) or an overactive parathyroid gland (hyperparathyroidism)
• a family history of osteoporosis, particularly history of a hip fracture in a parent  
• long-term use of certain medications that affect bone strength or hormone levels, such as oral prednisolone
• malabsorption problems
• heavy drinking and smoking

Causes of osteoporosis 

Osteoporosis causes bones to become less dense and more fragile. Some people are more at risk than others.

Bones are at their thickest and strongest in your early adult life and their density increases until your late 20s. But you gradually start losing bone density from around the age of 35.

This happens to everyone, but some people develop osteoporosis and lose bone density much faster than normal. This means they are at greater risk of a fracture.

Risk groups

Osteoporosis can affect men and women. It's more common in older people, but it can also affect younger people.

Women

Women are more at risk of developing osteoporosis than men because the hormone changes that occur in the menopause directly affect bone density.

The female hormone oestrogen is essential for healthy bones. After themenopause (when monthly periods stop), oestrogen levels fall. This can lead to a rapid decrease in bone density.

Women are at even greater risk of developing osteoporosis if they have:

• an early menopause (before 45 years of age)
• a hysterectomy (removal of the womb) before the age of 45, particularly when the ovaries are also removed
• absent periods for more than six months as a result of overexercising or too much dieting

Men

In most cases, the cause of osteoporosis in men is unknown. However, there's a link to the male hormone testosterone, which helps keep the bones healthy.

Men continue producing testosterone into old age, but the risk of osteoporosis is increased in men with low levels of testosterone.

In around half of men, the exact cause of low testosterone levels is unknown, but known causes include:

• the use of certain medications, such as oral glucocorticoids
• alcohol misuse
• hypogonadism (a condition that causes abnormally low testosterone levels)

Risk factors

Many hormones in the body can affect the process of bone turnover. If you have a condition of the hormone-producing glands, you may have a higher risk of developing osteoporosis.

Hormone-related conditions that can trigger osteoporosis include:

• hyperthyroidism (overactive thyroid gland)
• disorders of the adrenal glands, such as Cushing's syndrome
• reduced amounts of sex hormones (oestrogen and testosterone)
• disorders of the pituitary gland
• hyperparathyroidism (overactivity of the parathyroid glands)

Other risk factors

Other factors thought to increase the risk of osteoporosis and broken bones include:

• a family history of osteoporosis
• a parental history of hip fracture 
• a body mass index (BMI) of 19 or less
• long-term use of high-dose oral corticosteroids (widely used for conditions such as arthritis and asthma), which can affect bone strength
• having an eating disorder, such as anorexia or bulimia
• heavy drinking and smoking
• rheumatoid arthritis 
• malabsorption problems, as experienced in coeliac diseaseand Crohn's disease
• some medications used to treat breast cancer and prostate cancer which affect hormone levels
• long periods of inactivity, such as long-term bed rest

Diagnosing osteoporosis

If your doctor suspects you have osteoporosis, they can make an assessment using an online programme, such as FRAX or Q-Fracture. They may also refer you for a scan to measure your bone mineral density.

This type of scan is known as a DEXA (DXA) scan. It's a short, painless procedure and your bone mineral density can then be used to assess your fracture risk.

Diagnosing osteoporosis 

Osteoporosis is often diagnosed after weakened bones have led to a fracture.

If you're at risk of developing osteoporosis, your GP may refer you for a bone mineral density scan, known as a dual energy X-ray absorptiometry (DEXA, or DXA) scan.

Normal X-rays are a useful way of identifying fractures, but they aren't a reliable method of measuring bone density.

DEXA (DXA) scan

A DEXA scan can be used to help diagnose osteoporosis. It's a quick, safe and painless procedure that usually takes about five minutes, depending on the part of the body being scanned.

The scan measures your bone mineral density and compares it to the bone mineral density of a healthy young adult and someone who's the same age and sex as you.

The difference between the density of your bones and that of a healthy young adult is calculated as a standard deviation (SD) and is called a T score.

Standard deviation is a measure of variability based on an average or expected value. A T score of:

• above -1 SD is normal 
• between -1 and -2.5 SD is defined as decreased bone mineral density compared with peak bone mass
• below -2.5 is defined as osteoporosis

Although a bone density scan can help diagnose osteoporosis, your bone mineral density result isn't the only factor that determines your risk of fracturing a bone.

Your age, sex and any previous injuries will need to be taken into consideration before deciding whether you need treatment for osteoporosis.

Your doctor can help you take positive steps to improve your bone health. If you need treatment, they can also suggest the safest and most effective treatment plan for you. 

Treating osteoporosis

Treatment for osteoporosis is based on treating and preventing fractures and using medication to strengthen bones.

The decision about what treatment you have – if any – will depend on your risk of fracture. This will be based on a number of factors, such as your age and the results of your DXA scan.

Treating osteoporosis 

Treating osteoporosis involves treating and preventing fractures and using medication to strengthen bones.

Preventing falls and fractures

The Department of Health's National Service Framework (NSF) for Older People provides doctors and other healthcare professionals with guidance about caring for older people.

An important objective for health services across England is to try to prevent falls and fractures. This is of particular concern for people who've been diagnosed with osteoporosis and those with risk factors for osteoporosis.

The key messages for older people and their family and carers are:

• falls are a risk as you get older, but aren't inevitable – there are measures you can take to prevent falls or reduce the harm that might be caused by falling
• staying active and healthy – for example, through exercise and diet – is likely to keep you independent and reduce your risk of falling
• if you're unsteady on your feet or fall, speak to your GP so possiblecauses of falls, such as poor eyesight, certain medications, and poor muscle strength and balance, can be identified and treated

Treatment overview

Although a diagnosis of osteoporosis is based on the results of your bone mineral density scan (DEXA or DXA scan), the decision about what treatment you need – if any – will also be based on a number of other factors. These include your:

• age
• sex
• risk of fracture
• previous injury history

If you've been diagnosed with osteoporosis because you've had a fracture, you should still receive treatment to try to reduce your risk of further fractures.

You may not need or want to take medication to treat osteoporosis. However, you should ensure that you're maintaining sufficient levels of calcium and vitamin D. To achieve this, your healthcare team will ask you about your current diet and may recommend making changes or taking supplements.

NICE recommendations

The National Institute for Health and Care Excellence (NICE) has made some recommendations about who should be treated with medication for osteoporosis.

A number of factors are taken into consideration before deciding which medication to use. These include your:

• age
• bone mineral density (measured by your T score)
• risk factors for fracture

NICE has summarised its guidance for two groups of people:

• postmenopausal women with osteoporosis who haven't had a fracture (primary prevention)
• postmenopausal women with osteoporosis who've had a fracture (secondary prevention)

Preventing osteoporosis

If you're at risk of developing osteoporosis, you should take steps to help keep your bones healthy. This may include:

• taking regular exercise
• healthy eating, including foods rich in calcium and vitamin D
• making lifestyle changes, such as giving up smoking and reducing your alcohol consumption

Preventing osteoporosis 

Your genes are responsible for determining your height and the strength of your skeleton, but lifestyle factors such as diet and exercise influence how healthy your bones are.

Regular exercise

Regular exercise is essential. Adults aged 19 to 64 should do at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every week.

Weight-bearing exercise and resistance exercise are particularly important for improving bone density and helping to prevent osteoporosis.

As well as aerobic exercise, adults aged 19 to 64 should also do muscle-strengthening activities on two or more days a week by working all the major muscle groups, including the legs, hips, back, abdomen, chest, shoulders and arms.

If you've been diagnosed with osteoporosis, it's a good idea to talk to your GP or health specialist before starting a new exercise programme to make sure it's right for you.

Weight-bearing exercises

Weight-bearing exercises are exercises where your feet and legs support your weight. High-impact weight-bearing exercises, such asrunning, skipping, dancing, aerobics, and even jumping up and down on the spot, are all useful ways to strengthen your muscles, ligaments and joints.

When exercising, wear footwear that provides your ankles and feet with adequate support, such as trainers or walking boots.

Read more about choosing sports shoes and trainers.

People over the age of 60 can also benefit from regular weight-bearing exercise. This can include brisk walking, keep-fit classes or a game of tennis. Swimming and cycling aren't weight-bearing exercises, however.

Resistance exercises

Resistance exercises use muscle strength, where the action of the tendons pulling on the bones boosts bone strength. Examples include press-ups, weightlifting or using weight equipment at a gym.

If you've recently joined a gym or haven't been for a while, your gym will probably offer you an induction. This involves being shown how to use the equipment and having exercise techniques recommended to you.

Always ask an instructor for help if you're not sure how to use a piece of gym equipment or how to do a particular exercise.

Healthy eating

Eating a healthy balanced diet is recommended for everyone. It can help prevent many serious health conditions, including heart disease, diabetes and many forms of cancer, as well as osteoporosis.

Calcium is important for maintaining strong bones. Adults need 700mg a day, which you should be able to get from your daily diet. Calcium-rich foods include leafy green vegetables, dried fruit, tofu and yoghurt.

Vitamin D is also important for healthy bones and teeth because it helps your body absorb calcium. Vitamin D can be found in eggs, milkand oily fish.

However, most vitamin D is made in the skin in response to sunlight. Short exposure to sunlight without wearing sunscreen (10 minutes twice a day) throughout the summer should provide you with enough vitamin D for the whole year.

Certain groups of people may be at risk of not getting enough vitamin D. These include:

• people who are housebound or particularly frail
• people with a poor diet
• people who keep covered up in sunlight because they wear total sun block or adhere to a certain dress code
• women who are pregnant or breastfeeding

If you're at risk of not getting enough vitamin D through your diet or lifestyle, you can take a vitamin D supplement. For adults, 10 micrograms a day of vitamin D is recommended.

The recommended amount for children is 7 micrograms for babies under six months, and 8.5 micrograms for children aged six months to three years. Talk to your GP for more information.

Other factors

Other lifestyle factors that can help prevent osteoporosis include:

• quitting smoking – smoking is associated with an increased risk of osteoporosis
• limiting your alcohol intake – the recommended daily limit is 3-4 units of alcohol for men and 2-3 units for women; it's also important to avoid binge drinking

Get some sun!

Between May and September, sunlight triggers the production ofvitamin D, which helps your body absorb calcium.

This process helps strengthen teeth and bones, which in turn helps prevent conditions such as osteoporosis.

Living with osteoporosis

If you're diagnosed with osteoporosis, there are steps you can take to reduce your chances of a fall, such as removing hazards from your home and having regular sight tests and hearing tests.

To help you recover from a fracture, you can try using:

• hot and cold treatments such as warm baths and cold packs
• transcutaneous electrical nerve stimulation (TENS) – where a small battery-operated device is used to stimulate the nerves and reduce pain
• relaxation techniques

Speak to your GP or nurse if you're worried about living with a long-term condition. They may be able to answer any questions you have.

You may also find it helpful to talk to a trained counsellor or psychologist or other people with the condition.

The National Osteoporosis Society can put you in touch with local support groups, and they also have an online discussion forum.

At-risk groups

Osteoporosis often affects women, particularly after themenopause (when monthly periods stop). However, it can also sometimes affect men, younger women and children.

Other groups who are at risk of developing osteoporosis include:

• people who've been taking steroid medication for more than three months
• women who've had their ovaries removed
• people with a family history of osteoporosis
• people with an eating disorder, such as anorexia or bulimia 
• people who don't exercise regularly
• people who smoke or drink heavily

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Diarrhea

Diarrhea is the frequent passage of loose, watery, soft stools with or without abdominal bloating, pressure, and cramps commonly referred to as gas. Diarrhea can come on suddenly, run its course, and be helped with home care to prevent complications such as dehydration.

• Diarrhea is one of the most common illnesses in all age groups and ranks along with the common cold as a main cause of lost days of work or school.
  • People of all ages can suffer from diarrhea, and the average adult has one episode of acute diarrhea per year, and young children average two acute episodes per year.
• Diarrhea and related complications can cause severe illness. The most significant cause of severe illness is loss of water and electrolytes. In diarrhea, fluid passes out of the body before it can be absorbed by the intestines. When the ability to drink fluids fast enough to compensate for the water loss because of diarrhea is impaired, dehydration can result. Most deaths from diarrhea occur in the very young and the elderly whose health may be put at risk from a moderate amount of dehydration.
• Diarrhea can be further defined in the following ways:
• chronic diarrhea is the presence of loose or liquid stools for over two weeks;
• acute enteritis is inflammation of the intestine;
• gastroenteritis (stomach flu) is diarrhea associated with nausea and vomiting; or
• dysentery is diarrhea that contains blood, pus, or mucus.

• Diarrhea Causes

  
  
  The following are the common causes of diarrhea caused by viral infections:Viral infectionscause most cases of diarrhea and are typically associated with mild-to-moderate symptoms with frequent, watery bowel movements, abdominal cramps, and a low-grade fever. Viral diarrhea generally lasts approximately 3 to 7 days.
  
  
  • rotavirus is a common cause of diarrhea in infants;
  • norovirus (for example, Norwalk virus, caliciviruses) is the most common cause of epidemics of diarrhea among adults and schoolage children (for example, cruise ship infection, schools, nursing homes, day care facilities, and restaurants); and
  • adenovirus infections are common in all age groups.
  Bacterial infections cause the more serious cases of diarrhea. Typically, infection with bacteria occurs from contaminated food or drinks (foodpoisoning). Bacterial infections also cause severe symptoms, often with vomiting, fever, and severe abdominal cramps or abdominal pain. Bowel movements occur frequently and may be watery.
  The following are examples of diarrhea caused by bacterial infections: 
  • In more serious cases, the stool may contain mucus, pus, or blood. Most of these infections are associated with local outbreaks of disease. Family members or others eating the same food may have similar illnesses.
  • Foreign travel is a common way for a person to contract traveler's diarrhea.
  • Campylobacter, salmonellae, and shigella organisms are the most common causes of bacterial diarrhea.
  • Less common causes are Escherichia coli (commonly called E coli)Yersinia, and listeria.
  • Use of antibiotics can lead to an overgrowth of Clostridium difficile (C diff) bacteria in the intestines.
  Parasites cause infection of the digestive system by the use of contaminated water. Common parasitic causes of diarrhea include Giardia lamblia, Entamoeba histolytica, and Cryptosporidium.
  Intestinal disorders or diseases including inflammatory bowel disease, irritable bowel syndrome (IBS), diverticulitis, microscopic colitis, and celiac disease can cause diarrhea.
  Reaction to certain medications can cause diarrhea. Common medications include antibiotics, blood pressure medications, cancer drugs,gout medications, weight loss drugs, and antacids (especially those containing magnesium).
  Intolerance to foods such as artificial sweeteners and lactose (the sugar found in milk) can cause diarrhea.

• Diarrhea Symptoms
• Watery, liquid stools: The stools may be any color. The passage of red stools suggests intestinal bleeding and could be a sign of a more severe infection. The passage of thick, tarry black stools suggests significant bleeding in the stomach or upper portions of the intestine and is not usually caused by acute infections.
• Abdominal cramps: Occasionally diarrhea is accompanied with mild-to-moderate abdominal pain. Severe abdominal or stomach pain is not common and, if present, may suggest more severe disease.
• Fever: A high fever is not common. If present, the affected person may have a more severe illness than acute diarrhea.
• Dehydration: If diarrhea leads to dehydration, it is a sign of potentially serious disease.
• Signs and symptoms of dehydration include:
• Adults may be very thirsty and have a dry mouth.
• The skin of older people may appear to be loose. The elderly may also become very sleepy or have behavioral changes and confusion when dehydrated.
• Dehydrated infants and children may have sunken eyes, dry mouths, and urinate less frequently than usual. They may appear very sleepy or may refuse to eat or drink.

• When to Seek Medical Care

  Diarrhea can usually be treated with home care. In some cases, it may become more severe. A person should go to a hospitalemergency department in the following situations:
  • if the person has diarrhea along with high fever, moderate-to-severe abdominal pain, or dehydration that cannot be managed by drinking fluids;
  • if the diarrhea appears to contain blood (it may be bright red or may look like black, thick tar); or
  • if the person is sleepy and is not acting like their usual selves (others may notice this and take the person to the emergency department).
  Call a health care professional if a person has any of these complications:
  • vomiting and inability to tolerate any food or drink;
  • signs of dehydration;
  • high fever, significant abdominal pain, frequent loose bowel movements, or bloody diarrhea;
  • if he or she is elderly or has serious underlying medical problems, particularly diabetes, heart, kidney, or liver disease, or HIV or AIDS (contact a health care professional when diarrhea first begins as the person may be at higher risk for developing complications);
  • a parent or caregiver needs advice about preventing dehydration in newborns and infants;
  • symptoms do not improve in two to three days or appear to become worse; or
  • if he or she develops diarrhea after travel within their home country, or foreign travel.
  
  

• Diarrhea Diagnosis

  In healthy people with diarrhea, and who appear well otherwise, the health care professional may elect to do no tests at all. Stool cultures (when a sample of the stool is taken and examined in the lab for certain bacteria or parasites) are not usually necessary unless there is high fever, blood in the stool, recent travel, or prolonged disease.

  • In some cases, the health care professional may send a sample of the stool (or sometimes a cotton swab from the patient's rectum) to the laboratory to evaluate if the cause of diarrhea can be determined (such as certain bacteria or parasites present in the body). It usually takes approximately one to two days for the results of these tests.
  • Blood tests are sometimes necessary for patients with other medical problems or with severe disease.
  • A colonoscopy is an endoscope procedure that allows the physician to view the entire colon to evaluate for infections or structural abnormalities that could cause diarrhea.
  • Imaging tests such as X-rays or CT scans are performed to rule out structural abnormalities as the cause of diarrhea, particularly when pain is a prominent symptom

  
  

• Diarrhea Treatment Acute diarrhea may be treated at home. Diarrhea will generally subside in two to three days without specific medical therapy. 

• Diarrhea Self-Care at Home and Remedies

  Diarrhea Treatment in Adults
  Adults should drink plenty of fluids to avoid dehydration.
  • Replenishing water loss (due to diarrhea) is important. Avoid milk as it can make diarrhea worse. Sports beverages (for example, Gatorade or Powerade) can be beneficial because they replenish electrolytes in addition to providing hydration.
  • If the affected person is able to eat, avoid greasy or fatty foods. Adults, infants, toddlers, and children should be encouraged to follow the "BRAT" diet (bananas, rice, applesauce, and toast). The BRAT diet (diarrhea diet) is a combination of foods used for decades to treat diarrhea. If diarrhea is accompanied by nausea, have the person suck on ice chips until the nausea stops. After the diarrhea subsides, avoid alcoholic beverages and spicy foods for two additional days.
  • Individuals should continue their usual activities if they are mildly ill with diarrhea; however, strenuous exercise should be avoided because exercise increases the risk of dehydration.
  • Pregnant women with diarrhea should make sure to rehydrate to avoid dehydration, and should consult their physician.
  Diarrhea Treatment in Children
  Dehydration in children and toddlers can be a great concern.
• Infants and toddlers pose special problems because of their increased risk of dehydration. They should be offered a bottle frequently. Solutions such as Pedialyte may be more appealing than water. These fluids also contain necessary electrolytes lost with diarrhea. Never use salt tablets as they may worsen diarrhea.
• Children with frequent stools, fever, or vomiting should stay at home and avoid school and day-care until these symptoms go away. This allows the child to rest and recover and prevents other children from being exposed to possible infection.
• As mentioned previously, infants, toddlers, and children should be encouraged to follow the "BRAT" diet (bananas, rice, applesauce, and toast). The BRAT diet (diarrhea diet) is a combination of foods used for decades to treat diarrhea. 

• Diarrhea Medical Treatment

  To replace fluids, the health care professional will often start an IV line if the patient is dehydrated and cannot eat or drink. Solutions administered through IV replace the lost fluids and electrolytes, and often brings quick relief to the patient.
  Antibiotics
  Antibiotics are not effective in diarrhea caused by viruses. Even the more severe diarrhea caused by bacteria will usually go away in a few days without antibiotics. Antibiotics appear to make some bacterial diarrhea worse, specifically those caused by the E coli bacterium (often a source of food poisoning).
  In some cases, antibiotics may benefit some adults with diarrhea. If selected carefully, antibiotics may decrease the severity of illness and shorten the duration of symptoms. If a person has recently traveled to another country or has been camping (and may have been exposed to contaminated water in the wilderness), a health care professional may prescribe specific medication used to treat traveler's diarrhea for certain intestinal parasites.
  Over-the-counter antidiarrheal medications
  The health care professional may recommend using over-the-counter antidiarrheal medications. These drugs, such as loperamide (Imodium) andbismuth subsalicylate (Pepto-Bismol, Kaopectate, etc.) may help some individuals with diarrhea, but should be avoided by others. Antidiarrheal medications are not usually recommended for infants and children with diarrhea.
  Hospitalization
  If a person has severe diarrhea, especially accompanied with dehydration, he or she may require hospitalization to receive IV fluids and to be observed

• Diarrhea Medications

  The use of anti-motility medications, although controversial, does provide relief from diarrhea. These drugs slow down the intestinal movement. These medications include loperamide (Imodium) and bismuth subsalicylate (Pepto-Bismol, Kaopectate, etc).
  • Such medications are not recommended for infants and children younger than 5 years of age.
  • In otherwise healthy adults who are not severely ill with diarrhea, loperamide is probably safe and is effective in decreasing the number of stools per day and the total duration of the diarrhea.
  • Bismuth subsalicylate is also useful and may be more effective than loperamide when vomiting accompanies the diarrhea.
  • Adults with other serious medical problems and those with severe diarrhea (high fever, abdominal pain, or bloody stool) should see a health care professional before using either medication.
  Electrolyte solutions are available to prevent salt deficiency.
  • Oral electrolyte solutions are available at grocery and drug stores (Pedialyte, Rehydralyte, Naturalyte Solution).
  • Follow label directions, which may specify 1 teaspoonful every 15 minutes. If the child retains the initial doses, increase the dose to 1 tablespoonful every 15 minutes until the diarrhea stops.

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Deafness and hearing loss

Key facts

• 360 million people worldwide have disabling hearing loss1.
• Hearing loss may result from genetic causes, complications at birth, certain infectious diseases, chronic ear infections, the use of particular drugs, exposure to excessive noise and ageing.
• Half of all cases of hearing loss are avoidable through primary prevention.
• People with hearing loss can benefit from hearing aids, cochlear implants and other assistive devices; captioning and sign language; and other forms of educational and social support.
• Current production of hearing aids meets less than 10% of global need.

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Over 5% of the world’s population – 360 million people – has disabling hearing loss (328 million adults and 32 million children). Disabling hearing loss refers to hearing loss greater than 40 decibels (dB) in the better hearing ear in adults and a hearing loss greater than 30 dB in the better hearing ear in children. The majority of people with disabling hearing loss live in low- and middle-income countries.

Approximately one-third of people over 65 years of age are affected by disabling hearing loss. The prevalence in this age group is greatest in South Asia, Asia Pacific and sub-Saharan Africa.

Hearing loss and deafness

A person who is not able to hear as well as someone with normal hearing – hearing thresholds of 25 dB or better in both ears – is said to have hearing loss. Hearing loss may be mild, moderate, severe or profound. It can affect one ear or both ears, and leads to difficulty in hearing conversational speech or loud sounds.

‘Hard of hearing’ refers to people with hearing loss ranging from mild to severe. They usually communicate through spoken language and can benefit from hearing aids, cochlear implants and other assistive devices as well as captioning. People with more significant hearing losses may benefit from cochlear implants.

‘Deaf’ people mostly have profound hearing loss, which implies very little or no hearing. They often use sign language for communication.

Causes of hearing loss and deafness

The causes of hearing loss and deafness can be divided into congenital causes and acquired causes.

Congenital causes

Congenital causes may lead to hearing loss being present at or acquired soon after birth. Hearing loss can be caused by hereditary and non-hereditary genetic factors or by certain complications during pregnancy and childbirth, including:

• maternal rubella, syphilis or certain other infections during pregnancy;
• low birth weight;
• birth asphyxia (a lack of oxygen at the time of birth);
• inappropriate use of particular drugs during pregnancy, such as aminoglycosides, cytotoxic drugs, antimalarial drugs and diuretics;
• severe jaundice in the neonatal period, which can damage the hearing nerve in a newborn infant.

Acquired causes

Acquired causes may lead to hearing loss at any age, such as:

• infectious diseases such as meningitis, measles and mumps;
• chronic ear infections;
• collection of fluid in the ear (otitis media);
• use of particular drugs, such as some antibiotic and antimalarial medicines;
• injury to the head or ear;
• excessive noise, including occupational noise such as that from machinery and explosions, and recreational noise such as that from personal audio devices, concerts, nightclubs, bars and sporting events;
• ageing, in particular due to degeneration of sensory cells;
• wax or foreign bodies blocking the ear canal.

Among children, chronic otitis media is the leading cause of hearing loss.

Impact of hearing loss

Functional impact

One of the main impacts of hearing loss is on the individual’s ability to communicate with others. Spoken language development is often delayed in children with deafness.

Hearing loss and ear diseases such as otitis media can have a significantly adverse effect on the academic performance of children. However, when opportunities are provided for people with hearing loss to communicate, they can participate on an equal basis with others. The communication may be through spoken/-written language or through sign language.

Social and emotional impact

Limited access to services and exclusion from communication can have a significant impact on everyday life, causing feelings of loneliness, isolation and frustration, particularly among older people with hearing loss.

If a person with congenital deafness has not been given the opportunity to learn sign language as a child, he or she may feel excluded from social interaction.

Economic impact

In developing countries, children with hearing loss and deafness rarely receive any schooling. Adults with hearing loss also have a much higher unemployment rate. Among those who are employed, a higher percentage of people with hearing loss are in the lower grades of employment compared with the general workforce. Improving access to education and vocational rehabilitation services, and raising awareness especially among employers about the needs of people with hearing loss, would decrease unemployment rates among this group.

In addition to the economic impact of hearing loss at an individual level, hearing loss substantially affects social and economic development in communities and countries.

Prevention

Half of all cases of hearing loss can be prevented through primary prevention. Some simple strategies for prevention include:

• immunizing children against childhood diseases, including measles, meningitis, rubella and mumps;
• immunizing adolescent girls and women of reproductive age against rubella before pregnancy;
• screening for and treating syphilis and other infections in pregnant women;
• improving antenatal and perinatal care, including promotion of safe childbirth;
• following healthy ear care practices;
• screening of children for otitis media, followed by appropriate medical or surgical interventions;
• avoiding the use of particular drugs which may be harmful to hearing, unless prescribed and monitored by a qualified physician;
• referring infants at high risk, such as those with a family history of deafness or those born with low birth weight, birth asphyxia, jaundice or meningitis, for early assessment of hearing, prompt diagnosis and appropriate management, as required;
• reducing exposure (both occupational and recreational) to loud sounds by raising awareness about the risks; developing and enforcing relevant legislation; and encouraging individuals to use personal protective devices such as earplugs and noise-cancelling earphones and headphones.

Identification and management

Early detection and intervention are crucial to minimizing the impact of hearing loss on a child’s development and educational achievements. In infants and young children with hearing loss, early identification and management through infant hearing screening programmes can improve the linguistic and educational outcomes for the child. Children with deafness should be given the opportunity to learn sign language along with their families.

Pre-school, school and occupational screening for ear diseases and hearing loss is an effective tool for early identification and management of hearing loss.

People with hearing loss can benefit from the use of hearing devices, such as hearing aids, cochlear implants, and other assistive devices. They may also benefit from speech therapy, aural rehabilitation and other related services. However, global production of hearing aids meets less than 10% of global need and less than 3% of developing countries’ needs. The lack of availability of services for fitting and maintaining these devices, and the lack of batteries are also barriers in many low-income settings. Making properly-fitted, affordable hearing aids and cochlear implants and providing accessible follow-up services in all parts of the world will benefit many people with hearing loss.

People who develop hearing loss can learn to communicate through development of lip-reading skills, use of written or printed text, and sign language. Teaching in sign language will benefit children with hearing loss, while provision of captioning and sign language interpretation on television will facilitate access to information.

Officially recognizing national sign languages and increasing the availability of sign language interpreters are important actions to improve access to sign language services. Human rights legislation and other protections can also help ensure better inclusion for people with hearing loss.

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Disabling hearing loss refers to hearing loss greater than 40dB in the better hearing ear in adults and a hearing loss greater than 30dB in the better hearing ear in children.

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