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CloseIntracardiac and surface ECG tracings during radiofrequency catheter ablation of the right bundle branch in a patient with BBRVTIntracardiac and surface ECG tracings during radiofrequency catheter ablation of the right bundle branch in a patient with BBRVTShown are five surface ECG leads (I, II, aVF, V1, V6) and intracardiac recordings from the His bundle region (HBE2-3,1-2), the right ventricular apex (RVA3-4), and a mapping catheter (USER1) positioned distal to the His catheter along the RV septum. Application of radiofrequency (RF) energy to the tip of the mapping catheter causes two accelerated beats with a typical left bundle branch block (LBBB) morphology (black arrow), likely from heating and activating the right bundle branch. After these beats, complete right bundle branch block (RBBB) is present (red arrow), as evidenced by the change in QRS morphology, particularly in lead V1. Following right bundle branch ablation, the HV interval increased to 105 milliseconds, though no infranodal A-V block was noted. Right bundle branch reentrant tachycardia was no longer inducible. A permanent pacemaker was placed because of the markedly prolonged HV interval.H: His bundle electrogram; A: atrial electrogram; V: ventricular electrogram; ECG: electrocardiogram; RV: right ventricular.Graphic 80017 Version 6.0

The bites of insects and other arthropods may be a minor nuisance or may lead to serious medical problems, including transmission of insect-borne illnesses and severe allergic reactions. Reactions to the bites of mosquitoes, ticks, black flies, horse and deer flies, sand flies, stable flies, biting

CloseTEE of PFOTEE of PFOSystolic and diastolic views from a transesophageal echocardiogram (TEE) showing a "flap" of atrial septal tissue covering the patent foramen ovale (PFO). In early systole, the flap opens and the foramen ovale becomes patent, allowing right-to-left shunting of blood. In diastole, the flap closes, preventing left-to-right shunting.LA: left atrium; RA: right atrium.Courtesy of Thomas Binder, MD. University of Vienna.Graphic 78654 Version 3.0

Closevagin*l ringvagin*l ringThis picture shows the birth control ring. It is a flexible ring that you put in your vagin* for 3 weeks at a time. It delivers hormones into the body that help prevent pregnancy.Graphic 73663 Version 5.0

CloseGluten-free foodsGluten-free foods Amaranth Flax (seed, flax seed meal/flour) and Chia (seed, flour) Quinoa Arrowroot Legume flours (chick pea, lentil) Rice (flour, bran, rice blends), wild rice Bean flours (garbanzo, black bean, etc.) Mesquite flour Sorghum Buckwheat Millet Soy flour Cassava Nut flours (almond, hazelnut) and seed flours (pumpkin, sunflower) Tapioca (flour, starch, pearls) Coconut flour Oats (bran, flour) choose uncontaminated, labeled gluten-free oats Teff Corn (grits, meal, starch, flour, bran) Potato (flour, starch)  The foods listed above are naturally gluten- free. However, naturally gluten-free grains, flours, nuts, seeds, and products made from them may be contaminated with wheat, barley, and/or rye. All grains, starches, and flours made from the foods above must be labeled gluten-free, except for plain rice and plain wild rice: Choose labeled gluten-free nuts and seeds whenever possible, particularly seasoned or dry roasted.Adapted from: Dennis M, Case S. Going gluten-free: a primer for clinicians. Pract Gastroenterol 2004; 28:86.Graphic 54353 Version 11.0

ClosePatient education: Celiac disease in adults (Beyond the Basics)Patient education: Celiac disease in adults (Beyond the Basics)Authors:Ciarán P Kelly, MDMelinda Dennis, MS, RD, LDN Section Editor:J Thomas Lamont, MD Deputy Editor:Shilpa Grover, MD, MPH, AGAFLiterature review current through: Nov 2022. | This topic last updated: Mar 01, 2022.Please read the Disclaimer at the end of this page.CELIAC DISEASE OVERVIEW — Celiac disease is a condition in which the immune system responds abnormally to a protein called gluten, which then leads to damage to the lining of the small intestine. Gluten is found in wheat, rye, barley, and a multitude of prepared foods. Celiac disease was, in the past, also known as gluten-sensitive enteropathy or celiac sprue.The small intestine is responsible for absorbing food and nutrients. Thus, damage to the lining of the small intestines can lead to difficulty absorbing important nutrients; this problem is referred to as "malabsorption." Although celiac disease cannot be cured, avoiding gluten usually stops the damage to the intestinal lining and the malabsorption that results. Celiac disease can occur in people of any age, sex, and race.This article discusses celiac disease in adults. Celiac disease in children is discussed separately. (See"Patient education: Celiac disease in children (Beyond the Basics)".)CELIAC DISEASE SYMPTOMS — The symptoms of celiac disease vary from one person to another. In its mildest form, there may be no symptoms whatsoever. However, even if you have no symptoms, you may not be absorbing nutrients adequately; this can be detected with blood tests.Some people with celiac disease have gastrointestinal symptoms, which commonly include:●Abdominal pain●Diarrhea●Bowel movements that are oily and float●Weight loss●Feeling bloated, or too full all the time●Lack of appetite●Bad gasCertain other medical conditions are more common in people with celiac disease, including:●Osteopenia or osteoporosis (weakening of the bones)●Iron deficiency anemia (low blood count due to lack of iron)●Diabetes mellitus (type I or so-called juvenile onset diabetes mellitus)●Thyroid problems (usually hypothyroidism, an underactive thyroid) (see"Patient education: Hypothyroidism (underactive thyroid) (Beyond the Basics)")●A skin disease called dermatitis herpetiformis (see 'Skin conditions' below)●Nervous system disorders●Liver diseaseCELIAC DISEASE CAUSES — It is not clear exactly what causes some people to develop celiac disease. Both environmental and genetic factors play a role. Celiac disease occurs widely in Europe, North and South America, Australia, North Africa, the Middle East, and in South Asia. Celiac disease occurs rarely in people from other parts of Asia or sub-Saharan Africa.CELIAC DISEASE DIAGNOSIS — Celiac disease can be difficult to diagnose because it can cause so many different symptoms, many of which can also be caused by other conditions. Fortunately, testing is available that can easily distinguish untreated celiac disease from other disorders. Blood tests — A blood test can determine the blood level of antibodies (specific proteins) that become elevated in people with celiac disease. Over 95 percent of people with untreated celiac disease have elevated antibody levels (called IgA tissue transglutaminase, or IgA tTG), while these levels are rarely elevated in those without celiac disease. Levels of other antibodies (called IgA or IgG deamidated gliadin peptide) are also usually abnormally high in untreated celiac disease. Before having these tests, it is important to continue eating foods that contain gluten. Avoiding or eliminating gluten could cause the antibody levels to fall to normal, delaying the diagnosis.Small intestine biopsy — If your blood test is positive, the diagnosis of celiac disease must be confirmed with a biopsy; this involves taking a sample of the intestinal lining and examining it under a microscope. The sample is usually collected during an upper endoscopy, a test that involves swallowing a small flexible instrument with a camera. The camera allows the doctor to examine the upper part of the gastrointestinal system and remove a small piece of the small intestine. The biopsy is not painful. (See"Patient education: Upper endoscopy (Beyond the Basics)".)Normally, the lining of the small intestine has small finger-like structures that can be seen under a microscope, called "villi." Villi allow the small intestine to absorb nutrients from food. When a person with celiac disease ingests gluten, the villi become flattened, and the body cannot properly absorb nutrients. Once the person removes gluten from their diet, the villi can resume a normal growth pattern. More than 70 percent of people with celiac disease begin to feel better within two weeks after stopping gluten."Potential" celiac disease — People with a positive blood test but a normal small intestine biopsy are considered to have potential celiac disease. People with potential celiac disease are not usually advised to eat a gluten-free diet. However, ongoing monitoring (with blood tests) is recommended, and a repeat biopsy may be needed if you develop symptoms. Biopsies should be taken from several areas in the intestine."Silent" celiac disease — If you have a positive blood test for celiac disease and an abnormal small intestine biopsy, but you have no other symptoms of celiac disease, you are said to have "silent" celiac disease. It is not clear if adults with silent celiac disease should eat a gluten-free diet, as there is not sufficient evidence that this is beneficial. Blood tests for malabsorption are recommended, and a gluten-free diet may be needed if you have evidence of malabsorption. A temporary trial of the gluten-free diet for several months may be worthwhile to determine whether subtle, unrecognized celiac symptoms (eg, low energy or mild intestinal symptoms) improve. Testing for malabsorption — You should be tested for nutritional deficiencies if your blood test or biopsy indicates celiac disease. Common tests include measurement of iron, folic acid, or vitamin B12, and vitamin D. You may have other tests if you have signs of mineral or fat deficiency, such as changes in taste or smell, poor appetite, changes in your nails, hair, or skin, or diarrhea.Other tests — Other standard tests include a CBC (complete blood count), lipid levels (total cholesterol, HDL, LDL, and triglycerides), and thyroid levels. Once your celiac antibody levels return to normal, you should have a repeat test once per year. (See 'Blood tests' above.)Many clinicians recommend a test for bone loss 12 months after beginning a gluten-free diet. One method involves using a bone density (DEXA) scan to measures your bone density. The test is not painful and is similar to having an x-ray. If you have significant bone loss, you may need calcium and vitamin D supplements, an exercise program, and possibly a medicine to stop bone loss and encourage new bone growth. (See"Patient education: Bone density testing (Beyond the Basics)".)CELIAC DISEASE COMPLICATIONSNonresponsive celiac disease — Approximately 10 percent of people with celiac disease experience ongoing symptoms despite adhering to a gluten-free diet. There are many causes, including other food intolerances such as fructose (or other fermentable carbohydrates) malabsorption, food allergies, bacterial overgrowth in the small intestine or conditions such as microscopic colitis, irritable bowel syndrome, pancreatic exocrine insufficiency, or refractory celiac disease. However, the most common cause is ongoing, often inadvertent, gluten ingestion. Thus, an essential first step in evaluating nonresponsive celiac disease is consultation with an experienced celiac dietitian.Refractory celiac disease — A small percentage of people develop intestinal symptoms that do not improve despite use of a strict gluten-free diet. In other cases, intestinal symptoms initially improve with dietary changes but then return.People who have these problems may have refractory celiac disease. The cause of this problem is not known. Treatment involves medications that suppress the immune system's abnormal response (eg, steroids). Treatment is important because people with untreated celiac disease can develop anemia, bone loss, and other consequences of malabsorption.Ulcerative jejunitis — People with refractory celiac disease who do not improve with steroids (glucocorticoids) may have a condition known as ulcerative jejunitis. This condition causes the small intestine to develop multiple ulcers that do not heal; other symptoms may include a lack of appetite, weight loss, abdominal pain, diarrhea, and fever. This condition can be difficult to treat. Treatment may require surgery to remove the ulcerated area.Lymphoma — Cancer of the intestinal lymph system (lymphoma) is an uncommon complication of celiac disease. Avoiding gluten can usually prevent this complication.Skin conditions — Celiac disease is associated with a number of skin disorders, of which dermatitis herpetiformis is the most common. Dermatitis herpetiformis is characterized by intensely itchy, raised, fluid-filled areas on the skin, usually located on the elbows, knees, buttocks, lower back, face, neck, trunk, and occasionally within the mouth.The most bothersome symptoms are itching and burning. This feeling is quickly relieved when the blister ruptures. Scratching causes the area to rupture, dry up, and leave an area of darkened skin and scarring. The condition will improve after eliminating gluten from the diet, although it may take several weeks to see significant improvement. In the meantime, an oral medication called dapsone may be recommended. Dapsone relieves the itching but does not heal the lining of the small intestine; thus, the gluten-free diet is the most effective therapy for people with dermatitis herpetiformis.CELIAC DISEASE TREATMENTGluten-free diet — The cornerstone of treatment for celiac disease is complete elimination of gluten from the diet for life. Gluten is the group of proteins found in wheat, rye, and barley that are toxic to those with celiac disease. Gluten is not only contained in these most commonly consumed grains in the Western world, but is also hidden as an ingredient in a large number of prepared foods as well as medications and supplements.Maintaining a gluten-free diet can be a challenging task that may require major lifestyle adjustments. Strict gluten avoidance is recommended since even small amounts can aggravate the disease. It is important to avoid both eating gluten and being exposed to large amounts of flour particles in the air. (See"Management of celiac disease in adults".)Get help from a dietitian — An experienced celiac dietitian can help you to learn how to eat a gluten-free diet, what foods to avoid, and what foods to add for a nutritionally balanced diet. Your dietitian can tailor your gluten-free diet to your own food preferences, culture, lifestyle, calorie needs, and other medical conditions. They can also recommend gluten-free vitamins/minerals and other supplements, as needed.Your celiac dietitian can also educate you on grocery shopping, reading labels, food preparation, dining out, and lifestyle resources. Avoiding cross contact (when gluten-free foods come in contact with gluten-containing ingredients or foods) is also very important. Your dietitian can teach you common sources of cross contact in the kitchen, such as crumbs on the counter or sharing butter, jelly, or other condiments with those who eat gluten. Excellent resources are also available from celiac medical centers, organizations, and support groups. (See 'Where to get more information' below.)Fortunately, life on a gluten-free diet becomes increasingly easier each year due to the rising popularity of gluten-free foods among those with celiac disease, non-celiac gluten sensitivity, and wheat allergies. Excellent gluten-free substitute foods are widely available in supermarkets, health food stores, and online.General tips●Avoid foods containing wheat, rye, barley, malt, brewer's yeast, oats (unless uncontaminated, labeled gluten-free oats), and yeast extract and autolyzed yeast extract (unless the source is identified as gluten-free). "Malt" means "barley malt" unless another grain source is named, such as "corn malt." ●According to US Food and Drug Administration (FDA) regulations issued in 2013, foods with "gluten-free" labeling must contain less than 20 parts per million (ppm) of gluten; this is considered a safe limit for people with celiac disease. The following table has a list of prepared foods that contain or may contain gluten (table 1).●Naturally gluten-free foods include rice, wild rice, corn, potato, and other grains and foods listed in the table (table 2). However, these foods may be contaminated with wheat, barley, or rye. Choose labeled gluten-free versions of these products. Exceptions are fresh corn, fresh potatoes, plain rice and plain wild rice. These foods may not be labeled gluten-free but are still considered safe to eat. Unless they are labeled gluten-free, dried beans, lentils, and other legumes, such as chickpeas, are allowed by law to contain a certain percentage of foreign grain, including wheat, barley, and/or rye. Whether they are labeled gluten-free or not, sort through them carefully and rinse carefully under running water. Choose labeled gluten-free nuts and seeds when possible, particularly seasoned or dry roasted.●Typically, people who have just been diagnosed depend on low-fiber and low-nutrient grains and starches like rice, corn, and potatoes because they are familiar with them. Some foods that contain these products are fortified with extra nutrients, but most companies do not fortify their products. In addition, a low fiber diet can lead to constipation. Adding some of the whole gluten-free grains (quinoa, amaranth, teff, buckwheat, sorghum, and millet) can help improve bowel movements and also increase your nutrients. Make sure they are labeled gluten-free. Be sure to also include plenty of fruits, vegetables, nuts and seeds, legumes and beans (navy, pinto, black, cannellini, etc) in your diet. Add high-fiber foods slowly to give your stomach and intestines time to adjust. When eating a diet rich in fiber, it is important to drink water throughout the day to prevent constipation.●There is some concern over the potential for increased arsenic and other heavy metal exposure in people with celiac disease. Arsenic can be found in rice, and both children and adults with celiac disease consume a high intake of rice and rice-based products. We need more research to understand how this exposure may present a long-term health risk to those with celiac disease. In the meantime, it is another reason to rely less on rice and more on other labeled gluten-free grains. When you prepare rice, rinse it before cooking. Cook it in six times more water than rice (as when you cook pasta), and drain the excess water after the rice has finished cooking to remove about 50 percent of the arsenic [1].  ●If a food is regulated by the FDA and is not labeled gluten-free (such as prepared foods and condiments), read the ingredients list and "contains" statement carefully. The word "wheat" will be included if the product is FDA regulated and contains wheat protein. If you do not see any of the following words on the label of an FDA-regulated food (wheat, rye, barley, malt, brewer's yeast, oats, yeast extract, and autolyzed yeast extract) then the product is unlikely to include any gluten-containing ingredients. However, the Food Allergen Consumer Protection Act pertains to ingredients only. It does not cover wheat protein that may be in a product unintentionally due to cross-contact.●Unlike the FDA, there is no official standard for gluten-free labeling of United States Department of Agriculture (USDA) products. However, if an USDA regulated product has a gluten-free label, it should meet the same standard as FDA products. See USDA labeling information in the resources listed below. ●Distilled alcoholic beverages and vinegars, as well as wine, are gluten-free unless gluten-containing flavorings are added after production. However, malt beverages, including beer, are not considered gluten-free. There are specially produced beers that do not use malted barley that are labeled gluten-free and can be consumed on a gluten-free diet. Avoid beer that is labeled as gluten-removed or gluten-reduced. Please note that malt vinegar is not gluten-free.●You may not tolerate dairy products initially while your intestines are healing. If you tolerated lactose before your diagnosis, you may be able to tolerate it again after the intestine heals. In the meantime, choose lactose-reduced or lactose-free products if your symptoms are worsened by dairy products. Choose labeled gluten-free, dairy-free alternatives, such as rice, soy, or nut (almond, hazelnut) beverages that are enriched with calcium and vitamin D. Keep in mind that gluten-free rice and nut milks have minimal protein per serving compared with cow's or soy milk. Gluten-free lactase enzyme supplements are also available, which may help you to tolerate foods that contain lactose.●Discuss your need for calcium and vitamin D supplements with your health care provider or dietitian.●A small percentage of people with celiac disease cannot tolerate gluten-free oats for several reasons. Pure oats are naturally gluten free, but most are grown in or near barley, rye, and wheat. They can also be processed on the same equipment which contaminates them and makes them unsafe for someone with celiac disease to eat. At this time, there are two methods to produce gluten-free oats. Manufacturers of "purity protocol" oats follow several steps to avoid cross contact, such as separate equipment and facilities that do not share or process gluten-containing grains. Other companies use mechanical and optical sorting methods to "clean" oats. Their special equipment sorts oats from gluten-containing grains based on the differences in size, shape, and other factors. Regardless of the type of gluten-free oats, proper, rigorous testing by the company is the most important step to avoid cross-contact with gluten. All oats consumed, at the very least, must be labeled gluten-free or certified gluten-free. If you choose to eat gluten-free oats, first talk to your doctor who can check your tTG-IgA level and monitor any symptoms. Limit your intake of gluten-free oats to no more than 50 grams (approximately 1/2 cup dry rolled oats or 1/4 cup dry steel-cut oats) per day. If tolerated, you may be able to discuss eating more than 1/2 cup per day under the supervision of your doctor. People with severe or hard to manage disease should avoid even gluten-free oats.Is strict gluten avoidance really necessary? — People who have been diagnosed with celiac disease but have no symptoms often find it difficult to follow a strict gluten-free diet. Indeed, some health care providers have questioned the need for a gluten-free diet in this group. However, certain factors support a gluten-free diet, even in those without symptoms:●Strictly following a gluten-free diet sometimes helps you to feel more energetic and have an improved sense of health and wellbeing.●Some people with celiac disease have vitamin or nutrient deficiencies that do not cause them to feel ill, such as anemia due to iron deficiency or bone loss due to vitamin D deficiency. However, these deficiencies can cause problems over the long term.●Untreated celiac disease can increase the risk of developing certain types of gastrointestinal cancer. This risk can be reduced by eating a gluten-free diet.Ongoing monitoring — Once a person has been on a gluten-free diet for at least four to six weeks, blood tests can be used to confirm that antibody levels are declining (see 'Blood tests' above). The health care provider will also monitor the person for any new or worsening symptoms. IMPLICATIONS FOR THE FAMILY — Eliminating gluten requires a major lifestyle change for you as well as your family. However, with time and practice, it will be easier to know which foods, medications, supplements, and oral care products contain gluten and what alternatives are available. Although eating out can be challenging at first, restaurants have become increasingly interested in serving people with celiac disease by offering a gluten-free menu or ingredient substitutions.Families also need to be aware of their increased risk of celiac disease, as there is a genetic component. If you have been diagnosed with celiac disease, your first-degree relatives (parents, siblings, children) should consider being tested as well, especially if anyone has signs or symptoms of the condition. Testing is typically done with a blood antibody test, as described above. (See 'Blood tests' above.)WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Celiac disease (The Basics) Patient education: Microscopic colitis (The Basics) Patient education: Gluten-free diet (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Celiac disease in children (Beyond the Basics) Patient education: Hypothyroidism (underactive thyroid) (Beyond the Basics) Patient education: Upper endoscopy (Beyond the Basics) Patient education: Bone density testing (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Diagnosis of celiac disease in adults Management of celiac disease in adults Epidemiology, pathogenesis, and clinical manifestations of celiac disease in adultsResources — The following resources also provide reliable information and/or support for people living with celiac disease or non-celiac gluten sensitivity.●Academy of Nutrition and Dietetics (formerly American Dietetic Association)(www.eatright.org)●Beyond Celiac(www.beyondceliac.org)●Celiac Disease Foundation(www.celiac.org)●Gluten Intolerance Group of North Americahttps://gluten.org/●National Celiac Association(www.nationalceliac.org)●National Institute of Diabetes and Digestive and Kidney Diseases(www.niddk.nih.gov)●National Library of Medicine(www.nlm.nih.gov/medlineplus/celiacdisease.html)●Society for the Study of Celiac Disease(www.theceliacsociety.org)●FDA and USDA Labeling•https://www.fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/Allergens/ucm362880.htm•https://www.glutenfreewatchdog.org/news/usda-regulated-foods-and-gluten-free-labeling/•https://www.glutenfreewatchdog.org/news/words-to-look-for-in-usda-regulated-foods-not-labeled-gluten-free/●Thompson T. Academy of Nutrition and Dietetics Pocket Guide to Gluten-Free Strategies for Clients with Multiple Diet Restrictions, 2nd edition. Academy of Nutrition and Dietetics. Chicago 2016. ●Celiac List-serv•Send email message to: celiac@listserv.icors.org•Leave the subject line blank•Text: type SUB celiac your first name your last name (eg, "SUB celiac Joan Smith")Dartmouth Toxic Metals Superfund Research Program. Arsenic and the gluten-free diets. Available at: https://sites.dartmouth.edu/arsenicandyou/arsenic-and-gluten-free-diets/ (Accessed on February 25, 2021).This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 1999 Version 23.0References1 : Dartmouth Toxic Metals Superfund Research Program. Arsenic and the gluten-free diets. Available at: https://sites.dartmouth.edu/arsenicandyou/arsenic-and-gluten-free-diets/ (Accessed on February 25, 2021).

CloseImportant mosquito vector species in malarious areasImportant mosquito vector species in malarious areas Region Species Remarks Tropics (sub-genera Cellia and Nyssorhynchus) Tropical Africa Anopheles gambiae complexAnopheles funestus Highly anthropophilic and abundant in villages - very efficient vectors. South East Asia Anopheles dirusAnopheles minimus Anthropophilic but breed in jungle pools and streams. Indian subcontinent Anopheles culicifaciesAnopheles stephensi An. culicifacies is rural; An. stephensi is mainly urban. Brazilian Amazon Anopheles darlingi Biting time varies regionally. Central America Anopheles albimanus Bites in the evening. Multiple insecticide resistance. New Guinea Anopheles punctulatus Malaria transmission in lowlands as intense as in Africa. Temperate zone (sub-genus Anopheles) China Anopheles sinensis group Breeds in rice fields. Turkey and Central Asia Anopheles maculipennis complex These mosquitoes were the vectors when there was malaria in Europe and they are still present today. 8.00000000000000Table<a href="/Graphics/Pages/TableEditor.aspx?SPID=31098&Mode=Edit"></a>Important_mosquito_vectors.htmGraphic 56132 Version 1.0

CloseObtaining an exposure history in returned travelersObtaining an exposure history in returned travelers Exposure history Examples Typical infections/pathogens to consider General When did you travel?Rainy season Malaria, dengue, chikungunya, Japanese encephalitis, West Nile virus, and other mosquito-borne infections Dry season Meningococcal disease (Neisseria meningitidis) How long did you travel?Long stay Tuberculosis What kind of places did you stay in?Local house, rudimentary construction Numerous pathogens, especially vector borne and rodent borne Where did you visit?Rural areas Numerous vector-borne diseases and food- and water-borne pathogens What was the main reason for your trip?Visiting friends and relatives Malaria, enteric fever, tuberculosis Specific exposures What did you do?Visit relatives, field research, construction, safaris, visit slums, help in clinic, sightsee, attend meetings, teach/attend classes Pathogens vary depending on activities. Travelers active outdoors may have exposure to ticks, mosquitoes, and other vectors and associated infections (eg, malaria, rickettsiosis, leishmaniasis), whereas travelers with close contact with local people may have exposure via blood, secretions, or direct contact (eg, HIV, hepatitis B, meningococcus, tuberculosis). What did you eat or drink?Tap water, ice in drinks, raw vegetables, undercooked meats, questionable hygiene practices Salmonella spp, Shigella spp, Campylobacter spp, hepatitis A, hepatitis E, amebic dysentery or liver abscess, eosinophilic meningitis Did you have unpasteurized dairy, for example, home-made cheese?Unpasteurized dairy Brucella, other, Listeria Did you eat raw or undercooked foods?Undercooked meats Campylobacter, Salmonella, Escherichia coli O157, Toxoplasma, Trichinella Undercooked shellfish Hepatitis A, Vibrios, Clonorchis, Paragonimus Raw vegetables, watercress Fasciola Did you have any insect bites such as mosquito bites?Mosquitoes Malaria; many arboviruses, including dengue, Japanese encephalitis, West Nile virus, Rift Valley fever Did you have any tick bites or go hiking or walk through tall grasses or woods?Ticks Rickettsia (in travelers most commonly Rickettsia africae), Babesia, Anaplasma, Ehrlichia, Lyme disease, Crimean-Congo hemorrhagic fever, tick-borne encephalitis Did you notice any fleas or other vectors, or bugs, or were you around animals that might have had fleas or lice?Fleas Rickettsia typhi (endemic typhus), Yersinia pestis Lice Rickettsia prowazekii (epidemic typhus), Borrelia (relapsing fever) Mites Orientia tsutsugamushi (scrub typhus) Sandflies Leishmania Black flies Onchocerca volvulus Triatomine bugs American trypanosomiasis Tsetse flies African trypanosomiasis Were you in large gatherings?Air-borne particles, crowded living conditions Influenza, measles, other respiratory infections Did you participate in digging, excavating, or construction?Soil, excavations Coccidioides imitis (coccidioidomycosis), Histoplasma capsulatum (histoplasmosis) Did you swim, wade, or splash around in fresh water?Swimming in lakes, ponds, rivers, streams Schistosoma, Leptospira Did you have close contact with any animals? Any bites, scratches, or licks?Bites, spelunking Rabies Handling animals Brucella, anthrax, Yersinia pestis, Coxiella burnetti, Francisella tularensis, Toxoplasma Primates Simian B virus Rodents Yersinia pestis, hantaviruses, Lassa fever and other hemorrhagic fevers, rat-bite fever, Rickettsia typhi Birds Chlamydophila psittaci, avian influenza Did you have sexual contact or contact with blood, body fluids, secretions, or procedures that may expose you to these?Sexual contact; injections, transfusion, medical procedure, tattoos, piercings, dental work, shaving by barber with reused razor Acute HIV; hepatitis A, B, C, D; CMV, EBV; syphilis; viral hemorrhagic fevers Immunization history Have you had routine immunizations, and were they updated before travel?Verify immunity to these routine vaccines MMR, polio, Td/Tdap, hepatitis B, influenza, chickenpox Age-specific recommendations HPV, shingles, pneumococcal Asplenic host recommendations Haemophilus influenzae b, meningococcal, pneumococcal Have you had travel immunizations?– Hepatitis A, Japanese encephalitis, meningococcal, polio, rabies, typhoid, yellow feverReproduced with permission from: Wilson ME, Chen LH. Fever in returning travelers. Sci Am Med 2015. Copyright © 2017 Decker. All rights reserved.Graphic 113654 Version 5.0

Improvement in serum lipids can be achieved through lifestyle changes including dietary modification [1,2]. A dietary approach to lipid management, including an overall change in dietary pattern, the use of specific dietary components, and the use of supplements, may be used with or without adjuncti

CloseSurface 12-lead ECG showing left septal fascicular block (LSFB)Surface 12-lead ECG showing left septal fascicular block (LSFB)Surface 12-lead ECG depicting second-degree atrioventricular block and phase 4 or bradycardia-dependent LSFB.ECG: electrocardiogram; LSFB: left septal fascicular block.Original figure modified for this publication. From: Ibarrola M, Chiale PM, Pérez-Riera AR, Baranchuk A. Phase 4 left septal fascicular block. Heart Rhythm 2014; 11:1655. Illustration used with the permission of Elsevier Inc. All rights reserved.Graphic 118370 Version 2.0

CloseRigid bronchoscope and jet ventilation attachmentRigid bronchoscope and jet ventilation attachment(A) Rigid bronchoscope with port for jet ventilation and jet ventilation attachment. (B) Assembled rigid bronchoscope attached to jet ventilator.Graphic 130159 Version 1.0

CloseArteries of proximal upper limb: Anterior viewArteries of proximal upper limb: Anterior viewReproduced with permission from: Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy, 7th Edition. Lippincott Williams & Wilkins, Philadelphia 2013. Copyright © 2013 Lippincott Williams & Wilkins. www.lww.com.Graphic 94863 Version 3.0

CloseUSDA recommended daily or weekly caloric intake of different food groups (USDA recommended average daily food intake)USDA recommended daily or weekly caloric intake of different food groups (USDA recommended average daily food intake) Calorie level of pattern* 1000 1200 1400 1600 1800 2000 Food group¶ Daily amountΔ of food from each group (vegetable and protein foods subgroup amounts are per week) Vegetables 1 c-eq 1½ c-eq 1½ c-eq 2 c-eq 2½ c-eq 2½ c-eq Dark-green vegetables (c-eq/week) ½ 1 1 1½ 1½ 1½ Red and orange vegetables (c-eq/week) 2½ 3 3 4 5½ 5½ Legumes (beans and peas) (c-eq/week) ½ ½ ½ 1 1½ 1½ Starchy vegetables (c-eq/week) 2 3½ 3½ 4 5 5 Other vegetables (c-eq/week) 1½ 2½ 2½ 3½ 4 4 Fruits 1 c-eq 1 c-eq 1½ c-eq 1½ c-eq 1½ c-eq 2 c-eq Grains 3 oz-eq 4 oz-eq 5 oz-eq 5 oz-eq 6 oz-eq 6 oz-eq Whole grains◊ (oz-eq/day) 1½ 2 2½ 3 3 3 Refined grains (oz-eq/day) 1½ 2 2½ 2 3 3 Dairy 2 c-eq 2½ c-eq 2½ c-eq 3 c-eq 3 c-eq 3 c-eq Protein foods 2 oz-eq 3 oz-eq 4 oz-eq 5 oz-eq 5 oz-eq 5½ oz-eq Seafood (oz-eq/week) 3 4 6 8 8 8 Meats, poultry, eggs (oz-eq/week) 10 14 19 23 23 26 Nuts seeds, soy products (oz-eq/week) 2 2 3 4 4 5 Oils 15 g 17 g 17 g 22 g 24 g 27 g Limit on calories for other uses, calories (% of calories)§¥ 150 (15%) 100 (8%) 110 (8%) 130 (8%) 170 (9%) 270 (14%)USDA: United States Department of Agriculture.* Food intake patterns at 1000, 1200, and 1400 calories are designed to meet the nutritional needs of 2- to 8-year-old children. Patterns from 1600 to 3200 calories are designed to meet the nutritional needs of children 9 years and older as well as adults. If a child 4 to 8 years of age needs more calories and, therefore, is following a pattern at 1600 calories or more, their recommended amount from the dairy group should be 2.5 cups per day. Children 9 years and older and adults should not use the 1000-, 1200-, or 1400-calorie patterns.¶ Foods in each group and subgroup are: Vegetables Dark-green vegetables: All fresh, frozen, and canned dark-green leafy vegetables and broccoli, cooked or raw: for example, broccoli, spinach, romaine, kale, collard, turnip, and mustard greens.Red and orange vegetables: All fresh, frozen, and canned red and orange vegetables or juice, cooked or raw: for example, tomatoes, tomato juice, red peppers, carrots, sweet potatoes, winter squash, and pumpkin.Legumes (beans and peas): All cooked from dry or canned beans and peas: for example, kidney beans, white beans, black beans, lentils, chickpeas, pinto beans, split peas, and edamame (green soybeans). Does not include green beans or green peas.Starchy vegetables: All fresh, frozen, and canned starchy vegetables: for example, white potatoes, corn, green peas, green lima beans, plantains, and cassava.Other vegetables: All other fresh, frozen, and canned vegetables, cooked or raw: for example, iceberg lettuce, green beans, onions, cucumbers, cabbage, celery, zucchini, mushrooms, and green peppers.Fruits All fresh, frozen, canned, and dried fruits and fruit juices: for example, oranges and orange juice, apples and apple juice, bananas, grapes, melons, berries, and raisins.Grains Whole grains: All whole-grain products and whole grains used as ingredients: for example, whole-wheat bread, whole-grain cereals and crackers, oatmeal, quinoa, popcorn, and brown rice.Refined grains: All refined-grain products and refined grains used as ingredients: for example, white breads, refined grain cereals and crackers, pasta, and white rice. Refined grain choices should be enriched.Dairy All milk, including lactose-free and lactose-reduced products and fortified soy beverages (soymilk), yogurt, frozen yogurt, dairy desserts, and cheeses. Most choices should be fat-free or low-fat. Cream, sour cream, and cream cheese are not included due to their low-calcium content.Protein foods All seafood, meats, poultry, eggs, soy products, nuts, and seeds. Meats and poultry should be lean or low-fat and nuts should be unsalted. Legumes (beans and peas) can be considered part of this group as well as the vegetable group, but should be counted in one group only.Δ Food group amounts shown in cup-(c) or ounce-equivalents (oz-eq). Oils are shown in grams (g). Quantity equivalents for each food group are: Vegetables and fruits, 1 cup-equivalent is: 1 cup raw or cooked vegetable or fruit, 1 cup vegetable or fruit juice, 2 cups leafy salad greens, ½ cup dried fruit or vegetable.Grains, 1 ounce-equivalent is: ½ cup cooked rice, pasta, or cereal; 1 ounce dry pasta or rice; 1 medium (1 ounce) slice bread; 1 ounce of ready-to-eat cereal (about 1 cup of flaked cereal).Dairy, 1 cup-equivalent is: 1 cup milk, yogurt, or fortified soymilk; 1½ ounces natural cheese such as cheddar cheese or 2 ounces of processed cheese.Protein foods, 1 ounce-equivalent is: 1 ounce lean meat, poultry, or seafood; 1 egg; ¼ cup cooked beans or tofu; 1 Tbsp peanut butter; ½ ounce nuts or seeds.◊ Amounts of whole grains in the patterns for children are less than the minimum of 3 oz-eq in all patterns recommended for adults.§ All foods are assumed to be in nutrient-dense forms, lean or low-fat, and prepared without added fats, sugars, refined starches, or salt. If all food choices to meet food group recommendations are in nutrient-dense forms, a small number of calories remain within the overall calorie limit of the pattern (ie, limit on calories for other uses). The number of these calories depends on the overall calorie limit in the pattern and the amounts of food from each food group required to meet nutritional goals. Nutritional goals are higher for the 1200- to 1600-calorie patterns than for the 1000-calorie pattern, so the limit on calories for other uses is lower in the 1200- to 1600-calorie patterns. Calories up to the specified limit can be used for added sugars, added refined starches, solid fats, alcohol, or to eat more than the recommended amount of food in a food group. The overall eating pattern also should not exceed the limits of less than 10% of calories from added sugars and less than 10% of calories from saturated fats. At most calorie levels, amounts that can be accommodated are less than these limits. For adults of legal drinking age who choose to drink alcohol, a limit of up to 1 drink per day for females and up to 2 drinks per day for males within limits on calories for other uses applies; and calories from protein, carbohydrate, and total fats should be within the acceptable macronutrient distribution ranges (AMDRs).¥ Values are rounded.Reproduced from: U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans, 8th Edition, December 2015. Available at: https://health.gov/our-work/food-nutrition/previous-dietary-guidelines/2015 (Accessed on April 7, 2021).Graphic 106206 Version 6.0

CloseGeneration of target gene for knockout miceGeneration of target gene for knockout miceSchematic of targeting vector and positive/negative selection. A schematic depicting a targeting vector is shown at the top. Plasmid backbone sequences are shown with thin lines. The herpes simplex virus-thymidine kinase (HSV-TK) box represents the negatively selected marker herpes virus thymidine kinase. The hatched boxes represent sequences present in the target gene. The NEOR box represents the positively selected marker neomycin resistance. When this targeting construct is transfected into (embryonic stem) ES cells, a small fraction of the transfected cells will undergo hom*ologous recombination mediated by the target gene sequences included in the vector. This is shown schematically by the Xs representing crossover points. The location of the transcript of the target gene is shown by the heavy black arrow. A double recombination, as pictured, will substitute the neomycin resistance marker for the native portion of the gene lying between the crossover points. This deletion disrupts the gene, thereby "knocking out" its function. Positive selection is applied by growing the transfected cells in the presence of G418, a toxic drug that is inactivated by NEOR. Negative selection is applied by growing the transfected cells in the presence of gancyclovir, which is converted to a toxin by HSV-TK. Thus, the population is enriched for cells retaining NEOR and simultaneously losing HSV-TK.Courtesy of Robert D Blank, MD, PhD.Graphic 79203 Version 1.0

In the genus Yersinia, three species are important human pathogens: Yersinia pestis, Yersinia enterocolitica, and Yersinia pseudotuberculosis. The yersinioses are zoonotic infections of domestic and wild animals; humans are considered incidental hosts that do not contribute to the natural disease cy

Rickettsia rickettsii is the causative agent of Rocky Mountain spotted fever (RMSF) and the prototypic member of the genus Rickettsia. The basic biologic features of R. rickettsii and how it produces disease will be reviewed here. The clinical manifestations of RMSF and its treatment are discussed s

CloseIncreased C1 to C2 spinous process distanceIncreased C1 to C2 spinous process distance(A) This figure demonstrates an example of an enlarged C1–2:C2–3 ratio (20:6) in a patient with tectorial membrane disruption as the bones would appear on lateral cervical spine radiograph or sagittal computed tomography cervical spine reconstruction.(B) Disrupted. The enlarged C1–2:C2–3 ratio in tectorial membrane disruption may be created by the vectors illustrated on this sagittal figure. The craniocervical junction is flexed in an supine young child on a flat surface (long curved arrow). Without an intact tectorial membrane firmly strapping the flexed cranium to C-2, the occipital condyles push down on the anterior rim of cup-shaped C-1 articulation (red arrow) and rotate the posterior ring of C-1 superiorly (straight black arrow). This enlarges the C1–2 interspace relative to the C2–3 interspace to create the abnormal C1–2:C2–3 ratio.(C) Normal. The entire Oc—C2 complex moves up as a unit with an intact tectorial membrane (solid black line). Movement of the occipital condyle is limited to rotation within the cup-shaped C-1 articulation (curved black arrow), and the joint relationship is maintained (straight black arrow).Graphic 62857 Version 6.0

ST- and T-wave changes may represent cardiac pathology or be a normal variant. Interpretation of the findings, therefore, depends on the clinical context and presence of similar findings on prior electrocardiograms.NONSPECIFIC ST-T-WAVE CHANGES — Nonspecific ST-T-wave changes are very comm

Ticks transmit a number of infections to humans and other animals. However, the toxins of various ticks can also cause a disease known as tick paralysis, which can be confused with both infectious and noninfectious conditions.Tick paralysis was first described by explorers in the Australian outback

ClosePatient education: Acute diarrhea in adults (Beyond the Basics)Patient education: Acute diarrhea in adults (Beyond the Basics)Authors:Regina LaRocque, MD, MPHJason B Harris, MD, MPH Section Editor:Stephen B Calderwood, MD Deputy Editor:Elinor L Baron, MD, DTMHLiterature review current through: Nov 2022. | This topic last updated: May 24, 2022.Please read the Disclaimer at the end of this page.DIARRHEA OVERVIEW — Diarrhea is commonly defined as three or more loose or watery stools per day. Nearly everyone will have an episode of diarrhea at some point during their life, with the average adult experiencing it four times per year. Although most cases of diarrhea resolve within a few days without treatment, it's important to know when to seek help.This topic review discusses the causes and treatments of sudden onset (acute) diarrhea in adults in developed countries. A discussion of acute diarrhea in resource-limited countries and returning travelers is not included here. Diarrhea that lasts for more than 14 days (called chronic diarrhea) and acute diarrhea in children are discussed in separate topic reviews. (See"Patient education: Chronic diarrhea in adults (Beyond the Basics)" and"Patient education: Acute diarrhea in children (Beyond the Basics)".) A topic review that discusses antibiotic-associated diarrhea is also available. (See"Patient education: Antibiotic-associated diarrhea caused by Clostridioides difficile (Beyond the Basics)".)DIARRHEA CAUSES — Diarrhea can be caused by infections or a variety of other factors. The cause of diarrhea is not identified in most people, especially those who improve without treatment.Diarrhea caused by infections usually results from eating or drinking contaminated food or water. Signs and symptoms of infection usually begin 12 hours to four days after exposure and resolve within three to seven days. (See"Patient education: Foodborne illness (food poisoning) (Beyond the Basics)".)Diarrhea not related to an infection can occur as a side effect of antibiotics or other drugs, food allergies, gastrointestinal diseases such as inflammatory bowel disease, and other diseases. In addition, there are many less common causes of diarrhea. A summary of the various common causes of diarrhea is available in the table (table 1).DIARRHEA SYMPTOMS — A person with diarrhea may be mildly to severely ill. A person who has mild illness may have a few loose bowel movements but otherwise feels well. By contrast, a person with severe diarrhea may have 20 or more bowel movements per day, happening up to every 20 or 30 minutes. In this situation, a significant amount of water and salts can be lost, seriously increasing the risk of dehydration. Diarrhea may be accompanied by fever (temperature greater than 100.4°F or 38°C), abdominal pain, or cramping.DIARRHEA HOME CAREDrink adequate fluids — If you have mild to moderate diarrhea, you can usually be treated at home by drinking extra fluids. The fluids should contain water, salt, and sugar. Oral rehydration solution (ORS), a specific mixture of glucose and sodium, is the best first-line treatment and is available in over-the-counter commercial preparations. Sports drinks (eg, Gatorade) are not optimal for fluid replacement, although they may be sufficient for a person with diarrhea who is not dehydrated and is otherwise healthy. Diluted fruit juices and flavored soft drinks along with salted crackers and broths or soups may also be acceptable.One way to judge hydration is by looking at the color of your urine and monitoring how frequently you urinate. If you urinate infrequently or have urine that is dark yellow, you should drink more fluids. Normally, urine should be light yellow to nearly colorless. If you are well hydrated, you normally pass urine every three to five hours.If you become dehydrated and are unable to take fluids by mouth, a rehydration solution can be given into a vein (intravenous fluids) in a health care provider's office or in the emergency department.Diet — There is no particular food or group of foods that is best while you have diarrhea. However, adequate nutrition is important during an episode of acute diarrhea. If you do not have an appetite, you can drink only liquids for a short period of time. Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oats) with salt are recommended if you have watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be eaten.Antidiarrheal medications — Medications to reduce diarrhea are available, and are safe if there is no fever (temperature greater than 100.4°F or 38°C) and the stools are not bloody. These medications do not cure the cause of the diarrhea, but help to reduce the frequency of bowel movements.●Loperamide (Imodium®) is available without a prescription; the dose is two tablets (4 mg) initially, then 1 tablet (2 mg) after each unformed stool. No more than 16 mg is recommended per day. If you take loperamide, be careful to never exceed the dose on the label unless specifically instructed by your doctor. Taking more than the recommended dose has led to serious heart problems in some people.●Diphenoxylate-atropine (Lomotil®) is a prescription medication used to treat diarrhea; its benefit is similar to loperamide, although it can be associated with more bothersome side effects.●Bismuth subsalicylate (Pepto-Bismol®, Kaopectate®) has also been used for treatment of acute diarrhea, although it is not as effective as loperamide. Bismuth subsalicylate may be recommended in certain situations, such as if you have fever and bloody diarrhea. However, women who are pregnant should not take bismuth subsalicylate. The dose of bismuth subsalicylate is 30 mL or two tablets every 30 minutes for up to eight doses.Antibiotics — Antibiotics are not needed in most cases of acute diarrhea, and they can cause further complications if used inappropriately. Antibiotics may be recommended in certain situations, such as if you have the following signs or symptoms:●More than eight loose stools per day ●Fever●Bloody stool●Dehydration●Symptoms that continue for more than one week●A weakened immune system●You require hospitalizationHowever, the decision to use antibiotics must be made carefully after discussing the potential risks and benefits with a health care provider who is familiar with the situation.Preventing spread — Adults with diarrhea should be cautious to avoid spreading infection to family, friends, and co-workers. You are considered infectious for as long as diarrhea continues. Microorganisms causing diarrhea are spread from hand to mouth; hand washing, care with diapering, and staying out of work or school are a few ways to prevent infecting family and other contacts.Hand washing — Hand washing is an effective way to prevent the spread of infection. Hands should ideally be wet with water and plain or antibacterial soap and rubbed together for 15 to 30 seconds. Pay special attention to the fingernails, between the fingers, and the wrists. Rinse your hands thoroughly and dry with a single use towel.If a sink is not available, alcohol-based hand rubs are a good alternative for disinfecting hands. Spread the hand rub over the entire surface of your hands, fingers, and wrists until dry. Hand rubs may be used several times. Hand rubs are available as a liquid or wipe in small, portable sizes that are easy to carry in a pocket or handbag. When a sink is available and your hands are visibly dirty, it is best to wash them with soap and water.Clean your hands after changing a diaper, before and after preparing food and eating, after going to the bathroom, after handling garbage or dirty laundry, after touching animals or pets, and after blowing your nose or sneezing.DIARRHEA PREVENTIONFood safety — The following precautions have been recommended for all consumers by the Food Safety and Inspection Services (www.fsis.usda.gov) and the Centers for Disease Control and Prevention.●Do not drink raw (unpasteurized) milk or foods that contain unpasteurized milk.●Wash raw fruits and vegetables thoroughly before eating.●Keep the refrigerator temperature at 40°F (4.4°C) or lower; the freezer at 0°F (-17.8°C) or lower.●Eat precooked, perishable, or ready-to-eat food as soon as possible.●Keep raw meat, fish, and poultry separate from other food.●Wash hands, knives, and cutting boards after handling uncooked food, including produce and raw meat, fish, or poultry.●Thoroughly cook raw food from animal sources to a safe internal temperature: ground beef 160°F (71°C); chicken 170°F (77°C); turkey 180°F (82°C); pork 145°F (63°C) with a three minute rest time.●Seafood should be cooked thoroughly to minimize the risk of food poisoning. Eating raw fish (eg, sushi) poses a risk for a variety of parasitic worms (in addition to the risks associated with organisms carried by food handlers). Freezing kills some, although not all, harmful microorganisms. Raw fish that is labeled "sushi-grade" or "sashimi-grade" has been frozen.●Cook chicken eggs thoroughly, until the yolk is firm.●Refrigerate foods promptly. Never leave cooked foods at room temperature for more than two hours (one hour if the room temperature is above 90°F/32°C).Food safety for pregnant women or those with a weakened immune system — The following additional recommendations apply to pregnant women and those who have a weakened immune system:●Do not eat hot dogs, pâtés, luncheon meats, bologna, or other delicatessen meats unless they are reheated until steaming hot; avoid the use of microwave ovens since uneven cooking may occur.●Avoid spilling fluids from raw meat and hot dog packages on other foods, utensils, and food preparation surfaces. In addition, wash your hands after handling hot dogs, luncheon meats, delicatessen meats, and raw meat, chicken, turkey, or seafood or their juices.●Do not eat pre-prepared salads, such as ham salad, chicken salad, egg salad, tuna salad, or seafood salad.●Do not eat soft cheeses such as feta, Brie, and Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, or Panela, unless they have a label that clearly states that the cheese is made from pasteurized milk.●Do not eat refrigerated pates or meat spreads. Canned or shelf-stable products may be eaten.●Do not eat refrigerated smoked seafood unless it has been cooked. Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna or mackerel, is most often labeled as "nova-style," "lox," "kippered," "smoked," or "jerky." The fish is found in the refrigerator section or sold at deli counters of grocery stores and delicatessens. Canned or shelf-stable smoked seafood may be eaten.Travelers' diarrhea prevention — Recommendations to prevent travelers' diarrhea are available separately. (See"Patient education: General travel advice (Beyond the Basics)".)WHEN TO SEEK HELP FOR DIARRHEA — If your diarrhea is not severe, you do not always need to be seen by a doctor, especially if the diarrhea begins to improve within 48 hours. Self-care measures for this situation are discussed above (see 'Diarrhea home care' above).However, if you have one or more of the following signs or symptoms, you should be evaluated by a health care provider:●Profuse watery diarrhea with signs of dehydration. Early features of dehydration include sluggishness, becoming tired easily, dry mouth and tongue, thirst, muscle cramps, dark-colored urine, urinating infrequently, and dizziness or lightheadedness after standing or sitting up. More severe features include abdominal pain, chest pain, confusion, or difficulty remaining alert.●Many small stools containing blood and mucus●Bloody or black diarrhea●Temperature ≥38.5°C (101.3°F)●Passage of ≥6 unformed stools per 24 hours or illness that lasts more than 48 hours●Severe abdominal pain/painful passage of stoolIn addition, if you have persistent diarrhea following antibiotics, are older than 65 years, have other medical illness or a weakened immune system, you should also consult your health care provider.SUMMARY●Acute diarrhea is defined as three or more loose or watery stools per day.●Diarrhea can be caused by infections or other factors. Sometimes, the cause of diarrhea is not known. Diarrhea caused by an infection usually begins 12 hours to four days after exposure and resolves within three to seven days.●A person may have mild to severe diarrhea. Some people with diarrhea also have fever (temperature greater than 100.4°F or 38°C), abdominal pain, or cramping.●People with mild diarrhea do not usually need to go to the doctor, especially if the diarrhea begins to improve within 48 hours. If you develop any of the following, you should call your doctor or nurse immediately:•Profuse watery diarrhea with sluggishness, becoming tired easily, dry mouth and tongue, thirst, muscle cramps, dark-colored urine, urinating infrequently, and dizziness or lightheadedness after standing or sitting up. More severe features include abdominal pain, chest pain, confusion, or difficulty remaining alert.•Passage of many small stools containing blood and mucus•Bloody or black diarrhea•Temperature ≥38.5°C (101.3°F)•Passing 6 or more watery stools per 24 hours or illness that lasts more than 48 hours•Severe abdominal pain●In addition, if you have persistent diarrhea after finishing antibiotics, are older than 69, or have other medical illness or a weakened immune system, you should also consult your doctor or nurse.●The most important treatment for diarrhea is to drink fluids that contain water, salt, and sugar, such as oral rehydration solution (ORS). Sports drinks (eg, Gatorade) may be acceptable if you are not dehydrated and are otherwise healthy. Diluted fruit juices and flavored soft drinks along with saltine crackers and broths or soups may also be acceptable.●If you have dark yellow colored urine or do not pass urine frequently, you should drink more fluids. The urine should normally be light yellow to clear colored.●Medications to reduce diarrhea are available without a prescription, and are safe if there is no fever (temperature greater than 100.4°F or 38°C) and the stools are not bloody. These medications do not cure the cause of the diarrhea, but help to reduce the frequency of bowel movements. Common medications include loperamide (Imodium®), diphenoxylate-atropine (Lomotil®), and bismuth subsalicylate (Pepto-Bismol® or Kaopectate®).●If you do not have an appetite, you can drink only liquids for a short period of time. Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oat) with salt are recommended if you have watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be eaten.●Antibiotics are not needed for most people with diarrhea.●If you have diarrhea, be careful to avoid spreading the infection to family, friends, and co-workers. You are contagious for as long as diarrhea continues. Infections are usually spread from hand to mouth; hand washing, care with diapering, and staying out of work or school are a few ways to prevent infecting family and other contacts.WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Diarrhea in adolescents and adults (The Basics) Patient education: Diarrhea in children (The Basics) Patient education: Food poisoning (The Basics) Patient education: Lactose intolerance (The Basics) Patient education: C. difficile infection (The Basics) Patient education: Managing loss of appetite and weight loss with cancer (The Basics) Patient education: Dehydration in children (The Basics) Patient education: Ischemic bowel disease (The Basics) Patient education: Cryptosporidiosis (The Basics) Patient education: Salmonella infection (The Basics) Patient education: Travelers' diarrhea (The Basics) Patient education: E. coli diarrhea (The Basics) Patient education: Listeria (The Basics) Patient education: Campylobacter infection (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Chronic diarrhea in adults (Beyond the Basics) Patient education: Acute diarrhea in children (Beyond the Basics) Patient education: Antibiotic-associated diarrhea caused by Clostridioides difficile (Beyond the Basics) Patient education: Foodborne illness (food poisoning) (Beyond the Basics) Patient education: General travel advice (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Approach to the adult with acute diarrhea in resource-rich settings Clinical manifestations, diagnosis, and treatment of Campylobacter infection Clostridioides difficile infection in adults: Clinical manifestations and diagnosis Shigella infection: Clinical manifestations and diagnosis Shiga toxin-producing Escherichia coli: Clinical manifestations, diagnosis, and treatment Clinical manifestations and diagnosis of rotavirus infection Cryptosporidiosis: Epidemiology, clinical manifestations, and diagnosis Pathogenic Escherichia coli associated with diarrhea Causes of acute infectious diarrhea and other foodborne illnesses in resource-rich settings Norovirus Cholera: Clinical features, diagnosis, treatment, and prevention Acute viral gastroenteritis in adultsThe following organizations also provide reliable health information.●National Library of Medicine(www.nlm.nih.gov/medlineplus/healthtopics.html)●National Institute of Digestive and Diabetes and Kidney Diseases(www.niddk.nih.gov/health-information/digestive-diseases/diarrhea)●Center for Disease Control and Prevention(www.cdc.gov)●American College of Gastroenterology(www.acg.gi.org/patients/gihealth/diarrheal.asp)[1-3]Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis 2017; 65:e45.Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol 2016; 111:602.DuPont HL. Acute infectious diarrhea in immunocompetent adults. N Engl J Med 2014; 370:1532.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 4021 Version 32.0References1 : 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea.2 : ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults.3 : Acute infectious diarrhea in immunocompetent adults.