1. Acute tubular necrosis
2. Addison disease
3. Adenoid removal
6. Adjustment disorder
7. Adolescent development
8. Adolescent pregnancy
9. Adolescent test or procedure preparation
10. Adrenal glands
12. Adrenergic bronchodilator overdose
13. Adrenocortical carcinoma
15. Adult Still's disease
16. Advance care directives
18. Aerobic bacteria
20. After a C-section - in the hospital
Acute tubular necrosis is a kidney disorder involving damage to the
tubule cells of the kidneys, which can lead to acute kidney failure.
01. Acute tubular necrosis
CausesAcute tubular necrosis (ATN) is usually caused by a lack of oxygen to the kidney tissues (ischemia of the kidneys). It may also occur if the kidney cells are damaged by a poison or harmful substance.
The internal structures of the kidney, particularly the tissues of the kidney tubule, become damaged or destroyed. ATN is one of the most common structural changes that can lead to acute renal failure.
ATN is one of the most common causes of kidney failure in hospitalized patients. Risks for acute tubular necrosis include:
• Blood transfusion reaction
• Injury or trauma that damages the muscles
• Low blood pressure (hypotension) that lasts longer than 30 minutes
• Recent major surgery
• Septic shock due to severe infection
Liver disease and kidney damage caused by diabetes (diabetic nephropathy) may make a person more susceptible to the condition.
ATN can also be caused by:
• Dye (contrast) used for x-ray (radiology) studies
• Medications that are toxic to the kidneys (such as aminoglycoside antibiotics or amphotericin)
Symptoms• Decreased consciousness, coma, delirium or confusion, drowsy, lethargic, hard to arouse
• Decreased urine output or no urine output
• General swelling, fluid retention
• Nausea, vomiting
Note: Other symptoms of acute kidney failure may also be present.
Exams and TestsThe doctor will perform a physical exam. Your doctor may hear abnormal sounds when listening to the heart and lungs with a stethoscope (auscultation). This is due to too much fluid in the body.
Other tests that may be done include:
• BUN and serum creatinine
• Fractional excretion of sodium
• Kidney biopsy
• Urine sodium
• Urine specific gravity and osmolarity urine
TreatmentIn most people, ATN is reversible. The goal of treatment is to prevent life-threatening complications of acute kidney failure.
Treatment focuses on preventing the excess buildup of fluids and wastes, while allowing the kidneys to heal. Patients should be watched closely for deterioration of kidney function.
Treatment can include:
• Identifying and treating the underlying cause of the problem
• Restricting fluid intake to a volume equal to the volume of urine produced
• Restricting substances normally removed by the kidneys (such as protein, sodium, potassium) to minimize their buildup in the body
• Taking medications to help control potassium levels in the bloodstream
• Medicines taken by mouth or through an IV to help remove fluid from the body
Temporary dialysis can remove excess waste and fluids. This can make you feel better, and may make the kidney failure easier to control. Dialysis may not be necessary for all people, but is often lifesaving, especially if serum potassium is dangerously high.
Dialysis may be needed in the following cases:
• Decreased mental status
• Fluid overload
• Increased potassium levels
• To remove toxins that are dangerous to the kidneys
• Total lack of urine production
• Uncontrolled buildup of nitrogen waste products
Outlook (Prognosis)How long symptoms last can vary. You may make less urine for a few days to 6 weeks or more. This may be followed by a period of high urine output. This occurs because the healed and newly functioning kidneys try to clear the body of fluid and waste.
One or two days after your urine amount rises, symptoms reduce and test results begin to return to normal.
Possible Complications• Bleeding from the gastrointestinal tract
• Chronic kidney disease and permanent kidney damage
• High blood pressure
• Increased risk of infection
When to Contact a Medical ProfessionalCall your health care provider if your urine output decreases or stops, or if you develop other symptoms of acute tubular necrosis.
PreventionPromptly treating conditions that can lead to decreased blood flow as well as decreased oxygen to the kidneys can reduce the risk of acute tubular necrosis.
Blood transfusions are crossmatched to reduce the risk of incompatibility reactions.
Control conditions such as diabetes, liver disorders, and cardiac disorders to reduce the risk of acute tubular necrosis.
Carefully monitor exposure to medications that can be toxic to the kidney. Have your blood levels of these medications checked regularly. Drink a lot of fluids after having any radiocontrast dyes to allow them to be removed from the body and reduce the risk of kidney damage.
Alternative NamesNecrosis - renal tubular; ATN; Necrosis - acute tubular
ReferencesClarkson MR, Friedewald JJ, Eustace JA, Rabb H. Acute kidney injury. In: Brenner BM, ed.Brenner and Rector's The Kidney
Molitoris BA. Acute kidney injury. In: Goldman L, Ausiello D, eds.Cecil Medicine
Addison disease is a disorder that occurs when the adrenal glands do not produce enough hormones.
02. Addison disease
CausesThe adrenal glands are small hormone-releasing organs located on top of each kidney. They are made up of an outer portion, called the cortex, and an inner portion, called the medulla.
The cortex produces three hormones:
• Glucocorticoid hormones (such as cortisol) maintain sugar (glucose) control, decrease (suppress) immune response, and help the body respond to stress.
• Mineralocorticoid hormones (such as aldosterone) regulate sodium and potassium balance.
• Sex hormones, androgens (male) and estrogens (female), affect sexual development and sex drive.
Addison disease results from damage to the adrenal cortex. The damage causes the cortex to produce hormone levels that are too low.
This damage may be caused by the following:
• The immune system mistakenly attacking the adrenal glands (autoimmune disease)
• Infections such as tuberculosis, HIV, or fungal infections
• Hemorrhage into the adrenal glands
Risk factors for the autoimmune type of Addison disease include other autoimmune diseases:
• Chronic thyroiditis
• Dermatis herpetiformis
• Graves' disease
• Myasthenia gravis
• Pernicious anemia
• Testicular dysfunction
• Type I diabetes
Certain rare genetic defects may also cause adrenal insufficiency.
SymptomsSymptoms of Addison disease include:
• Chronic diarrhea, nausea, and vomiting
• Darkening of the skin in some places, causing the skin to look patchy
• Dizziness when standing up
• Extreme weakness, fatigue, and slow, sluggish movement
• Mouth lesions on the inside of a cheek (buccal mucosa)
• Salt craving
• Weight loss with reduced appetite
Exams and TestsLaboratory tests may show:
• Increased potassium
• Low blood pressure, especially with a change in body position
• Low cortisol level
• Low serum sodium
• Low blood pH
• Normal sex hormone levels
Additional laboratory tests may be ordered.
Other tests may include:
• Abdominal x-ray
• Abdominal CT scan
TreatmentTreatment with replacement corticosteroids will control the symptoms of this disease. These medicines usually need to be taken for life.
Never skip doses of your medication for this condition because life-threatening reactions may occur.
Your doctor may increase your dosage because of:
During an extreme form of adrenal insufficiency, called adrenal crisis, you must inject hydrocortisone right away. Treatment for low blood pressure is usually needed as well.
Some people with Addison disease are taught to give themselves an emergency injection of hydrocortisone during stressful situations. Always carry medical ID (card, bracelet, or necklace) that says you have adrenal insufficiency. The ID should also say the type of medicine and dosage you need in case of an emergency.
Outlook (Prognosis)With hormone therapy, many people with Addison disease are able to lead a nearly normal life.
Possible ComplicationsComplications can occur if you take too little or too much adrenal hormone.
Complications also may result from the following related illnesses:
• Hashimoto thyroiditis (chronic thyroiditis)
• Ovarian hypofunction or testicular failure
• Pernicious anemia
When to Contact a Medical ProfessionalCall your health care provider if:
• You are unable to keep your medicine down due to vomiting.
• You have stress such as infection, injury, trauma, or dehydration. You may need to have your medication adjusted.
• Your weight increases over time.
• Your ankles begin to swell.
• You develop new symptoms.
• On treatment, you develop signs of Cushing syndrome
If you have symptoms of adrenal crisis, give yourself an emergency injection of your prescribed medication. If it is not available, go to the nearest emergency room or call 911.
Symptoms of adrenal crisis include:
• Abdominal pain
• Difficulty breathing
• Dizziness or light-headedness
• Low blood pressure
• Reduced consciousness
Alternative NamesAdrenocortical hypofunction; Chronic adrenocortical insufficiency; Primary adrenal insufficiency
ReferencesChaker AJ, Vaidya B. Addison disease in adults: diagnosis and management. Am J Med
Guber HA, Farag AF. Evaluation of endocrine function. In: McPherson RA, Pincus MR, eds.Henry's Clinical Diagnosis and Management by Laboratory Methods
Stewart PM, Krone NP. The adrenal cortex. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds.Williams Textbook of Endocrinology
Adenoid removal is surgery to take out the adenoid glands. The adenoid
glands sit behind your nose above the roof of your mouth. Air passes
over these glands when you take a breath.
03. Adenoid removal
The adenoids are often taken out at the same time as the tonsils (tonsillectomy).
Adenoid removal is also called adenoidectomy. The procedure is most often done in children.
DescriptionYour child will be given general anesthesia before surgery. This means your child will be asleep and unable to feel pain.
• The surgeon places a small tool into your child's mouth to keep it open.
• The surgeon removes the adenoid glands using a spoon-shaped tool (curette). Or another tool that helps cut away soft tissue is used.
• Some surgeons use electricity to heat the tissue, remove it, and stop bleeding. This is called electrocautery. Another method uses radiofrequency (RF) energy to do the same thing. This is called coblation. A cutting tool called a debrider can also be used to remove the adenoid tissue.
• Absorbent material called packing material may also be used to control bleeding.
Your child will stay in the recovery room after surgery. You will be allowed to take your child home when your child is awake and can breathe easily, cough, and swallow. In most cases, this will be a few hours after surgery.
Why the Procedure is PerformedA health care provider may recommend this procedure if:
• Enlarged adenoids are blocking your child's airway. Symptoms in your child can include heavy snoring, problems breathing through the nose, and episodes of not breathing during sleep.
• Your child has chronic ear infections that occur often, continue despite use of antibiotics, cause hearing loss, or cause the child to miss a lot of school days.
Adenoidectomy may also be recommended if your child has tonsillitis that keeps coming back.
The adenoids normally shrink as children grow older. Adults rarely need to have them removed.
RisksRisks of any anesthesia are:
• Reactions to medicines
• Breathing problems
Risks of any surgery are:
Before the ProcedureYour provider will tell you how to prepare your child for this procedure.
A week before the surgery, do not give your child any medicine that thins the blood unless your doctor says to do so. Such medicines include aspirin and ibuprofen (Advil, Motrin).
The night before the surgery, your child should have nothing to eat or drink after midnight. This includes water.
You will be told what medicines your child should take on the day of surgery. Have your child take the medicine with a sip of water.
After the ProcedureYour child will go home on the same day as surgery. Complete recovery takes about 1 to 2 weeks.
Follow instructions on how to care for your child at home.
Outlook (Prognosis)After this procedure, most children:
• Breathe better through the nose
• Have fewer and milder sore throats
• Have fewer ear infections
In rare cases, adenoid tissue may grow back. This does not cause problems most of the time.
Alternative NamesAdenoidectomy; Removal of adenoid glands
ReferencesWetmore RF. Tonsils and adenoids. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.Nelson Textbook of Pediatrics.
Wooley AL, Wiatrak BJ. Pharyngitis and adenotonsilar disease. In: Flint PW, Haughey BH, Lund LJ, et al, eds.Cummings Otolaryngology: Head & Neck Surgery
Adenomyosis is a thickening of the uterus. It occurs when endometrial
tissue, which normally lines the uterus, moves into the outer walls of
CausesThe cause is unknown. Sometimes adenomyosis may cause a mass or growth within the uterus. This is called an adenomyoma.
The disease most often occurs in women ages 40 - 50 who have had at least one pregnancy.
SymptomsIn many cases, the woman may not have any symptoms. When symptoms occur, they can include:
• Long-term or heavy menstrual bleeding
• Painful menstruation, which gets worse
• Pelvic pain during intercourse
Exams and TestsThe health care provider will make the diagnosis if a woman has symptoms of adenomyosis that are not caused by other problems. The only way to confirm the diagnosis is by examining the tissue of the uterus after a hysterectomy.
During a pelvic exam, the doctor may find a soft and slightly enlarged uterus. The exam may also reveal a uterine mass or uterine tenderness.
An ultrasound of the uterus may help tell the difference between adenomyosis and other uterine tumors. MRI can be helpful when ultrasound does not give definite results.
TreatmentMost women have some adenomyosis as they get close to menopause. However, only a few will have symptoms. Most women do not need treatment.
Birth control pills and a progesterone-containing intrauterine device (IUD) can help decrease heavy bleeding. Anti-inflammatory medication such as ibuprofen or naproxen can also help manage symptoms.
A hysterectomy may be necessary in women with severe symptoms.
Outlook (Prognosis)Symptoms most often go away after menopause. A hysterectomy completely relieves symptoms.
When to Contact a Medical ProfessionalCall your health care provider if you develop symptoms of adenomyosis.
Alternative NamesEndometriosis interna; Adenomyoma
ReferencesKatz VL. Benign gynecologic lesions: vulva, vagina, cervix, uterus, oviduct, ovary. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds.Comprehensive Gynecology
Meredith SM, Sanchez-Ramos L, Kaunitz AM. Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and meta analysis. Am J Obstet Gynecol
Adhesions are bands of scar-like tissue that form between two surfaces inside the body and cause them to stick together.
CausesAs the body moves, tissues or organs inside are normally able to shift around each other. This is because these tissues have slippery surfaces. Inflammation (swelling), surgery, or injury can cause adhesions to form and prevent this movement. Adhesions can occur almost anywhere in the body, including:
• Joints, such as the shoulder
• Inside the abdomen or pelvis
Adhesions can become larger or tighter over time. Problems may occur if the adhesions cause an organ or body part to:
• Pull out of position
• Be unable to move normally
The risk of forming adhesions is high after bowel or female organ surgeries. Surgery using a laparoscope is less likely to cause adhesions than open surgery.
Other causes of adhesions in the abdomen or pelvis include:
• Appendicitis, most often when the appendix breaks open (ruptures)
• Infections in the abdomen and pelvis
• Radiation treatment
Adhesions around the joints may occur:
• After surgery or trauma
• With certain types of arthritis
• With overuse of a joint or tendon
SymptomsAdhesions in joints, tendons, or ligaments make it harder to move the joint. They may also cause pain.
Adhesions in the belly (abdomen) may cause a blockage of the intestines. Symptoms include:
• Bloating or swelling of your belly
• Nausea and vomiting
• No longer being able to pass gas
• Pain in the belly that is severe and crampy
Adhesions in the pelvis may cause chronic or long-term pelvic pain.
Exams and TestsMost of the time, the adhesions cannot be seen using x-rays or imaging tests.
• Hysterosalpingography may help diagnose adhesions inside the uterus or Fallopian tubes.
• X-rays of the abdomen, barium contrast studies, and CT scans may help diagnose a blockage of the intestines caused by adhesions.
Endoscopy (a way of looking inside the body using a flexible tube that has a small camera on the end) may help diagnose adhesions:
• Hysteroscopy looks inside the uterus
• Laparoscopy looks inside the abdomen and pelvis
TreatmentSurgery may be done to separate the adhesions. This can let the organ regain normal movement and reduce symptoms. However, the risk for more adhesions goes up with more surgeries.
Depending on the location of the adhesions, a barrier may be placed at the time of surgery to help reduce the chance of the adhesions returning.
Outlook (Prognosis)The outcome is good in most cases.
Possible ComplicationsAdhesions can cause various disorders, depending on the tissues affected.
• In the eye, adhesion of the iris to the lens can lead to glaucoma.
• In the intestines, adhesions can cause partial or complete bowel obstruction.
• Adhesions inside the uterine cavity, called Asherman syndrome, can cause a woman to have irregular menstrual cycles and be unable to get pregnant.
• Pelvic adhesions that involve scarring of the fallopian tubes can lead to infertility and reproductive problems.
• Abdominal and pelvic adhesions can cause chronic pain.
When to Contact a Medical ProfessionalCall your health care provider if you have:
• Abdominal pain
• An inability to pass gas
• Nausea and vomiting that do not go away
• Pain in the belly that is severe and crampy
Alternative NamesPelvic adhesion; Intraperitoneal adhesion; Intrauterine adhesion
ReferencesMunireddy S, Kavalukas SL, Barbul A. Intra-abdominal healing: gastrointestinal tract and adhesions. Surg Clin N Am
Kulaylat MN, Dayton, MT. Surgical complications. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds.Sabiston Textbook of Surgery
Paine R. Rehabilitation and therapeutic modalities: a language of exercise and rehabilitation. In: DeLee JC, Drez D Jr, Miller MD, eds.DeLee and Drez's Orthopaedic Sports Medicine
Adjustment disorder is a group of symptoms, such as stress, feeling sad
or hopeless, and physical symptoms that can occur after you go through a
stressful life event.
06. Adjustment disorder
The symptoms occur because you are having a hard time coping. Your reaction is stronger than expected for the type of event that occurred.
CausesMany different events may trigger symptoms of an adjustment disorder. Whatever the trigger is, the event may become too much for you.
Stressors for people of any age include:
• Death of a loved one
• Divorce or problems with a relationship
• General life changes
• Illness or other health issues in yourself or a loved one
• Moving to a different home or a different city
• Unexpected catastrophes
• Worries about money
Triggers of stress in teenagers and young adults may include:
• Family problems or conflict
• School problems
• Sexuality issues
There is no way to predict which people who are affected by the same stress are likely to develop adjustment disorder. Your social skills before the event, and how you have learned to deal with stress in the past may play roles.
SymptomsSymptoms of adjustment disorder are often severe enough to affect work or social life. Symptoms include:
• Acting defiant or showing impulsive behavior
• Acting nervous or tense
• Crying, feeling sad or hopeless, and possibly withdrawing from other people
• Skipped heartbeats and other physical complaints
• Trembling or twitching
To have adjustment disorder, you must have the following:
• The symptoms clearly come after a stressor, most often within 3 months
• The symptoms are more severe than would be expected
• There do not appear to be other disorders involved
• The symptoms are not part of normal grieving for the death of a loved one
Sometimes, symptoms can be severe and the person may have thoughts of suicide or make a suicide attempt.
Exams and TestsYour health care provider will do a mental health assessment to find out about your behavior and symptoms. You may be referred to a psychiatrist to confirm the diagnosis.
TreatmentThe main goal of treatment is to relieve symptoms and help you return to a similar level of functioning as before the stressful event occurred.
Most mental health professionals recommend some type of talk therapy. This type of therapy can help you identify or change your responses to the stressors in your life.
Cognitive behavioral therapy (CBT) is a type of talk therapy. It can help you deal with your feelings:
• First the therapist helps you recognize the negative feelings and thoughts that occur.
• Then the therapist teaches you how to change these into helpful thoughts and healthy actions.
Other types of therapy may include:
• Long-term therapy, where you will explore your thoughts and feelings over many months or more
• Family therapy, where you will meet with a therapist along with your family
• Self-help groups, where the support of others may help you get better
Medicines may be used, but only along with talk therapy. These medicines may help if you are:
• Nervous or anxious most of the time
• Not sleeping very well
• Very sad or depressed
Outlook (Prognosis)With the right help and support, you should get better quickly. The problem usually does not last longer than 6 months, unless the stressor continues to be present.
When to Contact a Medical ProfessionalCall for an appointment with your health care provider if you develop symptoms of adjustment disorder.
ReferencesAmerican Psychiatric Association.Diagnostic and statistical manual of mental disorders.
Powell AD. Grief, bereavement, and adjustment disorders. In: Stern TA, Rosenbaum JF, Fava M, et al., eds.Massachusetts General Hospital Comprehensive Clinical Psychiatry
The development of children ages 12 through 18 years old is expected to include predictable physical and mental milestones.
07. Adolescent development
InformationDuring adolescence, children develop the ability to:
• Understand abstract ideas, such as higher math concepts, and develop moral philosophies, including rights and privileges
• Establish and maintain satisfying relationships by learning to share intimacy without feeling worried or inhibited
• Move toward a more mature sense of themselves and their purpose
• Question old values without losing their identity
During adolescence, young people go through many changes as they move from childhood into physical maturity. Early, prepubescent changes occur when the secondary sexual characteristics appear.
• Girls may begin to develop breast buds as early as 8 years old. Breasts develop fully between ages 12 and 18.
• Pubic hair, armpit and leg hair usually begin to grow at about age 9 or 10, and reach adult patterns at about 13 to 14 years.
• Menarche (the beginning of menstrual periods) typically occurs about 2 years after early breast and pubic hair appear. It may occur as early as age 9, or as late as age 16. The average age of menstruation in the United States is about 12 years.
• Girls growth spurt peaks around age 11.5 and slows around age 16.
• Boys may begin to notice that their testicles and scrotum grow as early as age 9. Soon, the penis begins to lengthen. By age 17 or 18, their genitals are usually at their adult size and shape.
• Pubic hair growth -- as well as armpit, leg, chest, and facial hair -- begins in boys at about age 12, and reaches adult patterns at about 17 to 18 years.
• Boys do not start puberty with a sudden incident, like the beginning of menstrual periods in girls. Having regular nocturnal emissions (wet dreams) marks the beginning of puberty in boys. Wet dreams typically start between ages 13 and 17, with the average at about 14.5 years.
• Boys' voices change at the same time as the penis grows. Nocturnal emissions occur with the peak of the height spurt.
• Boys growth spurt peaks around age 13.5 and slows around age 18.
The sudden and rapid physical changes that adolescents go through make adolescents very self-conscious, sensitive, and worried about their own body changes. They may make painful comparisons about themselves with their peers.
Because physical changes may not occur in a smooth, regular schedule, adolescents may go through awkward stages, both about their appearance and physical coordination. Girls may be anxious if they are not ready for the beginning of their menstrual periods. Boys may worry if they do not know about nocturnal emissions.
During adolescence, it is normal for young people to begin to separate from their parents and establish their own identity. In some cases, this may occur without a problem from their parents and other family members. However, in some families, the adolescent's rebellion may lead to conflict as the parents try to keep control.
As adolescents pull away from their parents in a search for their own identity, their friends become more important.
• Their peer group may become a safe haven, in which the adolescent can test new ideas.
• In early adolescence, the peer group usually consists of non-romantic friendships, often including "cliques," gangs, or clubs. Members of the peer group often try to act alike, dress alike, have secret codes or rituals, and participate in the same activities.
• As the youth moves into mid-adolescence (14 to 16 years) and beyond, the peer group expands to include romantic friendships.
In mid- to late adolescence, young people often feel the need to establish their sexual identity by becoming comfortable with their body and sexual feelings. Through romantic friendships, dating, and experimenting, adolescents learn to express and receive intimate or sexual advances. Young people who do not have the opportunity for such experiences may have more difficulty with intimate relationships when they are adults.
Adolescents usually have behaviors that are consistent with several myths of adolescence:
• The first myth is that they are "on stage" and other people's attention is constantly centered on their appearance or actions. This normal self-centeredness may appear (especially to adults) to border on paranoia, self-love (narcissism), or even hysteria.
• Another myth of adolescence is the idea that "it will never happen to me, only the other person." "It" may represent becoming pregnant or catching a sexually-transmitted disease after having unprotected sex, causing a car crash while driving under the influence of alcohol or drugs, or any of the many other negative effects of risk-taking behaviors.
Adolescents become stronger and more independent before they've developed good decision-making skills. A strong need for peer approval may entice a young person to try dangerous feats, or take part in risk-taking behaviors.
Motor vehicle safety should be stressed, focusing on the roles of the driver/passenger/pedestrian, the risks of substance abuse, and the importance of using seat belts. Adolescents should not have the privilege of using cars and recreational motor vehicles unless they can show that they can use these vehicles safely.
Other safety issues are:
• Adolescents who are involved in sports should learn to use equipment and protective gear or clothing. They should be taught the rules of safe play and healthy approaches to activities that require more advanced skills.
• Young people need to be very aware of possible dangers -- including sudden death -- which may occur with regular substance abuse, and with the experimental use of drugs and alcohol.
• Adolescents who are allowed to use or have access to firearms need to learn how to use them safely, properly, and legally.
If adolescents appear to be isolated from their peers, uninterested in school or social activities, or doing poorly at school, work, or sports -- they need to be evaluated.
Many adolescents are at increased risk for depression and potential suicide attempts, because of pressures and conflicts in their family, school or social organizations, peer groups, and intimate relationships.
PARENTING TIPS ABOUT SEXUALITY
Adolescents usually need privacy to understand the changes taking place in their bodies. Ideally, they should be allowed to have their own bedroom. If this is not possible, they should have at least some private space.
Teasing an adolescent child about physical changes is inappropriate, because it may cause self-consciousness and embarrassment.
Parents need to remember that it is natural and normal for their adolescent to be interested in body changes and sexual topics. It does not mean that their child is involved in sexual activity.
Adolescents may experiment with or consider a wide range of sexual orientations or behaviors before feeling comfortable with their own sexual identity. Parents must be careful not to call new behaviors "wrong," "sick," or "immoral."
The Oedipal complex (a child's attraction to the parent of the opposite sex) is common during the adolescent years. Parents can deal with this by acknowledging the child's physical changes and attractiveness -- and taking pride in the youth's growth into maturity -- without crossing parent-child boundaries.
It is normal for the parent to find the adolescent attractive, especially because the teen often looks very much like the other (same-sex) parent did at a younger age. This attraction may cause the parent to feel awkward. The parent should be careful not to create a disconnect that may make the adolescent feel responsible. It is inappropriate for a parent's attraction to a child to be anything more than an attraction as a parent. Attraction that crosses the parent-child boundaries may lead to inappropriately intimate behavior with the adolescent, which is known as incest.
INDEPENDENCE AND POWER STRUGGLES
The teenager's quest to become independent is a normal part of development. The parent should not see it as a rejection or loss of control over the child. Parents need to be constant and consistent. They should be available as a sounding board for the youth's ideas, without dominating the child's newly independent identity.
Although adolescents always challenge authority figures, they need or want limits, which provide a safe boundary for them to grow and function. Limit-setting means having pre-set rules and regulations about their behavior.
Power struggles begin when authority is at stake or "being right" is the main issue. These situations should be avoided, if possible. One of the parties (typically the teen) will be overpowered, causing the youth to lose face. This can cause the adolescent to feel embarrassed, inadequate, resentful, and bitter.
Parents should be ready for and recognize common conflicts that may develop while parenting adolescents. The experience may be affected by unresolved issues from the parent's own childhood, or from the adolescent's early years.
Parents should know that their adolescents will repeatedly challenge their authority. Keeping open lines of communication and clear, yet negotiable, limits or boundaries may help reduce major conflicts.
Most parents feel like they have more wisdom and self-growth as they rise to the challenges of parenting adolescents.
Alternative NamesDevelopment - adolescent; Growth and development - adolescent
ReferencesCromer B. Adolescent Development. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.Nelson Textbook of Pediatrics
Adolescent pregnancy is pregnancy in girls age 19 or younger.
08. Adolescent pregnancy
CausesAdolescent pregnancy and babies born to adolescents have dropped since reaching an all-time high in 1990. This is mostly due to the increased use of condoms.
Adolescent pregnancy is a complex issue with many reasons for concern. Kids age 12 - 14 years old are more likely than other adolescents to have unplanned sexual intercourse . They are more likely to be talked into having into sex.
Up to two-thirds of adolescent pregnancies occur in teens age 18 - 19 years old.
Risk factors for adolescent pregnancy include:
• Younger age
• Poor school performance
• Economic disadvantage
• Older male partner
• Single or teen parents
SymptomsPregnancy symptoms include:
• Abdominal distention
• Breast enlargement and breast tenderness
• Light-headedness or actual fainting
• Missed period
• Frequent urination
Exams and TestsThe adolescent may or may not admit to being involved sexually. If the teen is pregnant, there are usually weight changes (usually a gain, but there may be a loss if nausea and vomiting are significant). Examination may show increased abdominal girth, and the health care provider may be able to feel the fundus (the top of the enlarged uterus).
Pelvic examination may reveal bluish or purple coloration of vaginal walls, bluish or purple coloration and softening of the cervix, and softening and enlargement of the uterus.
• A pregnancy test of urine and/or serum HCG are usually positive.
• A pregnancy ultrasound may be done to confirm or check accurate dates for pregnancy.
TreatmentAll options made available to the pregnant teen should be considered carefully, including abortion, adoption, and raising the child with community or family support. Discussion with the teen may require several visits with a health care provider to explain all options in a non-judgmental manner and involve the parents or the father of the baby as appropriate.
Early and adequate prenatal care, preferably through a program that specializes in teenage pregnancies, ensures a healthier baby. Pregnant teens need to be assessed for smoking, alcohol use, and drug use, and they should be offered support to help them quit.
Adequate nutrition can be encouraged through education and community resources. Appropriate exercise and adequate sleep should also be emphasized. Contraceptive information and services are important after delivery to prevent teens from becoming pregnant again.
Pregnant teens and those who have recently given birth should be encouraged and helped to remain in school or reenter educational programs that give them the skills to be better parents, and provide for their child financially and emotionally. Accessible and affordable child care is an important factor in teen mothers continuing school or entering the work force.
Outlook (Prognosis)Having her first child during adolescence makes a woman more likely to have more children overall. Teen mothers are about 2 years behind their age group in completing their education. Women who have a baby during their teen years are more likely to live in poverty.
Teen mothers with a history of substance abuse are more likely to start abusing by about 6 months after delivery.
Teen mothers are more likely than older mothers to have a second child within 2 years of their first child.
Infants born to teenage mothers are at greater risk for developmental problems. Girls born to teen mothers are more likely to become teen mothers themselves, and boys born to teen mothers have a higher than average rate of being arrested and jailed.
Possible ComplicationsAdolescent pregnancy is associated with higher rates of illness and death for both the mother and infant. Death from violence is the second leading cause of death during pregnancy for teens, and is higher in teens than in any other group.
Pregnant teens are at much higher risk of having serious medical complications such as:
• Placenta previa
• Pregnancy-induced hypertension
• Premature delivery
• Significant anemia
Infants born to teens are 2 - 6 times more likely to have low birth weight than those born to mothers age 20 or older. Prematurity plays the greatest role in low birth weight, but intrauterine growth retardation (inadequate growth of the fetus during pregnancy) is also a factor.
Teen mothers are more likely to have unhealthy habits that place the infant at greater risk for inadequate growth, infection, or chemical dependence. The younger a mother is below age 20, the greater the risk of her infant dying during the first year of life.
It is very important for pregnant teens to have early and adequate prenatal care.
When to Contact a Medical ProfessionalMake an appointment with your health care provider if you have symptoms of pregnancy.
Your health care provider can also provide counseling regarding birth control methods, sexually transmitted disease (STD) prevention, or pregnancy risk.
PreventionThere are many different kinds of teen pregnancy prevention programs.
• Abstinence education programs encourage young people to wait to have sex until marriage, or until they are mature enough to handle sexual activity and a potential pregnancy in a responsible manner.
• Knowledge-based programs focus on teaching kids about their bodies. It also provides detailed information about birth control and how to prevent sexually transmitted infections (STIs). Research shows knowledge-based programs help decrease teen pregnancy rates. Abstinence-only education without information about birth control does not.
• Clinic-focused programs give kids easier access to information, counseling by health care providers, and birth control services. Many of these programs are offered through school-based clinics.
• Peer counseling programs typically involve older teens, who encourage other kids to resist peer and social pressures to have sex. For teens who are already sexually active, peer counseling programs teach them relationship skills and give them information on how to get and successfully use birth control.
Alternative NamesTeenage pregnancy; Pregnancy - teenage
References. New York, NY: The Alan Guttmacher Institute; January 2010.U.S. Teenage Pregnancy Statistics: Overall Trends, Trends by Race and Ethnicity and State-by-State Information
Elfenbein DS, Felice ME. Adolescent pregnancy. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.Nelson Textbook of Pediatrics.
Kohler PK, Manhart LE, Lafferty WE. Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy.J Adolesc Health
Abma JC et al., Teenagers in the United States: sexual activity, contraceptive use, and childbearing, National Survey of Family Growth 2006–2008, Vital and Health Statistics
Preparing for a medical test or procedure can reduce anxiety, encourage
cooperation, and help your adolescent develop coping skills.
09. Adolescent test or procedure preparation
InformationThere are many ways to help an adolescent prepare for a medical test or procedure.
First, provide detailed information and explain the reasons for the procedure. Let your adolescent take part and make as many decisions as possible.
PREPARING BEFORE THE PROCEDURE
Explain the procedure in correct medical terms. Tell your adolescent why the test is being done. (Ask your health care provider to explain it if you are not sure.) Understanding the need for the procedure may reduce your adolescent's anxiety.
To the best of your ability, describe how the test will feel. Allow your adolescent to practice the positions or movements that will be required for the test, such as the fetal position for a lumbar puncture.
Be honest about discomfort your adolescent may feel, but don't dwell on it. It may help to stress the benefits of the test, and to say that the test results may provide more information. Talk about things that your adolescent may enjoy after the test, such as feeling better or going home. Rewards such as shopping trips or movies may be helpful if the adolescent is able to do them.
Tell your adolescent as much as you can about the equipment that will be used for the test. If the procedure will take place in a new location, it may help to tour the facility with your adolescent before the test.
Suggest ways for your adolescent to stay calm, such as:
• Blowing bubbles
• Breathing deeply
• Creating a quiet, peaceful environment
• Doing relaxation techniques (thinking pleasant thoughts)
• Holding the hand of a calm parent (or someone else) during the procedure
• Playing hand-held video games
• Using guided imagery
• Trying other distractions, such as listening to music through headphones, if allowed
When possible, let your adolescent make some decisions, such as deciding the time of day or the date of the procedure. The more control a person has over a procedure, the less painful and anxiety-producing it is likely to be.
Allow your adolescent to participate in simple tasks during the procedure, such as holding an instrument, if allowed.
Discuss possible risks. Adolescents are often concerned about risks, particularly about any effects on their appearance, mental function, and sexuality. Address these fears honestly and openly if at all possible. Provide information about any appearance changes or other possible side effects the test may cause.
Older adolescents may benefit from videos that show adolescents of the same age explaining and through the procedure. Ask your health care provider if such films are available for your adolescent to view. It may also be helpful for your adolescent to discuss any concerns with peers who have managed similar stressful situations. Ask your health care provider if they know any teens who are interested in doing peer counseling, or if they can recommend a local support group.
DURING THE PROCEDURE
If the procedure is done at a hospital or your health care provider's office, ask if you can stay with your adolescent. However, if your adolescent does not want you to be there, honor this wish. Out of respect for your adolescent's growing need for privacy and independence, do not allow peers or siblings to watch the procedure unless adolescent asks them to be there.
Do not show your own anxiety. Looking anxious will make your adolescent more upset and worried. Research suggests that children are more cooperative if their parents take measures (such as acupuncture) to reduce their own anxiety.
• Ask your health care provider to limit the number of strangers entering and leaving the room during the procedure. This can raise anxiety.
• Ask that the provider who has spent the most time with your adolescent be present during the procedure, if possible.
• Your adolescent may have a hard time with a new authority figure entering the situation. This complication can be reduced if someone he or she knows performs the test. Otherwise, your adolescent may show some resistance. Prepare your adolescent in advance for the possibility that the test will be done by someone he or she doesn't know.
• Ask that anesthesia be used, if appropriate, to reduce any discomfort.
• Assure your adolescent that his or her reactions are normal.
Alternative NamesTest/procedure preparation - adolescent; Preparing adolescent for test/procedure; Preparing for a medical test or procedure - adolescent
ReferencesAlexander M. Managing patient stress in pediatric radiology.Radiol Technol
Bray L, Callery P, Kirk S. A qualitative study of the pre-operative preparation of children, young people and their parents for planned continence surgery: experiences and expectations.J Clin Nurs
Fincher W, Shaw J, Ramelet A-S. The effectiveness of a standardized preoperative preparation in reducing child and parent anxiety: a single-blind randomized controlled trial.J Clin Nurs
Khan KA, Weisman SJ. Nonpharmacologic pain management strategies in the pediatric emergency department. Clin Ped Emerg Med. 2007;8:240-247.
LeRoy S, Elixson EM, O'Brien P, et al. Recommendations for preparing children and adolescents for invasive cardiac procedures: a statement from the American Heart Association Pediatric Nursing Subcommittee of the Council on Cardiovascular Nursing in collaboration with the Council on Cardiovascular Diseases of the Young.Circulation
Stock A, Hill A, Franz BE. Practical communication guide for pediatric procedures. Emergency Medicine Australasia
Yip P, Middleton P, Cyna AM, Carlyle AV. Non-pharmacological interventions for assisting the induction of anaesthesia in children. Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand.Cochrane Database Syst Rev
The adrenal glands are two triangle-shaped glands. One gland is located on top of each kidney.
10. Adrenal glands
InformationEach adrenal gland is about the size of the top part of the thumb. The outer part of the gland is called the cortex. It produces steroid hormones such as cortisol, aldosterone, and hormones that can be converted to testosterone. The inner part of the gland is called the medulla. It produces epinephrine and norepinephrine, which are also called adrenaline and noradrenaline.
When the glands produce more or less hormones than your body needs, you can become sick. Sometimes this happens right at birth. Sometimes it develops later in life.
The adrenal glands can be affected by many diseases, such as autoimmune disorders, infections, tumors, and bleeding.
• Addison disease
• Adrenal insufficiencyCongenital adrenal hyperplasia
• Cushing syndrome
• Diabetes mellitus - secondary
• Glucocorticoid medications
• Hump behind shoulders (dorsocervical fat pad)
• Primary aldosteronism (Conn syndrome)
• Waterhouse-Friderichsen syndrome
ReferencesStewart PM, Krone NP. The adrenal cortex. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds.Williams Textbook of Endocrinology.
Adrenalectomy is an operation in which one or both adrenal glands are
removed. The adrenal glands are part of the endocrine system and are
located just above the kidneys.
DescriptionAdrenalectomy can be performed in two ways. The type of surgery you undergo depends on the problem being treated.
• With open surgery, the surgeon makes one large surgical cut to remove the gland.
• With the laparoscopic technique, several small cuts are made.
The surgeon will discuss which approach is better for you.
For the surgery, you will be placed under general anesthesia (asleep and pain-free).
After the adrenal gland is removed, it is sent to a pathologist for examination under a microscope.
Why the Procedure is PerformedThe adrenal gland is removed when there is known cancer or a growth (mass) that might be cancer.
Sometimes a mass in the adrenal gland is removed because it releases a hormone that can cause harmful side effects.
• One of the most common tumors is a pheochromocytoma, which can cause very high blood pressure
• Other disorders include Cushing syndrome, Conn syndrome, and an adrenal mass of unknown cause
RisksWith any operation or anesthesia, there is a slight risk of:
• Blood clots in the legs that may travel to the lungs
• Breathing problems
• Damage to nearby organs in the body
• Heart attack or stroke
• Infection or bleeding
• Reactions to medicines
• Wound that breaks open or bulging tissue through the incision (incisional hernia)
Before the ProcedureAlways tell your doctor or nurse:
• If you could be pregnant
• What drugs you are taking, even drugs or herbs you bought without a prescription
During the days before the surgery:
• You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), clopidogrel (Plavix), warfarin (Coumadin), and other drugs like these.
• Ask your doctor which drugs you should still take on the day of the surgery.
• Do not smoke. This will help you recover more quickly.
On the day of the surgery:
• Your doctor or nurse will tell you what you can drink or eat the night before and the day of the surgery.
• Take the drugs your doctor told you to take with a small sip of water.
• Your doctor or nurse will tell you when to arrive at the hospital.
Outlook (Prognosis)As with any operation, there will be discomfort after surgery.
• Your health care provider will prescribe pain medications.
• You may need stool softeners to avoid constipation.
• Your surgeon will give you instructions about restricting your activities.
Most patients who undergo laparoscopic adrenalectomy have a shorter hospital stay, less pain, and faster recovery compared to the open procedure.
Complete recovery from the procedure may take several weeks or longer, depending on the type of surgical cuts you have.
Alternative NamesAdrenal gland removal; Removal of adrenal glands
ReferencesYeh MW, Duh QY. The adrenal glands. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds.Sabiston Textbook of Surgery
Adrenergic bronchodilators are inhaled medicines that help open up the
air passages. They are used to treat asthma and chronic bronchitis.
Adrenergic bronchodilator overdose occurs when someone accidentally or
intentionally takes more than the normal or recommended amount of this
12. Adrenergic bronchodilator overdose
This is for information only and not for use in the treatment or management of an actual poison exposure. If you have an exposure, you should call your local emergency number (such as 911) or the National Poison Control Center at 1-800-222-1222.
Poisonous Ingredient• Albuterol
Note: This list may not be all-inclusive.
Where Found• Albuterol (Proventil, Ventolin)
• Bitolterol (Tornalate)
• Ephedrine (Ephed II)
• Epinephrine (Adrenalin, AsthmaHaler, Bronitin Mist, Bronkaid Mist, Medihaler-Epi, Primatene Mist, EpiPen Auto-Injector, Sus-Phrine, Twinject)
• Ethylnorepinephrine (Bronkephrine)
• Isoetharine (Arm-a-Med Isoetharine, Bronkometer, Bronkosol, Dey-Dose Isoetharine, Dispos-a-Med Isoetharine, Dey-Lute Isoetharine)
• Isoproterenol (Aerolone, Dey-Dose Isoproterenol, Dispos-a-Med Isoproterenol, Isuprel, Medihaler-Iso, Norisodrine Aerotrol, Vapo-Iso)
• Metaproterenol (Alupent, Arm-a-Med Metaproterenol, Dey-Dose Metaproterenol, Dey-Lute Metaproterenol, Metaprel)
• Pirbuterol (Maxair)
• Racepinephrine (AsthmaNefrin, Dey-Dose Racepinephrine, Vaponefrin)
• Terbutaline (Breathaire, Brethine, Bricanyl)
Note: This list may not be all-inclusive.
SymptomsAirways and lungs:
• Difficulty breathing
• Shallow breathing
• Rapid breathing
• No breathing
Bladder and kidneys:
• No urine output
Eyes, ears, nose, and throat:
• Blurred vision
• Dilated pupils
• Throat burning
Heart and blood vessels:
• High blood pressure, which then leads to low blood pressure
• Rapid heartbeat
• Tingling of hands and feet
• Blue lips and fingernails
Stomach and intestines:
Home CareSeek immediate medical help.
Before Calling EmergencyDetermine the following information:
• Patient's age, weight, and condition
• The name of the product (ingredients and strengths if known)
• Time it was swallowed
• The amount swallowed
Poison ControlThe National Poison Control Center (1-800-222-1222) can be called from anywhere in the United States. This national hotline number will let you talk to experts in poisoning. They will give you further instructions.
This is a free and confidential service. All local poison control centers in the United States use this national number. You should call if you have any questions about poisoning or poison prevention. It does NOT need to be an emergency. You can call for any reason, 24 hours a day, 7 days a week.
Take the container with you to the hospital, if possible.
See: Poison control center - emergency number
What to Expect at the Emergency RoomThe health care provider will measure and monitor the patient's vital signs, including temperature, pulse, breathing rate, and blood pressure. Symptoms will be treated as appropriate. The patient may receive:
• Activated charcoal
• Blood and urine tests
• Breathing support
• EKG (electrocardiogram, or heart tracing)
• Intravenous (through the vein) fluids
• Tube placed down the nose and into the stomach (gastric lavage)
Blood tests may show changes in blood sugar and low potassium levels.
Outlook (Prognosis)Survival past 24 hours is usually a good sign that recovery will follow.
PreventionKeep all medications in childproof containers out of the reach of children.
ReferencesAkhtar J, Rittenberger JC. Clinical neurotoxicology. In: Shannon MW, Borron SW, Burns MJ.Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose
Adrenocortical carcinoma is a cancer of the adrenal glands.
13. Adrenocortical carcinoma
CausesAdrenocortical carcinoma is most common in children younger than 5 years old and adults in their 30s and 40s.
The condition may be linked to a cancer syndrome that is passed down through families (inherited). Both men and women can develop this tumor.
Adrenocortical carcinoma can produce the hormones cortisol, aldosterone, estrogen, or testosterone, as well as other hormones. In women the tumor often releases these hormones, which can lead to male characteristics.
Adrenocortical carcinoma is very rare. The cause is unknown. About 2 people per million develop this type of tumor.
SymptomsSymptoms of increased cortisol or other adrenal gland hormones:
• Fatty, rounded hump high on the back just below the neck (buffalo hump)
• Flushed, rounded face with pudgy cheeks (moon face)
• Stunted growth (short stature)
• Virilization - the appearance of male characteristics, including increased body hair (especially on the face), pubic hair, acne, deepening of the voice, and enlarged clitoris (girls)
Symptoms of increased aldosterone are the same as symptoms of low potassium, and include:
• Muscle cramps
Exams and TestsThe doctor or nurse will examine you. You may have high blood pressure and changes in body shape, such as breast growth in men (gynecomastia) or male signs in women (virilization). Blood tests will be done to check hormone levels:
• ACTH level will be low.
• Aldosterone level will be high.
• Cortisol level will be high.
• Potassium level will be low.
• Male or female hormones may be abnormally high.
Imaging tests may include:
• Abdominal x-ray
• CT scan of the abdomen
• MRI of the abdomen
TreatmentPrimary treatment is surgery to remove the tumor. Adrenocortical carcinoma may not improve with chemotherapy. Medications may be given to reduce production of cortisol, which causes many of the symptoms.
Outlook (Prognosis)The outcome depends on how early the diagnosis is made and whether the tumor has spread (metastasized). Tumors that have spread usually lead to death within 1 to 3 years.
Possible ComplicationsThe tumor can spread to the liver, bone, lung, or other areas.
When to Contact a Medical ProfessionalCall your health care provider if you or your child has symptoms of adrenocortical carcinoma, Cushing syndrome, or failure to grow.
Alternative NamesTumor - adrenal
ReferencesNational Comprehensive Cancer Network. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Neuroendocrine tumors. 2012. Version 1.2012.
Nieman LK. Adrenal cortex. In: Goldman L, Schafer AI, eds.Goldman's Cecil Medicine
Adrenoleukodystrophy describes several closely related inherited
disorders that disrupt the breakdown (metabolism) of certain fats (very
long chain fatty acids).
CausesAdrenoleukodystrophy is usually passed down from parent to child as an X-linked genetic trait. It therefore affects mostly males, although some women who are carriers can have milder forms of the disease. It affects approximately 1 in 20,000 people from all races.
The condition results in the buildup of very-long-chain fatty acids in the nervous system, adrenal gland, and testes, which disrupts normal activity. There are three major categories of disease:
• Childhood cerebral form -- appears in mid-childhood (at ages 4 - 8)
• Adrenomyelopathy -- occurs in men in their 20s or later in life
• Impaired adrenal gland function (called Addison disease or Addison-like phenotype) -- adrenal gland does not produce enough steroid hormones
SymptomsChildhood cerebral type:
• Changes in muscle tone, especially muscle spasms and spasticity
• Crossed eyes (strabismus)
• Decreased understanding of verbal communication (aphasia)
• Deterioration of handwriting
• Difficulty at school
• Difficulty understanding spoken material
• Hearing loss
• Worsening nervous system deterioration, including coma, decreased fine motor control, and paralysis
• Swallowing difficulties
• Visual impairment or blindness
• Difficulty controlling urination
• Possible worsening muscle weakness or leg stiffness
• Problems with thinking speed and visual memory
Adrenal gland failure (Addison type):
• Decreased appetite
• Increased skin color (pigmentation)
• Loss of weight, muscle mass (wasting)
• Muscle weakness
Exams and Tests• Blood levels of very long chain fatty acids and hormones that are produced by the adrenal gland
• Chromosome study to look for changes (mutations) in the ABCD1 gene
• MRI of the head
TreatmentAdrenal dysfunction my be treated with steroids (such as cortisol) if the adrenal gland is not producing enough hormones.
A specific treatment for X-linked adrenoleukodystrophy is not available, but bone marrow transplantation can be performed and can cure patients of the condition.
Outlook (Prognosis)The childhood form of X-linked adrenoleukodystrophy is a progressive disease. It leads to a long-term coma (vegetative state) about 2 years after nervous system symptoms develop. The child can live in this condition for as long as 10 years until death occurs.
The other forms of this disease are milder.
Possible Complications• Adrenal crisis
• Vegetative state (long-term coma)
When to Contact a Medical ProfessionalCall your health care provider if:
• Your child develops symptoms of X-linked adrenoleukodystrophy
• Your child has X-linked adrenoleukodystrophy and is getting worse
PreventionGenetic counseling is recommended for prospective parents with a family history of X-linked adrenoleukodystrophy. Mothers of affected sons have an 85% chance of being a carrier for this condition.
Prenatal diagnosis of X-linked adrenoleukodystrophy is also available. It is done by evaluating cells from chorionic villus sampling or amniocentesis for either a known genetic change in the family or for very long chain fatty acid levels.
Alternative NamesX-linked Adrenoleukodystrophy; Adrenomyeloneuropathy; Childhood cerebral adrenoleukodystrophy; ALD; Schilder-Addison Complex
ReferencesKwon JM. Neurodegenerative disorders of childhood. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.Nelson Textbook of Pediatrics.
Steinberg SJ, Moser AB, Raymond GV. X-Linked adrenoleukodystrophy.GeneReviews
Adult Still's disease is a rare illness that causes high fevers, rash,
and joint pain. It may lead to long-term (chronic) arthritis.
15. Adult Still's disease
Still's disease is a severe version of juvenile idiopathic arthritis (JIA), which occurs in children. Adults can have the same condition.
The disease is much less common and now called adult-onset Still's disease (AOSD).
CausesFewer than 1 out of 100,000 people develop adult Still's disease each year. It affects women more often than men.
Still's disease that occurs in children is called systemic juvenile idiopathic arthritis.
The cause of adult Still's disease is unknown. No risk factors for the disease have been identified.
SymptomsAlmost all people with the disease will have fever, joint pain, sore throat, and a rash.
• Joint pain, warmth, and swelling are common. Most often, several joints are involved at the same time. Often, patients have morning stiffness of joints that lasts for several hours.
• The fever comes on quickly once per day, most commonly in the afternoon or evening.
• The skin rash is often salmon-pink colored and comes and goes with the fever.
Additional symptoms include:
• Abdominal pain and swelling
• Pain with a deep breath (pleurisy)
• Sore throat
• Swollen lymph nodes (glands)
• Weight loss
The spleen or liver may become swollen. Lung and heart inflammation may also occur.
Exams and TestsAdult Still's disease can only be diagnosed after other diseases are ruled out. You may need many medical tests before a final diagnosis is made.
A physical exam may show a fever, rash, and arthritis. The health care provider will use a stethoscope to listen for changes in the sound of your heart or lungs.
The following blood tests can be helpful in diagnosing adult Still's disease:
• Complete blood count (CBC) may show a high number of white blood cells and reduced number of red blood cells.
• C-reactive protein (CRP), a measure of inflammation, will be higher than normal.
• ESR (sedimentation rate), a measure of inflammation, will be higher than normal.
• Ferritin level will be very high.
• Fibrinogen level will be high.
• Liver function tests will show high levels of AST and ALT.
• Rheumatoid factor and ANA test will be negative.
Other tests may be needed to check for inflammation of the joints, chest, liver, and spleen:
• Abdominal ultrasound
• CT scan of the abdomen
• X-rays of the joints, chest, or stomach area (abdomen)
TreatmentThe goal of treatment for adult Still's disease is to control the symptoms of arthritis. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are usually used first.
Prednisone may be used for more severe cases.
If the disease persists for a long time (becomes chronic), medicines that suppress the immune system might be needed. Such medicines include:
• Anakinra (interleukin-1 receptor agonist)
• Tumor necrosis factor (TNF) antagonists such as Enbrel (etanercept)
Outlook (Prognosis)Studies show that in about 1 in 5 people all symptoms go away in a year and never come back. In many people, symptoms go away but then come back several times over the next few years.
Symptoms continue for a long time (chronic) in about half of patients with adult Still's disease.
Possible Complications• Arthritis in several joints
• Liver disease
• Pleural effusion
• Spleen enlargement
When to Contact a Medical ProfessionalCall your health care provider if you have symptoms of adult Still's disease.
If you have already been diagnosed with the condition, you should call your health care provider if you have a cough or difficulty breathing.
Alternative NamesStill's disease - adult; AOSD
ReferencesLee LA, Werth VP. The Skin and Rheumatic Diseases. In: Firestein GS, Budd RC, Gabriel SE, et al, eds.Kelley's Textbook of Rheumatology
Clarke JT. Other Rheumatologic Diseases. In: Bolognia JL, Jorizzo JL, Schaffer JV, et al, eds.Dermatology
Pay S, Turkcapar N, Kalyoncu M, et al. A multicenter study of patients with adult-onset Still's disease compared with systemic juvenile idiopathic arthritis.Clin Rheumatol
Efthimiou P, Paik PK, Bielory L. Diagnosis and management of adult onset Still's disease. Ann Rheum Dis
Living will; Power of attorney; DNR - advance directive; Do not
resuscitate - advance directive; Do-not-resuscitate - advance directive
16. Advance care directives
Why write an advance directive?When you are very ill or injured, you may not be able to make health care choices for yourself. If you are unable to speak for yourself, your doctors may be unclear as to what type of care you would prefer. And your family members may be uncertain or disagree about the type of medical care you should receive. An advance care directive is a legal document that tells your doctor what care you agree to in advance of this type of situation. With this document, you can tell your doctors what medical treatment you do not want to have and what treatment you want no matter how ill you are.
Writing an advance care directive may be hard. You need to:
• Know and understand your treatment options
• Decide future treatment options you may want
• Discuss your choices with your family
Living willsA living will explains the care you do or do not want. In it, you can state your wishes about receiving:
• CPR (if your breathing stops or your heart stops beating)
• Feedings through a tube into a vein (IV) or into your stomach
• Extended care on a breathing machine
• Tests, medicines, or surgeries
• Blood transfusions
Each state has laws about living wills. You can find out about the laws in your state from your doctor, the state law organization, and most hospitals.
You should also know that:
• A living will is not the same as a last will and testament after a person's death.
• You are not able to name someone to make health care decisions for you in a living will.
Other types of advance directives• Special health care power of attorney is a legal document that allows you to name someone else (a health care agent or proxy) to make health care decisions for you when you cannot. It does not give power to anyone to make legal or financial decisions for you.
• A do-not-resuscitate order (DNR)is a document that tells health care providers not to do CPR if your breathing stops or your heart stops beating. Your doctor talks to you, the proxy, or family about this choice. The doctor writes the order on your medical chart.
• Fill out an organ donation card and carry it in your wallet. Keep a second card with your important papers. You can find out about organ donation from your doctor. You can also have this choice listed on your driver's license.
• Verbal instructions are your choices about care that you tell health care providers or family members. Verbal wishes usually replace those you made previously in writing.
What else?Write your living will or health care power of attorney according to your state's laws.
• Give copies to your family members, health care providers, and health care agent.
• Carry a copy with you in your wallet or the glove compartment of your car.
• Take a copy with you if you are in a hospital. Tell all medical staff involved in your care about these documents.
You can change your decisions at any time. Be sure to tell everyone involved -- family members, proxies, and health care providers -- if you make changes to your advance directive or a living will is changed. Copy, save, and share the new documents with them.
ReferencesKapp MB. Ethical and legal issues. In: Duthie EH, Katz PR, Malone ML, eds.Practice of Geriatrics.
Marchand LR. The plan of care. In: Walsh D, Caraceni AT, Fainsinger R, et al., eds.Palliative Medicine
Aerobic means oxygen is needed to:
• Work properly
For example, bacteria that need oxygen to grow are called aerobic bacteria.
Aerobic is the opposite of anaerobic.
Aerobic bacteria are bacteria that can grow and live in the presence of oxygen.
18. Aerobic bacteria
ReferencesScheld WM. Introduction to microbial disease. In: Goldman L, Schafer AI, eds.Cecil Medicine
Aflatoxins are toxins produced by a mold that grows in nuts, seeds, and legumes.
FunctionAlthough aflatoxins are known to cause cancer in animals, the U.S. Food and Drug Administration (FDA) allows them at low levels in nuts, seeds, and legumes because they are considered "unavoidable contaminants."
The FDA believes occasionally eating small amounts of aflatoxin poses little risk over a lifetime. It is not practical to attempt to remove aflatoxin from food products in order to make them safer.
Food SourcesThe mold that produces aflatoxin may be found in the following foods:
• Peanuts and peanut butter
• Tree nuts such as pecans
• Oil seeds such as cottonseed
RecommendationsTo help minimize risk, the FDA tests foods that may contain aflatoxin. Peanuts and peanut butter are some of the most rigorously tested products by FDA because they frequently contain aflatoxins and are widely consumed.
You can reduce aflatoxin intake by:
• Buying only major brands of nuts and nut butters
• Discarding any nuts that look moldy, discolored or shriveled
Most women will remain in the hospital for 2 to 3 days after a cesarean
delivery. Take advantage of the time to bond with your new baby, get
some rest, and receive some help with breastfeeding and caring for your
20. After a C-section - in the hospital
What to Expect after a C-sectionRight after surgery you may feel:
• Groggy from any medicines you received
• Nausea for the first day or so
• Itchy, if you received narcotics in your epidural
You will be brought to a recovery area right after surgery, where a nurse will:
• Monitor your blood pressure, heart rate, and the amount of your vaginal bleeding
• Check to make sure your uterus is becoming firmer
• Bring you to a hospital room once you are stable, where you will spend the next few days
After the excitement of finally delivering and holding your baby, you may notice just how tired you are, like the way one probably feels after running a marathon.
Your belly will be painful at first, but it will improve a lot over 1 to 2 days.
Some women feel sadness or an emotional letdown after delivery. These feelings are not uncommon. DO NOT feel ashamed. Talk with your health care providers and partner.
Seeing and Caring for Your BabyBreastfeeding can often begin right after surgery. The nurses can help you find the right position. Numbness from your anesthetic can limit your movement for a while, and pain in your incision can make it a little harder to become comfortable, but do not give up. The nurses can show you how to hold your baby so there is no pressure on your incision or abdomen.
Holding and caring for your new infant is exciting, making up for the long journey of your pregnancy and the pain and discomfort of labor. Nurses and breastfeeding specialists are available to answer questions and help you.
Also take advantage of the babysitting and room service the hospital provides for you. You are going home to both the joys of being a mother and the demands of caring for a newborn infant.
ActivityBetween feeling exhausted after labor and managing the pain from the surgery, getting out of bed may seem like too big of a task.
But getting out of bed at least once or twice a day at first can help speed your recovery. It also decreases your chance of having blood clots and helps your bowels move.
Make sure someone is around to help you in case you get dizzy or weak. Plan on taking your walks soon after you have received some pain medicine.
Contractions and BleedingOnce you deliver, the heavy contractions are over. But your uterus still needs to contract to shrink back to its normal size and prevent heavy bleeding. Breastfeeding also helps your uterus contract. These contractions may be somewhat painful, but they are important.
As your uterus becomes firmer and smaller, you are less likely to have heavy bleeding. Blood flow should gradually become slower during your first day. You may notice a few smaller clots passing when the nurse presses on your uterus to check it.
Pain ReliefYour epidural, or spinal, catheter can also be used for pain relief after surgery. It may be left in for up to 24 hours after delivery.
If you did not have an epidural, you may receive pain medicines directly into your veins through an intravenous line (IV) after surgery.
• This line runs through a pump that will be set to give you a certain amount of pain medicine.
• Often, you can push a button to give yourself more pain relief when you need it.
• This is called patient controlled analgesia (PCA).
You will then be switched to pain pills that you take by mouth, or you may receive shots of medicine. It is ok to ask for pain medicine when you need it. Do not be shy.
What Else?You will have a urinary (Foley) catheter in place right after surgery, but this will be removed on the first day after surgery.
The area around your incision may be sore, numb, or both. Sutures or staples are usually removed around the second day, just before you leave the hospital.
At first you may be asked to only eat ice chips or take sips of water, at least until your health care provider is certain you are not likely to have very heavy bleeding. Most likely, you will be able to eat a light diet 8 hours after your C-section.