Adolescent male health

Although adolescent males have as many health issues and concerns as adolescent females, they are much less likely to be seen in a clinical setting. This is related to both individual factors and the health care system itself, which is not always encouraging and set up to provide comprehensive male health care. Working with adolescent boys involves gaining the knowledge and skills to address concerns such as puberty and sexuality, substance use, violence, risk-taking behaviours and mental health issues. The ability to engage the young male patient is critical, and the professional must be comfortable in initiating conversation about a wide array of topics with the teen boy, who may be reluctant to discuss his concerns. It is important to take every opportunity with adolescent boys to talk about issues beyond the presenting complain, and let them know about confidential care. The physician can educate teens about the importance of regular checkups, and that they are welcome to contact the physician if they are experiencing any concerns about their health or well-being. Parents of preadolescent and adolescent boys should be educated on the value of regular health maintenance visits for their sons beginning in their early teen years.     

Febrile seizures]

The febrile seizures (FS) of the child are frequent. Their management is essentially based on the rigorous analysis of their characteristics, the clinical evaluation of the patient like on the collection of the family antecedents. In the case of "simple" FS, the forecast, always favourable, reduce the indications of assessment or treatment, including under possible repetitions. The possibility of an infection of the central nervous system must however always be isolated. In the case of "complicated" FS, the more important risk of later epilepsy makes often necessary of complementary explorations, as well as a treatment. Genetic predispositions were highlighted. In the case of a favourable forecast, contrast always large between the benignity of the FS and the parental dramatic experience. It must be taken into account in the evaluation and the choice of the therapeutic attitude.     

The adolescent trauma patient

Trauma poses the greatest medical problem for the adolescent in terms of morbidity, mortality, and years of productive life lost. The emergency physician caring for the adolescent trauma patient must consider physical and intellectual changes that occur during this period of life. Clinicians must be familiar with both the approach to the traumatized child as well as the adult, and decide on the apropriate approach to the individual adolescent. The emergency physician is also in a position to support greater preventive measures by continued contributions to trauma surveillance, and by serving as a spokesperson and educator about adolescent injuries.     

Low back pain in the adolescent athlete

There are several other entities such as infection, tumors, and fractures that I have not covered in this article. These entities are not common in adolescent athletes but must always be considered when athletes do no respond to typical treatment protocols for the problems I have discussed. The most important theme to take from this article is that low back pain in adolescent athletes is a problem that should not be ignored but instead fully evaluated because structural problems are quite common in this patient population.     

Adolescent bariatric surgery

Pediatric obesity has increased from a relatively uncommon problem to one of the most important public health problems facing children today. Typical "adult" diseases, such as type 2 diabetes mellitus, hypertension, and dyslipidemia, have become increasingly prevalent in the pediatric population. The earlier presentation of these comorbidities will have a significant impact for the future because this population of children will require more medical resources at an earlier age and will have a significantly decreased life expectancy. The significant morbidity of obesity in the pediatric population has led to consideration of more aggressive treatment protocols for obesity in children, including the introduction of surgical management at an earlier age. Surgery for obesity in adolescents has particular risks and benefits that must be accounted for when considering this approach. The unique psychological and emotional needs of adolescent patients make the patient selection process and perioperative management substantially different from those of adult patients. Initial outcomes of bariatric surgery in adolescents are comparable to those seen in adults in the short term. However, the long-term effects of these procedures on the adolescent population are not known. This review discusses the epidemiology of pediatric obesity, the indications for operative therapy in adolescent patients, the common surgical procedures used for weight loss, the reported outcomes of these procedures, and the importance of multidisciplinary management for this unique patient population.     

Testicular torsion versus epididymitis: a diagnostic challenge.

Unlike the patient who presents with a potentially acute abdomen, the child or adolescent with a potentially acute scrotum cannot simply be observed. If testicular torsion is present, the testicle must be detorted and orchiopexy performed as soon as possible for fertility to be maintained. Torsion of the appendix testis, however, can usually be managed without surgery. Since the presentations of epididymitis and testicular torsion overlap, it is sometimes difficult to rapidly make the correct diagnosis. Early genitourinary consultation is appropriate in this setting. Any patient in whom testicular torsion is strongly considered should undergo immediate exploratory surgery without diagnostic studies. If the findings overlap, immediate testicular radionuclide scanning should be arranged; alternatively, with experience, Doppler sonography can be carried out. If these radiographic studies cannot be arranged and interpreted within one to two hours, scrotal exploration should be performed. Any patient with an acute scrotal complaint and a negative scan should receive daily follow-up until the symptoms subside. Although our adolescent patient did well, his acute presentation and findings should have warranted immediate exploration. It is only through this aggressive approach that we can continue to increase testicular salvage rates.     

Depression in children

The field of child and adolescent affective disorders is relatively new and very challenging for research and clinical practice. A definite clinical entity of depression exists in significant numbers of children and adolescents. Signs and symptoms are different from those seen in adults and vary with different age levels. The syndrome must be recognized as early as possible to prevent a chronic illness from developing. Depression can cause serious difficulty in academic life because of its effects on concentration. Depression can affect relations with peers and, if acting out behavior ensues, can lead to serious delinquent behavior, sexual promiscuity, pregnancy, and substance abuse. Depression can also lead to suicide. Depression is often the common denominator in delinquency, promiscuity, teen pregnancy, to say nothing of alcohol and drug abuse. Adolescents often find substances on the street to "medicate" their own depression. When depression in children and adolescents is not properly identified, evaluated, and treated, it can lead to lifelong depression, antisocial behavior, and substance abuse. When depressed children receive appropriate therapy, the results can be rewarding. As one patient commented, "Every day was cloudy and gray. It always rained. Now I see some sun coming out."     

Growing pains: non-adherence with the immunosuppressive regimen in adolescent transplant recipients

One-year graft and patient survival are better in adolescent transplant recipients (age 11-19 years) than in younger (age < 11 years) pediatric transplant recipients. However, several groups found that long-term outcomes (> i.e. 5 year post-transplant) in the adolescent age group are significantly worse than in younger transplant recipients. A behavioral factor that could explain an important part of the poorer clinical outcome in adolescent transplant recipients is non-compliance with medication taking. Adolescents, like all organ transplant recipients irrespective of their age, must adhere to a life-long immunosuppressive regimen in addition to other aspects of their therapeutic regimen. Therefore, adolescent transplant recipients, as all transplant patients, should be regarded as a chronically ill patient population in whom behavioral and psychosocial management is equally important as state-of-the-art medical management. This paper provides an overview of the current knowledge on prevalence, clinical consequences, and risk-factors for non-compliance with the immunosuppressive regimen in adolescent transplant recipients and offers some suggestions for adolescent-tailored interventions to improve medication adherence.     

Developmental psychological aspects of scoliosis treatment

The diagnosis and treatment of idiopathic adolescent scoliosis can have significant psychological consequences for affected individuals. This article aims to provide an overview of the current state of empirical knowledge concerning the psychosocial aspects of scoliosis in adolescence. These research results are set against experience gained from practical work. Adolescence, as a sensitive phase of a young person's development, requires a special degree of adaptation in the event of a chronic illness. For scoliosis patients this means, for instance, facing up to cosmetic impairments and subjectively significant physical defects. Cognitively the patient must come to terms with a commitment of time-consuming, confining, and sometimes uncomfortable treatment for a condition that does not always cause physical symptoms and to achieve success which is not necessarily defined as an improvement in the state of health. Scoliosis is a risk factor for impairment of the quality of life of children and adolescents. Its impact is particularly marked if brace-wearing is indicated. Particular attention needs to be paid to aspects of brace compliance. Support for patients within the context of in-patient rehabilitative treatment has proved to be both necessary and helpful. Here, within the setting of psychological group sessions and individual discussions, the possibility exists for preventing psychosocial impairment.     

Medication non-adherence in the adolescent renal transplant recipient: a clinician's viewpoint

Recent advancements in immunosuppression and surgical techniques have significantly improved the outcome of kidney transplantation in the pediatric population. Adolescents enjoy the best 1-year graft survival of any age group. However, the long-term transplant outcome in adolescents is disappointing. Non-adherence with immunosuppressive medications is one of the most important contributing factors for graft rejection and loss in teenagers. The impact of non-adherence is perceived to be far more powerful in adolescent transplant recipients than in the transplant population as a whole. To better understand adolescent non-adherence, the process of transplantation must be placed in the context of adolescent development. Adolescents try to establish their identity and autonomy separately from the parents; however at the same time, adolescents with chronic illness require help, support and guidance from adults, including parents and medical personnel. Adolescents have limited ability to anticipate abstractly the long-term consequences of their immediate actions. This inconsistency can create frustration in both adolescents and in the supporting systems around them. Despite the significant consequences of adolescent non-adherence, research in this area is scarce. There are still no established definitions, standardized diagnostic methods and effective interventions to treat and prevent this problem. We propose the recommendations to approach the problems of adolescent transplant non-adherence from the transplant clinician's viewpoint. With early identification and appropriate interventions, significant improvement in adolescent graft survival is possible.     

Cleansing the blood. Hemodialysis, peritoneal dialysis, exchange transfusion, charcoal hemoperfusion, forced diuresis

ECDR can be a valuable adjunct to the therapy of pediatric poisonings. Careful consultation with a medical toxicologist and a nephrologist will be useful in reaching the decision as to which poisonings lend themselves to ECDR and which method is most appropriate for the specific case. Avoid advice that amounts to, "if you are not certain, dialyze." While the risks of many ECDR techniques are acceptable in major medical centers, it may not be good medicine to superimpose any morbidity from ECDR upon the poisoned patient when there can be little expectation of drug removal. It is wise to phrase your questions to consultants carefully. The question: "can this substance be dialyzed (hemoperfused, plasmaphoresed, etc.)?" is loaded and the answer frequently will be "yes!" The more proper questions are: "how much drug can be removed by ECDR, how long will the method take, how will this affect the present condition of the patient?" Clearly, a risk: benefit ratio must always be considered. There are lists of substances that "can" be removed by ECDR. It is more difficult to judge how much of the body burden is removed by such methods. Digoxin "can" be dialyzed, but it is not quantitatively removed from the body and there is no accepted benefit from ECDR in this instance. The volume of distribution is a useful guide to determine which substances may be removed quantitatively by ECDR. The exaggerated claims to increased plasma clearance of a hemoperfusion device may not be meaningful if the distribution space is large and plasma levels are correspondingly low. Finally, many of the advantages and disadvantages of ECDR are not likely to change markedly as a result of technology. We currently have very efficient machines for ECDR. It is the chemical characteristics of some toxic substances that limit the more global role of ECDR in poisoning. Serologic therapy, such as specific Fab antibody fragments for use in digoxin poisonings or the exciting work by Russell and colleagues using affinity chromatography to purify specific antibody fragments from horse serum, may be applicable to numerous intoxications. This approach, used in combination with ECDR or alone, will undoubtedly influence the future growth of clinical toxicology.     

The therapeutic approach to the infant, child, and adolescent with end-stage renal disease

Factors involved in choosing a treatment modality for the infant, child, and adolescent with ESRD differ from those used when counseling an adult patient. Age at the time ESRD develops, mental status, psychosocial status, and the primary renal disease must be taken into consideration when contemplating the optimal therapeutic modality for the pediatric patient with ESRD. The ideal approach to optimize growth in the pediatric patient with ESRD remains to be delineated.     

Adolescent gynecology for the pediatrician.

This article outlines some of the most common problems that a physician treating the female adolescent will encounter in his practice. It is important for the primary care pediatrician to initiate the gynecological examination in the adolescent. Few special instruments are required, no new techniques need be mastered, and if the pediatrician is patient and shows his concern, he will rapidly develop competence and find that this examination is as important as the evaluation of any other organ system in the care of the adolescent female.     

Pulmonology in adolescence

OBJECTIVE: To review concepts, long-term treatment schemes and peculiarities of the approach to adolescents with respiratory allergy, asthma and/or allergic rhinitis. METHODS: The data were obtained by systematic revision of studies published in the BIREME database between 1990 and 2001. RESULTS: Most teenagers with asthma and/or rhinitis prefer to view their disease as episodic and do not accept the need for regular medication. These factors combined with the fear of being different from their peer group are responsible for poor treatment adherence. CONCLUSIONS: It is extremely important that adolescent patients affected by asthma and/or allergic rhinitis be well-informed about their condition and receive proper medication; however, the following should also be considered: 1) open communication between the clinician and adolescent patients 2) inquiry into the fears and anxieties of the patient 3) shared responsibility for the treatment.     

Traumatic pelvic fractures in children and adolescents

Although traumatic pelvic fractures in children are relatively rare, these injuries are identified in about 5% of children admitted to level 1 trauma centers after blunt trauma.1, 2, 3, 4 Such injuries differ from adult pelvic fractures in important ways and require distinct strategies for management. While the associated mortality rate for children with pelvic fractures is much lower than that for adults, the patient may require urgent surgical intervention for associated life-threatening injuries such as head trauma and abdominal injury. Unstable pelvic ring fractures should be acutely managed using an initial approach similar to that used in adult orthopedic traumatology. Although very few pediatric pelvic fractures will ultimately need surgical treatment, patients with these injuries must be followed over time to confirm proper healing, ensure normal pelvic growth, and address any potential complications. The trauma team suspecting a pelvic fracture in a child must understand the implication of such a finding, identify fracture patterns that increase suspicion of associated injuries, and involve pediatric or adult orthopedic specialists as appropriate during the management of the patient.     

Current concepts for surgical treatment of cerebral movement disorders

In cerebral palsy orthopedic surgery can avoid deformity, existing deformities can be corrected, muscle imbalance can balanced and painful conditions--such as early osteoarthritis in hip dislocation--can be diminished. A tremendous functional improvement is not to be expected. In order to achieve good results the correct diagnosis is important, the natural course of the disease must be known. A team approach that includes the pediatric neurologist, physical therapist and the orthopedic surgeon is a must. The goals of therapy have to be discussed with the patient and his/her parents. If possible electromyography and gait analysis should be done but exact clinical evaluation is most important. The interactions between different groups of muscles must be known. It is important to differentiate primary and secondary, dynamic and fixed deformities. Orthopedic surgery can make life easier for a person with cerebral palsy, but cerebral palsy itself can never be over come.     

Substance use and abuse in pediatric transplant recipients: What the transplant provider needs to know

Substance abuse is infrequently addressed during pre‐ and post‐transplant care. However, the significant increase in the use of nicotine‐ and marijuana‐containing products in the general and transplant adolescent population is concerning. In addition, alcohol use/abuse remains prevalent in the US population as it is highly accessible. Pediatric transplant providers should be prepared to screen for the use of any of these substances (eg, alcohol, nicotine, marijuana, cocaine, opiates, amphetamines) and to counsel them about the dangers of substance use and abuse including the unique dangers of the substances as a transplant recipient. Formal screening tools (in children as young as 9 years) should always be used as casual assessment of substance abuse has a high failure rate. This review summarizes the substances most commonly used in adolescent transplant recipients and the approach that transplant providers should take in order to prevent, decrease, or halt use in this patient population.     

Problems with the biochemical diagnosis in mitochondrial (encephalo-)myopathies

Patients suffering from a mitochondrial (encephalo-)myopathy have a remarkable clinical heterogeneity. A reliable and extensive investigation must be performed in order to obtain a correct diagnosis, but many factors may influence the ultimate results of these investigations leading, under certain circumstances, to an incorrect diagnosis. Patients selection is of crucial importance. Metabolic examination of body fluids, particularly with respect to lactate accumulation, is used as a selection criterion for further examinations. Numerous aspects associated with this metabolic examination have been critically evaluated, including the phenomenon of other causes of lactic acidaemia apart from mitochondrial disorders. Correct performance of in vivo function tests may contribute to a reduction of the number of missed diagnoses. Selection of the controls for biochemical investigations must be accurately be performed to obtain reliable reference values. Knowledge of the age-dependancy of the biochemical parameters is necessary for a correct interpretation. It goes without saying that the choice of the tissue for biochemical investigations is of utmost importance. Knowledge of the tissue-specific occurrence of some defects in the mitochondrial respiratory chain is necessary. The biochemical examinations can be performed both in biopsy and autopsy material but only under certain conditions. Diagnostic approach requires application of reliable biochemical methods which are described. One of the most intriguing aspects in the diagnosis of mitochondrial disorders is the significance of a defect in relation to the residual enzyme activity found in the patient. Moreover, attention is paid to relevant items such as the occurrence of multiple and secondary defects. It may be concluded that there are many reasons for an incorrect diagnosis of a mitochondrial myopathy. Knowledge of these features is necessary to avoid diagnostic errors.     

Prise en charge d’une dépression chez une adolescente migrante de seconde génération. La place des étiologies culturelles

IntroductionIn our adolescent medical department in a Paris Hospital, psychiatrists and paediatrics always work together with a multidisciplinary approach. In our clinical practice, we often observe a resistance from migrant families to psychological care. The aim of this article was to understand the reasons for this resistance and to analyse, from a clinical situation, the specificities of these transcultural consultations.BackgroundSpecific vulnerabilities of children of migrants are well-known, especially during the adolescent period. Studies about second generation migration children show more psychiatric disorders, in particular for depression. Despite that, children of migrants and their families do not often seek psychiatric consultations perhaps because mental illness is stigmatized in their own culture.Clinical caseWe report the clinical case of a teenage girl, 17, born in France, child of migrants from the Ivory Coast. This teenager was hospitalized in our department because of depression and fainting with loss of consciousness. The cultural etiological hypotheses of her parents were presented (such as witchcraft or evil spirits).DiscussionThe discussion highlights the psychological object as an acculturative subject for the teenager, and cultural and religious reactions from her mother, in response to psychological care. We will see how much these cultural reactions are difficult to treat in a transcultural therapy because they could not be hybridized. The father's involvement during the transcultural therapy was very important to better understand the situation, regarding his migratory history. The teenager uses this therapy to learn about her origins and try to belong again to her family. The transcultural consultation seems to be very important to increase the means of filiation and affiliation.PerspectiveThe links between break of cultural/family transmission and depression during the adolescence of children of migrants deserve to be explored through future research.     

Computed tomography in children with lung disease. How,when and why? Myths and mystery unravelled

The respiratory tract is commonly affected by disease in children. There is a range of pathology which affects the lungs, including congenital abnormalities, infection and chronic conditions. Radiology plays a key role in the investigation of respiratory pathology in children. By far the commonest modality used in routine practice is the frontal chest X-ray, and in most scenarios this is sufficient for diagnostic purpose.When there is a need for more detailed imaging, computed tomography (CT) with its superior spatial resolution, is a more powerful tool. However, the better spatial resolution inherent with CT, and the resultant exquisite anatomical detail, results in a higher effective radiation dose delivered to the patient. Indeed the radiation burden as a result of CT usage is by far the most significant contribution of radiation dose as a consequence of medical diagnostic imaging. The potential resultant risk of this radiation exposure must always be balanced against the benefits gained by the patient.It is always important to justify the clinical need for an imaging technique, assessing how the test will aid patient management, and thence to optimize the technique such that the lowest radiation dose can be used to produce images which are ‘fit for purpose’ i.e. of diagnostic quality but delivered at a radiation dose which is As Low As Reasonably Achievable (ALARA principle).In this article we will discuss the techniques which may be employed to produce and optimize imaging of the thorax. We will catalogue how newer techniques may facilitate accurate radiological diagnosis and also address some important indications for CT usage in children's lung disease.