Glandular fever is an infection caused by the Epstein Barr virus (EBV).

What is Glandular Fever?

Glandular fever is an infection caused by the Epstein Barr virus (EBV). It is also called Infectious Mononucleosis and sometimes the ‘kissing disease’. It is an infectious disease that is spread by close person-to-person contact.  It causes symptoms similar to influenza (the flu) that vary in severity and can persist for several weeks or longer.

Almost anyone, at any age, can catch glandular fever. However, it most commonly occurs in teenagers and young adults. Studies suggest the infection occurs slightly more often in males than in females.

Pathophysiology

Epstein-Barr virus (EBV) is transmitted via intimate contact with body secretions, primarily oropharyngeal secretions and to a lesser degree through genital secretions. It infects the B cells in the oropharyngeal epithelium; after acute infection the virus has been detected in oro-pharyngeal secretions for up to 32 weeks and may persist for decades. On rare occasion, EBV is spread via blood transfusion and organ transplantation.

Epstein-Barr virus infection of B lymphocytes results in a humoral and cellular response to the virus. The humoral immune response directed against EBV structural proteins is the basis for the test used to diagnose EBV infectious mononucleosis, but the T-lymphocyte cellular response is critical in determining the clinical expression of EBV infection. Natural killer (NK) cells and predominantly CD8+ cytotoxic T cells control proliferating B lymphocytes infected with EBV.

Ineffective T-cell response may cause excessive and uncontrolled B-cell proliferation, resulting in B-lymphocyte malignancies (eg, B-cell lymphomas).

The immune response to EBV infection is fever, which occurs because of cytokine release consequent to B-lymphocyte invasion by EBV. Lymphocytosis observed in the reticuloendothelial system (RES) is caused by a proliferation of EBV-infected B lymphocytes and similar proliferation in the lymphatic tissue of the oropharynx causes pharyngitis.

What causes glandular fever?

Glandular fever is caused by the Epstein-Barr virus (EBV). This virus is found in the saliva of infected people and can be spread through:

kissing – glandular fever is often referred to as the “kissing disease”

exposure to coughs and sneezes

sharing eating and drinking utensils, such as cups, glasses and unwashed cutlery

EBV may be found in the saliva of someone who has had glandular fever for several months after their symptoms pass, and some people may continue to have the virus in their saliva on and off for years.

If you have EBV, it’s a good idea to take steps to avoid infecting others while you are ill, such as not kissing other people, but there’s no need no need to avoid all contact with others as the chances of passing on the infection are generally low.

Risk factors

People more likely to catch glandular fever include:

Adolescents

Those sharing food and drinking utensils with others

People in close contact with someone who has infectious mononucleosis

People with a weakened immune system

People with HIV

What are the symptoms of glandular fever?

One or more of the following symptoms commonly occur for about a week or so. Symptoms then usually gradually settle over another week.

Sore throat. Although this may be mild, your throat is usually very sore, red and swollen. Glandular fever is typically suspected when a tonsillitis is severe and lasts longer than usual. Swallowing is often painful and saliva may pool in your mouth.

Swollen glands. As your body’s immune system fights off the virus it causes the lymph glands to swell. Any lymph gland in the body can be affected. However, the glands in the neck are usually the most prominent. They can become quite large and tender.

Flu-like symptoms. Like other viral infections, glandular fever often causes a high temperature (fever), muscle aches and headaches. It can make you feel quite unwell.

Malaise. A feeling of intense tiredness often develops with glandular fever. This is often the last symptom to go.

Swelling around eyes. About 1 in 5 people with glandular fever become quite puffy and swollen around the eyes. This goes in a short time.

Spleen. This is an organ under the ribs on the left side of the tummy (abdomen). It is part of the immune system. Like the lymph glands, it swells and can sometimes be felt below the ribs if you have glandular fever. Very occasionally, it causes mild pain in the upper left abdomen.

No symptoms. Many people become infected with this virus but do not develop symptoms. This is called a subclinical infection. This is more common in children and in those aged over 40 years.

Glandular fever complications

Most people get better with no problems. But sometimes glandular fever may lead to other problems like:

Mild liver inflammation (hepatitis), which causes yellowing of the skin and whites of the eyes (jaundice)

Low levels of blood cells called platelets (thrombocytopenia)

Neurological conditions, such as Guillain-Barré syndrome or Bell’s palsy

Diagnosis

The doctor will discuss your symptoms and will perform a physical examination. This will include an assessment of whether there is:

Fever

Redness of the throat and swelling of the tonsils

Enlargement of the lymph nodes

Enlargement of the spleen

A rash (especially on the chest).

As these symptoms are so characteristic of glandular fever they are usually sufficient to make a diagnosis.

Blood tests

Antibody tests. If there’s a need for additional confirmation, a monospot test may be done to check your blood for antibodies to the Epstein-Barr virus. This screening test gives results within a day. But it may not detect the infection during the first week of the illness. A different antibody test requires a longer result time, but can detect the disease even within the first week of symptoms.

White blood cell count. Your doctor may use other blood tests to look for an elevated number of white blood cells (lymphocytes) or abnormal-looking lymphocytes. These blood tests won’t confirm mononucleosis, but they may suggest it as a possibility.

Treatment

There is no cure for glandular fever, and some people experience symptoms for 6 monthsTrusted Source or longer.

However, even without treatment, most people find that their symptoms go away within 2–4 weeksTrusted Source, though fatigue can last longer. In fact, studies have found that 9–22% of people continue to experience fatigue for 6 months after developing the infection.

A person can take the following steps to help the body heal:

Rest

A person with glandular fever often feels too tired and unwell to continue with their regular routine, but complete rest is key, especially in the first month after symptoms have appeared.

As the person recovers, light exercise may help them regain muscle strength.

Drink plenty of fluids

This will help prevent dehydration, especially if there is a fever.

A sore throat can make it hard to swallow, but it is important to consume enough fluids.

Pain relief medication

Pain relief medication, such as ibuprofen (Advil) and acetaminophenTrusted Source (Tylenol) are available over-the-counter and online. They may help keep any fever and pain at bay.

Aspirin is not suitableTrusted Source as it can increase the risk of bleeding. Children under 16 should also not use it due to the risk of developing Reye’s syndrome.

Gargling

Gargling with salt water or a solution from a pharmacy may help relieve a sore throat.

Steroids

If the tonsils are very inflamed or breathing is otherwise difficult, a doctor may prescribe a short course of corticosteroids.

Can glandular fever be prevented?

As with other infectious diseases, the spread of glandular fever can be reduced. People who have glandular fever, or those who come into contact with people with glandular fever, should:

Carefully wash their hands with soap and running water, especially after sneezing and coughing, and before touching other people

Avoid sharing eating and drinking containers and utensils

Avoid saliva contact with people who have, or may have, glandular fever (and if you have glandular fever, avoid saliva contact with others)

Hydronephrosis is the swelling of a kidney due to a build-up of urine.

What is Hydronephrosis?

Hydronephrosis is the swelling of a kidney due to a build-up of urine. It happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction. Hydronephrosis can occur in one or both kidneys.

The main function of the urinary tract is to remove wastes and fluid from the body. The urinary tract has four parts: the kidneys, the ureters, the bladder and urethra. The urine is formed when the kidneys filter blood and remove excess waste materials and fluid. Urine collects into a part of the kidney called the renal pelvis. From the renal pelvis, the urine travels down a narrow tube called the ureter into the bladder. The bladder slowly fills up with urine, which empties from the body through another small tube called the urethra. Hydronephrosis occurs when there is either a blockage of the outflow of urine, or reverse flow of urine already in the bladder (called reflux) that can cause the renal pelvis to become enlarged.

Pathophysiology

Hydronephrosis can result from anatomic or functional processes interrupting the flow of urine. This interruption can occur anywhere along the urinary tract from the kidneys to the urethral meatus. The rise in ureteral pressure leads to marked changes in glomerular filtration, tubular function, and renal blood flow. The glomerular filtration rate (GFR) declines significantly within hours following acute obstruction. This significant decline of GFR can persist for weeks after relief of obstruction. In addition, renal tubular ability to transport sodium, potassium, and protons and concentrate and to dilute the urine is severely impaired.

The extent and persistence of these functional insults is directly related to the duration and extent of the obstruction. Brief disruptions are limited to reversible functional disturbance with little associated anatomic changes. More chronic disruptions lead to profound tubular atrophy and permanent nephron loss.

Increased ureteral pressure also results in pyelovenous and pyelolymphatic backflow. Gross changes within the urinary tract similarly depend on the duration, degree, and level of obstruction. Within the intrarenal collecting system, the degree of dilation is limited by surrounding renal parenchyma. However, the extrarenal components can dilate to the point of tortuosity.

To distinguish acute and chronic hydronephrosis, one may consider acute as hydronephrosis that, when corrected, allows full recovery of renal function. Conversely, in chronic hydronephrosis the loss of function is irreversible even with correction of the obstruction. Early experiments with dogs showed that if acute unilateral obstruction is corrected within 2 weeks, full recovery of renal function is possible. However, after 6 weeks of obstruction, function is irreversibly lost.

Grossly, an acutely hydronephrotic system can be associated with little anatomic disturbance to renal parenchyma. On the other hand, a chronically dilated system may be associated with compression of the papillae, thinning of the parenchyma around the calyces, and coalescence of the septa between calyces. Eventually, cortical atrophy progresses to the point at which only a thin rim of parenchyma is present. Microscopic changes consist of dilation of the tubular lumen and flattening of the tubular epithelium. Fibrotic changes and increased collagen deposition are observed in the peritubular interstitium

What are the causes of Hydronephrosis?

Hydronephrosis is not a primarily caused disease. Instead, it is caused by internal or external conditions that affect the urinary collecting system. Another disease may be the underlying cause of hydronephrosis.

The most common cause for this blockage is kidney stones. Blood clots can also sabotage the flow of urine. The core reason for the problem is the sudden development of obstruction or blockage in any one of the ureters.

The ureters are the tubes that connect the kidneys to the bladder. Blocked urine goes back to the kidney, resulting in the swelling of the kidney. This backward flow of urine to the kidney is called vesicoureteral reflux.

Some of the other causes include:

Enlarged prostate glands

Pregnancy causes compression due to a growing fetus

Tumors near the ureter

Injuries and

Birth defects

Risk Factors

Learn about risk factors for hydronephrosis.

To date, there are no known risk factors for hydronephrosis. However, boys are four-to-five times more likely to be born with hydronephrosis than girls. Hydronephrosis does not run in families, although some causes of hydronephrosis, such as VUR, may run in families. Hydronephrosis is not linked to anything parents did or did not do during pregnancy so there is nothing you could have done to cause or prevent hydronephrosis of your child’s kidney(s).

Hydronephrosis may be due to factors such as kidney stones, blood clots, tissue outgrowths (polyps) or other abnormalities. Typically treatment of these issues results in a normal appearing kidney and no hydronephrosis.

What are the symptoms of hydronephrosis?

Most babies with hydronephrosis have no symptoms. Older children may also have no symptoms if they have mild or moderate hydronephrosis, and the condition may disappear on its own.

If your child has moderate to severe hydronephrosis, some symptoms may include:

Pain in the abdomen

Pain in the side (flank pain)

Blood in the urine (hematuria)

A child with hydronephrosis may develop a UTI. Symptoms of a urinary tract infection can include the following:

Strong urge to use the bathroom

Painful urination

Cloudy urine

Back pain

Fever

Vomiting

If your infant has had multiple urinary tract infections (UTIs) with (or without) a fever, it could indicate some kind of obstruction or reflux in the urinary system. However, UTIs can be difficult to spot in infants: In many cases, multiple, unexplained fevers are the only sign.

Older children may have more recognizable symptoms of UTIs, including a strong urge to urinate, painful urination, or cloudy urine. If your child tends to get repeat UTIs, you may want to have him evaluated for possible urinary tract obstruction.

Complications

The most common complication of hydronephrosis is the development of a urinary tract infection (UTI).

When the UTI is associated with a high fever, a kidney infection is (pyelonephritis) is suspected. This is caused by bacteria spreading from the bladder to the kidney and invading the kidney tissue.

Children with severe hydronephrosis (moderate-severe, grade 3 and 4) have a higher risk of UTI/pyelonephritis.

If pyelonephritis is severe or not treated in a timely manner, or if it affects both kidneys, complications such as permanent kidney damage (kidney scarring) can lead to problems such as high blood pressure and sometimes kidney failure.

How is Hydronephrosis diagnosed?

Physical examination: Your doctor will ask you about any symptoms you are having and will examine the area near the kidneys and bladder for tenderness or swelling. The doctor may ask about your medical history and your family’s medical history. Your doctor will look for pelvic swelling. Men may need to undergo a rectal exam to determine whether the prostate is enlarged. Women might require a pelvic exam to evaluate whether there are any problems with the uterus or ovaries.

Urine tests: A urine sample will be collected and analyzed to find out if there is blood, stone crystals or any infection and bacteria present.

Blood tests: A complete blood count may be performed to determine whether an infection is present. Tests of kidney function including creatinine, estimated GFR (eGFR) and blood urea nitrogen (BUN) may be done.

Imaging procedures: The main test done is an ultrasound. This does not require radiation. A CT scan or MRI may be necessary.

What are the treatment options for Hydronephrosis?

After considering the nature and cause of the hydronephrosis, doctors will decide between recommending observation or surgery.

Fetal intervention

In very rare instances, prenatal hydronephrosis is so severe that it puts the fetus at risk. This usually means the obstruction is in the child’s urethra, blocking drainage of the bladder and both kidneys. In turn, this results in a dangerously low amount of amniotic fluid (a condition called oligohydramnios).

Observation

If postnatal testing shows your child has mild to moderate hydronephrosis, your doctor may recommend allowing time for the condition to correct itself on its own. Your child may receive a low dose of antibiotics to prevent infection. Repeat ultrasounds will let us check for improvement.

Observation has become the accepted method of treatment in children with mild hydronephrosis. Even in children with moderate hydronephrosis, if kidney function is not lost and kidneys are growing well, observation can allow the condition to correct itself.

Surgery

Only in severe cases would surgery be needed. The goal of the operation is to reduce the swelling and pressure in the kidney by restoring the free flow of urine.

The most common surgical procedure is pyeloplasty. This repairs the most common type of blockage that causes hydronephrosis: ureteropelvic junction obstruction (UPJ). In pyeloplasty, the surgeon will remove the narrowed or obstructed part of the ureter. Then, the healthy portion is reconnected to the kidney’s drainage system. After open surgery (small incision over the kidney), children usually stay in the hospital for about two to three days. They heal in two to three weeks. The success rate is about 95 percent.

Other surgical treatments may be recommended for your child, depending on what’s causing the hydronephrosis and how severe it is. To learn more about these, see: ureteropelvic junction obstruction, vesicoureteral reflux, posterior urethral valves, and ureteroceles.

Robot-assisted and minimally invasive surgery

This innovative tool is used for about half of the pyeloplasties performed by our urological team.

A robot-assisted pyeloplasty is a minimally invasive laparoscopic procedure. With the use of a tiny camera, surgeons operate using very thin instruments inserted into three or four small incisions. Robot-assisted pyeloplasty removes an obstructed section of the ureter and reattaches the healthy portion to the kidney’s drainage system.

Robotic surgery can offer a number of benefits as compared to traditional (open) surgery, including:

Less discomfort after the operation

Smaller scars on the belly

A shorter hospital stay usually 24 to 48 hours

Quicker recovery

Earlier return to full activities

Even if pyeloplasty is recommended for your child, a robot-assisted procedure may or may not be suitable. Your doctor will recommend the best options for your child.

How can I prevent Hydronephrosis?

Since hydronephrosis is caused by an underlying condition, prevention depends on avoiding or promptly treating the cause. For instance, the chance of developing a kidney stone may be reduced by going to a stone clinic to find out what is causing the stones and start treatment to prevent recurrence (repeating).

Seek treatment immediately if you experience severe pain in the side or abdomen, vomiting, or a fever above 100.5 degrees Fahrenheit.

Nightmare disorder is a sleep disorder in which frequent disturbing dreams interfere with a person’s ability.

Definition

Nightmare disorder is a sleep disorder in which frequent disturbing dreams interfere with a person’s ability to function well during the day or cause emotional distress. Nightmares typically occur during a phase of sleep called rapid eye movement (REM) sleep. This phase usually occurs relatively late in the sleep period, often in the second half of the night. Some people may experience multiple nightmares during the night.

Nightmares are common in children, but they tend to decrease in frequency as a child gets older. By adolescence, nightmares are usually less frequent, although many adults continue to experience them throughout their lives. Most people have unpleasant dreams from time to time, but the disturbing dreams associated with nightmare disorder are exceptional in their frequency and impact on the dreamer’s emotional state.

Epidemiology

Nightmares are common, with three-quarters of children experiencing a nightmare at least once. Prevalence varies because of different diagnostic criteria and different study populations. Nightmares have been noted to occur in 2–11% of young children “always and often” and in 15–31% “now and then.” Some studies estimate as many as 50% of children aged 3–6 years have nightmares that disturb both their and parents’ sleep. Approximately one-third of adults with recurrent nightmares have onset of symptoms in childhood.

Risk factors

Nightmares can happen to anyone, and in most cases the reasons why the nightmares occur are unclear. Stress, anxiety, an irregular sleep routine, or being overtired can increase your risk for nightmares.

Some medications, such as antidepressants and medications for hypertension or Parkinson’s disease, may increase the frequency of nightmares. Nightmares that cause sleep problems may also be associated with factors such as:

Another sleep disorder

A medical condition

Medication use

A mental health disorder such as depression, anxiety, or PTSD

Substance abuse

Having the same nightmare repeatedly over time can also be common after severe stress or a traumatic event. These nightmares are often a way of “reliving” the traumatic event.

Causes of nightmare disorder

Nightmare disorder is referred to by doctors as parasomnia a type of sleep disorder that involves undesirable experiences that occur while you’re falling asleep, during sleep or when you’re waking up. Nightmares usually occur during the stage of sleep known as rapid eye movement (REM) sleep. The exact cause of nightmares is not known.

Nightmares can be triggered by many factors, including:

Stress or anxiety: Sometimes the ordinary stresses of daily life, such as a problem at home or school, trigger nightmares. A major change, such as a move or the death of a loved one, can have the same effect. Experiencing anxiety is associated with a greater risk of nightmares.

Trauma: Nightmares are common after an accident, injury, physical or sexual abuse, or other traumatic events. Nightmares are common in people who have post-traumatic stress disorder (PTSD).

Sleep deprivation: Changes in your schedule that cause irregular sleeping and waking times or that interrupt or reduce the amount of sleep you get can increase your risk of having nightmares. Insomnia is associated with an increased risk of nightmares.

Medications: Some drugs including certain antidepressants, blood pressure medications, beta-blockers, and drugs used to treat Parkinson’s disease or to help stop smoking can trigger nightmares.

Substance misuse: Alcohol and recreational drug use or withdrawal can trigger nightmares.

Other disorders: Depression and other mental health disorders may be linked to nightmares. Nightmares can happen along with some medical conditions, such as heart disease or cancer. Having other sleep disorders that interfere with adequate sleep can be associated with having nightmares.

Scary books and movies: For some people, reading scary books or watching frightening movies, especially before bed, can be associated with nightmares.

Nightmare disorder symptoms

It occurs when people experience vivid and terrifying dreams frequently. Generally, patients wake up in the middle of their sleep. Some symptoms are:

Fear having more nightmares

Fatigue, sleepiness, unknown fear and low energy during the day

Nightmares occurring many times at night

Concentration problems and memory loss

Changes in behavior

Fear of the dark

Daytime activities suffering due to the disorder

Anybody can suffer from a nightmare disorder. A patient feels insecure and fearful throughout the day and at night.

Complications

Nightmare disorder may cause:

Excessive daytime sleepiness, can lead to difficulties at school or work, or problems with everyday tasks, such as driving and concentrating

Problems with mood, such as depression or anxiety from dreams that continue to bother you

Resistance to going to bed or to sleep for fear you’ll have another bad dream

Suicidal thoughts or suicide attempts

Diagnosis and test

There are no tests routinely done to diagnose nightmare disorders. Nightmares are only considered a disorder if disturbing dreams cause you distress or keep you from getting enough sleep. To diagnose a nightmare disorder, your doctor reviews your medical history and your symptoms. Your evaluation may include:

Exam: You may have a physical exam to identify any conditions that may be contributing to the nightmares. If your recurrent nightmares indicate underlying anxiety, the doctor may refer you to a mental health professional.

Symptoms discussion: Nightmare disorder is usually diagnosed based on your description of your experiences. Your doctor may ask about your family history of sleep problems. Your doctor may also ask you or your partner about your sleep behaviors and discuss the possibility of other sleep disorders if indicated.

Nocturnal sleep study (polysomnography): If your sleep is severely disturbed, your doctor may recommend an overnight sleep study to help determine if the nightmares are connected to another sleep disorder. Sensors placed on your body will record and monitor your brain waves, the oxygen level in your blood, heart rate and breathing, as well as eye and leg movements while you sleep. You may be videotaped to document your behavior during sleep cycles.

Nightmare disorder treatment and medications

Infrequent nightmares don’t normally need any treatment, but both psychotherapy and medications can help people who have nightmare disorders. By reducing nightmares, treatments can promote better sleep and overall health.

Treatment for nightmares should always be overseen by a health professional who can identify the most appropriate therapy based on a patient’s overall health and the underlying cause of their nightmares.

Psychotherapy

Psychotherapy, also known as talk therapy, is a category of treatment that works to understand and reorient negative thinking. Talk therapy has broad applications in addressing mental health disorders and sleeping problems like insomnia.

Many types of psychotherapy fall under the umbrella of cognitive-behavioral therapy (CBT), including a specialized form of CBT for insomnia (CBT-I) that may be used to treat nightmares. A central component of CBT is reorienting negative thoughts and feelings and modifying detrimental patterns of behavior.

There are numerous types of talk therapy and CBT that may help reduce nightmares:

Image Rehearsal Therapy: This approach involves rewriting a recurring nightmare into a script that is rewritten and then rehearsed when awake in order to change how it unfolds and impacts the sleeper.

Lucid Dreaming Therapy: In a lucid dream, a person is actively aware that they are dreaming. Lucid dreaming therapy seizes on this idea to give a person the ability to positively modify the content of a nightmare through their awareness of it in the moment.

Exposure and Desensitization Therapies: Because many nightmares are driven by fears, a number of approaches utilize controlled exposure to that fear to reduce the emotional reaction to it. Examples of these techniques to “face your fears” include self-exposure therapy and systematic desensitization.

Hypnosis: This approach creates a relaxed, trance-like mental state in which a person can more easily take in positive thoughts to combat stress.

Progressive deep muscle relaxation: While not a direct form of talk therapy, progressive deep muscle relaxation is a technique for calming the mind and body. It involves deep breathing and a sequence of tension and release in muscles throughout the body. Relaxation methods like this are a tool developed in talk therapy to counteract stress buildup.

Behavioral recommendations associated with talk therapy frequently involve changes to sleep hygiene. This includes making the bedroom more conducive to sleep as well as cultivating daily routines and habits that facilitate consistent sleep.

Much psychotherapy for nightmares involves a combination of methods. Examples include CBT-I, Sleep Dynamic Therapy13 and Exposure, Relaxation, and Rescripting Therapy (ERRT)14. Mental health professionals can tailor talk therapy for nightmares to fit a patient, including, when appropriate, account for a coexisting mental health disorder.

Medication

Several types of prescription medications may be used to treat nightmare disorders. Most often, these are medications that affect the nervous system such as anti-anxiety, antidepressants, or antipsychotic drugs. Different medications may be used for people who have nightmares associated with PTSD.

Medications benefit some patients, but they can also come with side effects. For that reason, it is important to talk with a doctor who can describe the potential benefits and downsides of prescription drugs for nightmare disorders.

Prevention of nightmare disorder

Don’t avoid sleep, and keep a regular sleep-wake schedule

Decrease alcohol intake and review your psychiatric and sleep medications with your doctor

Wake up fully and be ready for a quick check-in with reality

Seek treatment for PTSD and other mental health needs

With the help of a qualified therapist, you can work through the imagery during your waking hours to cope with your symptoms and reduce the occurrences of nightmares. For instance, the targeted psychotherapy techniques such as IRT or ERRT combined with improved sleep hygiene practices may help reduce future instances of PTSD-associated nightmares. Additionally, a 2015 study shows a link between nightmares, insomnia, sleep deprivation, and poor sleep quality.

You might try these tips to improve your sleep hygiene and get a better night’s rest:

Establish to a regular bedtime routine.

Commit to a regular sleep schedule.

Set a no-screen rule at least 1 hour before bed.

Charge your electronic devices in another room.

Lower the thermostat to 65–70°F (18–21°C).

Make your room as dark as possible.

Diffuse calming essential oils like lavender.

Invest in a quality pillow.