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By: M. Sancho, M.A., Ph.D.
Clinical Director, Donald and Barbara School of Medicine at Hofstra/Northwell
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Feet to meters conversion reference: Feet Meters 8000 ft Approximately 2400 m 5000 ft Approximately 1500 m 7000 ft Approximately 2100 m 500 ft Approximately 150 m 1000 ft Approximately 300 m Patient Care Goals 1. Safe but rapid transport from the high-altitude environment to a lower altitude environment Patient Presentation Inclusion Criteria 1. High altitude cerebral edema Exclusion Criteria Patients who have not been exposed to altitude. Patient Management 314 Assessment Assessment should target the signs and symptoms of altitude illness but should also consider alternate causes of these symptoms. Patients with acute mountain sickness only may remain at their current altitude and initiate symptomatic therapy b. Administer supplemental oxygen, if available, with goal to keep oxygen saturations? Descent is the mainstay of therapy and is the definitive therapy for all altitude related illnesses. If severe respiratory distress is present and pulmonary edema is found on exam, provider should start positive pressure ventilation b. However, they should not be used in lieu of decent, only as an alternative should descent be unfeasible. Acetazolamide speeds acclimatization and therefore helps in treating acute mountain sickness iv. Dexamethasone helps treat the symptoms of acute mountain sickness and may be used as an adjunctive therapy in severe acute mountain sickness when the above measures alone do not ameliorate the symptoms. In these circumstances, patients should also initiate descent, as dexamethasone does not facilitate acclimatization b. Multiple pulmonary vasodilators should not be used concurrently Patient Safety Considerations 1. Rescuers must balance patient needs with patient safety and safety for the responders 2. Rapid descent by a minimum of 500-1000 feet is a priority, however rapidity of descent must be balanced by current environmental conditions and other safety considerations Notes/Educational Pearls Key Considerations 1. Patients suffering from altitude illness have exposed themselves to a dangerous environment. By entering the same environment, providers are exposing themselves to the same altitude exposure. Descent of 500-1000 feet is often enough to see improvements in patient conditions 3. Consider airway management needs in the patient with severe alteration in mental status 2. Wilderness Medical Society consensus guidelines for the prevention and treatment of acute altitude illness. Wilderness Medical Society Practice guidelines for the prevention and treatment of acute altitude illness: 2014 update.
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In conclusion, Child Health Plus appears well positioned to continue its effective operations into the future. Appendix A Mathematica Policy Research the Urban Institute New York Site Visit February 13-16 Site Visitors Urban Institute Ian Hill Sarah Benatar Mathematica Policy Research Sheila Hoag U. Appendix B Mathematica Policy Research the Urban Institute 39 Appendix B Mathematica Policy Research the Urban Institute 40 Appendix B Mathematica Policy Research the Urban Institute 41 Appendix B Mathematica Policy Research the Urban Institute 42 Appendix B Mathematica Policy Research the Urban Institute 43 Appendix B Mathematica Policy Research the Urban Institute 44 Appendix B Mathematica Policy Research the Urban Institute 45 Appendix B Mathematica Policy Research the Urban Institute 46 Appendix B Mathematica Policy Research the Urban Institute 47 Appendix B Mathematica Policy Research the Urban Institute 48 Appendix B Mathematica Policy Research the Urban Institute 49 PartNers Center for Research to Practice Distinguished University Professor; Director, Child Development Laboratory, University of Maryland College Park the frameworks Institute william Greenough, Ph. Developmental Biology; Director, Center for Advanced Study the National Governors Regents Professor and Distinguished McKnight University at University of Illinois, Urbana-Champaign Professor, Institute of Child Development, University association center for of Minnesota eric knudsen, Ph. Dean, Yale School of Medicine Professor of Psychology and Associated Faculty, Public Policy Institute; Co-Director, Research Center on Children in the U. Mirsky Professor; Head, Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, arthur J. When developing biological systems are strengthened by positive early experiences, healthy children are more likely to grow into healthy adults. Altering these regula with adversity, feel a sense of personal well-being, and inter tory mechanisms. Nations with the most positive indicators of and chronic disease, and even a shortened life span, by un population health, such as longer life expectancy and lower dermining the normally adaptive response of the body to the infant mortality, typically have higher levels of wealth and challenges and stressors of everyday life. For example, when large numbers of hood can have lifelong consequences for both physical and children become ill because they did not receive their immu nizations, the entire population becomes vulnerable to epidemics of infectious diseases. For ex social and economic burdens of illness, not only in child ample, exposure of expectant mothers to highly stressful en hood but also throughout the adult years. Traumatic experiences during childhood, such dren, and it suggests that most current attempts to prevent as physical abuse or the adversities that accumulate for chil adult disease and create a healthier workforce may be starting dren reared in deep and persistent poverty, are also capable too late. Progress to Driven by converging evidence from neuroscience, mo ward this goal will be most effective if innovative actions lecular biology, genomics, and advances in the behavioral are guided by an understanding of four interrelated dimen and social sciences, this call for a broader perspective on sions that together comprise a new framework for improv health promotion and disease prevention is guided by the ing physical and mental well-being: (1) the biology of health; following three overarching concepts: (2) the foundations of health; (3) caregiver and community a framework for reconceptualizing early childhood Policies and Programs to strengthen lifelong health Preconception Prenatal Policy and Program Caregiver and Foundations Biology Levers for Innovation Community Capacities of Health of Health Early Public Health Physiological Childhood Stable, Responsive Adaptations or Child Care and Early Education Time and Commitment Relationships Disruptions Health and Child Welfare Development Across Financial, Psychological, and Safe, Supportive Early Intervention ?Cumulative the Lifespan Middle Institutional Resources Environments Over Time Childhood Family Economic Stability Skills and Knowledge Appropriate. Embedded Community Development Nutrition During Primary Health Care Adolescence Sensitive Private Sector Actions Periods Adulthood Settings Workplace Home Programs Neighborhood It is also important to underscore of infuence that establish a context within the role that private-sector practices as well as which the early roots of physical and mental government-sponsored programs can play in well-being are either nourished or disrupted: strengthening the capacities of families to raise. In either case, sci linked to processes and experiences occurring ence shows that there can be a lag of many years, decades before, in some cases as early as prena even decades, before early harm is expressed in tally. Researchers have ic backgrounds are more likely to show height hypothesized that this association may be the ened activation of stress response systems,47,48 result of excessive stress related to high rates of and some emerging research suggests that dif neighborhood risk factors such as crime, vio ferences in caregiving related to income and lence, boarded-up houses, abandoned lots, and education?such as responsiveness in parent inadequate municipal services.
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Systemic causes should also be considered: stress or pathological fractures, neoplasia, sickle cell anaemia, myeloma, vitamin D deficiency, herpes zoster. Gastro-oesophageal causes the heart and oesophagus share some common neurologic innervation. Thus, it may be difficult to distinguish between chest pain due to myocardial ischaemia and pain originating from the oesophagus based upon the history alone. Oesophageal disease may cause symptoms thought "classical" for myocardial ischaemia, including a sensation of chest pressure, provocation with exercise or emotion, palliation by rest or nitrates, or a crescendo pattern. A motility disorder or oesophageal spasm should be entertained if chest pain is associated with dysphagia Pulmonary causes of chest pain Pulmonary causes of chest pain may be related to the pulmonary vessels, lung parenchyma, airways, or pleural tissue. Pulmonary embolus and tension pneumothorax are two pulmonary causes of chest pain that may be imminently life threatening. It should be considered in any patient who presents with chest pain that is usually but not necessarily pleuritic in nature or dyspnoea that is not fully explained by the clinical evaluation, chest radiograph, or electrocardiogram. Most patients present with exertional dyspnoea, which is indicative of an inability to increase cardiac output with exercise. Exertional chest pain, syncope, and oedema are indications of more severe pulmonary hypertension and impaired right heart function. Psychogenic/psychosomatic causes of chest pain Chest pain may be a presenting symptom of panic disorder, depression, and hypochondriasis, as well as cardiac, cancer or other phobias. More subtle hyperventilation disorders include dysfunctional breathing which can present as chest pain. A Nijmegen questionnaire can help identify these patients who can be helped with respiratory physiotherapy. The clinical manifestations of myocarditis are highly variable ranging from subclinical disease to fatigue, chest pain, heart failure, cardiogenic shock, arrhythmias, and sudden death. Myocarditis can mimic myocardial ischaemia and/or infarction both symptomatically and on the electrocardiogram, particularly in younger patients. The aetiological classification comprises: infectious pericarditis, pericarditis in systemic autoimmune diseases, type 2 (auto) immune processes, post myocardial infarction syndrome, and auto-reactive (chronic) pericarditis. Major symptoms are retrosternal or left precordial chest pain (radiates to the trapezius ridge, can be pleuritic or sound ischaemic, varies with posture worse lying flat) and shortness of breath. Treatment is usually symptomatic but in more severe cases with recurrent episodes, specific anti-viral therapy may be indicated when a specific virus is implicated. Systemic corticosteroid therapy should be restricted to connective tissue diseases, auto reactive or uraemic pericarditis. An echocardiogram is warranted to exclude effusions and look for myocardial dysfunction. Chronic recurrent effusions may need treatment with balloon pericardiotomy or surgical pericardiectomy. Pericarditis in renal failure is common especially in those just pre-dialysis or those who have just started dialysis. Carcinoma lung and breast account for more than half, leukaemia and lymphoma about a quarter.
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Her eyes widened in surprise, and then narrowed while her hand curled around the tip. Maybe she?ll disappear?maybe I?ll write my number on his plate with ketchup She wandered away, listing slightly to the side. The hostess was only semi-coherent at the moment, describing her incorrect assessment of me to her friend on the wait staff. But before I had time to too deeply regret speaking the words aloud she answered, ?Frequently. My silent heart swelled with a hope more intense than I could ever remember having felt before. Her thoughts were loud, and more explicit than the hostess?s, but I tuned her out. I continued to stare at Bella, and the waitress grudgingly turned to look at her, too. I?ve always been very good at repressing unpleasant things, she answered, a little breathless. She put them in front of me, and asked for my order, trying to catch my eye in the process. I indicated that she should attend to Bella, and then went back to tuning her out. She drank until the glass was entirely empty, so I pushed the second coke toward her, frowning a little. The pretty blouse she wore looked too thin to protect her adequately; it clung to her like a second skin, almost as fragile as the first. I handed her the jacket across the table, and she put it on at once, and then shuddered again. She took a deep breath, and then pushed the too-long sleeves back to free her hands. Her color was still good; her skin was cream and roses against the deep blue of her shirt. Instead of running, she lingered, drawn to what should frighten her How could I protect her from myself when neither of us wanted that? I could see her turning my words over in her head, and I wondered what she made of them. I paid the server little attention as she set the plate in front of Bella and then asked if I wanted anything. Her questions would probably be enough to tell me where her thoughts were heading. It gave away nothing, while my answer, if truthful, would give away much too much.
