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Kapolani Kids Fall 2005

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Ka Psoh405

  1. 1. Kapi`olani VOLUME 3. ISSUE 2. NOVEMBER 2005 VOL 1. ISSUE 1 kids T H E L AT E S T I N C H I L D R E N ’ S H E A LT H F R O M K A P I ` O L A N I C H I L D R E N ’ S H O S P I TA L An Rx for RSV This cold-like virus hits some infants hard As a child, you probably never heard of respiratory syncytial virus (RSV). But today it’s better known, and doctors believe RSV is the most common cause of respiratory infections in young children. BABY TALK RSV is prevalent in Hawaii. “We know that many children are infected in their first year of life and essentially all chil- How to Stop a Crying Baby dren are infected by age 2,” says Galen Chock, M.D., pediatrician and vice presi- Pick him up, turn on some white dent, American Academy of Pediatrics noise and take a stress break (AAP), Hawaii Chapter. RSV outbreaks usually hit in late fall, You’ve fed, burped, changed and winter or early spring. “We have no way rocked your baby, but he’s still crying. of predicting at the beginning of a season And crying. Your nerves are frayed, your whether it’s going to be a particularly sleep is wrecked and you’re losing confi- severe season or not,” says David K. Shay, dence as a new parent. Now what? M.D., a medical epidemiologist at “First, don’t blame yourself,” says the Centers for Disease Control and John Nagamine, M.D., pediatrician. Prevention. “Most babies have extended crying episodes with no easy explanation.” “Young infants tend to have Some babies cry for long stretches at smaller airways, making their 3 and 12 weeks of age during steps in development when their sleep is less breathing vulnerable. RSV can RSV can cause a more severe lower res- settled. “Colicky” babies — generally, be life threatening for some piratory infection, such as bronchiolitis those who cry non- young children.” or pneumonia, with coughing, wheezing John Nagamine, stop for more than and severe difficulty breathing that may M.D. three hours a day, —Galen Chock, M.D., lead to a low level of oxygen in the blood. more than three pediatrician and vice president, days a week — are When to seek treatment American Academy of Pediatrics, thought to have a How can you tell if Hawaii Chapter your child’s infection Galen Chock, M.D. built-in tendency to is serious? If your overreact to any RSV usually causes mild symptoms — child is laboring for stimulation, be it a “often very much like a common cold, each breath — nostrils continued on page 7 at least initially,” says Dr. Chock. Signs flaring, grunting, include a stuffy, runny nose, coughing, coughing, unable to slight fever and sometimes wheezing. drink or sleep — Symptoms may linger a week or two. “that’s a child I worry Ask your pediatrician about fluids, about and would rest and medication to reduce fever. continued on page 7
  2. 2. muscle contraction. Chronic strains are the result of overuse — prolonged, repeti- tive movement — of muscles and ten- dons. Inadequate rest during intense training can cause a strain. Typical indications of strain include pain, muscle spasm, muscle weakness, swelling, inflammation and cramping. In severe strains, the muscle or tendon is partially or completely ruptured, leaving a person incapacitated. Some muscle func- tion will be lost with a moderate strain, where the muscle or tendon is over- stretched and slightly torn. With a mild strain, the muscle or tendon is stretched or pulled slightly. Breaks Breaks are a fracture, splinter or com- plete break in bone, often caused by acci- dents, sports injuries or bone weakness. Bone breaks should always be looked at by a physician to ensure proper healing and connection. Treat injuries with RICE Sprains, Strains, Breaks: In all but mild cases, a doctor should evaluate the injury and establish a treat- What’s the Difference? ment and rehabilitation plan, says Dr. Durkin. Meanwhile, RICE (rest, ice, compression If you’ve sprained your ankle before, you A sprain is caused by trauma (a fall, a and elevation) usually will help minimize know what severe pain is. twist, a blow to the body) that knocks a damage caused by sprains and strains. But that “sprain” could have been a joint out of position and overstretches or Begin RICE immediately after the injury “strain” or possibly even a “break.” even ruptures supporting ligaments. Some and continue off-and-on for about 72 hours, The amount of pain examples are when a person lands on an says Dr. Durkin. Robert Durkin, in each case can be outstretched arm, slides into a base, lands RICE relieves pain, minimizes swelling M.D. virtually equal, so if on the side of the foot or runs on an and speeds healing, and it is often the your child suffers an uneven surface. best treatment for soft-tissue injuries, injury, the best way Though the intensity varies, pain, such as sprains and strains. to find out what your bruising and inflammation are common ■ Rest: Avoid moving the injured area child has is to see a to all three categories of sprains: mild, to allow healing to begin. doctor, advises Robert moderate and severe. The child may feel ■ Ice: Apply it immediately to reduce Durkin, M.D., pedi- a tear or pop in the joint. With a severe inflammation, which causes more pain atric orthopedic sur- sprain, ligaments tear completely or and slows healing. Cover the injured geon. separate from the bone. This loosening area with an ice pack (inside a wet “The most common impairs joint function. A moderate sprain reason for an ankle partially tears the ligament, producing cloth) and apply the ice for 10 to sprain is having had one already,” says joint instability and some swelling. A liga- 20 minutes intermittently for 48 to Dr. Durkin. “The best prevention of a ment is stretched in a mild sprain, but 72 hours. Never ice for more than second sprain is appropriate treatment of there is no joint loosening or instability. 20 minutes, because that can cause a the first.” “The tendency is to think of sprains as nerve injury. Dr. Durkin offers some helpful facts on a minor injury, but repeated sprains can ■ Compression: Use an elastic, or ACE, common injuries for parents: lead to ankle arthritis, a loose ankle or bandage to help prevent or reduce tendon injury,” cautions Dr. Durkin. swelling. Wrap the injured area without Sprains making it so tight that it will cut off the Sprains are a stretch and/or tear of Strains blood supply. a ligament, the tissue connecting two Strains are a twist, pull or tear of a ■ Elevation: Prop up the injured area bones. Ligaments stabilize and support the muscle or tendon. Tendons are cords of body’s joints. For example, ligaments in tissue that connect muscles to bones. above the level of the heart. You may the knee connect the upper leg with the Acute strains are caused by a direct blow need to lie down to get your leg above lower leg, enabling people to walk and run. to the body, overstretching or excessive your heart level. 2 Kapi`olani Children’s Hospital 808-983-6000
  3. 3. TEEN CORNER New Meningitis Shot Shields Teens and Young Adults What Every Vaccine could save hundreds of lives each year A new vaccine can help head off one type of bacterial meningitis for 11- and 12-year-olds, the rest of your life,” says Dr. Melish. “This new vaccine also makes you less able to Parent teens entering high school and college freshmen in dormitories. transmit the bacteria to someone else.” The new vaccine protects against four Should Know Though somewhat rare, meningitis can of the five bacteria groups that cause be deadly. Caused by bacteria that infect meningococcal infection. “That means it We talk a lot about how to keep your the bloodstream, brain lining and spinal protects you against about 70 percent of children healthy, and signs and symp- cord, it kills one in 10 victims — up to the meningococcal cases,” says Dr. Melish. toms of illness. But, could you also 300 Americans a year. One in five sur- use some assistance with parenting? vivors may face permanent disabilities. Is your preteen beginning to test his boundaries? Most meningitis patients are less than Meningitis Symptoms Don’t wait until you’re in a crisis to 2 years old. That’s why infants get shots Meningitis at first looks like the flu or a seek help. that fight bacteria that can cause this con- migraine, says the National Meningitis tagious disease. Association (NMA). But it worsens But meningitis due to the meningococcus quickly. Symptoms include: germ peaks again in adolescents and young adults. “More deaths actually occur in teen- ■ A headache, which may seem like agers,” says Marian Melish, M.D., pediatric the worst you’ve ever had infectious disease specialist at Kapi`olani ■ A fever (perhaps very high) Medical Center for Women & Children. ■ Vomiting The federal Advisory Committee on Immunization Practices (ACIP) has long ■ Numbness, cold or loss of feeling in backed immunizations against meningo- extremities Help is a phone call away coccus for college freshmen — especially ■ Stiff neck TeenLine is a 24-hour automated those who live in packed dormitories. An information and referral service older vaccine (sold since 1981) protected ■ Eye pain from bright light which with more than 125 taped messages them for three to five years. causes you to avoid light on a variety of subjects, including But early this year the ACIP approved ■ Disorientation or confusion sexuality, physical health, emo- a new vaccine to help block meningitis: ■ Seizures tional concerns, drugs, tobacco, and the meningococcal where you and your teen can go for conjugate vaccine Marian Melish, ■ A rash or purple spots help. Taped messages can be heard (Menactra). It’s sug- M.D. The NMA suggests you call your doctor by dialing 521-TEEN (8336) on gested for adolescents or go to an emergency room if you Oahu and toll-free from the neigh- and lasts longer than have one or two of these symptoms. bor islands at 877-521-TEEN. the old vaccine. “The Antibiotics are used to treat bacterial Peer Listeners, who are trained advantage of Menactra meningitis. People who have been in teen volunteers, are available week- is that one shot can close contact with the patient also may days 3:30 to 6:30 p.m. to answer protect you for a long be given an antibiotic. questions by phone or e-mail time, even possibly for (teenline@kapiolani.org). www.kapiolani.org 3
  4. 4. Kapi`olani Nurtures Hawaii’s Tiniest Babies Saving premature infants takes medical expertise and technology, and the right touch MADISON CHARLES CELEBRATED her Highest level of medical care baby’s safety. The pediatric transport team 5th birthday this year, which for her par- for newborns at Kapi`olani manages facility-to-facility ents, Yavette and Glenn, marked more Born more than 10 weeks early, Madison transfers for the entire state. than just a milestone in their daughter’s was immediately taken to the NICU where The NICU sees about 850 babies each life: It marked a miracle. That’s because at she was cared for by a highly trained team year. Its multidisciplinary team of physi- birth, Madison weighed only 1.69 pounds of neonatologists. These doctors specialize cians, nurses, respiratory and rehabilitation and struggled for the first six months of in caring for pre-term babies, and are therapists and social workers excels at nur- her life in the neonatal intensive care unit on-site 24 hours a day to attend to new- turing these little babies, encouraging their (NICU) at Kapi`olani Medical Center for borns at delivery and in the weeks and development and supporting their families Women & Children. months that follow. In some cases, babies through this difficult time. “If it hadn’t been for the doctors and are transferred from other Hawaii hospitals nurses at Kapi`olani, we couldn’t have to Kapi`olani’s NICU. Moving these frail The right touch celebrated this miracle,” says Madison’s infants from another facility is no small While today’s medical technology gives mother, Yavette Charles. task. It’s a complex process, requiring a babies who are born as early as 23 weeks a dedicated team of specialists to ensure chance at survival, it is critical that premature “They were always there for us no matter what.” Premature Births: On the Rise in Hawaii —Yavette Charles, in reference to the physicians, nurses and According to the March of Dimes, pre-term birth is the nation’s No. 1 obstetric social workers in the Kapi`olani NICU challenge. “It’s a common problem for everyone,” says Scott Berns, M.D., National March of Dimes vice president of chapter programs. ■ In an average week, 46 babies are born premature (before 37 weeks gestation) Yavette’s pregnancy was going fine until in Hawaii her 20-week prenatal checkup. Her blood ■ Between 1992 and 2002, the rate of infants born pre-term in Hawaii increased pressure and protein levels were high — an indicator of preeclampsia, a life-threatening 33 percent complication that prevents the placenta What can we do about it? While we know the risk factors, the exact cause is from adequately supplying nutrients to still unknown, making all pregnant women potential candidates for early delivery. the fetus. Yavette’s doctor referred her to It’s critical that we raise awareness and educate couples so that they can recognize Kapi`olani’s Fetal Diagnostic Center for fur- the signs of pre-term labor. ther testing. The Center is the first compre- hensive obstetrical clinic in Hawaii, and offers highly specialized tests and consulta- tion for pregnant women. An ultrasound exam revealed that Yavette had almost no amniotic fluid, a result of the preeclampsia. She was admitted to Kapi`olani that day and Madison was delivered a few weeks later by C-section at 26 weeks. Kapi`olani Kids is printed by Kapi`olani Medical Center for Women & Children. This is the November 2005 issue. Kapi`olani Kids is published twice a year as a service to parents in the community served by Kapi`olani Medical Center for Women & Children, 1319 Punahou, Honolulu, HI 96826. The information is provided as education about physical, mental and psychosocial health. It is not intended as a substitute for consultation with a physician. If you have questions or con- cerns about specific items that appear in Kapi`olani Kids, please contact your child’s doctor. To advise us of changes to your mailing address, please contact us at 808-535-7554. 4 Kapi`olani Children’s Hospital 808-983-6000 Kapi`olani Children’s Hospital 808-983-6000
  5. 5. Kapi`olani in the late 1990s. “The changes closed the loop on the continuum of care we’ve made to the NICU are a natural she received at Kapi`olani’s NICU. evolution,” says Venkataraman Balaraman, “They were always there for us no matter M.D., Kapi`olani neonatologist. what,” says Yavette about the physicians, The developmentally supportive care con- nurses and social workers in the NICU. She cept is meant to calm babies’ families, too, even keeps in touch with some of the nurses since the families spend many hours, days, and shares Madison’s successes with them. and possibly months in the NICU encourag- Madison has had pneumonia twice and ing their babies’ development. “The parents she catches colds easily, but her biggest are such an important part of the progress developmental challenge was difficulty of these infants because they’ll be caring for eating. She had a feeding tube for nourish- their babies long after they leave the unit,” ment during her first 18 months, which her says Dr. Balaraman. “We realize that having parents learned to use. She only began a baby in the intensive care unit can be a chewing and eating regular food when she traumatic and scary experience.” was 3 years old. What was her incentive? The unit even has a “practice” room, a Bubble gum! Madison always saw people transitional space in which parents can be chewing gum and blowing bubbles and alone with their babies with the comfort she wanted to do those things, too. of knowing that nurses and physicians are Today, Madison is doing well. She just close by if they need help. started kindergarten and recently joined a soccer league. Yavette and Madison Charles Family support program Kapi`olani Medical Center has teamed up For more information on having a baby babies have all of their needs met. Beyond with the March of Dimes to provide infor- and the specialized care for newborns medical attention, the caring team at mation, resources and support to parents only available at Kapi`olani, call Kapi`olani helps to foster babies’ develop- and family members of newborns admitted 808-535-7000. ment so they can go home with their to the NICU. Services are available to fami- families sooner. lies throughout hospitalization and during The team offers what the medical com- munity calls, “developmentally supportive baby’s transition home. The March of Dimes tailors the support program to hos- What Every Expectant care,” which is designed to provide a softer pitals across the country according to the touch to their babies and the family mem- specific needs of the families and staff at bers who visit and care for them. The goal each facility, complementing the services of the initiative is to provide babies the intensive care required in a more baby- friendly and family-friendly environment already offered by Kapi`olani. The program includes a dedicated family support special- ist who works with the families of babies in Mother by reducing noise and light, keeping new additions to the family swaddled, and talk- the unit, as well as the families of past NICU graduates, providing a supportive Should Know ing to babies in soothing voices. network for everyone involved. While we do not yet know the cause of pre-term birth, there are many Kangaroo Care things you and your partner can do Beyond medical attention, the to help your baby grow healthy and As part of its developmentally supportive strong. One important step is to get care program, the staff helps parents bond caring team at Kapi`olani helps the information and support you’ll with their babies using a technique called need in months ahead. to foster babies’ development Kangaroo Care (KC). Like a mother kanga- roo that carries her baby inside her warm so they can go home with their Free Pregnancy Class & Guide pouch, the nurses help parents position families sooner. Kapi`olani Medical Center for baby between their breasts so that baby Women & Children and HMSA can receive skin-to-skin contact from a invite you and your partner to our “human incubator.” Research indicates Going home Free Positively Pregnant Class. that KC has multiple benefits for premature While the NICU staff readied Madison to Whether this is your first or second infants, including improvement in sleep, live at home with her parents, she was still child, this class can help you have greater weight gain and earlier discharge in need of extra care. Kapi`olani’s Mobile the healthiest pregnancy, and baby, from the hospital. Therapy Team of specialists — including possible. HMSA membership is not required. The “softer” techniques implemented in speech, occupational and physical therapists Register today! Our two-hour the unit first gained notice in a 1994 article — provided services at the Charles’s home class was developed with the in the Journal of the American Medical until she was 3. The therapy was essential assistance of our physicians. Call Association and began to be adopted at to Madison’s continued development and 535-7000 to register, or sign-up online at www.kapiolani.org. www.kapiolani.org 5
  6. 6. Rotavirus Infection in Children Rotavirus is a germ that infects the small juices. These have high sugar content intestines. Rotavirus infection often occurs and can make diarrhea worse. in the winter months. “It is a common ■ Do not give your child solid food until cause of diarrhea in children,” says Claire he or she has not vomited for several Wilson, M.D., pediatric gastroenterologist hours. When your child is able to eat, at Kapi`olani. “It is also very contagious.” start with complex carbohydrates like Only a few tiny germs are needed to pass bread or rice, lean meat, yogurt, fresh on the infection. Most rotavirus infections fruits and vegetables. This is better than are not serious and last only a few days. the “BRAT” diet (bananas, rice, apple- But they put children at risk for dehydra- sauce and toast), which restricts nutri- tion, a loss of water from the body. tion unnecessarily. Dr. Wilson adds that frequent hand wash- ■ It is not necessary to restrict dairy ing can help prevent rotavirus infection. products or give them half strength, These steps may help lessen the chances unless they cause much more diarrhea. that you or your child will get or pass on a Common symptoms of rotavirus Breastfed infants should continue rotavirus infection: infection to breastfeed. ■ Wash your hands with warm water and ■ Fever over 100.5 degrees soap often, especially after going to the ■ Watery diarrhea bathroom or diapering your child, and ■ Stomach pain or cramping before preparing, serving or eating food. ■ Nausea and vomiting ■ Wash soiled clothing promptly. ■ Disinfect with soap and water or a chlo- Treatment rine-bleach-based cleanser any areas Most cases of rotavirus get better with- that may have become contaminated. out treatment. “Antibiotics are not helpful ■ Use diapers with waterproof outer against viral infections,” says Dr. Wilson. covers or use plastic pants. “The goal of treatment is to make the child ■ Keep your sick child home from child care. comfortable and to prevent dehydration.” ■ Prevent contact between the child and These tips can help: those who are sick. ■ Know the signs of dehydration. If the ■ Keep food preparation areas clean. inside of your child’s mouth is dry or ■ Have your child wash his or her hands sticky, if there are no tears when your often, especially before eating. child cries, and if urine output is signif- icantly reduced, you should call your child’s doctor. ■ Do not give your child over-the-counter medications to stop the diarrhea. These can be dangerous. ■ Be sure your child gets plenty of rest. ■ Have your child sip water or suck on ice chips if possible, but don’t give your child only water. This will lead to an imbalance in the body’s salts. ■ Give the child 1 teaspoon of an oral Preventing rotavirus infection rehydration solution (such as Pedialyte) Rotavirus spreads very easily. Most every 1 to 2 minutes until vomiting children will be infected with rotavirus stops and the child is at least once in their first five years of life. able to keep down Claire Wilson, The virus is passed by hand-to-mouth larger amounts of M.D. contact with stool from an infected Get medical help right away if your child: liquid. Avoid “sports person. A child can become infected by ■ Has a fever of 102 degrees or more drinks,” which don’t touching someone’s hand that has been ■ Has bloody diarrhea have the right mix contaminated by the virus. The virus can ■ Is lethargic of water, sugar and also be passed by touching a surface or ■ Has severe stomach pain mineral salts, and object that has been contaminated by an ■ Can’t keep down even the small may make your child infected person. The virus then enters a amounts of liquid mentioned above worse. Avoid carbon- child’s body through contact with the ■ Shows signs of dehydration, such as ated drinks, Jell-O, mouth. Children can spread rotavirus both very dark or very little urine, excessive and commercial before and after they develop symptoms. thirst, dry mouth or dizziness 6 Kapi`olani Children’s Hospital 808-983-6000
  7. 7. RSV continued from page 1 advise parents to seek medical assistance,” says Dr. Chock. Who’s at risk “Young infants tend to have smaller air- ways, making their breathing vulnerable,” explains Dr. Chock. “RSV can be life threatening for some young children.” Kapi`olani Medical Center is working with the RSV Consensus Committee of Hawaii, composed of local pediatricians and pediatric specialists, and the Hawaii Chapter of the AAP to ensure that chil- Heading Off RSV dren at risk are identified so they can receive monthly injections of the preven- You can help limit RSV. “It is spread by tive medication palivizumab. Please con- close contact with infected individuals tact your doctor if your child falls into or contaminated surfaces, particularly one of the following at-risk groups: ■ Less than 6 months of age, and born in group settings like day care,” says premature at 32 weeks or earlier Dr. Chock. To avoid infection: ■ Less than 12 months of age, and born ■ Wash hands often. premature at 28 weeks or earlier ■ Use tissues on runny noses. ■ Less than 24 months of age with con- Soap and water help prevent the spread of ■ Avoid smoke and dust. RSV, which is transmitted by close contact genital heart disease ■ Avoid unnecessary exposure to ■ Less than 24 months of age with with infected individuals or contaminated crowds. chronic lung disease surfaces. ■ Avoid contact with sick people. How to Stop a Crying Baby continued from page 1 bowel movement or slight temperature Skin-to-skin contact is best (and bathing change. In short, they don’t easily adjust together is ideal). But wearing baby in a to the world outside the snug womb until sling for several hours a day also cuts age 4 months, when colic often disappears. crying and provides constant sound, tem- Other babies are just hard-wired to cry perature and motion that signal comfort. more. And the longer a baby cries, the ■ Switch on shusshing. A running harder it tends to be to get him to stop. shower, a whirring fan, a white noise machine or a recording of the vacuum “Don’t blame yourself; most babies cleaner (watch the volume) helps block outside stimulation and may mimic the have extended crying episodes with steady sounds of the womb. no easy explanation.” ■ Get moving. Take a stroll or a spin in the —John Nagamine, M.D., pediatrician car. Motion swings or dancing are espe- cially helpful at the dinner hour, when Once your doctor has ruled out any fussy babies tend to kick it up a notch. underlying reason for crying, Dr. Nagamine ■ Drape her. Draping your baby along Infant Care/CPR/Breastfeeding Class suggests these tear-stopping techniques: your forearm with her head in the crook This three-week series includes ■ Wrap him like a burrito. Swaddling of your elbow provides warmth and “Breastfeeding for Expectant Parents;” babies snugly in a soft blanket helps pressure to relax a tense, colicky belly. baby basics (includes bathing and keeps their arms and legs from flailing, ■ Take a stress break. Have your spouse, diapering, information on wellness and can switch on relaxation. family or neighbor take over while you and illness, child-proofing your home, ■ Wear your baby. Babies who are crying, colic, car seat safety); and walk, bathe and calm yourself so you pediatric CPR. Fee: $85 per couple carried more cry less, studies show. can better handle crying. Call 808-535-7000. www.kapiolani.org 7
  8. 8. Injury Prevention for All Children It’s every parent’s worst nightmare: prevention, and avoiding sports and play A child is trapped in a burning house, injuries. They also teach parents and found floating facedown in a swimming caregivers how to keep children with pool or thrown from a car. Unintentional disabilities safe. injuries are the leading cause of death for Children’s hospitals work with local American children under age 14. That’s and state legislators to improve child why children’s hospitals are taking the safety laws and to increase funding for lead to ensure all children lead active but programs that help protect children injury-free lives. from childhood injuries. Many hospitals Nearly all children’s hospitals (94 percent) provide free or discounted protective engage in injury prevention advocacy, equipment, such as bike helmets and according to a NACHRI survey of member booster seats, to families who need them hospitals. Through educational activities, and also supply educational materials such as safety fairs, school visits and com- in different languages. munity classes, children’s hospitals pro- To help support children’s hospitals’ vide families with information on injury injury prevention efforts, NACHRI and prevention topics, including motor vehi- Dorel Juvenile Group USA launched “Get For more information about the injury cle safety, drowning, burn and poisoning on Board with Child Safety,” a nationwide prevention efforts of children’s hospitals, injury prevention campaign. The campaign visit www.childrenshospitals.net. Web site — www.getonboardwithsafety.com NACHRI — provides injury prevention information National Association of Children’s for families and free copies of the Essential Get your car seat checked Hospitals and Related Institutions Home & Travel Childproofing Guide in both Kapi`olani offers free car seat checks. www.childrenshospitals.net English and Spanish. Call 808-983-6800. Articles in this newsletter are written by professional journalists or physicians who strive to present reliable, up-to-date information. But no publication can replace the care and advice of medical professionals, and readers are cautioned to seek such help for personal problems. ©2005 Health Ink Communications, 780 Township Line Road, Yardley, PA 19067, 267-685-2800. Some images in this publication may be provided by ©2005 PhotoDisc, Inc. All models used for illustrative purposes only. Some illustrations in this publication may be provided by ©2005 The Staywell Company; all rights reserved. (405) Would you like to Non-Profit U.S. Postage continue to receive PAID Permit No. this newsletter? 1319 Punahou Street 733 Effingham, IL Please be sure that you’re on our Honolulu, HI 96826 subscriber mailing list. There’s no charge. Look at the mail panel to the right. If it says, “Call 535-7000 to subscribe,” you are not on our permanent mailing list. Please visit www.kapiolani.org or call 808-535-7000 to sign up.

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