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Management Full mobilisation should be achieved after about 3 days r Nitrates and calcium antagonists are useful as pro- and discharge at 5 days baclofen 25 mg visa, if there are no complications order cheap baclofen line. The patient Prognosis may return to work after 23 months order 25mg baclofen, depending on the The prognosis in patients with angina without underly- typeofwork. Rheumatic fever Prognosis Denition 50% 30-day mortality; 25% die before reaching hospital. Recurrent inammatory disease affecting the heart; it Of those who leave hospital alive, 1525% die within the occurs following a streptococcal infection. Incidence 1in100,000 United Kingdom/United States population peryear; incidence has declined over the last 100 years. Variant/Prinzmetals angina Denition Age Angina of no obvious provocation not as a direct result First attack usually 515 years. Sex Aetiology/pathophysiology M = F Causedbyspasmofacoronaryarterymostoftenwithout atheroma or in association with a mild eccentric lesion. Common in Middle and Far East, South America and Central Africa, declining in the West. Clinical features Pain is usually more severe and more prolonged than Aetiology classical angina occurring at rest particularly in the early Cell-mediated autoimmune reaction following a pha- morning. Risk fac- centre over the trunk and limbs, which appear and tors forstreptococcalinfectionincludepovertyandover- disappear over a matter of hours. Non-specic symptoms include It appears that antistreptococcal antibodies crossre- malaise and loss of appetite. Macroscopy r Pericarditis: Nodules are seen within the pericardium Fibrinous vegetations form on the edges of the valve associated with an inammatory pericardial effusion. Valve leaets may fuse r Myocarditis:Nodulesdevelopwithinthemyocardium and scar, particularly affecting the mitral and aortic associated with inammation. These may result in an acute disturbance thesecellsarereplacedbyhistiocytes,whichmaybemult- of valve function. Complications Clinical features More than 50% of patients with acute rheumatic cardi- There may be a history of pharyngitis in up to 50% of tis will develop chronic rheumatic valve disease 1020 patients. The diagnosis is made on two or more major years later, particularly mitral and aortic stenosis. These manifestations or one major plus two or more minor may be complicated by atrial brillation, heart failure, manifestations (Duckett Jones criteria). A pericardial friction r Cultures of blood and tissues are sterile by the time rubmay be audible due to pericarditis. Management Pathophysiology r Patients with a clinical diagnosis of rheumatic fever Inacutemitralregurgitation,retrogradebloodowfrom should be treated with benzylpenicillin regardless of the left ventricle into the left atrium causes the left atrial culture results. There is an increase in the pul- r Pain, fever and inammation are treated with high- monary venous pressure and there may be pulmonary dose aspirin. This allows the r Patients may require treatment for heart failure (see increased volume of atrial blood to be compensated for page 63) and chorea may respond to haloperidol. The left ventricu- r Following recovery patients should receive prophy- lar stroke volume increases due to volume overload and lactic penicillin for at least 5 years after the last at- over time this results in left ventricular hypertrophy. In Although symptomatic improvement occurs with treat- most cases mitral regurgitation is chronic and is asymp- ment, therapy does not appear to prevent subsequent tomatic for many years. On examination the pulse is normal volume, but may be ir- Mitral regurgitation regular due to atrial brillation. On aus- Flow of blood from the left ventricle to the left atrium cultation the rst heart sound is soft due to incomplete during systole through an incompetent mitral valve. There may be a prominent third heart sound due to the Aetiology sudden rush of blood back into the dilated left ventricle In developing countries rheumatic disease accounts for in early diastole. In developed countries other causes predomi- Complications nate: Patients develop left ventricular failure due to chronic r Prolapsing mitral valve. Atrial brillation is common due r Myocardial infarction may lead to papillary muscle to atrial dilation, with an increased risk of throm- dysfunction or rupture. Other complications include pulmonary r Any disease that causes dilation of the left ventricle, oedema and infective endocarditis. Congestive heart fail- ure may also cause mitral regurgitation due to down- Investigations ward displacement of the papillary muscle. This leads r The chest X-ray shows cardiomegaly due to left atrial to a failure of the valve cusps to meet and regurgita- and left ventricular enlargement. Valve calcication tion ranging in severity according to the degree of left may be seen in cases due to rheumatic fever. It is thought to be due to progressive stretching of the The clinical effect of the valve lesion is however best valve leaets. The normal anatomy of the mitral valve prevents pro- lapse thus one or more anomalies must be present: ex- Management cessively large mitral valve leaets, an enlarged mitral r Mild mitral regurgitation in the absence of symptoms annulus, abnormally long chordae or disordered pap- is managed conservatively, more severe disease with illary muscle contraction. During systole one of the evidence of progressive cardiac enlargement is treated valve leaets (usually the posterior) balloons up into surgically. In some cases this causes retraction at the of choice, but valve replacement may be required for normal point of contact of the valve cusps and hence severely diseased valves. The condition does not often cause and chordal rupture may require emergency valve re- signicant regurgitation. Mitral valve prolase Denition Complications Prolapsing mitral valve is a condition in which the valve Rupture of one of the chordae may occur leading to se- cusps prolapse into the left atrium during systole. A particular form of supraventricular tachycardia and complex ventricular prolapse may result from myxomatous degeneration of ectopy may occur. Echocardiography reveals prolapsing mitral valve in 5% r Echocardiography shows the mid-systolic bulging of of the normal population; however, not all are clinically signicant, especially in the absence of any mitral in- the valve leaets. There is an Denition opening snap after S2 caused by the stiff mitral valve, An abnormal narrowing of the mitral valve. If the Incidence patient is in sinus rhythm there is a pre-systolic increase Declining in the Western world due to the decline of in the volume of the murmur due to increased ow dur- rheumatic fever. Pulmonary hypertension may re- sult in pulmonary regurgitation with an early-diastolic Sex murmur (GrahamSteell murmur). The pathological process of rheumatic fever results in brous scarring and fusion of the valve cusps with cal- Investigations cium deposition. The valve becomes stiff, failing to open r Chest X-ray shows selective enlargement of the left fully. When the normal opening of 5 cm2 is reduced to1 atrium (bulge on the left heart border). The pressure within the within the mitral valve may be visible and there may left atrium rises and left atrial hypertrophy occurs. Signs of right ventricular hyper- falls with little increase possible on exertion. The condition is asymptomatic until the valve is nar- r Echocardiography is diagnostic showing the narrow- rowedbyaround 50%. Doppler studies can to pulmonary venous hypertension and the resultant assess the degree of stenosis and any concomitant mi- oedema, with dyspnoea, orthopnoea and paroxysmal tral regurgitation. A cough productive of r Cardiac catheterisation is used if Doppler is inconclu- frothy,blood-tingedsputummayoccur(frankhaemopt- sive and to assess for coronary artery disease if valve ysisisrare). On examination the patient may have mitral facies (bi- Management lateral, dusky cyanotic discoloration of the face).

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The people and groups engaged in personalized medicine and helping to drive it forward The realization of personalized medicine relies on the input and contributions of a broad community of stakeholders order 10mg baclofen, all working together toward a shared goal of harnessing breakthroughs in science and technology to improve patient care order baclofen overnight delivery. The regulatory process must evolve in response to advances that are targeted to smaller patient populations based on genetic profles order baclofen 10mg with amex, and policies and legislation must be enacted that provide incentives for innovative research and adoption of new technologies. Together, progress in the research, clinical care, and policy enabling personalized medicine has great potential to improve the quality of patient care and to help contain health care costs. A Service of Personalized medicine is rapidly having an impact on how drugs are discovered and developed; how patients are diagnosed and treated; and how health care delivery is channeling its resources to maximize patient benefts. The Age of Personalized Medicine website is dedicated to highlighting the advances being made in the feld, the individuals working to enable those advances, and the implications for health and health care policy. In order to prevent errors before, the establishment of protective measures is pivotal. Purpose: To explore the protective measures taken by nurses to prevent medication errors in clinical practice. Method and material: A search of Medline, Science Direct and Cochrane Library was conducted to retrieve literature published from January 2000 until August 2011. Conclusions: This review paper summarizes the preventive measures of medication errors made by nurses. As it is obvious, there is a plenty of factors that need to be applied in health units to succeed low medication error rate. Because of the significance of the subject, further research is warranted to prove the effectiveness of every measure in the prevention of medication errors. Thus, to avoid as any preventable event that any type of medication error may cause or lead to made by nurse, the inappropriate medication use or implementation of preventive patient harm while the measures is undoubtedly medication is in the control of beneficial. Nurses taking into health professional, patient or account all precautions for 1 consumer. However, this culture of safe hospital estimation represents the number environment and ensure safe of medication errors that medications management by them. Actually, the A breakdown of the relevant possibilities of medication literature showed that the errors to result to death is protective measures for 2 0,1%. Thus, the reduction of medications errors use of calculator will serve rates, their earlier as a "useful tool" for identification before patient resolving the various gets harm and their timely mathematical functions and 5 10 treatment. Preventive strategies conversions, of medication errors include the the delivery of premixed standardization and the medications from pharmacy to simplification of medication nursing wards without needed procedures and others. Emanuel the apparent separation of and Prynce-Miller, considered medications with similarities the establishment of protocols either in color or in name, by in clinical practice, as a duty. Another protective measure Subjects in which knowledge was against medication errors lessen were pharmacodynamics and consider to be the improvement 20 pharmacokinetics, dosing of dosing calculation skills calculation of liquid solutions through nursing education. In a study, to can make nursing students assess unsafe events for prepared for their clinical patients, found that 56% of duties afterwards. Directly unsafe events related to related to the above, are the medication errors and 20% of mathematical competencies of the 16 those associated with lack of nursing students. The existence of voices nursing administrators possess or noises in the environment of central role in the management 30 the speakers, the unfamiliarity of medication errors. The head with patients situation, bad nurses have strong influence in phone connection and rapid way clinical nurses conduct to keep of speaking, are some factors positive attitude towards the that make communication through reporting of medication 26 30,31 phone difficult. The cooperation of errors in these cases, it is head nurses and nurses aims to important firstly to write down the understood of each group the order, then confirm beliefs of creating a safe 32 patients name, medications environment of health care. By topics and provision of providing to nurses the educational opportunities opportunity of voluntary report concerning all procedures their medication errors without involving the use of mentioning their name, makes 36 medication, them feel comfortable and the differentiation of increases the possibilities to medication package with report their error. Medication calculation measures about medication errors skills of practicing are key factors for preventing paramedics. Washington: elimination of medication errors American Pharmacists of course is difficult to be Association; 2007. Choosing the their frequency remains still right strategy for medication achievable. What attitudes to single checking clinical learning contracts medications: before and after reveal about nursing its use. Clarian and Spectrum practical guide to working Health Systems Prove It Is out drug calculations. Exploring the factors Nursing management of contributing to drug errors medication errors. The relationship between to the root of medication incidence and report of errors. Factors administration of intravenous associated with reporting of medication in Brazilian medication errors by Israeli hospitals. After talking to his doctor, he decides J to see a therapist and go on medication. Joes doctor gives him two weeks worth of samples for a brand name drug called SteadyMood and asks him to come back to see him in two weeks. When he returns, Joes feeling a little better and agrees to keep taking SteadyMood for another month. When he gets to the pharmacy, Joe learns that his insurance plans co-pay for a months supply of SteadyMood is $40. His pharmacist tells him that hes fortunate to have insurance coverage; without it, the brand name would cost $100. His insurance co-pay would be $10 for a months supply of the generic, but his doctor would have to approve it. The pharmacist calls Joes doctor and gets approval to fill his prescription with the generic. Hes confused and believes there must be some kind of mistake since the SteadyMood samples his doctor gave him were pink ovals. Joe calls his phar- macist who tells him that the round, white pills are the generic form for SteadyMood and they should work just fine. He returns to the drugstore with another prescription from his doctor, and this time, it allows for generic substitution. The next morning, he opens the bottle to find a completely different-looking medi- cinenow, the pills are yellow and square. Should he simply stay with the brand name version that his doctor originally gave him? Many of us have found ourselves in situations like Joes and can understand his frustration. Youll you want your prescription filled with learn that the decision to choose a the brand name medicine or the generic brand name or a generic is one that medicine. This brochure will The decision to choose a brand name or a generic is one that involves you and your health care team. Generics only thats dis- become available after the patent expires covered, on a brand name drug.

Pediatr Dia- way to prevent an intercurrent illness that could complicate diabetes man- betes 2014 baclofen 10 mg lowest price;15:13541 generic 10mg baclofen with mastercard. The effect of intensive treatment of diabetes on the development and progression of long- term complications in insulin-dependent diabetes mellitus discount 25 mg baclofen overnight delivery. Formal smoking prevention and cessation counselling should be part of 1993;329:97786. Effect of intensive diabetes treatment on the development and progression of long-term com- 31. Adolescents should be regularly counselled around alcohol and sub- plications in adolescents with insulin-dependent diabetes mellitus: Diabetes stance use [Grade D, Consensus]. Adolescent females with type 1 diabetes should receive counselling on management is associated with metabolic control: The Hvidoere childhood dia- contraception and sexual health in order to prevent unplanned preg- betes study group centre differences study 2005. White matter structural differences diagnosis with repeat screening every 2 years using a serum thyroid- in young children with type 1 diabetes: A diffusion tensor imaging study. Alterations in white matter struc- tive anti-thyroid antibodies, thyroid symptoms or goiter [Grade D, ture in young children with type 1 diabetes. The effect of recurrent severe hypogly- cemia on cognitive performance in children with type 1 diabetes: A meta- 34. Children with type 1 diabetes and symptoms of classic or atypical celiac analysis. Frequency and timing of severe sus] and, if conrmed, be treated with a gluten-free diet to improve symp- hypoglycemia affects spatial memory in children with type 1 diabetes. Dia- toms [Grade D, Level 4 (147)] and prevent the long-term sequelae of betes Care 2005;28:23727. Cognitive function in children with type 1 the pros and cons of screening and treatment of asymptomatic celiac diabetes: A meta-analysis. International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the Study of Diabetes. Insulin pump therapy in children and adolescents: Improvements in key parameters of diabetes management Dr. Long-term outcome of insulin pump therapy in children with type 1 diabetes assessed in a large population- in the eld of articial pancreas. Flexible insulin therapy with glargine insulin improved glycemic control and reduced severe hypoglycemia among preschool- 1. A randomized, controlled trial com- tes mellitus: A systematic review and meta-analysis. Ann Intern Med paring twice-a-day insulin glargine mixed with rapid-acting insulin analogs 2015;163:83647. Physical activity interventions in children ticenter data from Germany and Austria. Factors associated with glycaemic and sedentary behavior intervention studies in youth with type 1 diabetes: outcome of childhood diabetes care in Denmark. Continuous glucose monitoring in type 1 dia- betes onset: Still an all too common threat in youth. Impact of continuous glucose monitor- betic ketoacidosis at initial presentation of type 1 diabetes in a prospective ing on quality of life, treatment satisfaction, and use of medical care resources: cohort study of children. Social factors associated with prolonged hos- system to reduce nocturnal hypoglycemia in type 1 diabetes. Home use of an articial beta cell in ric ketoacidosis in Sweden: Predisposing conditions and insulin pump use. Long-acting insulin analogs and the risk of ucts and Food Branch, Oce of Nutrition Policy and Promotion: Health Canada; diabetic ketoacidosis in children and adolescents with type 1 diabetes: A pro- 2011. Assessment of the effect of a compre- dered eating in diabetes: Internal consistency and external validity in a con- hensive diabetes management program on hospital admission rates of chil- temporary sample of pediatric patients with type 1 diabetes. Neuro-cognitive performance in chil- with poorly controlled type 1 diabetes: Reduced diabetic ketoacidosis dren with type 1 diabetesa meta-analysis. Effectiveness of continuous glucose monitoring in a clinical care envi- children and adolescents with type 1 diabetes. Acta Biomed ronment: Evidence from the Juvenile Diabetes Research Foundation Continu- 2003;74:458. Risk factors for cerebral edema in chil- and meta-analysis of observational studies. Eating problems in adolescents with type 1 orative research committee of the American Academy of Pediatrics. Demographic and personal factors tion during treatment of diabetic ketoacidemia: A retrospective and prospec- associated with metabolic control and self-care in youth with type 1 diabe- tive study. Diabetes management and glycemic 5-year prospective pediatric experience in 231 episodes. Arch Pediatr Adolesc control in youth with type 1 diabetes: Test of a predictive model. A psychosocial risk index for poor gly- in young children with diabetic ketoacidosis and new onset type I diabetes. Psychological interventions to improve complicating diabetic ketoacidosis in children. Diabetologia 2006;49:2002 glycaemic control in patients with type 1 diabetes: Systematic review and 9. The use of an insulin bolus in low-dose insulin infusion impact on glycemic control. The impact of psychiatric comorbidities lality to minimize the likelihood of cerebral edema during treatment of chil- on readmissions for diabetes in youth. Low-dose vs standard-dose insulin sion, quality of life, and glycemic control in type 1 diabetes mellitus. Increasing use of hypertonic saline over youth depressive symptoms: A test of the depression-distortion hypothesis in mannitol in the treatment of symptomatic cerebral edema in pediatric dia- pediatric type 1 diabetes. Disordered eating and insulin restric- current cigarette smoking are major determinants of the onset of tion in youths receiving intensied insulin treatment: Results from a nation- microalbuminuria in type 1 diabetes. Teenage pregnancy in type 1 diabetes mel- in pediatric type 1 diabetes: A review of the recent literature. Symptoms of depression and anxiety tions that improve both physical and mental health in patients with diabe- in youth with type 1 diabetes: A systematic review and meta-analysis. Preventing poor psychological and health out- cussing health-related quality of life in adolescents with type 1 diabetes improve comes in pediatric type 1 diabetes. Depressive symptoms in children and ado- diabetes mellitus: A systematic review and meta-analysis. Gen Hosp Psychia- lescents with type 1 diabetes: Association with diabetes-specic character- try 2010;32:38095.

Coughing disperses these bacilli into the at- Poor immune system eg Good immune response generic 25 mg baclofen with amex, e generic baclofen 10 mg line. This disease is sometimes Use of appropriate antibiotics called galloping consumption cheap baclofen line. By that time there may be no evidence of tu- comesinfectedbymiliarydisseminationwithmultiple berculosis elsewhere. The hypersensitivity reaction may produce patient mounts a good immune response, organisms atransient pleural effusion or erythema nodosum. Microscopy Formal culture of material is the only way of accu- The characteristic lesion, the tubercle (granuloma) con- rately determining virulence and antibiotic sensitivity sists of a central area of caseous tissue necrosis within and should be attempted in every case, results may which are viable mycobacteria. It relies on the hypersensitivity reaction, usually heals spontaneously but occasionally may per- and is rarely helpful in the diagnosis of tuberculosis: sist giving rise to bronchiectasis particularly of the i The Tine test and Heaf test are for screening: 4/6 middle lobe (Brocks Syndrome). If the spots are conuent, logicalfractures,particularlyofthespinetogetherwith the test is positive, indicating exposure. The reaction is read at Investigations 4872 hours and is said to be positive if the indura- r An abnormal chest X-ray is often found incidentally tion is 10 mm or more in diameter, negative if less in the absence of symptoms, but it is very rare for a than 5 mm. The X-ray shows puried protein derivative this can indicate active patchy or nodular shadowing in the upper zone with infection requiring treatment. In an immunocom- brosis and loss of volume; calcication and cavita- promised host (such as chronic renal failure, lym- tion may also be present. Human immunity depends largely on the haemag- niazid, ethambutol and pyrazinamide, and a further glutinin (H) antigen and the neuraminidase (N) antigen 4months of rifampicin and isoniazid alone. Major shifts in these antigenic re- taken 30 minutes before breakfast to aid absorption. Thesecancauseapandemic,whereasantigenicdrift organism is sensitive for a full 6 months to avoid de- causes the milder annual epidemics. Other upper and lower respiratory symptoms to6weeks after birth (without prior skin testing) in ar- may develop. Individuals are infective for 1 day prior to eas with a high incidence of tuberculosis. Less commonly, secondary Five per cent of patients do not respond to therapy, only Staph. Inuenza A causes worldwide annual epidemics and is Retrospective diagnosis can be made by a rise in spe- infamous for the much rarer pandemics, the most seri- ciccomplement-xingantibodyorhaemagglutininan- ous of which occurred in 1918 when 40 million people tibody measured 2 weeks apart, but this is usually un- died worldwide. Spread is by respiratory r Bed rest, antipyretics such as paracetamol for symp- droplets. Clinical features They are particularly indicated in the elderly, those Patients present with worsening features of pneumonia, with underlying respiratory disease such as chronic usually with a swinging pyrexia, and can be severely ill. Some are manufactured in strates one or more round opacities often with a uid chickembryosandtheseshouldnotbegiventoanyone level. Echocardiogram should be considered to look for infec- These predications depend on global surveillance or- tive endocarditis. This surveillance depends on viruses being cultured Complication and therefore on nose/throat swabs being taken and Breach of the pleura results in an empyema. Management Lung abscess Posturaldrainage,physiotherapyandaprolongedcourse of appropriate antibiotics to cover both aerobic and Denition anaerobic organisms will resolve most smaller ab- Localisedinfectionanddestructionoflungtissueleading scesses. Largerabscessesmayrequirerepeatedaspiration, to acollection of pus within the lung. Organismswhichcausecav- Denition itation and hence lung abscess include Staphylococcus Thereareessentiallythreepatternsof lungdiseasecaused and Klebsiella. Pathophysiology Aetiology The abscess may form during the course of an acute It is a lamentous fungus, the spores (5 mindiame- pneumonia, or chronically in partially treated pneu- ter) are ubiquitously present in the atmosphere. This results from Aspergillus growing within an area of previously damaged lung such as an old tuberculous Allergic bronchopulmonary aspergillosis cavity (sometimes called a mycetoma). Seen on X-ray as a round lesion with an air halo above i Initially it causes bronchospasm which commonly it. In immunosuppressed individuals with a low granulo- iii Chronic infection and inammation leads to irre- cyte count, the organism may proliferate causing a severe versible dilatation of the bronchi (classically proximal pneumonia, causing necrosis and infarction of the lung. The organisms are present as masses of hyphae invad- iv If left untreated progressive pulmonary brosis may ing lung tissue and often involving vessel walls. Investigation Theperipheralbloodeosinophilcountisraised,andspu- Management tum may show eosinophilia and mycelia. Eosinophilic Invasive aspergillosis is treated with intravenous am- pneumonia causes transient lung shadows on chest X- photericin B (often requiring liposomal preparations ray. Itraconazole and voriconazole have been used more re- Lung function testing conrms reversible obstruction in cently but current studies comparing efcacy with am- all cases, and may show reduced lung volumes in cases photericin B have yet to prove denitive. Management Obstructive lung disorders Generally it is not possible to eradicate the fungus. Itra- conazole has been shown to modify the immunologic Asthma activation and improves clinical outcome, at least over the period of 16 weeks. Oral corticosteroids are used to Denition suppress inammation until clinically and radiograph- A disease with airways obstruction (which is reversible ically returned to normal. Maintenance steroid therapy spontaneously or with treatment), airway inammation may be required subsequently. The asthmatic compo- and increased airway responsiveness to a number of nent is treated as per asthma guidelines. With time this repeated stimula- Can present at any age, predominantly in children. They secrete mediators of acute and 2 Intrinsic asthma tends to present later in life. There is chronic inammation including enzymes and oxygen no identiable allergic precipitant. Patients with occupational asthma from the listed causes are entitled to compensation under in- inammation recruiting and activating broblasts dustrial injuries legislation in the United Kingdom. The pattern of airway reaction following inhalation of an allergen: i An acute reaction occurring within minutes, peaking Table3. Non IgE related Isocyanates, colophony fumes (from ii A late reaction occurring 48 hours after inhalation solder), hardwood dust, complex (the chronic inammatory response). If there is diagnostic difculty in patients with mild symp- Mildmoderate Life-threatening attack Severe attack attack toms or just cough, exercise tests or peak ow diary card r r r recordings as above. Occasionally, a trial of oral corti- Speech normal Unable to Silent chest costeroids for 2 weeks can be used. Skin tests are used complete sentences to identify specic allergens and serum can be taken for r Pulse <110 r Pulse 110 r Cyanosis total and specic IgEs. An asthma attack is characterised by rapid inspiration, r Allergen avoidance can be advised, e. However these rarely have a major im- tial severity of asthma patients require rapid assessment pact on disease. An acute asthma attack is classied r Drug therapy includes: short acting agonists for 2 according to clinical severity (see Table 3. Night-time waking, early phyllines and other agents with additional activities morning wheeze, acute exacerbations in the preceding (see Fig. Once disease control is achieved the steroid dose is reduced under regular review to Complication the minimum dose required to maintain disease Pneumothorax, surgical emphysema due to rupture of control.

G. Yespas. Manhattanville College.