高血压英文PPT精品课件Hypertensioninthe
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高血压英文PPT精品课件Antihypertensive
• Diagnosis is generally based on repeated, reproducible measurements of elevated blood pressure and not on patient symptoms. Patient compliance is a major obstacle to therapy
Kidney
Na loss
Thiazides
Summary of Long Term Renal Control of BP
Regulates BP by Changing:
1.
Directly – by allowing more or less fluid to enter kidney tubules
• Pakistan (NHSP):the prevalence of hypertension is 17.9%
• 24% of the USA adult population representing 43,186,000 persons had hypertension.
Diagnosis
CNS
BV
Na retention Clonidine
CO
Venous tone
NE release
Sympathetic tone
TPR
Arteriolar tone
dry mouth sexual dysfunction
The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.
Kidney
Na loss
Thiazides
Summary of Long Term Renal Control of BP
Regulates BP by Changing:
1.
Directly – by allowing more or less fluid to enter kidney tubules
• Pakistan (NHSP):the prevalence of hypertension is 17.9%
• 24% of the USA adult population representing 43,186,000 persons had hypertension.
Diagnosis
CNS
BV
Na retention Clonidine
CO
Venous tone
NE release
Sympathetic tone
TPR
Arteriolar tone
dry mouth sexual dysfunction
The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.
--高血压英文PPT精品课件_5
Hypertension is often symptom less, so screening is vital - before damage is done. Many surveys continue to show that hypertension remains under diagnosed, undertreated and poorly controlled in the UK
Approximately 25% are due to Reno vascular disease - most frequently atheromatous (e.g. elderly cigarette smokers with peripheral vascular disease) or fibromuscular dysplasia (more common in younger females). Endocrine disease
Secondary hypertension 5% Underlying cause
Causes of Secondary Hypertension
Renal disease
Approximately 75% are from intrinsic renal disease: glomerulonephritis, polyarteritis nodosa, systemic sclerosis, chronic pyelonephritis, or polycystic kidneys.
Hypertension, Introduction.
Hypertension is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for stroke (ischemic and haemorrhagic), myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension may result in vascular and renal damage that can culminate in a treatment-resistant state.
Approximately 25% are due to Reno vascular disease - most frequently atheromatous (e.g. elderly cigarette smokers with peripheral vascular disease) or fibromuscular dysplasia (more common in younger females). Endocrine disease
Secondary hypertension 5% Underlying cause
Causes of Secondary Hypertension
Renal disease
Approximately 75% are from intrinsic renal disease: glomerulonephritis, polyarteritis nodosa, systemic sclerosis, chronic pyelonephritis, or polycystic kidneys.
Hypertension, Introduction.
Hypertension is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for stroke (ischemic and haemorrhagic), myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension may result in vascular and renal damage that can culminate in a treatment-resistant state.
高血压(英文版) ppt课件
Hypertension
Introduction
Hypertension is a major public health problem throughout the world because of its high prevalence and its association with increased risk of cardiovascular disease.
<90
130140-159 140-149
Epidemiology
Prevalence rate （ 患 病 率 ） China: In 1959, In 1979, 5.11% 7.73% of hypertension in
In 1991,
11.88%
The prevalence of high BP increases with age. Hypertension is more common in men than in women up to age 50, after that age, hypertension is more common in women. Hypertension is more common in northern China than in southern China.
For instance:
21/3 1st visit: 146/98mmHg, 150/98mmHg 23/3 2nd visit: 128/84, 126/80
27/3 3rd visit: 130/80, 130/82
Notes(continue)
4. Optimal BP with respect to cardiovascular risk is less than 120/80 mmHg. However, unusually low readings should be evaluated for clinical significance. For example, 70/50 mmHg is less than 120/80 mmHg, but it is not optimal.
Introduction
Hypertension is a major public health problem throughout the world because of its high prevalence and its association with increased risk of cardiovascular disease.
<90
130140-159 140-149
Epidemiology
Prevalence rate （ 患 病 率 ） China: In 1959, In 1979, 5.11% 7.73% of hypertension in
In 1991,
11.88%
The prevalence of high BP increases with age. Hypertension is more common in men than in women up to age 50, after that age, hypertension is more common in women. Hypertension is more common in northern China than in southern China.
For instance:
21/3 1st visit: 146/98mmHg, 150/98mmHg 23/3 2nd visit: 128/84, 126/80
27/3 3rd visit: 130/80, 130/82
Notes(continue)
4. Optimal BP with respect to cardiovascular risk is less than 120/80 mmHg. However, unusually low readings should be evaluated for clinical significance. For example, 70/50 mmHg is less than 120/80 mmHg, but it is not optimal.
英文疾病介绍——Hypertension(高血压病)PPT课件
Who is at risk?
➢Your chances of having high blood pressure are higher if you:
• Are overweight • Eat foods high in salt • Do not get regular exercise • Smoke • Drink alcohol heavily • Under Stress,anger,frightened or
Diagnosis
systolic blood
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Classification Of Hypertension
➢Hypertension
Essential Secondary Hypertension Hypertensio ①pr原im发ar性y o高r e血s压sennt继ial发性高血 hype（rte高n血sio压n:病h）igh blood压 pressu➢9rPer0im–war9yito5hr %Esnseontiaol bHyvpei5orte–un1ssio0n % underlying(潜在的,根本的) meBdeicnailgcnause. Malignant ②HSyepceorntednasriyoHn ypHeyrpteenrtseionnsi:on
高血压(英文版) ppt课件
Etiology and pathogenesis of EH
No
cause can be established Possible mechanisms Genetic tendency
Spontaneous hypertension rat EH tends to cluster in families
Classification of Blood Pressure Levels (mmHg)
Category Systolic Diastolic Hypotension??? <60 Optimal <120 <80 Normal <130 <85 High-normal 139 85-89 Grade 1 hypertension(mild) 90-99 Subgroup: borderline 90-94
Optional investigations
Plasma renin( 肾 素 ) activity & aldosterone (醛固酮), urinary VMA（香草杏仁酸），to identify secondary hypertension Echocardiography, to detect ventricular hypertrophy Vascular ultrasonography should be performed if arterial disease is suspected. Renal ultrasonography should be performed if renal disease is suspected.
perhaps by catecholamines儿茶酚胺
【高血压精品英文课件】高血压 Hypertension
Pathophysiology
Hypertensive Emergency
Failure of normal autoregulatory function Leads to a sharp increase in systemic
vascular resistance Endovascular injury with arteriole necrosis Ischemia, platelet deposition and release of
Epidemiology
Why should we care about hypertension?
One of the most common chronic medical concerns in the US
Affects >30% of the population > age 20 Risk factor for
vasoactive substances Further loss of autoregulatory mechanism Exposes organs to increased pressure
Diagnosis and Recognition
Presentation
Always present with a new onset symptom
Take a good history
History of HTN and previous control Medications with dosage and compliance Illicit drug use, OTC drugs
Diagnosis and Recognition
Normal BP
高血压英文PPT精品课件HYPERTENSIONDIABETESADANGEROUS
IL- 6, TNF- @, and RAS
liver(NASH)
(↑CRP) (Endothelial
Dysfunction)
• ↑Small, dense LDL • ↑triglyceridemia
Atherosclosis
Activation • ↓HDL
Reduced • Hypertension
Renal Na+ Reabsorption
Hypertension
Cardiometabolic Syndrome:
Large
(Insulin resistant) ( ↑Central Fat)
Fat Cells
(Fatty
Visceral Obesity
Enhanced
Lipolysis > FreeFA
Millions of Cases
60 50 40 30 20 10
0
India
China
1995 2025
US
Data from King H et al. Diabetes Care. 1998;21:1414-1431.
CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment*
<200 mg/dL (5.18 mmol/L)
Vascular Disease Risk Factors
Saydah SH et al. JAMA. 2004;291:335-342.
Metabolic Syndrome: NCEP/ATP III Definition
Presence of at least 3 of 5 risk factors: Abdominal obesity Elevated blood pressure Elevated fasting glucose Elevated triglycerides Low HDL-C
liver(NASH)
(↑CRP) (Endothelial
Dysfunction)
• ↑Small, dense LDL • ↑triglyceridemia
Atherosclosis
Activation • ↓HDL
Reduced • Hypertension
Renal Na+ Reabsorption
Hypertension
Cardiometabolic Syndrome:
Large
(Insulin resistant) ( ↑Central Fat)
Fat Cells
(Fatty
Visceral Obesity
Enhanced
Lipolysis > FreeFA
Millions of Cases
60 50 40 30 20 10
0
India
China
1995 2025
US
Data from King H et al. Diabetes Care. 1998;21:1414-1431.
CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment*
<200 mg/dL (5.18 mmol/L)
Vascular Disease Risk Factors
Saydah SH et al. JAMA. 2004;291:335-342.
Metabolic Syndrome: NCEP/ATP III Definition
Presence of at least 3 of 5 risk factors: Abdominal obesity Elevated blood pressure Elevated fasting glucose Elevated triglycerides Low HDL-C
hypertension高血压全英语版--PPT课件
medical condition(医疗条件) or medication(药物).
High blood pressure that is caused by another
5-10%
Contents
1
Signs And Symptoms
4
2
Treatment
Complications
5
3
Medical Qigong
Hypertension – Stage 3
180
110
Classification Of Hypertension
ØPrimary or Essential Hypertension 原发性高血压
在的，根本的） medical cause.
high blood pressure with no obvious underlying（潜 90-95%
Causes And Pathogenesis
6
Precaution
Signs And Symptoms
üPotential üUnnoticed üThe Silent killቤተ መጻሕፍቲ ባይዱr
Signs And Symptoms
üHeadache üDizziness üShortness of breath üBlurred vision üEar noise or buzzing ünosebleed üFatigue üNausea üIrregular heartbeat
Complications
---Heart failure
uThe heart will get larger or weaker, which may lead to heart failure.
High blood pressure that is caused by another
5-10%
Contents
1
Signs And Symptoms
4
2
Treatment
Complications
5
3
Medical Qigong
Hypertension – Stage 3
180
110
Classification Of Hypertension
ØPrimary or Essential Hypertension 原发性高血压
在的，根本的） medical cause.
high blood pressure with no obvious underlying（潜 90-95%
Causes And Pathogenesis
6
Precaution
Signs And Symptoms
üPotential üUnnoticed üThe Silent killቤተ መጻሕፍቲ ባይዱr
Signs And Symptoms
üHeadache üDizziness üShortness of breath üBlurred vision üEar noise or buzzing ünosebleed üFatigue üNausea üIrregular heartbeat
Complications
---Heart failure
uThe heart will get larger or weaker, which may lead to heart failure.
【高血压英文PPT精品课件】 HYPERTENSION IN THE INPATIENT SETTING
• End Organ Injury
– Myocardial ischemia – Stroke – Renal failure
• Pulmonary Edema
Sympathetic Nervous System Regulation of Blood Pressure
CNS
Adrenal Gland
Parenteral Treatment of Hypertension May Be Required During/After Perioperative Period
• Cardiac Surgery • Major Vascular Surgery
– carotid endarterectomy – aortic surgery
Parenteral Treatment of Hypertension May be Required in ...
• EM • MICU • SICU • OR • PACU • Obstetrics Suite
Parenteral Treatment of Hypertension May be Required for Medical Emergencies
• Uncontrolled or Malignant Hypertension • Drug-Induced Hypertension
– cocaine, amphetamines – drug withdrawal – drug-drug interactions
• Endocrine Disorders
OR
PACU
Myocardial Ischemia
Hypercarbia/ Hypoxemia
Vascular clamping (afterload)
– Myocardial ischemia – Stroke – Renal failure
• Pulmonary Edema
Sympathetic Nervous System Regulation of Blood Pressure
CNS
Adrenal Gland
Parenteral Treatment of Hypertension May Be Required During/After Perioperative Period
• Cardiac Surgery • Major Vascular Surgery
– carotid endarterectomy – aortic surgery
Parenteral Treatment of Hypertension May be Required in ...
• EM • MICU • SICU • OR • PACU • Obstetrics Suite
Parenteral Treatment of Hypertension May be Required for Medical Emergencies
• Uncontrolled or Malignant Hypertension • Drug-Induced Hypertension
– cocaine, amphetamines – drug withdrawal – drug-drug interactions
• Endocrine Disorders
OR
PACU
Myocardial Ischemia
Hypercarbia/ Hypoxemia
Vascular clamping (afterload)
【高血压英文PPT精品课件】 PREECLAMPSIA
hypertension
PREECLAMPSIA
• Definition of hypertension
– a systolic blood pressure of 140 mmHg or above,
– or a diastolic blood pressure of 90mmHg or above,
PREECLAMPSIA
Reinaldo Figueroa, MD Winthrop-University Hospital
PREECLAMPSIA
• Hypertensive disorder specific to pregnancy
– affects nearly 6% of all pregnancies – a major cause of maternal and neonatal
PREECLAMPSIA
• Screening tests for gestational hypertension
• routine components of antepartum care trimester • early detection of vasoconstriction • early detection of altered renal function • early detection of altered hemodynamics • detection of placental hypoperfusion / ischemia • detection of endothelial activation or injury • detection of an activated coagulation / fibrinolytic
PREECLAMPSIA
• Definition of hypertension
– a systolic blood pressure of 140 mmHg or above,
– or a diastolic blood pressure of 90mmHg or above,
PREECLAMPSIA
Reinaldo Figueroa, MD Winthrop-University Hospital
PREECLAMPSIA
• Hypertensive disorder specific to pregnancy
– affects nearly 6% of all pregnancies – a major cause of maternal and neonatal
PREECLAMPSIA
• Screening tests for gestational hypertension
• routine components of antepartum care trimester • early detection of vasoconstriction • early detection of altered renal function • early detection of altered hemodynamics • detection of placental hypoperfusion / ischemia • detection of endothelial activation or injury • detection of an activated coagulation / fibrinolytic
高血压英语PPTPPT课件
Blood pressure readings of 180/110 mmHg or higher
Headache
Vision changes
Shortness of Breath
Fatigue
Dizziness
Chest pain or discomfort
01
02
03
04
05
06
Symptoms of Hypertension
Mental stress
Sleep quality
Chronic stress
03
The HAZARDS of Hypertension
Increased risk of heart disease
High blood pressure can damage the heart muscle, leading to heart disease
Hypertension English PPT courseware
contents
目录
Introduction to Hypertension The causes of hypertension The HAZARDS of Hypertension Diagnosis and prevention of hypertension
Diagnostic method
ቤተ መጻሕፍቲ ባይዱ
Preventive measure
Healthy die: A balanced die rich in fruits, vegetables, whole grains, and lean protein can help reduce blood pressure Limiting salt and reducing intake of saturated fat and trans fat are also important
Headache
Vision changes
Shortness of Breath
Fatigue
Dizziness
Chest pain or discomfort
01
02
03
04
05
06
Symptoms of Hypertension
Mental stress
Sleep quality
Chronic stress
03
The HAZARDS of Hypertension
Increased risk of heart disease
High blood pressure can damage the heart muscle, leading to heart disease
Hypertension English PPT courseware
contents
目录
Introduction to Hypertension The causes of hypertension The HAZARDS of Hypertension Diagnosis and prevention of hypertension
Diagnostic method
ቤተ መጻሕፍቲ ባይዱ
Preventive measure
Healthy die: A balanced die rich in fruits, vegetables, whole grains, and lean protein can help reduce blood pressure Limiting salt and reducing intake of saturated fat and trans fat are also important
英文疾病介绍——Hypertension(高血压病)ppt课件
Hypertension
英文疾病介绍——Hypertension(高血压病)
What Is Hypertension?
➢Hypertension (HTN) is a chronic medical condition in which the blood pressure in the arteries is elevated(提高的).
In fact, one in five people with the condition don‘t know they have it. Internally([ɪnˈtɜ:nəlɪ],在体内地), it can quietly damage the heart, lungs, blood ve英ss文e疾l病s,介b绍r—a—inH,ypaerntednsiokni(d高n血e压y病s) if left untreated. It’s a major risk factor for strokes(中风/脑卒中) and heart attacks(心脏病).
Who is at risk?
➢ Anyone can have high blood pressure. Some people are more likeressure including:
• African Americans(more sensitive to salt) • People over age 55 • People with a family history of high blood pressure
Malignant Hypertension
(Chronic Hypertension)
(Accelerated Hypertension)
英文疾病介绍——Hypertension(高血压病)
What Is Hypertension?
➢Hypertension (HTN) is a chronic medical condition in which the blood pressure in the arteries is elevated(提高的).
In fact, one in five people with the condition don‘t know they have it. Internally([ɪnˈtɜ:nəlɪ],在体内地), it can quietly damage the heart, lungs, blood ve英ss文e疾l病s,介b绍r—a—inH,ypaerntednsiokni(d高n血e压y病s) if left untreated. It’s a major risk factor for strokes(中风/脑卒中) and heart attacks(心脏病).
Who is at risk?
➢ Anyone can have high blood pressure. Some people are more likeressure including:
• African Americans(more sensitive to salt) • People over age 55 • People with a family history of high blood pressure
Malignant Hypertension
(Chronic Hypertension)
(Accelerated Hypertension)
高血压英文PPT精品课件Hypertensionin
Trial
Viberti; JAMA 94 REIN, KI 98
POPULATION
Type 1 DM Nephrotic
DRUG
Captopril Ramipril
AASK; JAMA 02 AA pts w CKD Ramipril
IRMA 2; NEJM 01 Type 2 DM
Valsartan
how you get there • Multiple interventions are necessary in most
Hypertensive Emergencies
• Hypertension is a chronic outpatient disease with rare acute side effects
Home BP Monitoring
• Patients need to be taught proper methods
– No wrist cuffs – Semi-automated electronic cuffs
• Cuff needs to be checked against office readings
• Confirm 2 readings 5 minutes apart in both arms for initial diagnosis
• If taken in wrist or legs, the cuff must be at the level of the heart
BP Measurement
– Should be considered in all stages – If tolerated then reduced development of ESRD,
高血压英文PPT精品课件HYPERTENSIVE
In Young ...
Protein C levels Protein S levels Platelet Analysis Sr. & Urine for Homocysteine levels
Others ...
Hb Electrophoresis PT / PTT Anti-Phospholipid antibody Complete Cardiovascular evaluation
Microaneurysyms Optociliary vessels – collaterals between retinal & ciliary
vessels
Cilioretinal artery occlusion
Combined with CRVO
Cilioretinal artery occlusion
• HRVO (Hemi Retinal Vein Occlusion)
• BRVO (Branch Retinal Vein Occlusion) Constitutes 69.5 % of all RVO cases
CRVO ...
Classic Appearance
Mildest Form
CRVO
Combined with anterior ischaemic optic neuropathy
HRVO ...
HRVO ...
Superior & Inferior vein do not merge into Central Vein before entering into lamina cribrosa
Traditional Rx Options ...
高血压英文PPT精品课件HYPERTENSIVE
GRADE 2 HTR
SEVERE GENERALIZED AND FOCAL ARTERIOLAR CONSTRICTION
A-V CROSSING CHANGES (SALUS SIGN)
GRADE 3 HTR
Copper wiring of arterioles Venous banking distal to A-V
the arterial & venous circulation
Green et al – Thrombus formation in the region of lamina cribrosa is the primary event
GRADE 4 HTR
All changes of grade 3
Silver wiring of arterioles
Disc edema
Ocular associations of hypertension
Retinal vein occlusion
• CRVO (Central Retinal Vein Occlusion)
crossing (bonnet’s sn) Venous tapering on either
side of crossing (gunn’s sn) Right angle deflection of
veins. Flame shaped hemorrhages
cotton wool spots, hard exudates.
• HRVO (Hemi Retinal Vein Occlusion)
• BRVO (Branch Retinal Vein Occlusion) Constitutes 69.5 % of all RVO cases
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– Cocaine/crack
– Amphetamines
– PCP
– Witdrawal from antihypertensive Rx
– MAOI interactions
Others
• Autonomic hyper-reactivity
– Guillan-Barre – Autonomic dysreflexia – Porphyria
Question 1
• Define hypertensive urgency and hypertension emergency. What are some clinical findings associated with hypertensive emergenices? (Ibrahim)
– Thyrotoxicosis/Thyroid storm, Hypothyroidism/Myxedema, goiter – HPT: hypercalcemia (psychosis, constipation, inc QTc, cataract,
nephrocalcinosis, N-DI, dystrophic calcifications of soft tissue (Xray) – Cushing’s: Cushinoid – Conn’s: hypokalemic metabolic alkalosis – Pheochromocytoma: perspiration, palpitation, pain (chest, h/a, AP), labile pressure (+/- orthostatic hypotension), pallor – RAS: Renal bruits – OSA/Pickwikian Syndrome: Obesity wt think/short neck, day time somnolence, apnea attacks – Pregnancy: HELLP, Ecclampsia (edema, protienuria, sz, inc DTR)
– Cardiovascular (heart failure, volume status, arrhythmias)
– Respiratory (pulmonary edema) – Abdominal exam
• Systolic/diastolic bruits, palpable aneurysm • masses occupying the entire epigastrium and
– Including microvascular thrombosis
• TTp, HUS, vasculitis, acute glomerulonephritis
• Renal vascular disease (Renal artery stenosis) • Pregnancy Induced Hypertension/Pre-
Байду номын сангаас
Investigations, continued
• Physical exam:
– Vital signs… HR as well as BP, to guide therapy
• Arterial line, particularly if IV medications are used
– Neuro (LOC/encephalopathy, seizures, focal deficits)
– History of HTN (and detailed history of Rx, compliance and course of care as available), drug use, pregnancy (and pregnancy hx), systemic vascular disease, etc.
• CT Chest if aortic dissection is a concern
No Image
Here it is: Internal medicine-type stuff
• Plasma renin and aldosterone • Urine metanephrines (24-hr collection)
amphetamine metabolites
Investigations, continued
• Chest X-ray (pulmonary edema) • ECG ( Myocardial ischemia or clues to
chronicity, such chamber enlargement and strain patterns.) • Echocardiogram (systolic/diastolic function, hypertrophy, chamber size)
No Image
Question 2
• What is the differential diagnosis of hypertensive emergencies/urgencies? What work up would you order for this patient? (Todd)
Investigations, continued
• CT Brain: intracranial hemorrhage, tumor, posterior leukoencephalopathy
• CT Abdomen/Pelvis
– If contrast is possible (renal failure), this can be used to assess renal arteries as well as look at adrenals and extra-adrenal masses
M acintosh P IC T M a c in to s h P IC T
im age form at
im a g e fo rm a t is n o t s u p p o rte d
is not supported
No Image
Clinical Findings
• Of predisposing disease
Hypertensive
Emergency/Urgency: Differential
Diagnosis
• Untreated or suboptimally treated essential hypertension (most common)
• Renal parenchymal disease
stroke 2. Retina: Grade IV retinopathy (papilledema) 3. CVS: ACS, Acute pulmonary edema, CHF, Aortic dissection 4. Kidneys: accelerated nephrosclerosis, nephritic syndrome 5. Blood: MAHA, HELLP 6. Pregnancy: HELLP, Ecclampsia
Case Based Presentation: Hypertension in the ICU
By Noemie Chessex and colleagues
UBC
Case
• A 19-year-old man presents to ED with episodic headaches that resolved spontaneously.
• Elevated ICP
No Image
Investigations
• Book for history and physical examination
– Need for resuscitation (LOC, arrhythmias, pulmonary edema, seizures, tearing chest pain, etc)
Clinical Findings
• Of Complications/TOD
– Brain: H/A, N/V, meningism, FND, delirium, decreased LOC, seizures, coma
– Retina: blurred vision, papilledema (IV) +/- cotton wool exudate, flame shape hg, AV nipping and silver wiring (G I-III in chronic Htn)
Investigations
– Previous difficulty managing BP, or flares of symptoms (pheo can’t be that rare if we’ve seen 2 spectacular cases within a year)
– Medications including OTC and recreational drugs
– Serum metanephrines would be nice, if you could find a lab that would do them in a timely fashion
eclampsia/Eclampsa • Endocrine:
– Pheochromocytoma (or exogenous catecholamines)
– Cushing’s syndrome – Renin-secreting tumors
No
• Drugs
Image
– Sympathomimetic consumption/overdose (SPH/RCH)