Different Types of Asthma

Portrait of a young smiling Muslim woman sitting on the sofa at home in a shirt, holding an inhaler for breathing, and showing a bottle of medicine to the camera.Asthma is a chronic respiratory illness that causes airways to become inflamed, swollen, and narrow, making breathing difficult.  It affects millions of people living in the United States. According to the Centers for Disease Control and Prevention (CDC), approximately 26 million people in America have asthma.

Asthma isn’t a single disease but rather a group of related conditions with shared symptoms, which include:

  • Wheezing
  • Shortness of breath
  • Cough
  • Chest tightness
  • Mucus production

Asthma is categorized into different types based on severity and triggers. Some common clinical types of asthma are:

  • Allergic asthma – triggered by allergens such as pollen
  • Non-allergic asthma – triggered by non-allergens such as stress or irritants such as smoke or weather
  • Exercise-induced asthma- occurs when airways narrow during physical activity, especially in dry or cold air
  • Occupational asthma -caused by exposure to irritants such as chemicals, dust, or fumes at the workplace
  • Aspirin‑Exacerbated Respiratory Disease (AERD)- triggered by aspirin or other NSAIDs
  • Cough-variant asthma- where a chronic dry cough is the only or primary symptom, lasting weeks
  • Nighttime asthma – where symptoms worsen at night or early morning

Your doctor may evaluate your medical history, symptoms, and triggers to diagnose your type of asthma.  Testing may include allergy tests, sputum, or lung function tests.

Treatment for asthma may vary by type.  They may include inhaled corticosteroids, biologic therapies, allergy medications, a bronchodilator used before exercise, trigger avoidance, avoidance of aspirin or NSAIDs, or rescue inhalers.

To schedule an appointment with a doctor at Jamaica Hospital Medical Center, please call 718-206- 7001.

 

 

 

 

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Nearsightedness

The city center of Madrid as seen from some myopia glasses.Myopia, or nearsightedness, occurs when the eyeball grows too long or oval-shaped rather than round. People living with myopia can see objects that are near but have trouble seeing objects that are farther away. It is estimated that more than 40% of adults living in the United States have myopia. According to the American Academy of Ophthalmology, nearsightedness has been on the rise for several decades.

Nearsightedness typically begins in childhood or adolescence. It progresses during childhood and the teen years, then stabilizes in adulthood.  The primary cause of nearsightedness is axial myopia, which is caused by the eye being too long from front to back. Because of this extra length, light entering the eye focuses in front of the retina rather than directly on it, causing distant objects to appear blurry.  This eye elongation can be driven by the following risk factors:

  • Genetics passed down from parents. If one or both parents have myopia, a person has an increased chance of developing the condition
  • Ethnicity – some ethnic groups are more at risk than others
  • Limited outdoor time – not spending enough time outdoors
  • Doing close-up activities, or near-vision work, such as reading or viewing screens for extended periods

People who are nearsighted may experience symptoms such as:

  • Difficulty seeing objects far away
  • Eye strain
  • Squinting
  • Headaches
  • Tiredness when doing certain activities, such as driving

If you are experiencing these symptoms, it is recommended that you see an eye specialist.  Your eye doctor can diagnose myopia by conducting a comprehensive eye examination.

Myopia is permanent; however, in most cases, vision can be corrected with eyeglasses, contact lenses, laser procedures such as LASIK or LASEK, lens implants, or vision therapy. People living with pathological myopia, which is a severe and progressive form of the condition, may not be able to have their vision corrected with eyeglasses or contact lenses.

At Jamaica Hospital Department of Ophthalmology, we are passionate about providing patient-centered adult and pediatric care. To schedule an appointment, please call 718-206-5900.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

The New 2026 Cholesterol Guidelines

Approximately 1 in 4 adults in the United States has high levels of low-density lipoprotein (LDL) cholesterol, often referred to as “bad” cholesterol. Elevated LDL cholesterol increases the risk of atherosclerotic cardiovascular disease, which can lead to heart attacks and strokes. The longer an individual has high LDL cholesterol, the greater their lifetime risk of experiencing a heart attack or stroke, both of which remain among the leading causes of death in the United States.

Experts agreed that stricter and clearer guidelines were needed to address these trends. Furthermore, new scientific evidence showed that earlier, more personalized, and more aggressive management of cholesterol can prevent cardiovascular disease and complications more effectively over a person’s lifetime.

In response to these findings, the American Heart Association (AHA) and the American College of Cardiology (ACC), in collaboration with nine other leading medical organizations, updated the guidelines for managing cholesterol and other blood lipids for the first time since 2018.

According to the AHA, a major focus of the new guidelines is earlier intervention through healthy lifestyle changes. These include maintaining a healthy weight, engaging in regular physical activity, avoiding tobacco products, prioritizing healthy sleep habits, and taking cholesterol-lowering medication when recommended by a healthcare professional.

The new guidelines strongly emphasize the importance of preventing cardiovascular disease earlier by identifying individuals at higher risk sooner and implementing screening and interventions at younger ages. Adults aged 30 and older are now included in the risk assessment group, instead of the previously recommended age of 40 and older.

Other new recommendations for the management of cholesterol include:

  • Using the new Predicting Risk of Cardiovascular Disease EVENTs (PREVENT™) risk calculator, a new tool to assess risk earlier in adults ages 30-79 years. The PREVENT™ tool estimates a person’s risk of developing heart disease over the next 10 and 30 years.
  • Testing for lipoprotein (a) in all adults at least once in their lifetime. Lipoprotein (a) is a genetic biomarker for heart disease.
  • The consideration of additional testing to improve cardiovascular risk assessment. These tests include a non-contrast coronary artery calcium (CAC) scan and Apolipoprotein B
  • Cholesterol screening in children who may have high cholesterol due to lifestyle habits or inherited conditions, such as familial hypercholesterolemia. Guidelines recommend that screening begin for children aged 9 to 11 who have not previously been screened.
  • Clear targets for LDL cholesterol. Doctors now aim for LDL levels below 100 mg/dL in most patients without risk factors, below 70 mg/dL in those at high risk, and below 55 mg/dL in individuals with heart disease.

The guidelines also advise against taking supplements to lower cholesterol due to insufficient evidence and safety risks.

The primary objective of the new cholesterol guidelines is to reduce LDL cholesterol levels significantly in order to decrease an individual’s overall and lifetime risk of heart attacks and strokes. This approach is personalized and based on individual risk factors. Individuals can apply these guidelines to improve their health by understanding their risk for cardiovascular disease, consulting their healthcare providers for recommended screening tests, comprehending their cholesterol levels, adopting healthier lifestyle choices, and taking any prescribed medications as directed by their doctor.

To schedule an appointment with a doctor at Jamaica Hospital Medical Center, please call 718-206-7001.

 

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

American Diabetes Alert Day

American Diabetes Alert Day is observed each year on the fourth Tuesday in March.  The observance was created by the American Diabetes Association to raise awareness of the seriousness of diabetes and highlight the importance of understanding your risk.

According to the Centers for Disease Control and Prevention (CDC), diabetes is the seventh leading cause of death in the United States. Furthermore, the CDC reports that, “More than 40 million Americans have diabetes, and more than 1 in 4 adults with diabetes don’t know they have it.”

Diabetes is a chronic disease that occurs when blood glucose (or blood sugar) levels are too high. This happens because the pancreas does not produce enough insulin to help regulate the amount of sugar that enters the body’s cells. As a result, excess sugar accumulates in the bloodstream.

If diabetes is not managed properly or is left untreated, it can lead to complications and increase the risk of serious health problems.  Diabetes complications include:

  • Damage to the nerves in the body
  • Kidney problems
  • Skin problems
  • Bladder problems
  • Eye diseases that can lead to blindness
  • Gum disease
  • Foot complications that can lead to limb loss
  • Cardiovascular disease, potentially increasing the risk of hypertension, heart attack, or stroke

Some people are more at risk of developing diabetes than others. You may have an increased risk if you:

  • Are overweight or obese
  • Are physically inactive
  • Have non-alcoholic fatty liver disease
  • Have a parent or sibling with diabetes
  • Have ever had gestational diabetes
  • Are age 45 and older
  • Are a Hispanic or Latino, African American, American Indian, or Alaska Native person. (The CDC states that some Pacific Islander and Asian American people also have a higher risk.)

Diabetes Alert Day serves as a “wake up call” to pay attention to these risk factors and properly manage your health.  If you are at risk of developing diabetes, you should speak with your doctor about ways to improve your health and lower the chances of complications occurring.  To schedule an appointment with a doctor at Jamaica Hospital Medical Center, please call 718-206-7001.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

How Is Sleep Apnea Diagnosed?

Sleep apnea is a common and potentially serious breathing disorder that causes breathing to stop and restart several times during sleep. These involuntary breathing pauses are called apneic events.

Sleep apnea happens when there is a blockage of the airway or when the brain fails to regulate breathing. This can prevent your body from getting adequate oxygen and lead to various health problems, including:

  • High blood pressure
  • Increased risk of heart attack, arrhythmia, and other cardiovascular problems
  • Increased risk of diabetes
  • Sleep deprivation

Common symptoms of sleep apnea include:

  • Loud snoring
  • Gasping or choking for air during sleep
  • Restless sleep
  • Breathing pauses
  • Daytime fatigue
  • Trouble staying asleep
  • Hypersomnia (excessive daytime sleepiness)
  • Dry mouth

Sleep apnea is diagnosed by a healthcare professional who may ask you about your symptoms, medical history, and sleep history. They may refer you to a sleep specialist or a sleep center to undergo testing. The most common tests for sleep apnea are:

  • Polysomnogram, an overnight sleep study conducted in a sleep lab. Here you will be hooked up to equipment that monitors your heart rate, breathing, arm and leg movements, and other functions
  • Home sleep apnea test, which is the at-home version of the sleep study. Key metrics and functions are measured with a portable device. Home sleep apnea tests may sometimes miss certain metrics. Therefore, your healthcare provider may still recommend a polysomnogram.

Once diagnosed with sleep apnea, your healthcare provider will recommend treatment based on the severity of your symptoms, general health, and age. Treatment may include lifestyle modifications, oxygen, devices such as a CPAP machine, dental appliances, orofacial therapy, or surgery.

Jamaica Hospital Medical Center’s Department of Sleep Medicine utilizes state-of-the-art technology to diagnose sleep disorders. Several testing options are available at our sleep lab in Queens. We also offer home sleep studies to diagnose obstructive sleep apnea and several treatment devices and therapies, including Inspire Therapy.  To schedule an appointment with a sleep specialist, please call 718-206-5916.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Herniated Disc

A herniated disc occurs when one of the discs in the spine tears or ruptures, allowing the jelly-like substance, or nucleus, in the disc to leak and irritate surrounding nerves.

A herniated disc can affect any part of the spine; however, this problem is most likely to occur in the lower spine. Herniated discs in the lumbar spine (the lower back) typically result in symptoms that affect the legs, feet, lower back, or buttocks. A common cause of lower back pain is a herniated disc. This pain is often described as sharp and radiating.  In addition to lower back pain, a herniated disc can also cause leg pain, or sciatica.

A herniated disc in the cervical spine (the neck) may lead to neck pain, pain between the shoulder blades, or pain in the arms, hands, or fingers.  Herniation in the neck or lower spine may also result in numbness, tingling, or muscle weakness, and in some instances bladder problems.

Herniated discs can be caused by age-related weakening or wear and tear of the discs; this is called disc degeneration. Other causes include:

  • Sudden or traumatic injuries
  • Repeated minor injuries
  • Repeated bending, strain, or twisting
  • Improper lifting of heavy objects
  • Poor posture
  • Obesity or excess body weight

Some people are at risk of getting a herniated disc more than others. Risk factors include:

  • Living a sedentary life
  • Being overweight
  • Smoking
  • Working in a career that requires frequent heavy lifting
  • Having a previously herniated disc
  • Having close blood relatives with spinal disc problems
  • Having a connective tissue disorder
  • Being seated for long periods

Most herniated discs heal on their own; however, in some instances, they may not. Symptoms of a herniated disc can worsen over time if left untreated, leading to complications such as bladder or bowel dysfunction, significant tingling, numbness, or weakness.  It is advisable that you see a doctor if you are experiencing these complications.

Your physician may perform a thorough physical examination and order neurological examinations, imaging tests, or nerve tests to help diagnose a herniated disc. Once diagnosed, treatment may involve medications, physical therapy, spinal injections, or surgery.

To schedule an appointment with a doctor at Jamaica Hospital Medical Center, please call 718- 206-7001.

 

 

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

Scar Revision

A scar is a visible mark that is made of fibrous tissue.  Scars may form as a result of surgery, injury, infection, burns, or sores.

Less severe scars may fade (appearing lighter or less prominent) over time. However, thicker, more severe scars may remain prominent and cause physical discomfort, such as pain or tenderness to the touch. In addition, severe scars, particularly those resulting from burns, prior surgeries, or injuries, can restrict motion by tightening the skin. People may consider scar revision to address these issues.

Scar revision is a treatment performed to cosmetically improve the appearance of scars or potentially minimize the discomfort caused by scars.  It is important to note that scar revision will not completely erase your scar.

There are several scar revision treatments, including:

  • Injectables/ steroid injections
  • Topical treatments
  • Resurfacing treatments
  • Surgery

Scar revision surgery is plastic surgery performed to alter the appearance or condition of scars.  Surgery typically involves advanced, minimally invasive techniques such as surgical excision, tissue expansion, Z-plasty or W-plasty, skin flap surgery, or skin grafts.

It is important to note that all surgical procedures carry risks; however, serious complications are rare in scar revision surgery.  Potential risks include:

  • Poor wound healing
  • Bleeding
  • Infection
  • Recurrence of keloid scars
  • Asymmetry
  • Anesthesia risks (if general anesthesia is used)
  • New scar may not look exactly as desired (though usually better than the original)

If you are considering scar revision surgery, you will first meet with a plastic surgeon for a consultation.  Your surgeon will evaluate your scar to determine which treatments or methods may work best for you.   A qualified plastic surgeon evaluates risks based on your health and scar type.

To learn more about scar revision surgery or to schedule an appointment with a plastic surgeon at Jamaica Hospital Medical Center, please call 718-206-6713.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

High Blood Pressure and Heart Health

The American Heart Association defines hypertension, or high blood pressure, as a condition that occurs when the force of your blood pushing against the walls of your blood vessels is too high.

Hypertension causes the heart to work harder, which can lead to serious cardiovascular problems, including heart failure, stroke, and heart disease. When the heart works harder, it also greatly increases the risk of a heart attack.

Managing high blood pressure and keeping it under control can significantly reduce the risk of these issues.  You can reduce heart risks caused by high blood pressure by:

  • Monitoring your blood pressure at home
  • Eating a heart-healthy diet
  • Lowering sodium intake
  • Maintaining a healthy weight
  • Taking blood pressure medications as prescribed

Understanding the risk factors of high blood pressure is also crucial, as this can help you manage your heart health.  The risk factors are:

  • Family history (Having a parent or close blood relative with high blood pressure increases the likelihood that you develop hypertension)
  • Age (As you get older, your risk for developing high blood pressure increases)
  • Sex (According to the American Heart Association Until age 64, men are more likely than women to get high blood pressure. At 65 and older, women are more likely to get high blood pressure)
  • Race (African Americans have a higher risk of developing high blood pressure compared to other races)
  • Obesity (Too much weight puts strain on your heart and circulatory system)
  • Tobacco use (Using tobacco can damage the heart and arteries, leading to elevated blood pressure levels)
  • Drinking too much alcohol (Drinking excessive amounts of alcohol regularly can raise blood pressure. Heavy drinking can weaken and damage blood vessels, potentially leading to hypertension)
  • Lack of physical activity (Regular exercise strengthens the heart; when you are inactive, the heart must work harder to circulate blood, and harder pumping leads to high blood pressure)
  • Eating an unhealthy diet (Eating a diet that is high in sodium, trans fats, saturated fats, and sugar increases your risk)

One of the dangers of living with high blood pressure is that many people are unaware that they have it.  This is why hypertension is called “The Silent Killer.” Living with untreated high blood pressure can cause significant damage to the cardiovascular system over time.

Early detection and treatment of high blood pressure can delay or prevent complications that affect cardiovascular health. Treatment may involve medications and lifestyle modifications.

Jamaica Hospital Medical Center’s cardiology department features a specialized Hypertension Center that offers high-quality, patient-centered care for hypertension and incorporates the latest treatment advances. This center was established specifically to assist patients who do not respond effectively to traditional hypertension medications.

The American Heart Association has recognized our Hypertension Practice Center for meeting or exceeding its standards for hypertension treatment. To schedule an appointment with our Cardiology Department, please call 718) 206-7100

 

 

 

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

High Doses of Supplements May Lead To Liver Damage

Dietary supplements are products we ingest that contain concentrated forms of nutrients or substances that are found in food or plants.

Supplements can come in capsule, liquid, gummy, or powder form. We take them to ensure our nutritional needs are met, to address certain deficiencies, or to help us manage certain health conditions.

Although supplements can help us maintain or improve our overall health, they also pose risks, especially when taken at higher-than-recommended doses.

Certain supplements, when taken in excess, can cause serious damage to our organs.  Our liver is most susceptible to this type of injury or damage because it filters and processes everything we ingest.  Research published in the journal Hepatology and indexed by the National Library of Medicine estimates that 20% of drug-induced liver damage or injury is tied to herbal and dietary supplements. The following supplements are among those associated with liver damage or toxicity, when overused:

  • Glutamine
  • Turmeric
  • Vitamin A
  • Niacin
  • Kava
  • Green tea extract
  • Black cohosh
  • Bodybuilding or weight loss supplements
  • Ma huang (Ephedra)
  • Ashwagandha
  • Skullcap
  • John’s wort

The effects of overusing these supplements may be acute or develop over time. Signs and symptoms of liver damage include:

  • Nausea and vomiting
  • Jaundice (yellowing of the eyes or skin)
  • Itching
  • Dark urine
  • Pale-colored stools
  • Fluid in the abdomen

Researchers believe the prevalence of drug-induced liver damage, linked to supplements, is growing because more people are taking supplements, and a lot more of them.

Furthermore, supplements are not regulated by the U.S. Food & Drug Administration (FDA) like prescription medications and may not always contain the exact dose listed on the label. Therefore, you may not always know what you are getting.

If you are considering adding supplements to your healthcare regimen, there are a few steps you can take to ensure your safety:

  • Speak with your doctor before taking supplements
  • Buy from reputable brands
  • Look for third-party testing certifications from public health organizations such as NSF or USP

If you are experiencing symptoms of liver damage, schedule an appointment with your doctor as soon as possible to avoid complications.

To schedule an appointment with a doctor at Jamaica Hospital Medical Center, please call 718-206-7001.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.

What Happens to The Body on Long Flights

The airline industry classifies long-haul flights as those with a flight time of six hours or more. Flying for extended periods can take a toll on our bodies. It can make us tired and uncomfortable, but it can also affect us in the following ways:

  • Dehydration– The low levels of humidity in the cabin air can lead to dehydration. Dry recycled air can make our skin and mucosal areas, such as the nose, throat, and mouth, feel excessively dry. It can also lead to a lack of lubrication in our body’s systems. Therefore, it’s important that you drink water before boarding the plane and during your flight.
  • Muscle stiffness and soreness – Staying seated for extended periods can lead to muscle stiffness and soreness. A lack of movement can compress joints and reduce blood flow, which further contributes to muscle discomfort. Additionally, dehydration can result in cramps, spasms, or joint pain. To alleviate these issues, stay hydrated and take breaks to walk or stretch whenever possible.
  • Airplane ear or barotrauma – Changes in cabin pressure affect the air pressure in your ears, which places stress on your eardrums. This may lead to earaches, muffled hearing, or discomfort. Chewing gum, yawning, or swallowing can usually improve symptoms.
  • Gut issues- Sitting for too long can affect our digestive system and trigger stomach issues such as diarrhea, gas, constipation, or bloating. Factors such as cabin pressure, dehydration, changes in eating schedule, and lack of movement can contribute to these problems. Drinking water, walking in the aisles, avoiding certain foods, or taking medication may provide some relief.
  • Blood clots /deep vein thrombosis – Long-distance flights increase the risk of blood clots and deep vein thrombosis. Remaining sedentary for hours can lead to blood clots forming in the deep veins of the legs. If these blood clots break off and travel to the lungs, they can cause a serious condition known as pulmonary embolism (PE), which is a blockage in the lungs that can lead to shortness of breath, fainting, or even death.  To reduce the risk of complications, long-distance travelers are encouraged to walk around, when possible, move their legs frequently, or wear compression socks.

When flying long distances, it’s crucial to be aware of potential medical issues you may encounter. Pay attention to warning signs and take the proper precautions needed to protect your health.

All content of this newsletter is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Please consult a medical professional before adopting any of the suggestions on this page. You must never disregard professional medical advice or delay seeking medical treatment based upon any content of this newsletter. PROMPTLY CONSULT YOUR PHYSICIAN OR CALL 911 IF YOU BELIEVE YOU HAVE A MEDICAL EMERGENCY.