SECONDS COUNT IN TRAUMA CARE Pages 2 & 3

HIGH RISK CLINIC FOR BREAST CANCER SCREENING Page 13

TREATING HEEL PAIN Page 14

EATING GLUTEN FREE Pages 4 & 5

Fall 2015/Winter 2016 • www.elliothospital.org Treat yourself to a healthier mind & body, see classes on pages 6 to 9 E

R Seconds Count A C

Y in Trauma Care! C by Miguel Gaeta, MD, Trauma Medical Director, General Surgeon in the Division of Trauma and Acute Care, N Instructor of Surgery, Harvard Medical School, Assistant in Surgery, Massachusetts General Hospital E G R E M E is well known that trauma 2009 to develop a mature ACS verified Level 2 Trauma It is the leading cause of Center to care for the population of southern New death in children and adults ages Hampshire. 1 to 44 years old. Regional data has also forced us to After joining in collaboration with the Division of acknowledge a disparity in the availability of American Trauma at Massachusetts General Hospital (MGH), Elliot College of Surgeons (ACS) certified Level 1 and Level 2 Hospital has developed and fostered a team of highly Trauma Centers in Northern New England. It has been specialized general surgeons with critical care experience to recognized that essentially half of New Hampshire’s citizens form the Division of Trauma and Acute Care Surgery were being placed at risk of not having access to a Level 1 (TRACS). or Level 2 trauma center within the critical first hour after Since the establishment of a formal trauma program, an injury. Despite the best efforts of our first responders, Elliot Hospital has seen the trauma volume increase by over harsh weather frequently grounds our air transport. 500% while at the same time decreasing the transfer rate Transportation of the injured patient is therefore limited to out of the Elliot from more than 60% of its trauma patients ground transportation placing the patient at risk if there to less than 5%. During this time Elliot Hospital’s isn’t a near-by trauma center. Elliot made it a priority in departments of Critical Care, Emergency Medicine,

2 Fall 2015/Winter 2016 | www.elliothospital.org | Elliot Direct 603-663-1111 Neurosurgery, Orthopedic, Oral Maxillary Facial, and Radiology have grown to provide comprehensive care to meet the needs of our critically injured patients. A robust quality and performance improvement program insures we maintain the highest level of care for our patients. The TRACS team has also extended their care to the critically ill and those in our community who require emergency surgical services 24/7 year round. A critically injured patient who enters the emergency department should expect rapid triage to a fully staffed intensive care unit within minutes of their arrival if the injuries require ICU level care. Maintenance of our initiatives, like our Fast Track initiative (Fig. 1), reflects our multi- disciplinary approach to assessing the needs of our patients as a team and rapidly triaging to where they can receive the highest and most appropriate level of care. Our close connection with the Division of Trauma at MGH also allows for continuous dialogue with our partners at MGH to insure our patients receive all the benefits and support of our two institutions. In 2013, the mortality for trauma patients admitted to the Elliot was almost two times lower than the national average (EH – 2.2% vs. national average – 4.2%). With the growth of New Hampshire’s Hospital for Children at the Elliot, we have become a referral center for adult and pediatric trauma patients. In the past 18 months we have seen our pediatric volume steadily increase (Fig. 2), allowing us to receive patients from throughout the state from over 12 different medical centers. This past May, we had our busiest trauma month in six years (Fig. 3). As the confidence in our services grow, we hope to continue to make our community proud of the Elliot and to exceed the expectations of our patients.

Elliot Direct 603-663-1111 | www.elliothospital.org | Fall 2015/Winter 2016 3 N O

I Eating Gluten Free – T I

R Do you need to be? T by Marilyn Mills, MS, RD, CDE – Clinical Dietitian, Elliot Advanced Nutrition Therapy; Supermarket Dietitian U N

Where’s the gluten free section?” As a supermarket symptoms of diarrhea or bloating, iron deficiency anemia, dietitian, I am asked this question weekly, while hypothyroidism and osteoporosis. As a healthcare working in the grocery store aisles. Sometimes, professional, I am concerned that people are self-diagnosing customers tell me that they have celiac disease, gluten intolerance without finding out if they may have while others say that they just feel better when celiac disease or another gastrointestinal issue that may they avoid eating wheat products. require treatment and a specific diet. Recent research Is gluten free eating better for you? Does reveals people who have been diagnosed with IBS gluten free eating lead to weight loss? Is it a (Irritable Bowel Disease) and other intestinal dietary fad or it is here to stay? intolerances (fructose, lactose intolerance or In the past 10 years, the production SIBO) complain of bloating and abdominal and advertising of gluten free foods has distention, constipation or diarrhea. These grown into big business for small and people may benefit from eating low large food companies alike. “In dollars FODMAP foods. FODMAP foods and cents, sales of gluten free contain a carbohydrate that causes products were expected to total irritation to the bowel. Choosing low $10.5 billion last year,” FODMAP foods is advisable and according to Mintel, a market will help with these research company, which gastrointestinal issues because estimates the category high FODMAP foods will produce more than often contain gluten. $15 billion in annual sales in 2016. What does eating Additionally, a gluten free recent ruling of gluten involve? free food labeling has Wheat and gluten produced an increased free eating is not for interest, as consumers everyone. Wheat free see the phrase or means gluten free, but certified symbol on gluten free doesn’t just their salad dressings, family mean avoiding wheat. cereal boxes and even on soda Gluten free eating involves cans. Given all the growing avoidance of all foods made from curiosity, should more of us be eating or containing ingredients from wheat, gluten free foods? barley, rye and contaminated oats. These grains contain a protein called gluten. For many people, What conditions lead to dietary change? they believe gluten free eating will lead to weight loss and Going gluten free is permanent for 1% of the U.S. they expect to feel more energetic. For some, beginning to population diagnosed with celiac sprue disease, an inherited eat gluten fre e may result in desired changes in weight as auto-immune disease diagnosed by both blood antibody they pass on high caloric baked goods, bowls of pasta and tests and upper GI (gastrointestinal) biopsy. Dr. Peter H.R. sandwich bread. Many who are irritated by the Green, of Columbia University, believes that physicians are carbohydrate may feel relief from bloating and abdominal still under diagnosing the disease which manifests itself with discomfort. 4 Fall 2015/Winter 2016 | www.elliothospital.org | Elliot Direct 603-663-1111 Eating gluten free may be difficult for people who do not gluten and low FODMAP lifestyles: cook or lack cooking skills. Many gluten free convenience- www.csaceliacs.org; www.celiac.org ; packaged foods are not necessarily low in carbohydrates or and calories, so weight loss is not guaranteed. Many of these www.nlm.nih.gov/medlineplus/digestivediseases.html convenience-packaged products are processed from rice, potato and corn flour, which are not always whole grain flours, lacking Many people following a gluten free diet may benefit from dietary fiber. Additionally, many food companies do not fortify guidance of a registered licensed dietitian familiar with designing the ir foods with B vitamins and iron. While these gluten free gluten free eating plans, dietary supplementation and healthy packaged foods may add convenience, they are not always the shopping tours in the supermarket. To find out more about best nutritional options for your overall diet. setting up a personal nutrition therapy appointment visit: Eating gluten free ingredients includes fresh fruits, vegetables, www.elliothospital.org or call 663-3130. Also, check out our lean protein and milk-based foods and beverages. Seeking sides gluten free recipe on page 15 of this issue. of protein and plant based meals or snacks and avoiding wheat, barley, rye and contaminated oats is optimal. There are some Marilyn is a Senior Clinical Dietitian with substitutes on supermarket shelves to avoid eating the same foods Elliot Advanced Nutrition Therapy at the over and over, which can be boring and nutritionally limiting. Elliot Pavillion and Supermarket Dietitian The chart below suggests substitutions for commonly requested consultant to Hannaford Supermarket® wheat/gluten based foods. serving Manchester, Hooksett, Goffstown, Additionally, gluten free food websites offer great recipes Derry and Hudson stores. using fresh food ingredients. Two websites available to support

IF YOU LIKE: TRY: OR GLUTEN FREE BRANDS:

Boxed Rice Pilaf (contains pasta) Bird’s Eye SteamFresh® Brown and Boxed Lundberg brand Risotto Wild Rice with vegetable blend

Dry Pasta (semolina) Rice or Corn or Quinoa blend Tinkyada™, GF Ronzoni®, GF Barilla or Ancient Grains®

Boxed Couscous Quinoa or Lundberg Brown Rice Couscous

Boxed Pancake Mix (wheat flour) Gluten Free Baking Mix GF King Arthur®, GF Bisquick®, Bob’s Red Mill® GF baking mix

Boxed Macaroni & Cheese Boxed Rice based Pasta or Annie’s® Gluten Free

Frozen Macaroni & Cheese Frozen GF Macaroni & Cheese Udi’s® GF Macaroni and Cheese, Amy’s ®GF macaroni and cheese

Deli located pre-made Tabouleh Quinoa Tabouleh Ancient Grains® (contains Bulgur wheat)

Pre-made Pizza crust (fresh or frozen) Portland Pie Gluten free Udi’s® Pizza crust, Amy’s® Pizza crust dough (deli dept) (frozen)

Family Cereals Rice and Corn based cereals without Chex® Rice Chex, Corn Chex (all malt (barley or wheat) flavors) and Kashi Indigo Morning®

Frozen Waffles Gluten free waffle mix or Eggo’s® GF or Van’s® GF waffles

Elliot Direct 603-663-1111 | www.elliothospital.org | Fall 2015/Winter 2016 5 SOME CLASSES MAY BE JOINED WHILE ALREADY IN PROGRESS.

S LOCATION OF CLASSES ARE DENOTED IN EACH DESCRIPTION E Register by calling the specific number provided in class listing, or 603-663-4567.

S Community S Wellness • EBHS: Elliot Behavioral Health Services, 445 Cypress Street, #8, Manchester A • EH: Elliot Hospital, One Elliot Way, Manchester L Take time for your health • EMMC: Elliot Memory & Mobility Center, 40 Buttrick Road, Londonderry C

GENERAL HEALTH EDUCATION • EWC: Elliot Wellness Center, 1070 Holt Avenue, Manchester American Heart Association CPR & Basic First Aid S The American Heart Association strongly promotes knowledge and • LON: Elliot Medical Center at Londonderry, 40 Buttrick Road, Londonderry S proficiency in BLS, ACLS and PALS and has developed instructional • E materials for this purpose. Use of these materials in an educational RE: The Elliot at River’s Edge, 185 Queen City Avenue, Manchester course does not represent course sponsorship by the American Heart • N Association. Any fees charged for such a course, except for a portion SHC: Senior Health Center, 138 Webster Street, Manchester

L of fees needed for AHA course material, do not represent income to the Association. good. Our certified counselor works with you those with dementia and reduce their own stress. L privately to formulate a quit plan based on Learn how to communicate in a way that E Heartsaver CPR $40 current clinical guidelines. minimizes frustrations, decreases anxiety, and

W RE: Sat, Sep 19, Nov 7 or Jan 9, 8 to 11 AM avoids disagreements. Emotional Eating $45 per session* II. Understanding Behaviors: Actions, or

Y CPR for New Healthcare Professionals EBHS: Wed, Sep 9-Nov 11, 1:30 to 3 PM or Th, behavior, may be telling us something, like “Slow

T or Those with Expired Certification $65 Sept 3-Nov 5, 6 to 7:30 PM . A minimum of 4 down” or “I need something to do.” Learning to I RE: Sat, Oct 3, Dec 5 or Feb 6, 8 AM to 12:30 PM people is necessary to run a group. *Most insurances understand the message and making changes to N including Medicaid are accepted. Due to licensing CPR Renewal for Healthcare Professionals $50 care can prevent outbursts and arguments.

U restrictions Medicare can only be accepted for the RE: Sat, Sep 19, Nov 7 or Jan 9, 11:30 AM to III. Safety at Home: For someone with Wed group. If using self-pay, cost is $45 per week if 2:30 PM dementia, a safe and supportive home can prevent M paid in full on the day of each group or $60 per injury and enhance independence and a sense of Heartsaver First Aid $40 week if not paid on the day of the group. To register security. Learn to adapt your home environment, M RE: Tue, Oct 13 or Jan 12, 6 to 9 PM call 603-663-8621. make it dementia-safe and supportive. O Learn techniques to give immediate care to an Do you turn to food for comfort, stress relief, as

C BARIATRIC SURGERY injured, suddenly ill person, or someone involved a reward or even out of boredom? If so, you are an emotional eater. It isn’t all about willpower. Dartmouth-Hitchcock Manchester, 100 in a life threatening situation, and when to alert Hitchcock Way, Manchester: All classes meet in medical personnel. Topics covered in this 10-week group for adults (ages 21+) include the brain’s reward system, how Conference Room A, 2nd floor. Pre-registration is Women’s Health Pre-operative habits are formed and changed, how to identify required for all meetings, please call 695-2628. Patient Education Class Free! and manage emotions without using food, Dartmouth-Hitchcock Manchester’s Bariatric EH: On-going. Physician referral required, to mindful eating and stress management. Surgery program offers monthly introduction participate, speak with your surgeon. and informational meetings to start you on a For women with scheduled gynecological Programs Sponsored by the Alzheimer’s Ass’n: successful weight loss journey. After attending an procedures at Elliot Hospital. Learn how to To register, call 552-1670. Introductory meeting, you will be eligible to call prepare for surgery, what to expect following • Healthy Habits for a Healthier You Free! and register for the monthly Informational surgery, pain management and more. Your EMMC: Th, Sep 3, 5 to 6 PM . meetings. You are required to attend a minimum questions will be answered. You are encouraged For centuries, we’ve known that the health of the of three monthly Informational meetings before to bring a family member or support person. brain and the body are connected. But now, proceeding with the program. science is able to provide insights into how to • Intro Meetings (for new patients to the 1-Day Surgery Center Tour for Children Free! optimize our physical and cognitive health as we program): 2nd Fri monthly, 12:15 to 12:45 PM RE, 1-Day Surgery Center: 1st & 3rd Wed age. Join us to learn about research in the areas • Informational Meetings: 2nd Fri monthly, 2 monthly, 3 PM , registration required. of diet and nutrition, exercise, cognitive activity to 4 PM . Different rotating topics each month. Parents, children ages 12 and younger, and their and social engagement, and use hands-on tools • Post Bariatric Surgery Support Groups: 1st siblings are invited to attend our special pediatric to help you incorporate these recommendations Tues monthly (except Nov 3rd due to voting), 5 tours. Meet with staff, review the surgical process into a plan for healthy aging. to 6 PM , no registration is required. and tour the facility. • Essential Skills for Family Caregivers Free! GENERAL FITNESS EMMC: Th, Oct 1, 8 & 15, 2 to 4 PM . Elliot Center for Tobacco Treatment All classes require registration by calling 663-4567. This three-part series provides education and Payment is due when you register; your spot on the RE: By appt., call 663-2201. Sessions may be practical tools to those caring for someone with reimbursed by Anthem or other insurances . roster is not confirmed until payment is received. All dementia. Improved day-to-day living and classes are 8-weeks. • Four, 1-hour private sessions $125 overall quality of life for the person with • One, 1-hour private sessions $45 dementia and the caregiver is the goal. Gentle Yoga I $80 • One, hypnosis private session $90 I. It Starts with Communication: There are RE: Mon, Sep 28-Nov 16; 3 wk-pre holiday Nov Studies show that intense support and counseling many proven communication techniques that 30-Dec 14; Jan 11-Feb 29; Mar 21-May 9; 5:45 with a trained tobacco treatment specialist caregivers can learn to improve day-to-day life for to 6:45 PM . increase the chances you can quit smoking for EH: Mon, Sep 28-Nov 16; 3 wk-pre holiday Nov Register by calling the specific number provided in class listing, or 603-663-4567. 6 COMMUNITY WELLNESS 30-Dec 14; Jan 11-Feb 29; Mar 21-May 9; 5:15 to aerobics and strenth training utilizing free weights, professional. Supports people who would like to 6:15 PM . resistance bands, and stability balls. Floor exercises, maintain their weight loss. Promotes total health and well-being through core work and stretching are also included. For ages stretching, strengthening and relaxing. This class uses 50+. Instructor: Cecily. Comprehensive Weight Mgt Program Free Intro! breath and movement to feel the release of physical EH, Pavilion: Intro Class, Wed, Oct 7, 6:30 to and mental tension and to increase body/mind Full Body Fusion $85 7:30 PM or Tue, Jan 12, 5:30 to 6:30 PM . awareness. Good for the beginner level participant. RE: T/Th, Sep 29-Nov 19; 3 wk pre-holiday Dec 1- This introductory session outlines the 10-week Dec17; Jan 12-Mar 3; Mar 22-May 12; 6 to 7 PM . comprehensive weight mgt program focusing on Gentle Yoga II $80 A fusion of strength training exercise using body & total health, not just pounds on a scale. RE: Wed, Sep 30-Nov 18; 3 wk pre-holiday Dec 2- free weights, cardiovascular intervals utilizing steps, Dec 16; Jan 13-Mar 2; Mar 23-May 11; 5:30 to plyometrics, yoga, pilates, core work and stretching. Jump Start Your Health $125 6:30 PM . Keeps your body guessing! Geared towards EH, Pavilion: Wed, Oct 14-Nov 18, 6:30 to 7:30 PM . A Vinyasa Flow Yoga class performed at a slower intermediate levels. Instructor: Cheryl. This 6-week series will teach the basics of healthy pace. This class will help build strength, flexibility eating, how to plan and cook quick and easy meals ® and balance; connecting movement with breath. Zumba GOLD $40 along with a focus on exercise. Modifications will be given to suit everyone’s ability. RE: Thu, Oct 1-Nov 19; 3 wk pre-holiday Dec 3-Dec S C R E E N I N G S a n d C L I N I C S 17; Jan 14-Mar 3; Mar 24-May 12, 1 to 2 PM . Breast & Cervical Cancer Screenings Free! ® Thriving with Yoga Free! Zumba Gold is a dance-fitness class that is friendly FREE breast and cervical cancer screening tests to RE: Wed, Sep 30-Nov 18; 3 wk pre-holiday Dec 2 and fun for all ages and genders. The Zumba eligible women. For more info, call 668-3067. Dec 16; Jan 13-Mar 2; Mar 23-May 11; 1:30 to formula is used with modified moves and pacing to S U P P O R T G R O U P S 2:30 PM . To register, please contact YogaCaps at suit the needs of the active older participant, as well NICU Parent Support Group Free! 603-674-3770 or [email protected]. as those just starting their journey to a fit and healthy EH, NICU Family Rm, 5th Floor: Designed especially for those with experience of lifestyle. The exhilarating easy-to-follow moves, the Tue, noon. Call cancer. It will empower you to: relieve tension and zesty Latin music, and the invigorating, party-like 663-4360 or [email protected] anxiety, rebuild strength and restore range-of- atmosphere will help you have fun while you achieve Postpartum Emotional Support Group Free! motion, witness emotion with compassion, and a great workout. Instructor: Cammie. Elliot Childcare Ctr Activity Rm, EH campus, manage the side effects of treatment and medications 450 Massabesic St.: Mon, 10:30 AM to noon. Call naturally. This includes pain, lymphedema, hot Body Sculpt $80 EH, Welliot: T/Th, Sep 29-Nov 19; 3 wk pre- Alison Palmer, RNC, MS, at 663-3052 for info. flashes, neuropathy, depression and insomnia. You This group helps support women experiencing holiday Dec 1-Dec17; Jan 12-Mar 3; Mar 22-May may bring a family member or friend to class. mood, anxiety, and thought disorders during 12; 5:15 to 6:15 PM . Yoga for Runners and Cyclists $80 A total body toning class designed to strengthen and pregnancy and the first year after their baby’s birth. We discuss issues and coping strategies related to the RE: Fri, Oct 2-Nov 20; 3 wk pre-holiday Dec 4-Dec sculpt every muscle group utilizing free weights, adjustment period and challenges of new 18; Jan 15-Mar 4; Mar 25-May 13, 5:30 to 6:30 PM . resistance bands, and your own body weight. Join Shauna in this all-levels yoga class where she Strength training is proven to help improve muscle motherhood. takes you through a series of highly effective strength, maintain bone health and aids in S.H.A.R.E. Free! strengthening and stretching exercises that are key improving metabolism. This class welcomes all 3rd Wed monthly, 7 to 9 PM . Call 663-3396. to the demands of an elite runner or cyclist. Focus is fitness levels. Instructor: Cheryl. For parents who have experienced a miscarriage, put on opening the calves, hamstrings, quads, hips, stillbirth or neonatal death. and shoulders. An emphasis on building core Welliot at RE Gym Membership $35 monthly strength will be visited to give the runner/cyclist the RE, Welliot: M-F, ongoing, 6:30 AM to 4 PM . Call 663- Chronic Pain Support Group Free! advantage over the competition. Instructor: Shauna. 4200 to get started. RE, Conf Rm: 2nd & 4th Tue, Sep 28-Jun 28, 5 to The Welliot at River’s Edge fitness center consists of 6:30 PM . Call 663-2881 with questions. Guest speakers. Tai Chi $40 the latest and greatest cardiovascular equipment, Peer support group focused on education; bringing RE: Tue, Sep 29-Nov 17; 3 wk pre-holiday Dec 1-Dec Nautilus strength training machines, and several new thinking to what chronic pain patients can do 15; Jan 12-Mar 1; Mar 22-May 10; 8:45 to 9:45 AM . group exercise classes for all ages and levels. Our to more fully engage in life. A Chinese martial art and form of stylized, experienced team of friendly fitness professionals will meditative exercise, characterized by methodically design an exercise program specific to your current Living Beyond Breast Cancer Free! slow circular and stretching movements and level and goals. If you are looking for a safe, non- EH, ERCC: 2nd Wed monthly, 6 to 7:30 PM . Call positions of bodily balance. Tai Chi will allow you competitive, supportive environment to help you 663-1804 for more information. to experience the ancient way to improve balance, reach your fitness goals, this is the facility for you. A group that provides support and sharing for strengthen the body, and cleanse the mind. Seniors and first time exercisers encouraged. women who have experienced breast cancer. Beginners welcome. Instructor: Bill. NUTRITION For any Nutrition Class, call 663-4524 to register or for Living with Cancer Free! Fit & Feisty $60 more information. EH, ERCC: 3rd Wed monthly, 5:30 to 7 PM . Call RE: T/Th, Sep 29-Nov 19; 3 wk pre-holiday Dec 1- 663-1804 for more information. Dec 17; Jan 12-Mar 3; Mar 22-May 12; 10 to 11 AM LBI Support Group $25 per 3 sessions A support group for people living with cancer, and 11:10 AM to 12:10 PM . EH, Pavilion: 2nd Wed monthly, 5 to 6 PM . including family and caregivers. A low-impact aerobic and strength class with easy- Includes weigh-in and group session with a to-follow moves in a fun environment. Includes Register by calling the specific number provided in class listing, or 603-663-4567. 7 COMMUNITY WELLNESS Prostate Cancer Free! environment. A womens only group that will use and genders. The Zumba formula is used with EH, ERCC: 4th Mon monthly, 6 to 7:30 PM . Call mindfulness techniques, self exploration and self care modified moves and pacing to suit the needs of the 663-1804 for more information. strategies you can use immediately. Tracey Coulon, active older participant, as well as those just starting Support and education for men with prostate cancer, facilitator. their journey to a fit and healthy lifestyle. The their families and/or support person. exhilarating easy-to-follow moves, the zesty Latin Healing from Trauma Women’s Group $60 per session music, and the invigorating, party-like atmosphere Look Good, Feel Better Free! EBHS: Thu, Sep 24-Dec 14 (no class Nov 26) 3 to will help you have fun while you achieve a great EH, Conference Rm: Monthly, for dates and times, 4PM . To register or for more information, call 663-8617 workout. Instructor: Ginger. call 663-1804. In conjunction with the American or 663-8618. Cancer Society. For survivors of trauma. The discussion of personal Zumba ® Gold Toning $40 Cosmetology help is provided to those receiving trauma will be extremely limited as the focus will be SHC: Fri, Oct 2-Nov 20; 3 wk pre-holiday Dec 4- cancer treatment. learning new and effective coping skills for regulation Dec 18; Jan 15-Mar 4; Mar 25-May 13; 9 to 9:45 AM . of emotions, impulses, self-care, grounding It’s the dance-fitness party that moves at your pace. Positive Coping with Health Conditions $60 per session techniques, acknowledging and celebrating resiliency. Shake and sculpt your way to a healthy body for an EBHS: Thu, Sep 17-Nov 19, 1 to 2 PM . To register, Includes take home sheets, hands-on, creative and optimum active, healthy lifestyle. Whether you’re an call 663-8617 or 663-8618. expressive activities in a safe and nurturing active adult or just starting your fitness journey – the environment. Tracey Coulon and Kristy Moen, Zumba ® Gold Toning Program combines the Support Group for Caregivers facilitators. enticing international rhythms of a slower-paced of Those with Dementia Free! Zumba ® Gold dance-fitness class with the sculpting SHC: 1st & 3rd Tue monthly, 10 to 11:30 AM . Call Women’s Stress Management moves of a Zumba ® Toning class. An easy-to-follow, Barbara MacPhee, MSW, LICSW at 663-7051. and Self-Care Group $60 per session health-boosting dance-fitness program anyone can Learn strategies for caring for yourself, identify ways EBHS: Tue, Sep 15-Oct 20 (6 weeks), 10 AM . To enjoy! Instructor: Ginger. Must buy your own to build a support system, and learn new coping register or for more info, call 663-8617. Zumba Toning sticks, available from instructor. strategies. Confidential. Do you find it difficult to find time in your day to take care of yourself? Feel guilty about saying now? Chair Aerobics $62 EMMC Caregiver Support Groups Free! Just cant unwind? Join us for six weeks to learn how SHC: M/W, Sep 28-Nov 18; 3 wk pre-holiday Nov30- 1st Wed monthly, 5 to 6:30 PM – general support group; to take better care of yourself. We will talk about stress Dec 16; Jan 11-Mar 2; Mar 21-May 11; 11 to 2nd Wed monthly, 10:30 AM to 12 noon – and the toll it takes on your body and how you can 11:45 AM . Frontotemporal Degeneration; 3rd Wed monthly, reduce anxiety, relaxation skills, with hands on This seated light to moderate intensity class consists 10:30 AM to 12 noon – general support group. For more practice and much more! Participants will leave of a variety of upper and lower body movements to info or to register, please call 552-1670. relaxed and hopeful about practicing at home. Self increase cardiovascular endurance, as well as strength Our support groups are free and open to the public. care starts with you! Tracey Coulon, facilitator. and range-of-motion. Resistance bands and light We are here to help you cope with caring for a loved weights are used to increase intensity. Stretching and one experiencing memory loss or dementia. Healthy Relationships Group balance exercises at the end of each class. All fitness for Women ages 18+ $60 per session AICD (Automatic Internal Cardiac Defibrillator) Free! levels welcome. Instructor: Jennifer. EBHS: Mon, Nov 9-Dec 14 (no class Nov 26) 4 to 1st Fri monthly, 11 AM to noon. Call 663-2959 for 5PM . To register or for more information, call 663-8617 Seniors in Motion $62 information. or 663-8618. SHC: T/Th, Sep 29-Nov 19; 3 wk pre-holiday Dec The only AICD support group in the tri-state area. Dating again? Keep attracting the same type of 1-Dec 17; Jan 12-Mar 3; Mar 22-May 12; 12 noon Designed to help patients with internal cardioverter undesireable partner? What is a healthy relationship. to 12:45 PM . defibrillators & their families deal with unique issues. Learn new ways of being in a relationship with This class is primarily seated and incorporates an easy Parkinson’s Free! someone without sacrificing who you are. How does to follow fitness routine for increased stamina, internet dating work? What does it mean to have strength, flexibility, and balance. Resistance bands SHC: 3rd Wed monthly, 3 to 4:30 PM . Call 663-7063 for information. boundaries? How do I say no without feeling guilty? and light weights are used for total body For people with Parkinson’s, family members, Come and discuss relationships with other women conditioning. Any fitness level encouraged. friends, or anyone who has an interest in learning who are struggling to find relationship find and be Instructor: Jennifer. in a healthy relationship. Tracey Coulon, facilitator. more about this disease. Tai Chi $40 SENIOR HEALTH and FITNESS SHC: Thu, Oct 1-Nov 19; 3 wk pre-holiday Dec 3- Women’s Coping Skills $60 per session All classes require registration, please call 663-7016 to Dec 17; Jan 14-Mar 3, Mar 24-May 12; 10 to EBHS: Tue, Nov 10-Dec 15, 10 PM . Most insurance register. Payment is due when you register; your spot 10:45 AM . accepted as well as Medicaid. on the roster is not confirmed until payment is received. A Chinese martial art and form of stylized, Do you often feel overwhelmed would you like to All classes are 8-weeks. improve your ability to handle stress? Do you have meditative exercise, characterized by methodically any self destructive patterns you would like to change Zumba GOLD ® $80 slow circular and stretching movements and like over eating, over spending or poor relationship SHC: M/W, Sep 28-Nov 18; 3 wk pre-holiday Nov positions of bodily balance. Tai Chi will allow you choices? Often times these patterns have developed 30-Dec 16; Jan 11-Mar 2; Mar 21-May 11; 9 to to experience the ancient way to improve balance, strengthen the body, and cleanse the mind. to avoid emotions we find overwhelming. Come in 9:45 AM and 10 to 10:45 AM . and learn some coping strategies that can help you This dance-fitness class is friendly and fun for all ages Beginners welcome. Instructor: Bill. better manage your feeling and emotions in a safe Register by calling the specific number provided in class listing, or 603-663-4567. 8 COMMUNITY WELLNESS Massage Therapy $70; $55 for Seniors 65+ your life. We offer an equipment orientation with Expecting parents will focus on breast feeding, infant No gratuities accepted an individualized exercise program designed to fit care, and the transition into parenthood. This class The Elliot at Hooksett, 20 Chambers Drive, your needs and goals. Membership is on- going – will help you understand the benefits of Hooksett. Call 663-5730 to schedule an appt. join at any time. breastfeeding, the basics to help you get off to a great Massage therapy is manipulation of the soft tissues start, and put an end to any concerns about of the body, including muscles, connective tissue and Elder Law Free! pumping and storing mother’s milk. tendons. It can help alleviate the soft tissue SHC: 4th Wed Monthly, 4 to 5 PM . No cost, but discomfort associated with everyday home and registration is necessary by calling 663-7041. Infant Child & CPR Safety $50 per couple occupational stresses, muscular overuse as well as Round table discussion with an Elder Law Attorney, RE, Conference Room: On-going many chronic conditions. You can have the wellness in which participants are able to identify general areas This non-certification class teaches the fundamentals you deserve. Massage benefits include: enhancing of interest and ask questions. Areas addressed include: of infant and child CPR techniques as well as safety sleep, releasing chronic muscular pain/tension/joint long term care planning options including Medicaid issues specific to both age groups. stiffness, reducing stress and mental and physical and Veterans benefits; How to maximize Medicare benefits; and Estate Planning documents including Sibling Class $15 per child, fatigue, increasing energy levels, strengthening the $5 for additional child immune system and heling to relieve anxiety. powers of attorney, wills and trusts. CHILDBIRTH and FAMILY EDUCATION EH, Maternity Conference Room: On-going Massage Therapists: Bruce Wood, LMT, KMI, This interactive class prepares children 2 1/2 to 9 yrs Licensed Massage Therapist and Kinesis Myofascial To register for all Childbirth Education programs, call Elliot on becoming a sibling. Children participate in Integration/Structural Integration Therapist and class registration at 663-4567. For dates and times log activities to learn about the baby and their new role Melissa Lower, LMT, Licensed Massage Therapist onto elliothospital.org or call 663-4567. in the family. A maternity tour in included. and nationally certified in therapeutic massage and body work. Labor Series $130 per couple Maternity Tours Free! EH, Nursing Center: On-going EH, Meet in the main lobby: Wed, 5:30 PM ; 1st & Gym Membership $25 per month This class prepares the expectant mother and her 3rd Sat monthly, 11 AM registration required. SHC: Mon to Fri, ongoing, 6:30 AM to 4 PM . Call 663- partner for the stages of labor and delivery. Includes 7016 to get started. knowledge of the natural labor process, as well as Mom’s Group Free! The Elliot Senior Fitness Center is designed coping measures for relaxation and breathing RE, Conference Rm: Wed, call for times. specifically for those 50 and older. The fitness center through contractions. Maternity tour included. Offered to mothers and their babies as an consists of a variety of easily accessible cardiovascular opportunity to share and network. Weekly topics equipment and strength training machines. Our Care & Breastfeeding your Newborn $50 per couple include: feeding, crying, sleep, caring for yourself, friendly team of fitness specialists are here to help EH, Maternity Conference Room: On-going growth & development, nutrition, dealing with guide you as you integrate physical activity safely into relationships, preventing illness and more. Register by calling the specific number provided in class listing, or 603-663-4567.

SUPPORT S ERVICES

VNA Hospice Bereavement Services. Death is a painful loss experience, Men’s or Women’s Drop-In Support Groups. Participants are given the and one of the hardest from which to recover. Death takes away, but opportunity to grieve the loss of a spouse or loved one. Members help facing it and grieving can result in peace, new strengths and purpose. each other answer the question: “What Now?” Participants will better understand the grief process, dealing with their emotions, and how to Adult Bereavement Support Groups. These groups will help participants honor and celebrate their loved ones who have died. No registration explore and better understand the grief process and how to celebrate required. and honor the loved ones we have lost. The groups meet weekly for 8 weeks and are held several times throughout the year. If you are • Men’s Drop-In Support Group. The Men’s Group meets twice monthly, interested in attending our next group, please register and you will be the fourth Friday, 9 to 11 AM and the second Wednesday, 6 to 8 PM , notified for our next session. at Southside Bible Fellowship Church, 200 So. Jewett Street.

Stepping Stones through Grief. A bereavement group for children and • Women’s Drop-In Support Group. The Women’s Group meets first and adolescents ages 5-18. The groups will help explore and better third Friday monthly, 9:30 to 11 AM , at Elliot at River’s Edge, 185 understand such topics as the meaning of death, the feelings generated Queen City Ave. Please contact our bereavement support team at around loss and how to celebrate and honor the loved ones we have lost. 663-4005 for more information. Parents are required to stay and support their children by attending their own adult support group. Groups meet weekly for 8 weeks. Stepping- Hospice Services. For more information, please contact the Bereavement Stones is held in the spring and fall. The group meets from 6 to 7:30 PM . Coordinator, Chuck Johnson, at 603-663-4005. You may also obtain Pre-registration is required and applicants will be notified by the information online at www.manchestervna.org. Unless noted, all classes facilitators prior to the start of the session. require pre-registration.

Elliot Direct 603-663-1111 | www.elliothospital.org | Fall 2015/Winter 2016 9 S W E

N Bridget Stewart, WVice Preslidceontm of Pe hysician Services

T Elliot Health System is pleased to announce the addition of Bridget Stewart to their Senior

O Leadership team as the Vice President of Physician Services. Bridget will be responsible for the I strategic planning and operations of the Elliot Physician Network. L

L Bridget joined Elliot from the Joslin Diabetes Clinic where she was the Vice President of

E Clinical Operations responsible for the overall clinical operations of a large multi-specialty diabetes clinic. Prior to her tenure at Joslin, she worked at Children’s Hospital for over 8 years as the Administrative Director of Cardiology, and Brigham and Women’s Hospital as Associate Administrator for the Department of Medicine. Bridget holds a Doctorate of Law and Policy from Northeastern University, a Masters of Business Administration from Saint Ambrose University and her Bachelors of Science from the University of New Hampshire. She has had academic appointments at the University of New Hampshire and Regis College. Bridget has nearly 20 years of healthcare and management experience.

FIVE CONSECUTIVE YEARS! We are pleased to announce that Elliot Health System has received the distinction of Most Wired by The College of Healthcare Information Management Executives (CHIME) and The American Hospital Association. This marks the fifth year EHS has been awarded this distinction and something to be celebrated as not all organizations nationwide receive this recognition or achieve this level of sophistication in their information technology systems. In addition, each year the characteristics to receive/maintain this distinction continue to increase. “Over the years, a lot of hard work has taken place, both within the Information Technology department as well as in the clinical/business departments, to initially achieve and then continue to maintain this title,” explained Joe Kulle, Chief Information Officer. “This distinction is also rarely sustained for five consecutive years, so this is an overwhelmingly positive acknowledgement for our commitment to be, and remain, cutting edge in a complex healthcare environment.”

Patient & Family Advisory Council – Your Voice Impacting Patient Experience Elliot Health System is pleased to announce that it is in the process of establishing a Patient Family Advisory Council (PFAC). The primary purpose of the PFAC is to partner with patients and families to promote quality, improve safety, increase patient engagement, and support the patient experience. Our PFAC members will play an integral role in the future of Elliot as we hope to assure better alignment and integration of patient and family centered care across Elliot Health System. In addition to establishing the PFAC, Elliot will soon be announcing a Director of Patient Experience. This person will work closely with the volunteer members of the PFAC as well as with our clinical teams providing care to assist us in enhancing the patient experience so that we can exceed our patients’ expectations with each interaction.

10 Fall 2015/Winter 2016 | www.elliothospital.org | Elliot Direct 603-663-1111

lliot Health System and New

Hampshire’s Hospital for

Children are giving the gift of

life by placing an Automatic External

Defibulator (AED) at the Manchester East

Little League ball field. “I am so proud to be E affiliated with a hospital that wants to

support the community in this way,” said

Dr. Amy Roy of the Pediatric Emergency

Department at Elliot Hospital. “It shows our commitment to the community and our willingness to extend care well beyond the doors of our hospital.”

$125,000 gift in support of the City of Manchester’s Neighborhood Health Improvement Strategy

Ellio t Health System ha s alway s played an important role in the city’s health and wellness. In fact, Elliot Hospital is celebrating 125 year s delivering healthcare to the loca l community . This year, Elliot will be donating $125,000 to support the City and specifically the creation o f a wellness/fitness/childhood obesity program at the Beech Street School. By partnering with the City of Manchester, Elliot hope s to tak e a leading role in addressing health related issues facing our youngest population.

Elliot provides over $127 million in Unfunded Care to the Community

FY 2014 Financial Benefit Charity Care ...... $12,484,826 Community Benefit Activities ...... $16,009,354 – Community Health ...... $150,475 – Health Professions Education ...... $1,120,245 – Subsidized Health Services ...... $13,957,489 – Medical Research ...... $10,576 – Financial Contributions ...... $510,171 – Community Building ...... $34,468 – Community Benefit Operations ...... $225,930 Medicaid ...... $44,182,942 Medicare ...... $39,359,946 Bad Debt ...... $15,350,901 TOTAL UNFUNDED CARE ...... $127,387,969

Elliot Direct 603-663-1111 | www.elliothospital.org | Fall 2015/Winter 2016 1111 Y P or information on any of these programs, or to find out how you can support any of our O F

R benefits, please call the Mary & John Elliot Charitable Foundation Office at 603-663-8934 . H

T Elliot Tees Up for Tots! 16th ANNUAL

N ot Hospi Elli tal The 16th Annual Elliot Hospital Golf Classic was Golf Classic A held on Thursday, June 11 at Passaconaway

L Country Club in Litchfield, NH. There were I June

th more than 50 sponsoring businesses including H 11 Masters Sponsors, EPIC Systems Corporation, P Granite Group Benefits, LogixHealth and People’s United Bank. This sold out event exceeded its fundraising goal by raising more than $106,000 The winning group from Cube 3 Studio included for New Hampshire’s Hospital for Children Nik Middleton, Peter Bartash, Bruce Ignacio and (NHHC) at the Elliot. Keith Boyle.

3rd Annual Korks for Kids benefits Pediatric Emergency Department The Mary & John Elliot Charitable Foundation would like to thank everyone who attended the 3rd Annual Korks for Kids wine pairing dinner. The event took place at Manchester Country Club on April 14 and was well attended by 118 guests. This year’s Korks for Kids raised $6,500 which will be used to purchase an infant warmer for the Pediatric Emergency Department at New Hampshire’s Hospital for Children. Many thanks to The Anagnost Companies, Bellman Jewelers, Dr. Holly Neefe, Patricia Spagnuolo for sponsoring this event; and Horizon Beverage Company for providing wine.

Gearing Up for the 2015-2016 Annual you: Bequests, Trusts, Charitable Gift Annuities, Charitable Campaign Lead Trust, Life Insurance, Retirement Plans The Mary & John Elliot Charitable Foundation asks for For further information, please visit our webpage your help to reach the 2015-2016 annual campaign goal of http://elliothospital.org/website/gift_plannedgiving.php, $247,500. If you are interested in contributing to the call the Foundation office, or your financial advisor, to campaign please call the Foundation office. find out how you can make a lasting impact with your The Foundation sincerely thanks each and every donor planned gift. who gave to the 2014-2015 iGive campaign. Contributions from Elliot Health System employees and from community DCU for Kids Funds Period of Purple Crying members exceed the goal of $225,000 by raising more than Digital Federal Credit Union awarded a $2,500 grant $239,000. Each donation directly impacts the healthcare award toward funding the Period of Purple Crying program delivered in our community. at New Hampshire’s Hospital for Children. The Period of Purple Crying is a highly valuable program, teaching Are you interested in leaving a legacy? families about newborn behavior, soothing techniques for There are many ways to leave a lasting impact on a the crying newborn and the risks to the newborn if handled charitable organization. Planned gifts are the best means for roughly or shaken. With 1,950 families delivering at guaranteeing that your charitable wishes are fulfilled while NHHC last year alone, this program helps protect these ensuring income and stability for you and your loved ones. innocent lives from Shaken Baby Syndrome. Thank you Here are a few examples of the different options available to DCU!

12 Fall 2015/Winter 2016 | www.elliothospital.org | Elliot Direct 603-663-1111 E

R High Risk Clinic for A C Breast Cancer Screening

H by Teresa Ponn, MD, Breast Surgeon T L A E H

T reast cancer is the most common cancer in women. Approximately 231,000 American women are S diagnosed annually with invasive breast carcinoma. Mammogram screening, although controversial A for normal risk patients is definitely NOT controversial for those women at high risk for breast cancer. E The average risk of breast cancer to age 90 is 1 in 8 American women. We consider those at high risk R to have a 1 in 5 or 20% lifetime risk of breast cancer. Those are the patients who are selectively considered B B at high risk for breast carcinoma. How do you know your risk? Well, it depends on several factors; the most significant of which are your family history and your personal history. Do you have a first degree relative (mother, sister, daughter, father, brother or son) with a history of breast or ovarian cancer, especially under the age of 60? Do you have more than three relatives on one side of your family with a diagnosis of breast cancer? Have you had a diagnosis of atypical hyperplasia, a change in the lining of the breast ducts found on a biopsy? Have you personally had breast cancer? Is there a family history of a genetic mutation of the BRCA genes 1 or 2 (Breast Cancer genes)? There are other genes that have been identified as well that lead to a higher risk for breast cancer. The Elliot Breast Health Center has an advanced practice nurse with a special certification in genetics and is available for consultations to help women understand their personal risk of breast cancer. Our three specially trained breast radiologists read mammograms daily and for our high risk patients, the mammogram is read while the patient is waiting! Ultrasounds are also used as indicated and done on the spot for our high risk patients and those who are undergoing mammograms and clinical visits with our three (soon to be four) breast surgeons and nurse practitioner. We also offer MRI’s to those women with over a 20% lifetime risk of breast cancer as a screening tool to help identify small tumors in dense breasts. In addition, we calculate lifetime risk to determine who may be eligible for additional imaging and or chemoprevention, which means taking oral medication for breast cancer prevention. Our goal is to diagnose breast cancer as early as possible, find those at highest risk, and instruct women on how to avoid breast cancer by exercising regularly and eating a healthy diet. With our newest software program in mammography, we can better identify those women at high risk and offer them personalized screening and evaluation in our high risk clinic. We work to find breast cancer at its earliest stage and help women live longer and better! For more information, call us at 603-668-3067.

Elliot Direct 603-663-1111 | www.elliothospital.org | Fall 2015/Winter 2016 13 Y

R Treating Heel T A

I PAIN

D by Kevin Souza, DPM, FACFAS O Foot pain afflicts thousands of people • Fracture/Stress Fracture P each year and there is a multimillion • Gout dollar industry dedicated to self-help • Heel spur foot care products. Unfortunately many • Myositis people do not seek medical attention • Osteomyelitis (Bone infection) and spend their hard earned income on • Peripheral neuropathy these readily available on-the-shelf • Pinched nerve (may be localized to the There are products without knowing the true foot or any point from the spine to the various nature of their condition. foot) ways to address While many of these remedies may • Plantar fasciitis the root causes of work to lessen symptoms, without a • Rheumatoid arthritis heel pain. Some proper understanding of the actual • Tarsal tunnel syndrome treatments are prescription based such condition many people continue to • Tendinitis as custom fabricated devices and suffer unnecessarily and may be making While any of these conditions can physical therapy while others are their condition worse. As time passes present with “classic” heel pain purchasable items. A discussion with and pain continues the condition symptoms by location or occurring or your physician is the best way to becomes chronic and can become more worsening at certain times of the day, determine the best plan of care. And debilitating, possibly affecting the identifying which condition is causing while there are over counter products ankles, knees, hips and back and the pain is important to determining available, before spending well earned becomes more difficult to treat. the appropriate treatment. There is no income, evaluation and treatment plans Heel pain is one such category of one size fits all approach. A proper exam should be performed, administered and foot pain and is the most commonly and diagnosis is critical to treatment. guided by a trained physician. reported pain of the foot. Reports have Determining the cause of the While there is no way to guarantee been published that state the majority of condition is equally important. Treating you will avoid heel pain or foot pain in people will have heel pain at some point the symptoms will be of little value your lifetime, using some caution will in their lifetime. While some of these unless the underlying cause is addressed. go a long way to help prevent foot pain. cases will heal with rest many do not. For example a person with one leg And when foot pain does occur seeking Seeking medical attention is vital. shorter than the other may experience medical attention and determining the Recognizing that heel pain is not a heel pain due to the limb length appropriate treatment is the best way to condition but a symptom and a inequality. Treating the pain without ensure the better outcome. generalized term which encompasses addressing the difference in leg length many painful conditions of the could result in failure of treatment. Dr. Souza graduated from hindfoot is important. People will often Some causes of the conditions which Temple University School of say they have heel pain and someone cause heel pain are: Podiatric Medicine, else will say they know what it is and • Biomechanics (improper foot Philadelphia, PA and label it. This can prevent people from function, foot type – flat, high arched, continued his training at Morristown Memorial seeking medical help and prolong and limb length) Hospital, Morristown, NJ, a three year foot worsen their condition. Some • Body mass/weight and ankle surgical residency program, training conditions that cause heel pain are: • Footwear (improper fit, worn out, with orthopedic and podiatric surgeons, • Achilles tendinitis activity inappropriate) assisting with not only foot and ankle • Back or Spinal conditions • Muscle tightness operations, but hip, legs, knees, shoulders, and • Bone tumor • Overuse (under/over training, lack of hands. He continued his training for a 4th • Bruising rest, nutrition) year with a fellowship program at the Hospital • Bursitis • Trauma of Central Connecticut, New Britain, CT.

14 Fall 2015/Winter 2016 | www.elliothospital.org | Elliot Direct 603-663-1111

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Nonprofit Org. One Elliot Way U.S. Postage Manchester, NH 03103 PAID Manchester, NH Permit No. 6147

Our DOCTORS are in! OUR DOCTORS ARE ACCEPTING NEW PATIENTS.

Mahendra Panesar, MD Lou Nackman, MD Hilary Yehling, MD Pediatric Health Associates at Manchester Elliot Pediatrics at Windham Elliot Pediatrics and Primary Care at Raymond 275 Mammoth Road | Suite 1-C 5 Industrial Drive | Unit B Raymond Shopping Center | 15 Freetown Road Manchester | 603-663-8350 Windham | 603-685-0150 Raymond | 603-895-8000 www.pediatrichealthassociates.com www.elliotfmwindham.com www.elliotdocraymond.com

Andrea Galasso, DO Andrea Palumbo, MD Jennifer Holzinger, DO Elliot Internal Medicine at Londonderry Pediatric Health Associates at Bedford Elliot Family Medicine at Hooksett 40 Buttrick Road Pine Tree Place | Unit 8 | 360 Rte. 101 20 Chambers Road | Suite 1200 Londonderry | 603-434-1919 Bedford | 603-472-5860 Hooksett | 603-624-8652 www.elliotimlondonderry.com www.pediatrichealthassociates.com www.hooksettmedicalcenter.com

Elliot Health System is a non-profit organization serving your healthcare needs since 1890.

ELLIOT CARES Follow us on Facebook ABOUT YOUR WELLNESS MATTERS is published as a community service for the PATIENT SAFETY friends and patrons of Elliot Hospital, One Elliot Way, Manchester, NH If you have a concern regarding the safety or 03103, 603-669-5300, www.elliothospital.org. quality of care given to our patients, we want James Woodward President and CEO Dianne Mercier Chair, Board of Trustees to hear from you! We encourage you to and Twitter @elliothealthsys. Susanna Fier Vice President, Public Affairs & Marketing contact our Patient Relations /Safety line at Anne Marie Hafeman Marketing & Communications Specialist

603-663-2666, or contact the Joint Information in YOUR WELLNESS MATTERS comes from a wide range of Commission at 1-800-994-6610 or the State medical experts. If you have any concerns or questions about specific of New Hampshire at 1-800-852-3345. content that may affect your health, please contact your healthcare provider. Models may be used in photos and illustrations.