<P>Research consistently shows that as many as one in five children and adolescents have mental health problems, and primary care providers (PCPs) identify 19% of children with behavioral and emotional disorders. Although these providers frequently refer children for mental health treatment, significant barriers exist to referral, including lack of available specialists, insurance restrictions, appointments delays, and stigma. Approximately 25% of the population lives in rural settings, and rural departments of health report an even greater problem with access to specialists for rural residents than their urban counterparts. In adults, and probably children and adolescents, the lack of mental health services leads to undertreatment, poor outcomes such as higher rates of suicide and homicide, as well as increased use of emergency services, hospitalizations, and placement in mental health institutions.</P><H4>ABOUT THE AUTHORS</H4><P>Donald M. Hilty, MD, is Professor of Psychiatry and Behavioral Sciences, and Director, Rural Program in Medical Education (Rural-PRIME), UC Davis School of Medicine and Medical Center. Peter M. Yellowlees, MD, MRCP, is Professor of Clinical Psychiatry and Behavioral Sciences and Director of Academic Information Systems, UC Davis School of Medicine and Medical Center. Priya Sonik, MD, is Resident of Psychiatry and Behavioral Sciences, UC Davis School of Medicine and Medical Center. Mikla Derlet, MD, is Assistant Clinical Professor of Pediatrics, UC Davis School of Medicine and Medical Center. Robert L. Hendren, DO, is Professor of Psychiatry and Behavioral Sciences, and Chief; Child and Adolescent Psychiatry; Tsakopoulos-Vismara Chair and Executive Director, M.I.N.D. Institute, UC Davis School of Medicine and Medical Center.</P><P>Address correspondence to: Donald M. Hilty, MD, Department of Psychiatry and Behavioral Sciences, University of California, Davis, 2230 Stockton Boulevard, Sacramento, CA 95817; fax: 916-734-3384; or e-mail <A HREF="MAILTO:dmhilty@ucdavis.edu">dmhilty@ucdavis.edu</a>. </P><P>Dr. Hilty; Dr. Yellowlees; Dr. Sonik; Dr. Derlet; and Dr. Hendren have disclosed no relevant financial relationships.</P>

<P>Children of all ages are commonly exposed to altitude during family-trips to ski resorts, summer camps, and national parks in the American West Parents may be unaware that infants and children, particularly those with underlying pulmonary or cardiac conditions, are uniquely susceptible to high altitude. Furthermore, youth groups involved in educational trekking or humanitarian relief work frequently travel to very high-altitude international destinations, such as the South American Andes and the Asian Himalayas.</P> <H4>ABOUT THE AUTHORS</H4><P>Mark C. Duster, MD, is Clinical Professor of Pediatrics, Pediatric Cardiology, The Children’s Hospital, Denver, Colorado. Mikla N. Derlet, MD, is Assistant Clinical Professor of Pediatrics, University of California Davis School of Medicine, Sacramento, California. </P><P>Address correspondence to Mark C. Duster, MD, 1725 East Boulder, Suite 202, Colorado Springs, CO 80909; fax 719-634-6807; e-mail <A HREF="MAILTO:mcdmd@aol.com">mcdmd@aol.com</a>. </P><P>Dr. Duster and Dr. Derlet have disclosed no relevant financial relationships.</P><H4>CME OBJECTIVES </H4><P><OL></P><P><LI> Identify the three syndromes associated with acute exposure to high altitude.</LI> </P><P><LI>Describe the treatment and prevention of each form of acute altitude illness. </li></P><P><LI>Classify the unique risk factors for acute altitude illness in children </LI></P>

A 15-year-old girl is hospitalized with right upper quadrant abdominal pain, vomiting, and weakness of 3 days' duration. She has a history of hyperlipidemia, polycystic ovary syndrome (PCOS), metabolic syndrome, and left ovarian cystadenectomy. She has been taking oral contraceptives (OCPs) and metformin for the past 2 years and started spironolactone 8 weeks ago. She experienced menarche at age 12 years and had one menstrual cycle for the whole first year. There is no history of dysmenorrhea or menorrhagia. Her family history is positive for type 2 diabetes mellitus (DM), obesity, and gallstones.On physical examination, her body mass index (BMI) is 28.0 kg/m 2 (95th percentile), and she is in mild distress due to pain. Her blood pressure is 128/76 mm Hg (90th percentile for age and height); the remainder of her vital signs are normal. She has acanthosis nigricans and hirsutism. She is at Sexual Maturity Rating 5. She has mild tenderness in the right upper abdominal quadrant, but there is no organomegaly or rigidity. The rest of the physical findings are normal.Laboratory results reveal serum amylase of 660 units/L, lipase of 263 units/L, AST of 868 units/L, ALT of 1,573 units/L, cholesterol of 216 mg/dL (5.6 mmol/L), triglycerides of 181 mg/dL (2.0 mmol/L), high-density lipoprotein (HDL) cholesterol of 33 mg/dL (0.9 mmol/L), and glucose ranging from 120 to 148 mg/dL (6.7 to 8.2 mmol/L). Frequently Used Abbreviations ALT: alanine aminotransferase AST: aspartate aminotransferase BUN: blood urea nitrogen CBC: complete blood count CNS: central nervous system CSF: cerebrospinal fluid CT: computed tomography ECG: electrocardiography ED: emergency department EEG: electroencephalography ESR: erythrocyte sedimentation rate GI: gastrointestinal GU: genitourinary Hct: hematocrit Hgb: hemoglobin MRI: magnetic resonance imaging WBC: white blood cell index of suspicion

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