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Background:Enteral sildenafil may be used in the intensive care unit for treatment of pulmonary arterial hypertension. We aimed to determine if initial enteral sildenafil dosing is safe in children receiving concurrent vasoactive infusions.Methods:We performed a single-centre retrospective chart review that included patients less than 2 years of age in paediatric and cardiovascular intensive care units at an academic medical centre from 1 January, 2010 to 30 November, 2016. Included patients received concomitant enteral sildenafil and a continuously infused vasoactive agent. Exclusion criteria consisted of mechanical circulatory support, any form of dialysis, or a suspicion of septic shock at the time of sildenafil initiation. We sought to identify patients who developed worsening hemodynamic instability after initiation of enteral sildenafil defined as one or more of the following observations within 24 hours of sildenafil initiation: sildenafil discontinuation, total fluid bolus receipt >10 ml/kg, increased vasoactive support, epinephrine intravenous push administration, and/or the initiation of mechanical circulatory support.Results:Worsening hemodynamic instability was identified in 35% of the 130-patient cohort. Patients younger than 4 months were at increased risk of further hemodynamic instability compared with older patients (56% versus 44%, p = 0.0003) despite receiving lower median doses (1.28 mg/kg/day versus 1.78 mg/kg/day, p = 0.01).Conclusions:Critically ill children receiving vasoactive infusions may be at increased risk for further hemodynamic instability after initiation of enteral sildenafil, particularly in younger patients. This population may benefit from lower starting enteral sildenafil doses of 0.25 mg/kg/dose or less every 8 hours to avoid further hemodynamic compromise.

Engaging communities can increase the speed of translating health and health equity research into practice. Effective engagement requires a shared understanding of the health of a community. This can be challenging without timely and accurate local health data, or ways to provide that data, that are directly applicable to improving community health outcomes. The University of Wisconsin Institute for Clinical and Translational Research formed the Neighborhood Health Partnerships Program (NHP) to overcome this challenge, making sub-county health data available to researchers and community stakeholders while incorporating community voice into data delivery processes. The NHP team used a human-centered design approach to facilitate community engagement. Through co-design, the team created NHP reports and data-to-action tools to maximize accessibility and utility for a diverse set of community stakeholders. Early indicators show that the final co-designed NHP reports and data-to-action tools will be immediately useful in promoting community–academic partnerships and in planning, implementing, and evaluating research and other initiatives in communities. The NHP program demonstrates that an effective co-design strategy can lead to increased usability and adoption of Clinical and Translational Science Award resources, enabling a shared understanding of community health and ultimately leading to the successful translation of research into practice.

Background and aims: An inverse relationship between lipid levels and atrial fibrillation (AF) has been suggested, but whether the association is upheld for all age groups remains unclear. The aim of the study was to examine associations between lipid levels and AF by age groups in a nationwide study in Poland. Methods: Multivariate Poisson regression models were used to estimate prevalence ratios (PRs) for AF by lipid levels. Low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), total cholesterol (TC), non-HDL-C and LDL-C/HDL-C ratios were grouped into quartiles. Results: Of the 13,724 participants, 5.2% (n = 708) had AF. People with AF were older with more comorbidities, but lower lipid levels (all p < 0.05). The prevalence of AF was inversely associated with LDL-C (Adjusted PR (95% Confidence Interval) highest versus lowest quartile: 0.60 (0.48, 0.75)), TC (0.61 (0.49, 0.75)) and non-HDL-C (0.63 (0.51, 0.78)). The prevalence of AF was inversely associated with HDL-C (0.58 (0.46, 0.74)), but this was not statistically significant for people aged 75 years and older. For the LDL-C/HDL-C ratio, the prevalence of AF was only inversely associated with higher levels for people aged 75 years and older (0.75 (0.61, 0.94)). There was no statistically significant difference in prevalence of AF by TG levels. Conclusions: The results suggest an inverse relationship between lipid levels and AF. The inverse association between higher HDL-C and AF was only significant for people aged

Background Little is known about the preferred treatment strategies of chiropractors in managing low back pain patients with prior lumbar fusions. There are several case reports which describe chiropractic care following surgical intervention, but there are no cohort or experimental studies published. Therefore, we sought to examine self-reported management approaches and practice patterns related to the management of patients with prior surgical lumbar fusion, among United States Veterans Affairs (VA) chiropractors. Methods An electronic survey was administered nationwide to all chiropractors providing clinical care within VA. Questions were informed by a prior survey and piloted on a sample of chiropractors external to VA. Statistical analysis included respondent background information, and quantitative analysis of chiropractic referral patterns and practices. This survey collect information on 1) provider demographics, 2) VA referral patterns, and 3) attitudes, beliefs, practices and interventions utilized by VA chiropractors to manage patients with a history of surgical lumbar fusion. Results The survey response rate was 46.3% (62/134). The respondents were broadly representative of VA chiropractic providers in age, gender, and years in practice. The majority of respondents (90.3%) reported seeing at least 1 post-fusion patient in the past month. The most common therapeutic approaches utilized by VA chiropractors were healthy lifestyle advice (94.9%), pain education (89.8%), exercise prescription (88.1%), stretching (66.1%) and soft tissue manual therapies (62.7%). A relatively smaller proportion described always or frequently incorporating lumbar (16.9%), thoracic (57.6%) or pelvic (39.0%) spinal manipulation. Conclusion This survey provides preliminary data on VA chiropractic services in the management of patients with prior lumbar fusion. These patients are often seen by VA chiropractors, and our findings support the need for further study to advance understanding of interventions utilized by chiropractors in this patient population.

INTRODUCTION: There are no population-level estimates in the United States for achievement of blood pressure goals in patients with diabetes and hypertension by obesity weight class. AIM: We sought to examine the relationship between the extent of obesity and the achievement of guideline-recommended blood pressure goals and other quality of care metrics among patients with diabetes. METHODS: We conducted an observational population-based cohort study of electronic health data of three large health systems from 2010–2012 in rural, urban and suburban settings of 51,229 adults with diabetes. Outcomes were achievement of diabetes quality of care metrics: blood pressure, A1c, and LDL control, and A1c and LDL testing. Two blood pressure goals were examined given the recommendation for adults with diabetes of 130/80 mmHg from JNC7 and the recommendation of 140/90 mmHg from JNC8 in 2014. RESULTS: Patients in obesity classes I, II, and III with diagnosed hypertension were less likely to achieve blood pressure control at both the 140/90 mmHg and 130/80 mmHg control levels. The patients from obesity class III had the lowest likelihood of achieving control at the 130/80 mmHg goal, and control was markedly worse for the 130/80 mmHg threshold in all weight classes. There were minimal to no differences by weight class in LDL and A1c control and LDL and A1c testing. CONCLUSIONS: Although the cardiovascular risk for patients with obesity and diabetes is greater than for non-obese patients with diabetes, we found that patients with obesity are even further behind in achieving blood pressure control.

Objective The purpose of this study is to describe the state of chiropractic continuing education vis-à-vis interprofessional education (IPE) with medical doctors (MD) in a survey of a sample of US doctors of chiropractic (DC) and through a review of policies. Methods Forty-five chiropractors with experience in interprofessional settings completed an electronic survey of their experiences and perceptions regarding DC-MD IPE in chiropractic continuing education (CE). The licensing bodies of the 50 US states and the District of Columbia were queried to assess the applicability of continuing medical education (CME) to chiropractic relicensure. Results The majority (89.1%) of survey respondents who attend CE-only events reported that they rarely to never experienced MD-IPE at these activities. Survey respondents commonly attended CME-only events, and 84.5% stated that they commonly to very commonly experienced MD-IPE at these activities. More than half (26 of 51) of the licensing bodies did not provide sufficient information to determine if CME was applicable to DC relicensure. Thirteen jurisdictions (25.5%) do not, and 12 jurisdictions (23.5%) do accept CME credits for chiropractic relicensure. Conclusion The majority of integrated practice DCs we surveyed reported little to no IPE occurring at CE-only events, yet significant IPE occurring at CME events. However, we found only 23.5% of chiropractic licensing bodies allow CME credit to apply to chiropractic relicensure. These factors may hinder DC-MD IPE in continuing education.

Background: The majority of health care utilization decisions in the United States are made by persons with multiple chronic conditions. Existing public reports of health system quality do not distinguish care for these persons and are often not used by the consumers they aim to reach. Objective: Our goal was to determine if tailoring quality reports to persons with diabetes mellitus and co-occurring chronic conditions would increase user engagement with a website that publicly reports the quality of diabetes care. Methods: We adapted an existing consumer-focused public reporting website using adult learning theory to display diabetes quality reports tailored to the user’s chronic condition profile. We conducted in-depth cognitive interviews with 20 individuals who either had diabetes and/or cared for someone with diabetes to assess the website. Interviews were audiotaped and transcribed, then analyzed using thematic content analysis. Results: Three themes emerged that suggested increased engagement from tailoring the site to a user’s chronic conditions: ability to interact, relevance, and feeling empowered to act. Conclusions: We conclude that tailoring can be used to improve public reporting sites for individuals with chronic conditions, ultimately allowing consumers to make more informed health care decisions. [J Med Internet Res 2016;18(12):e332]

We study the optical response of Frenkel excitons in molecular J aggregates with a cylindrical geometry. Such aggregates have recently been prepared for a class of cyanine dyes and are akin to the rod- and ring-shaped light-harvesting systems found in certain bacteria. The linear absorption spectrum exhibits two lines with perpendicular polarization that are separated by a “ring energy scale”, which is set by the circumference of the cylinder and the intermolecular transfer interaction in the circumferential direction. On the other hand, the pump-probe spectrum shows bleaching and induced absorption features that are separated by a much smaller energy scale, which is determined by an effective Pauli gap imposed by the length of the cylinder and the transfer interaction in its longitudinal direction. We show that this can be well-understood from the approximate separation of the set of two-exciton states, into classes of inter-ring and intra-ring two-exciton states. Our calculations show that the experimental linear absorption spectrum may be used to estimate the cylinder circumference, while the pump-probe spectrum yields information on the length of the cylinder or on the delocalization length of the excitons in its longitudinal direction. We apply this method to cylindrical aggregates of cyanine dyes.

Physical appearance is important to everyone. Becauseofthis fact, the dermatologist should be able to give patients sound advice on cosmetics that are safe and effective. For persons with certain skin conditions, the dermatologist should be knowledgeable to advise them on what cosmetics they can use to cover various defects or enhance desirable features. During acne treatment, the dermatologist can suggest cosmetics that can cover lesions without causing new ones. People who are predisposed to contact dermatitis or who have sensitive skin can be better managed by the dermatologist who has a working knowledge of cosmetics. Lesions such as scars from removal of skin cancers, precancerous lesions, and nevi can also be covered with cosmetics. Hemangiomas, telangiectases, and lentigines can be camouflaged with cosmetics. Asymmetry can be partially hidden, and a patient's better features emphasized. Alopecia can often be disguised through use of appropriate hair products and styling procedures. The aim of this article is to provide fundamental information for dermatology residents about cosmetics, especially as they relate to the diagnosis and treatment ofreactions which may result from the use of cosmetics. I

This article presents the US experience from periodical business failures and collapses of the financial markets. It could be a lesson for the Central and Eastern European countries on their economies during the post-transition era. International management is one of the strongest aspects of major US corporations, and risk management is their day-to-day concern. It emphasises the importance of risk management and needs for the international management education.

The report has been prepared on the basis of seven independent provided research projects, realised by experts from all countries of CEE. The seven research projects are: 1) Development of risk analyses on energy and environmental conservation; 2) Strategic forecast on energy and environment conservation; 3) Main risk sources identification on energy conservation policy; 4) Risk valuation methods on energy and environment conservation; 5) Used risk valuation methods on energy and environment conservation; 6) Efficient possibilities to decrease economic delinquency; 7) Future ICEEP research on risk management; in CEE countries and completed with used bibliography.

Small businesses play an important part in the US economy. The private non-farm sector share of the GDP (Gross Domestic Product) is about 50%. The Office of Advocacy defines a small business for research purposes as an independent business having fewer than 500 employees. Small employer businesses pay 44.5% of the total US private payroll. Small businesses create two-thirds to three-quarters of net new jobs. However, the small firm's share of employment is about 50%. Since its founding on July 30, 1953, the US Small Business Administration has delivered about 20 million loans, loan guarantees, contracts, counselling sessions and other forms of assistance to small businesses.

The ability of hepatobiliary scintigraphy (HBS) to influence accurately the clinical diagnosis of acute cholecystitis was assessed prospectively in 70 consecutive patients with suspected acute cholecystitis. Before and after HBS, the referring surgeons completed a questionnaire on the probability of acute cholecystitis. Accuracy of diagnosis was assessed by clinical follow-up and chart review in all patients and by surgical and pathological evaluation in the 31 patients who underwent laparotomy. There were 27 patients with positive HBS results and 40 with negative HBS results; the results for three patients were indeterminate. None of the positive or negative HBS results were confirmed to be inaccurate. Negative results influenced diagnosis more often than did others. Results were negative in 13 patients whose assigned probability of acute cholecystitis was very high before HBS; in all 13 the assigned probability was very low after HBS, and in none of these patients was acute cholecystitis confirmed subsequently. These results support the use of hepatobiliary scintigraphy before proceeding to urgent cholecystectomy in patients with a clinical diagnosis of acute cholecystitis.