ResearchPad - public-health Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Active Learning and Technology Approaches for Teaching Immunology to Undergraduate Students]]> Immunology is a fascinating and extremely complex field, with natural connections to many disciplines both within STEM and beyond. Teaching an undergraduate course in immunology therefore provides both opportunities and challenges. Significant challenges to student learning include mastering the volume of new vocabulary and figuring out how to think coherently about a physiological system that is so anatomically disseminated. More importantly, teaching immunology can be complicated because it requires students to integrate knowledge derived from prior introductory courses in a range of fields, including cell biology, biochemistry, anatomy and genetics. However, this also provides an opportunity to use the study of the immune system as a platform on which students can assemble and integrate foundational STEM knowledge, while also learning about a new and exciting field. Pedagogical theory has taught us that students learn best by engaging with complicated questions and by thinking metacognitively about how to approach solutions. Building this skill set in today's students, who now hail from a broad demographic and who are accustomed to acquiring their knowledge from a variety of different media, requires a new set of teaching tools. Using perspectives from four different immunology educators, we describe a range of student-centered, active learning approaches that have been field-tested in a number of different immunology classrooms and that are geared to a variety of learning styles. In this paper, we explore the hypothesis that active learning approaches to immunology improve comprehension and retention by increasing student engagement in class and their subsequent mastery of complex topics.

<![CDATA[Characteristics of Dental Services in Rural, Suburban, and Urban Areas Upon the Implementation of Indonesia National Health Insurance]]> Introduction: The implementation of Indonesia National Health Insurance (NHI) for oral health needs to be evaluated by observing the dental disease patterns and dental therapy patterns from community health centers (CHCs) in the rural area, suburban area, and urban area. The aim of the study is to describe the characteristics of dental services in rural, suburban, and urban areas after the implementation of NHI on CHCs in the Special Region of Yogyakarta in 2014.

Materials and methods: This is an observational study with a cross-sectional research design. The study used quantitative data obtained from dental records at selected CHCs. Using a purposive sampling method, 30 CHCs as unit analysis were collected from rural, suburban, and urban areas. The data were collected from January 2014 to December 2014.

Results: Data from 26,554 patients were collected from dental records of dental clinics at CHCs. There were 5829 patient dental records from rural areas, 12,327 from suburban areas, and 8938 from urban areas. The primary dentist tends to provide services without clinical intervention on periodontal problems, abscesses, and lesions. Clinical interventions were mostly provided for prolonged retention and deposits on teeth. Primary dentists in suburban areas tend to provide clinical intervention on caries disease compared to those in rural and urban areas. Statistically significant differences (p < 0.05) were observed among locations in the pattern of providing clinical interventions on caries, abscess, lesion, prolonged retention, deposits on teeth, and other problems. No difference was recorded only on periodontal disease.

Discussion: This study found that each area has different characteristics of dental disease and dental therapy patterns. Each area has a significant difference in the pattern of the clinical intervention of dental disease except in periodontal problems.

<![CDATA[An Extension of RE-AIM to Enhance Sustainability: Addressing Dynamic Context and Promoting Health Equity Over Time]]> RE-AIM is a widely adopted, robust implementation science (IS) framework used to inform intervention and implementation design, planning, and evaluation, as well as to address short-term maintenance. In recent years, there has been growing focus on the longer-term sustainability of evidence-based programs, policies and practices (EBIs). In particular, investigators have conceptualized sustainability as the continued health impact and delivery of EBIs over a longer period of time (e.g., years after initial implementation) and incorporated the complex and evolving nature of context. We propose a reconsideration of RE-AIM to integrate recent conceptualizations of sustainability with a focus on addressing dynamic context and promoting health equity. In this Perspective, we present an extension of the RE-AIM framework to guide planning, measurement/evaluation, and adaptations focused on enhancing sustainability. We recommend consideration of: (1) extension of “maintenance” within RE-AIM to include recent conceptualizations of dynamic, longer-term intervention sustainability and “evolvability” across the life cycle of EBIs, including adaptation and potential de-implementation in light of changing and evolving evidence, contexts, and population needs; (2) iterative application of RE-AIM assessments to guide adaptations and enhance long-term sustainability; (3) explicit consideration of equity and cost as fundamental, driving forces that need to be addressed across RE-AIM dimensions to enhance sustainability; and (4) use or integration of RE-AIM with other existing frameworks that address key contextual factors and examine multi-level determinants of sustainability. Finally, we provide testable hypotheses and detailed research questions to inform future research in these areas.

<![CDATA[Effects of a Participatory School-Based Intervention on Students' Health-Related Knowledge and Understanding]]> Introduction: The development of knowledge and understanding in relation to movement and health is a basic requirement to facilitate lifelong engagement in physical activity with its accompanying possible health benefits. To train teachers in applying adequate strategies, implementation studies have often shown little acceptance of traditional top-down approaches. Thus, the purpose of the project was to develop, implement and evaluate effective and feasible measures addressing students' health-related knowledge and understanding (HKU) in physical education (PE) via a participatory approach.

Materials and Methods: For evaluation, a controlled pre-post-test study with 233 students from eight different secondary schools in Germany was carried out. Four schools (with two PE teachers at each school) comprised the intervention group and they participated in a 1-year participatory planning process to conceptualize and implement evidence-based PE lessons addressing students' HKU. Control schools carried out their regular PE lessons. Evaluation followed a mixed-methods research design, assessing program implementation via written documentary technique as well as program effectiveness using a standardized questionnaire.

Results: Results show a significant intervention effect on students' HKU with a medium effect size. However, due to the participatory process, there were considerable differences between the intervention schools that were involved. Student's HKU improved most in schools where program implementation corresponded to relevant principles of fostering HKU.

Discussion: The present study purposefully dispensed with any structured intervention programs for PE teachers to follow. The results show the potential effects of this participatory approach to strengthen student's HKU. However, the participatory planning does not always work in the intended manner, emphasizing that numerous contextual factors influence the implementation process.

<![CDATA[Effectiveness of a self-managed digital exercise programme to prevent falls in older community-dwelling adults: study protocol for the Safe Step randomised controlled trial]]> Exercise interventions have a strong evidence base for falls prevention. However, exercise can be challenging to implement and often has limited reach and poor adherence. Digital technology provides opportunities for both increased access to the intervention and support over time. Further knowledge needs to be gained regarding the effectiveness of completely self-managed digital exercise interventions. The main objective of this study is to compare the effectiveness of a self-managed digital exercise programme, Safe Step, in combination with monthly educational videos with educational videos alone, on falls over 1 year in older community-dwelling adults.Methods and analysisA two-arm parallel randomised controlled trial will be conducted with at least 1400 community-living older adults (70+ years) who experience impaired balance. Participants will be recruited throughout Sweden with enrolment through the project website. They will be randomly allocated to either the Safe Step exercise programme with additional monthly educational videos about healthy ageing and fall prevention, or the monthly education videos alone. Participants receiving the exercise intervention will be asked to exercise at home for at least 30 min, 3 times/week with support of the Safe Step application. The primary outcome will be rate of falls (fall per person year). Participants will keep a fall calendar and report falls at the end of each month through a digital questionnaire. Further assessments of secondary outcomes will be made through self-reported questionnaires and a self-test of 30 s chair stand test at baseline and 3, 6, 9 and 12 months after study start. Data will be analysed according to the intention-to-treat principle.Ethics and disseminationEthical approval was obtained by The Regional Ethical Review Board in Umeå (Dnr 2018/433-31). Findings will be disseminated through the project web-site, peer-reviewed journals, national and international conferences and through senior citizen organisations’ newsletters.Trial registration numberNCT03963570. ]]> <![CDATA[Place, poverty and prescriptions: a cross-sectional study using Area Deprivation Index to assess opioid use and drug-poisoning mortality in the USA from 2012 to 2017]]> To identify the relationships between county-level area deprivation and patterns of both opioid prescriptions and drug-poisoning mortality.Design, setting and participantsFor this retrospective cross-sectional study, we used the IQVIA Xponent data to capture opioid prescriptions and Centres for Disease Control and Prevention National Vital Statistics System to assess drug-poisoning mortality. The Area Deprivation Index (ADI) is a composite measure of social determinants of health comprised of 17 US census indicators, spanning four socioeconomic domains. For all US counties with available opioid prescription (2712 counties) and drug-poisoning mortality (3133 counties) data between 2012 and 2017, we used negative binomial regression to examine the association between quintiles of county-level ADI and the rates of opioid prescriptions and drug-poisoning mortality adjusted for year, age, race and sex.Primary outcome measuresCounty-level opioid prescription fills and drug-poisoning mortality.ResultsBetween 2012 and 2017, overall rates of opioid prescriptions decreased from 96.6 to 72.2 per 100 people, while the rates of drug-poisoning mortality increased from 14.3 to 22.8 per 100 000 people. Opioid prescription and drug-poisoning mortality rates were consistently higher with greater levels of deprivation. The risk of filling an opioid prescription was 72% higher, and the risk of drug-poisoning mortality was 36% higher, for most deprived compared with the least deprived counties (both p<0.001).DiscussionCounties with greater area-level deprivation have higher rates of filled opioid prescriptions and drug-poisoning mortality. Although opioid prescription rates declined across all ADI quintiles, the rates of drug-poisoning mortality continued to rise proportionately in each ADI quintile. This underscores the need for individualised and targeted interventions that consider the deprivation of communities where people live. ]]> <![CDATA[Effectiveness of psychological, psychoeducational and psychosocial interventions to prevent postpartum depression in adolescent and adult mothers: study protocol for a systematic review and meta-analysis of randomised controlled trials]]> The prevalence of postpartum depression (PPD) is 17%, and the incidence is 12% worldwide. Adverse consequences for mothers and babies have been associated with this disease. To assess the effectiveness of psychological, psychoeducational and psychosocial interventions in preventing PPD, a systematic review and meta-analysis (SR/MA) will be conducted.Methods and analysisA SR/MA will be performed following the indications of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies will be identified through MEDLINE (Ovid and PubMed), PsycINFO, Web of Science, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, OpenGrey, Australian New Zealand Clinical Trial Registry, and from inception until 31 January 2020. Bridging searches will be also conducted until the review is completed. The selection criteria will be as follows: (1) subjects will be pregnant females or females who have given birth in the last 12 months and who were non-depressive at baseline; (2) psychological, psychoeducational and psychosocial interventions; (3) comparator will be usual care, attention control, waiting list or no intervention; (4) outcomes will be specific results on PPD; and (5) the design of the studies will be randomised controlled trials. No restrictions regarding the year of publication, the setting of the intervention or the language of publication will be considered. Pooled standardised mean differences and 95% CIs will be calculated. The risk of bias of the studies will be assessed through the Cochrane Collaboration risk of bias tool. Heterogeneity between the studies will be determined by the I2 and Cochran’s Q statistics. Sensitivity and subgroup analyses will also be performed. Publication bias will be checked with funnel plots and Egger’s test. Heterogeneity will be explored by random-effects meta-regression analysis.Ethics and disseminationThe ethical assessment was not required. The results will be presented at conferences and disseminated through publications.PROSPERO registration numberCRD42018109981. ]]> <![CDATA[Rates, causes, place and predictors of mortality in adults with intellectual disabilities with and without Down syndrome: cohort study with record linkage]]> To investigate mortality in adults with intellectual disabilities: rates, causes, place, demographic and clinical predictors.DesignCohort study with record linkage to death data.SettingGeneral community.Participants961/1023 (94%) adults (16–83 years; mean=44.1 years; 54.6% male) with intellectual disabilities, clinically examined in 2001–2004; subsequently record-linked to their National Health Service number, allowing linkage to death certificate data, 2018.Outcome measuresStandardised mortality ratios (SMRs), underlying and all contributing causes of death, avoidable deaths, place, and demographic and clinical predictors of death.Results294/961 (30.6%) had died; 64/179 (35.8%) with Down syndrome, 230/783 (29.4%) without Down syndrome. SMR overall=2.24 (1.98, 2.49); Down syndrome adults=5.28 (3.98, 6.57), adults without Down syndrome=1.93 (1.68, 2.18); male=1.69 (1.42, 1.95), female=3.48 (2.90, 4.06). SMRs decreased as age increased. More severe intellectual disabilities increased SMR, but ability was not retained in the multivariable model. SMRs were higher for most International Statistical Classification of Diseases and Related Health Problems, 10th Revision chapters. For adults without Down syndrome, aspiration/reflux/choking and respiratory infection were the the most common underlying causes of mortality; for Down syndrome adults ‘Down syndrome’, and dementia were most common. Amenable deaths (29.8%) were double that in the general population (14%); 60.3% died in hospital. Mortality risk related to percutaneous endoscopic gastrostomy/tube fed, Down syndrome, diabetes, lower respiratory tract infection at cohort-entry, smoking, epilepsy, hearing impairment, increasing number of prescribed drugs, increasing age. Bowel incontinence reduced mortality risk.ConclusionsAdults with intellectual disabilities with and without Down syndrome have different SMRs and causes of death which should be separately reported. Both die younger, from different causes than other people. Some mortality risks are similar to other people, with earlier mortality reflecting more multimorbidity; amenable deaths are also common. This should inform actions to reduce early mortality, for example, training to avoid aspiration/choking, pain identification to address problems before they are advanced, and reasonable adjustments to improve healthcare quality. ]]> <![CDATA[Innovative equipment to monitor and control salt usage when cooking at home: iMC SALT research protocol for a randomised controlled trial]]> Excessive salt intake is a public health concern due to its deleterious impact on health. Most of the salt consumed come from those that are added when cooking. This study will improve knowledge on the effectiveness of interventions to reduce salt consumption among consumers.Methods and analysisIn this randomised clinical trial, we will be evaluating the efficacy of an intervention—the Salt Control H, an innovative prototype equipment to monitor and control use of salt when cooking—among workers from a public university, with the aim of reducing their dietary salt intake. We will randomly select 260 workers who meet the eligibility criteria and who are enrolled to an occupational health appointment and randomise them into one of the two arms of the study (either control or intervention), with matched baseline characteristics (sex and hypertension). The intervention will last for 8 weeks, during which the participants will use the equipment at home to monitor and control their use of salt when cooking. The main outcome will be 24-hour urinary sodium excretion at baseline, at fourth and eighth weeks of intervention, and at 6 months after intervention.Ethics and disseminationEthical approval for the study has been obtained from the Ethics Committee of the Centro Hospitalar Universitário São João. The results of the investigation will be published in peer-reviewed scientific papers and presented at international conferences.Trial registration numberNCT03974477Equipment provisional patent numberRegistered at INPI: 20191000033265. ]]> <![CDATA[Could vitamin D reduce obesity-associated inflammation? Observational and Mendelian randomization study]]> Obesity is associated with inflammation but the role of vitamin D in this process is not clear.ObjectivesWe aimed to assess the associations between serum 25-hydroxyvitamin D [25(OH)D], BMI, and 16 inflammatory biomarkers, and to assess the role of vitamin D as a potential mediator in the association between higher BMI and inflammation.MethodsNorthern Finland Birth Cohort 1966 (NFBC1966) 31-y data on 3586 individuals were analyzed to examine the observational associations between BMI, 25(OH)D, and 16 inflammatory biomarkers. Multivariable regression analyses and 2-sample regression-based Mendelian randomization (MR) mediation analysis were performed to assess any role of vitamin D in mediating a causal effect of BMI on inflammatory biomarkers [soluble intercellular adhesion molecule 1 (sICAM-1), high sensitivity C-reactive protein (hs-CRP), and α1-acid glycoprotein (AGP)] for which observational associations were detected. For MR, genome-wide association study summary results ranging from 5163 to 806,834 individuals were used for biomarkers, 25(OH)D, and BMI. Findings were triangulated with a literature review of vitamin D supplementation trials.ResultsIn NFBC1966, mean BMI (kg/m2) was 24.8 (95% CI: 24.7, 25.0) and mean 25(OH)D was 50.3 nmol/L (95% CI: 49.8, 50.7 nmol/L). Inflammatory biomarkers correlated as 4 independent clusters: interleukins, adhesion molecules, acute-phase proteins, and chemokines. BMI was positively associated with 9 inflammatory biomarkers and inversely with 25(OH)D (false discovery rate < 0.05). 25(OH)D was inversely associated with sICAM-1, hs-CRP, and AGP, which were positively associated with BMI. The MR analyses showed causal association of BMI on these 3 inflammatory biomarkers. There was no observational or MR evidence that circulating 25(OH)D concentrations mediated the association between BMI and these 3 inflammatory markers. Review of randomized controlled trials (RCTs) supported our findings showing no impact of vitamin D supplementation on inflammatory biomarkers.ConclusionsThe findings from our observational study and causal MR analyses, together with data from RCTs, do not support a beneficial role of vitamin D supplementation on obesity-related inflammation. ]]> <![CDATA[When cancer encounters COVID-19 in China: what have we suffered, experienced and learned]]> We share the experience of the medical management of cancer patients from China in the situation of exhaustion of medical resources during the epidemic.

<![CDATA[Clinical and Biochemical Assessment of Liver Function Test and Its Correlation with Serum Ferritin Levels in Transfusion-dependent Thalassemia Patients]]> Aims

The aim of our study was to correlate liver function tests with serum ferritin levels in multi-transfused thalassemia patients.


This was a descriptive cross-sectional study conducted in the department of hematology, Khyber Medical University, from January 2018 to December 2018. Thalassemia patients of either sex dependent on transfusion ≥ 1 year and having a confirmatory report of the disease were included in our study. The nonprobability convenience sampling technique was used. The Pearson correlation coefficient was applied to observe the correlation between serum ferritin level and liver function tests. A p-value of ≤0.05 was considered statistically significant. SPSS version 23 (SPSS Inc., Chicago, Illinois) was used for data analysis.


A total of 138 subjects of age range 2-23 years, with a mean age of 12.08 ± 6.02 years, were included in our study. The mean serum ferritin of patients in our study was 3278.64 ng/ml with the lowest of 285.2 ng/mL and the highest of 10940.2 ng/ml. With the increase in serum ferritin levels, a rapid increase in alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) levels was seen. When serum ferritin levels were correlated with total bilirubin level, the bilirubin level remains static with a further increase in serum ferritin levels.


It was deduced that iron deposition is the ultimate reason for increased liver enzymes. There was a positive correlation between serum ferritin and ALT, AST, and ALP while a weak connection was found between serum ferritin and bilirubin levels.

<![CDATA[Chronic Vaping Related Tracheomalacia (TM): A Case of Vaping Induced Altered Innate Immunity that Culminated in Severe TM]]> Tracheomalacia (TM) is a weakness of the trachea either due to impaired cartilage integrity or atrophy of muscular elastic fibers. We present the first-ever case of chronic vaping induced altered immunological defenses that led to frequent pulmonary infections, ultimately culminating in severe TM which we successfully treated with positive airway pressure (PAP) therapy.

A 53-year-old male presented with hypoxia and pneumonia refractory to outpatient antibiotics and steroids. He underwent bronchoscopy which showed severe TM, prompting transfer to our institution. He started vaping seven years ago and noted frequent bronchitis requiring antibiotics and steroids along with 10 life-time surgeries. He underwent repeat bronchoscopy noting TM, worst 3 cm above the carina and extending 4 cm proximally. The lesion was deemed not suitable for stenting, so PAP therapy was initiated. Bronchoalveolar lavage (BAL) confirmed 40% alveolar macrophages positive for lipid in Oil-O-Red stain consistent with EVALI. He tolerated PAP therapy with significant improvement in his ground glass opacities (GGO) and TM on subsequent imaging.

TM is generally defined as >50% narrowing in the sagittal diameter. It is often further characterized into primary (congenital) or secondary (acquired) causes. Notable secondary causes include postintubation, chronic infection/bronchitis, chronic inflammation, and frequent steroid exposure -- all present in this case. Furthermore, there is existing literature that chronic inflammation due to irritants like cigarette smoke may be an important contributor to the development of TM. However, such data are lacking for EVALI.

Our patient started experiencing repeated bronchitis episodes after he started vaping, leading to chronic inflammation and frequent antibiotics/steroids. Given his additional risk factor of multiple surgeries, this case not only presents a perfect storm for TM, but also a novel manifestation of EVALI. This case, to our knowledge, is the first-ever manifestation of EVALI presenting with TM. Management with PAP therapy helped avoid major surgery. 

<![CDATA[Prevalence of Vitamin D Deficiency in Children with Type 1 Diabetes Mellitus]]> Background

In the recent years, controversy has emerged regarding the relationship between vitamin D deficiency and the potential effects it could have on glycemic control in patients with type 1 diabetes mellitus (T1D). This study investigates the prevalence of vitamin D insufficiency/deficiency in pediatric patients with T1D from a single, large volume practice.


This was a retrospective chart review that collected clinical/demographic data as well as serum 25(OH) D levels from medical records of 395 children between the ages of 3 and 18 years with T1D followed at Nemours Children’s Hospital. This data was compared to the National Health and Nutrition Examination Survey (NHANES) database. A Pearson’s Chi-square test was used between group associations. All statistical tests were two-sided and p < 0.05 was used for statistical significance.


Of the 395 children included in these analyses, 4% were vitamin D deficient and 60% were vitamin D insufficient. There were no significant associations of vitamin D deficiency based on sex and age. Vitamin D deficiency was more common among White children when compared to Hispanic children and African American children (42% vs 29%; p < 0.001). Of those that were vitamin D insufficient (n = 235), most were Hispanic (51%), 36% White and 13% African American. There was a significant association between vitamin D deficiency and body mass index (BMI) (p = 0.035). In the summer, children were less likely to be vitamin D deficient (3% vs 6% in winter) and less likely to be vitamin D insufficient (55% vs 71% in winter) (p = 0.007).


Vitamin D insufficiency is highly prevalent among pediatric type 1 diabetics of Central Florida and statistically significant correlation was found between vitamin D status and ethnicity, BMI as well as seasonal variation.

<![CDATA[Social Media Data Analytics on Telehealth During the COVID-19 Pandemic]]> Introduction: Physical distancing during the coronavirus Covid-19 pandemic has brought telehealth to the forefront to keep up with patient care amidst an international crisis that is exhausting healthcare resources. Understanding and managing health-related concerns resulting from physical distancing measures are of utmost importance.

Objectives: To describe and analyze the volume, content, and geospatial distribution of tweets associated with telehealth during the Covid-19 pandemic.

Methods: We inquired Twitter public data to access tweets related to telehealth from March 30, 2020 to April 6, 2020. We analyzed tweets using natural language processing (NLP) and unsupervised learning methods. Clustering analysis was performed to classify tweets. Geographic tweet distribution was correlated with Covid-19 confirmed cases in the United States. All analyses were carried on the Google Cloud computing service “Google Colab” using Python libraries (Python Software Foundation).

Results: A total of 41,329 tweets containing the term “telehealth” were retrieved. The most common terms appearing alongside ‘telehealth’ were “covid”, “health”, “care”, “services”, “patients”, and “pandemic”. Mental health was the most common health-related topic that appeared in our search reflecting a high need for mental healthcare during the pandemic. Similarly, Medicare was the most common appearing health plan mirroring the accelerated access to telehealth and change in coverage policies. The geographic distribution of tweets related to telehealth and having a specific location within the United States (n=19,367) was significantly associated with the number of confirmed Covid-19 cases reported in each state (p<0.001).

Conclusion: Social media activity is an accurate reflection of disease burden during the Covid-19 pandemic. Widespread adoption of telehealth-favoring policies is necessary and mostly needed to address mental health problems that may arise in areas of high infection and death rates.

<![CDATA[Coronavirus Disease 2019 (COVID-19) in Cancer Patients]]> The Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become the most talked-about clinical entity in early 2020. As an infection that spreads easily and has a significant mortality rate, it has caused global panic rarely seen before. Many of the measures taken by governments worldwide will have long-lasting impacts on the wellbeing of the population at large. It has been widely reported that the most vulnerable patients have been most negatively affected by SARS-CoV-2 (COVID-19). In this study, we have tried to search the currently available data on the outcomes of infected cancer patients. Most of the data points to the very challenging nature of treating such patients. Their overall outcomes seem to be worse than in the general population, and it may be difficult to differentiate which potential complications are a result of the primary oncologic disease versus the infection. Management presents its own set of challenges, including but not limited to, deciding whether postponing cancer treatment until the infection resolves is going to benefit the patient and how to organize all aspects of patient care when social contact is as limited as it is for patients newly diagnosed with COVID-19. We believe that as more data becomes available, it is going to be necessary to publish detailed guidelines on how to approach this unique clinical challenge.

<![CDATA[An analysis of the costs of treating aged patients in a large clinical hospital in Poland under the pressure of recent demographic trends]]> The aging of modern societies increases the general healthcare burden due to the growing demand for inpatient services, which lack adequate financing.Material and methodsData concerning the costs of 312,250 hospitalizations at University Clinical Hospital in Wrocław, Poland in the years 2012–2015 were analyzed according to the age of the patients: below 65 years and 65 years and older, with subgroups (65–74, 75–84 and 85 years and older).ResultsThe mean length of stay (LOS) differed significantly for patients below 65 years and for patients 65 years old or older (3.5 vs. 4.7 person-days); over the 4 years covered by our data, these increased by 0.4 person-days, mostly among patients 85 years and older (by 0.7 person-days). The mean direct cost of hospitalization differed significantly for patients below 65 years and those 65 years or older (PLN 4,907.12 vs. PLN 6,357.15). The mean cost of laboratory tests and radiologic diagnostics was significantly higher among those in the 65+ group, and the difference had a rising trend. The differences between age groups in cost-related hospitalization characteristics and direct hospitalization costs that have been suggested by the medical literature have also been confirmed in Poland.ConclusionsThe mean hospitalization costs of patients aged 65 years and older in Poland are higher than for younger patients due to longer LOS and more complex and expensive treatment, especially laboratory and radiologic diagnostics, which is increasingly common in the oldest age groups. This demands an urgent systemic solution, especially in terms of adjusted financing of elderly patients’ hospital treatment. ]]> <![CDATA[ST-elevation Myocardial Infarction and Complete Heart Block in a Nitrate-free Patient using a New Emerging Substance called Rhino]]> The pervasive use of counterfeit sexual enhancement supplements is increasing worldwide. There are thousands of vendors on the internet while local gas stations and convenience stores are selling it across the United States (US). We report a case of right coronary artery ST-segment elevation and complete heart block in a nitrate-free patient shortly after consuming three 950 mg pills of a sexual enhancer known as rhino and completing sexual intercourse. Coronary angiography revealed 100% occlusion of the right coronary artery and a drug-eluting stent was inserted with a transvenous pacer that he tolerated well, and recovered without complications. The counterfeit drug has gained traction for its high user satisfaction and low cost among recreational customers. The Food and Drug Administration (FDA), through its MedWatch program, has frequently released citations to consumers warning them against rhino since 2015, while their labs have recognized two prime ingredients: sildenafil and tadalafil. Although adverse cardiac risk with this therapeutic class is low, we aim to parse out its temporal relationship with rhino, an enhancer containing 14-200 times the prescription limits of sildenafil and tadalafil.

<![CDATA[Creating an Age-Friendly Public Health System]]> The public health system in America—at all levels—has relatively few specialized initiatives that prioritize the health and well-being of older adults. And when public health does address the needs of older adults, it is often as an afterthought. In consultation with leaders in public health, health care, and aging, an innovative Framework for an Age-Friendly Public Health System (Framework) was developed outlining roles that public health could fulfill, in collaboration with aging services, to address the challenges and opportunities of an aging society.Research Design and MethodsWith leadership from Trust for America’s Health and The John A. Hartford Foundation, the Florida Departments of Health and Elder Affairs are piloting the implementation of this Framework within Florida’s county health departments and at the state level. The county health departments are expanding data collection efforts to identify older adult needs, creating new alliances with aging sector partners, coordinating with other agencies and community organizations to implement evidence-based programs and policies that address priority needs, and aligning efforts with the age-friendly communities and age-friendly health systems movements.Results, and Discussion and ImplicationsThe county health departments in Florida participating in the pilot are leveraging the Framework to expand public health practice, programs, and policies that address health services and health behaviors, social, and economic factors and environmental conditions that allow older adults to age in place and live healthier and more productive lives. The model being piloted in Florida can be tailored to meet the unique needs of each community and their older adult population. ]]> <![CDATA[Spirometric traits show quantile-dependent heritability, which may contribute to their gene-environment interactions with smoking and pollution]]> “Quantile-dependent expressivity” refers to a genetic effect that is dependent upon whether the phenotype (e.g., spirometric data) is high or low relative to its population distribution. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and the FEV1/FVC ratio are moderately heritable spirometric traits. The aim of the analyses is to test whether their heritability (h2) is constant over all quantiles of their distribution.MethodsQuantile regression was applied to the mean age, sex, height and smoking-adjusted spirometric data over multiple visits in 9,993 offspring-parent pairs and 1,930 sibships from the Framingham Heart Study to obtain robust estimates of offspring-parent (βOP), offspring-midparent (βOM), and full-sib regression slopes (βFS). Nonparametric significance levels were obtained from 1,000 bootstrap samples. βOPs were used as simple indicators of quantile-specific heritability (i.e., h2 = 2βOP/(1+rspouse), where rspouse was the correlation between spouses).ResultsβOP ± standard error (SE) decreased by 0.0009 ± 0.0003 (P = 0.003) with every one-percent increment in the population distribution of FEV1/FVC, i.e., βOP ± SE were: 0.182 ± 0.031, 0.152 ± 0.015; 0.136 ± 0.011; 0.121 ± 0.013; and 0.099 ± 0.013 at the 10th, 25th, 50th, 75th, and 90th percentiles of the FEV1/FVC distribution, respectively. These correspond to h2 ± SEs of 0.350 ± 0.060 at the 10th, 0.292 ± 0.029 at the 25th, 0.262 ± 0.020 at the 50th, 0.234 ± 0.025 at the 75th, and 0.191 ± 0.025 at the 90th percentiles of the FEV1/FVC ratio. Maximum mid-expiratory flow (MMEF) h2 ± SEs increased 0.0025 ± 0.0007 (P = 0.0004) with every one-percent increment in its distribution, i.e.: 0.467 ± 0.046, 0.467 ± 0.033, 0.554 ± 0.038, 0.615 ± 0.042, and 0.675 ± 0.060 at the 10th, 25th, 50th, 75th, and 90th percentiles of its distribution. This was due to forced expiratory flow at 75% of FVC (FEF75%), whose quantile-specific h2 increased an average of 0.0042 ± 0.0008 for every one-percent increment in its distribution. It is speculated that previously reported gene-environment interactions may be partially attributable to quantile-specific h2, i.e., greater heritability in individuals with lower FEV1/FVC due to smoking or airborne particles exposure vs. nonsmoking, unexposed individuals.ConclusionHeritabilities of FEV1/FVC, MMEF, and FEF75% from quantile-regression of offspring-parent and sibling spirometric data suggest their quantile-dependent expressivity. ]]>