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WELCOME TO CLINICAL FUTURES | A CHOP Research Institute Center of Emphasis
Clinical Futures, formerly the Center for Pediatric Clinical Effectiveness (CPCE), is powering progress in pediatric care. As a Center of Emphasis within the Children's Hospital of Philadelphia (CHOP) Research Institute, one of the largest pediatric research institutes in the country, we are committed to improving the care delivered to children. The center consists of dynamic multidisciplinary teams of clinicians, researchers, biostatisticians, and public health experts dedicated to advancing the conduct and outcomes of clinical research for children.
1 week ago
A study by Dr. @dus10flan and researchers from @CHOP_CPCE and @Penn was recently published in @JAMA_current. The… https://t.co/mrxZKP6pOK
1 week ago
The Clinical Futures blog posts credible and timely commentary on recent publications. Our current post shares deta… https://t.co/JIuZzhvjJv
1 week 1 day ago
Dr. Halley Ruppel and researchers from @ChildrensPhila, recently published a cross-sectional study in… https://t.co/5C57QDKB9F
1 week 1 day ago
Clinical Futures is powering progress in pediatric care. Stay informed about the latest news and research from our… https://t.co/1ErHKZRXb8
Nighttime sleep duration and variability in children with obstructive sleep apnea syndrome: Sociodemographic disparities and neurobehavioral outcomes
Sleep medicine 2023
Discrepancies Between Caregiver Reported Early Childhood Sleep Problems and Clinician Documentation and Referral
Academic pediatrics 2023
Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period?
Journal of pediatric urology 2023

subset: commoncrawl


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Due to the satin finish of our aluminum prints you won't have any disturbing reflections when viewing the picture, even in the most challenging lighting conditions. Because of this and because of the minimalist elegance of our Minimalist Collection, the observer can concentrate on the essentials – the motif.
Art printed on aluminum di-bond looks amazing and lasts a lifetime. The print is matte and glare-free. The white and bright areas have a faint silky gloss.
– Aluminum di-bond 3mm with a white coating
– Print directly on the aluminum top grade inks
– Matte and glare-free
– Includes a hanging kit- style depends on country of fulfillment
– Worldwide shipping
– 2006 Mitsubishi Lancer Evolution IX


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- Straight Plug
- 3-Wire
- 14 Gauge
- 125/250v
All orders take about 2-24 business hours to process and ship out. All packages will ship Monday-Friday.
Your order will be packaged with care and discretion. Items are securely wrapped to prevent shifting while in transit.
When your order is shipped, you will receive an email notification which includes a tracking number. You can also track your order through your profile page here.
Orders Over A Certain Weight Are Subject To Pallet Deliveries Which Could Be Subject To Higher Shipping Costs, However Shipping Speeds Remain The Same 1-4 Days, Depending On Location.
Please note: Tracking numbers often take up to 24 hours to be recognized by carriers. If you attempt to track your order and the tracking number returns a non-trackable message, please try again later as your tracking number may not have yet been fully recognized by your carrier.
-We have a 30-day return policy, which means you have 30 days after receiving your item to request a return.
-Please note: After 30-Days a Restocking Fee will be applied to all returns after 30-Days.
-To be eligible for a return, your item must be in the same condition that you received it, unused, with tags, and in its original packaging. You'll also need the receipt or proof of purchase.
-To start a return, you can contact us at firstname.lastname@example.com or come in-store.
- Items sent back to us without first requesting a return will not be accepted.
-Unfortunately, WE CANNOT accept returns on Clearance, Sales Items & Gift Cards
Damages and issues
Please inspect your order upon reception and contact us immediately if the item is defective, damaged or if you receive the wrong item, so that we can evaluate the issue and make it right.
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Certain types of items cannot be returned, like perishable goods (such as food, flowers, or plants). We also do not accept returns for hazardous materials, flammable liquids, or gases. Please get in touch if you have questions or concerns about your specific item.


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YUCAIPA, Calif. – Gerardo Barrientos and his girlfriend Lluvia Ramirez wanted a week away from the suffering they see every day at a government hospital in Tijuana, Mexico. Looking for a break, they paid $40 apiece for a day trip to the snowy mountains of Southern California.
But when the tour bus they were riding in careened out of control and collided with a car and truck as it came down the mountain from the ski resort town of Big Bear, they found themselves in a scene more gruesome than any they had seen back home.
'I saw many people dead. There are very, very horrendous images in my head, things I don't want to think about,' Barrientos, who works in a hospital pharmacy, said Monday.
Authorities said seven people died and three dozen others were injured in the wreck Sunday.
'I was overwhelmed,' said Ramirez. 'I'm a surgical resident and I usually know how to react, but I was so in shock I didn't know what to do. I just stayed with my friend.'
A day after the crash, they were waiting outside the Loma Linda University Medical Center emergency room to hear about the condition of their friend, another medical resident whose neck was broken.
Barrientos, who was uninjured, sprang into action following the crash, moving his friends to safety. He tried to help the bus driver, whose hand was pinned between rocks.
Ramirez, who had a bloody ear, dark bruises and a scratch on her neck, suffered a hairline vertebra fracture.
The severity of the injuries made it difficult for authorities to determine how many people had died. They initially said eight, then reduced the number to seven Monday after determining no more bodies were in the wrecked bus.
The dead included San Diego residents 13-year-old Victor Cabrera-Garcia, Elvira Garcia Jimenez, 40, and Guadalupe Olivas, 61; and Tijuana residents Aleida Adriana Arce Hernandez, 38, Rubicelia Escobedo Flores, 34, and Mario Garcia Santoyo 32, said San Bernardino County coroner's supervisor Tony Campisi. One woman remained unidentified.
Just before the crash, the driver had shouted to the passengers that the brakes had failed, and urged them to call 911.
As passengers frantically tried to get a cellphone signal, a group of teenage girls shrieked and prayed aloud. Others cried and shielded their heads as they careened downhill.
The bus rear-ended a Saturn sedan, swerved, flipped and slid on its side. A Ford pickup in the oncoming lane plowed into it, righting the bus and tossing passengers out shattered windows before it came to a halt.
The crash littered Route 38, a two-lane highway in the San Bernardino National Forest 80 miles east of Los Angeles, with body parts, winter clothing and debris. The bus stood across both lanes with its windows blown out, front end crushed and part of the roof peeled back like a tin can.
Federal investigators at the scene said they would begin on Tuesday a thorough investigation of the bus and the circumstances that surrounded the crash. They will determine if mechanical failure or driver error was to blame.
Government records showed the bus, operated by Scapadas Magicas LLC of National City, Calif., recorded 22 safety violations in inspections in the year ending October – including brake, windshield and tire problems.
Though the company retained an overall 'satisfactory' rating from the Federal Motor Carrier Safety Administration, it had been targeted for a higher rate of inspections linked to bus maintenance, the agency said.
The driver, Norberto B. Perez, 52, of San Ysidro, suffered major injuries but before going to the hospital told authorities the vehicle had brake problems.
A person involved in the investigation who spoke on condition of anonymity because the probe was ongoing said the bus was moving slowly downhill and was passed by other vehicles, including the Saturn, when it suddenly sped up.
The bus traveled about a mile from the point it struck the Saturn until it came to a stop, California Highway Patrol Officer Leon Lopez said.
At least 17 people remained hospitalized Monday, including at least five in critical condition.
The pickup driver was in extremely serious condition, said Peter Brierty, assistant county fire chief.
No one answered the door at the Scapadas Magicas office in a sprawling complex that houses more than 1,300 storage lockers and about 30 small offices.
Jordi Garcia, marketing director of Interbus Tours, said his company rented the bus from Scapadas Magicas, which supplied the driver.
Interbus offers near-daily bus tours to the western U.S. from Tijuana. Its office in a Tijuana strip mall displays photographs of some of its destinations, including Hollywood, the Las Vegas Strip and the San Diego Zoo.
Garcia said 38 people were aboard the bus that crashed, including the driver and a tour guide. The bus left Tijuana at 5 a.m. Sunday and planned to return late that night.
He said he spoke briefly with his tour guide, who suffered bruises. She told him she heard a loud pop before the crash.
Maria Salazar's daughter, 28-year-old Diana Maldonado of San Diego, was among those injured. Salazar said her daughter described the terror of the bus flipping and her head smashing through a window as she was propelled out of the vehicle. She lost consciousness and awoke as paramedics tended to her.
Maldonado hurt her back and shoulder but did not break any bones, according to her mother, who said her two other daughters had planned to make the trip but did not.
'I just thank God they did not go,' Salazar said in Spanish as she choked back tears.
Associated Press reporters contributing to this report included Julie Watson in San Diego, Raquel Maria Dillon in San Bernardino County and Michael R. Blood, Andrew Dalton and Bob Jablon in Los Angeles. Flaccus reported from Loma Linda, Calif.


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Easy Homemade Christmas Ornaments
Vintage postcard ornament
Cut circles from inexpensive vintage postcards for easy, stylish ornaments. Search by theme, such as winter sports or holiday cooking, on Etsy or Ebay. (If you have a vintage card you don't want to cut, scan a color copy and hang the copy instead.)
Easy-fill ornaments
Nestle special "ingredients" inside ball ornaments for thoughtful, budget-friendly party favors or decorations. You can use wintry natural materials like we did, or let your imagination fly.
What you'll need
Plastic ball ornaments
Artificial snow
Pine tree clippings
Place items inside one ornament half. (Leave them loose, or secure with a dot of hot glue.) Top with the other half, string with ribbon, and presto, you're done!
Painted-scene ornament
Use white and red acrylic paints to create this snowy scene. Paint the bottom with two coats of white paint; let dry after each. Then add trees in different sizes. After they've dried, dab on red acrylic paint to look like cardinals.
Paper-strip ornament
Stuff a clear ornament with strips of paper from old books or sheet music for holiday decor that also makes a great gift for book- or music-lovers.
- Photo by Ginger Crichton
Glittery music
Attach a favorite Christmas carol to cardstock and cover the edges with glitter for an easy, meaningful ornament.
Add some bling
Are you a scrapbooker or crafter? Go through your supplies for embellishments like this little snowflake. Hot-glue to glass ornaments.
Stamp it
Holiday stamps—vintage or current—look pretty inside clear glass ornaments.
Embroidered style
Embroider a snowflake onto bright color linen or cotton for a mini ornament (they make great gifts, too!). Trace a design on cloth and embroider, then place in a miniature embroidery hoop, using hot glue to seal the edges.
Rope accents
Place slivers of decorative paper in a clear ornament, then glue on strands of jute or another string to the top half.
Scrapbook swirls
Turn leftover scrapbooking paper (or even brown grocery bags) into rosette ornaments. Cut long paper rectangles (ours are 1-inch-wide by 6 inches long) and glue ends together. Punch two circles out of cardstock and hot-glue the cardstock ends to one circle; let dry and glue the second circle to the other side. Use adhesive letters to add a holiday message.
Jeweled touches
Costume earrings with glittery stones make gorgeous accents for holiday ornaments. Use wire cutters to remove earring posts or clips, then hot-glue the earrings to ornaments.
Ribbon candy
Make pretty candy-like ornaments from paper craps and beads. Thread a needle with embroidery floss and knot one end. Use clear acrylic beads and one-inch-wide paper strips to create the candy shape; place two beads between each bend of the paper strip. Secure the top bead by running the floss through it twice, and make a loop for hanging.
Tissue treasures
Cover an ornament with tiny tissue paper shapes for a pretty geometric look. Cut solid or patterned tissue paper into small squares. Coat a white matte-finish ornament with decoupage glue, add tissue paper pieces, and coat with another layer of decoupage. Hang to dry.
Jingle bell ornament
Here's another idea for clear ornaments: Fill with small red bells, wrap ribbon around the top and glue the long tails of the ribbon in place. We also glued a tiny felt tree to the front.
Printouts of the lyrics of Silent Night hang along with a garland of buttons, framed silhouettes and other homemade decorations.
Glitter balls
Glitter adds a special touch to any plain ornament. Try mixing two colors, such as turquoise and green, matching one of the colors to the ornament. A bow in coordinating colors finishes the festive look.
Cookie ornaments
Create a cookie-theme Christmas tree by making ornaments from cookie cutters, miniature rolling pins, bundles of cinnamon sticks and gingerbread men. Clear balls covered in twine and accented with bells add texture and shape to the tree.
- Photo by Ginger Crichton
Reuse game pieces
Do you have games at home that no one uses anymore? Use cards, tiles and other pieces to make garlands, spell holiday words or fill plastic ornaments.
- Photo by Ginger Crichton
Crayon ornaments
Crayons—glued, melted and shaped, and swirled—inspired these red ornaments.
Holiday message
Sparkly stick-on letters from a scrapbooking store spell out Christmas tidings.
Tower of gifts
Make an ornament from tiny craft boxes covered in wrapping paper, tissue or decorative paper scraps. Use different papers to cover lids and bottoms, then stack and tie with a ribbon.
More holiday decorating ideas
Click below for more great holiday decorating tips and ideas.Related Links


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CNN's Randi Kaye reports on a Twitter smear campaign against a 24-year-old undecided voter who asked the candidates a question about equal pay during the second presidential debate.
Post by: Randi Kaye
Filed under: 2012 Election
I thought that was the objection of a debate, to ask questions. She deserved an answer.
Another brave young woman attacked by the right-wing. It's HER future, and her future should not be dictated by a bunch of middle-age white men who think they know better – better than what? Men do get paid more. It's an inconvenient fact. It will take the next generation to right all the wrongs that are happening right now, to fight the battles that have already been fought, and hopefully come out unscathed. Women have been battling for equal rights for 40 years now. How long does it take to kill the elephant in the room?
They take a swipe at you. They treat you the way they treated Iraq and afganistan, these short sighted ones. We have to be patient with them, show them that humans have minds and hearts to live by. Some of them will bite the hand that feeds them. Remember the Golden Calve. Read Exodus and learn how to show them a better way,
Making a friend is a tedeous long process, I have to earn it. I must have bitten many hands in lives passed, so when my hand get bitten I understand that there is more work for humanity to do. Plato tought: Let those who know...
I also must add, if this lady is in fact a employed full time teacher, then she most likely is part of a teachers union or has had opportunity to become one. So her pay or contracts would be negotiated by a Union and then signed into a binding long term contract. This mean no President or anyone else for that matter could change or alter her pay.
This is exactly why Unions are killing the government and business. The people blame politicians, but they themselves join and support these Unions negotiating and handling their pay and benefits.
So that would be her fault, if she is in fact in a teachers Union, which most likely she is.
So we see the right wing won't even allow a question that they don't like to be asked. So much for freedom of speech.
Trying to intimidate this young 24 yr old teacher is really over the top and disgraceful, You couldn't ask the 'wrong' questions in Nazi Gernany either.
I can't imagine a world where it's okay that my daughter would receive less pay than a man doing the same job, where Government controls a woman's reproductive rights, where an abortion would be a crime, where the poor are unable to receive health care and education, a world where the EPA did not exist, where clean air and water standards were lifted, where corporations would have more rights than individuals, or a world where the military budget continues to grow and the tax cuts for the wealthy live on? What happened while I was sleeping; this looks more like a nightmare?
I want to criticise CNN for asking the question. In this country we have what is known as a SECRET BALLOT. How dare you ask people how they are going to vote. I never talk politics or religion, because you only have a 50/50 chance that you won't offend the person that you talk to. Even though I have already voted, I would tell you that I am undecided if you ask me, because it is none of your business!
The tragedy in this, virtually everything we know how to do – read, write, add, speak – we owe to teachers; so, how does the republican party show the appreciation – by waging a smear attack against an indivudal who asked for equality. I guess she is considered part of the 47%
Anderson Cooper goes beyond the headlines to tell stories from many points of view, so you can make up your own mind about the news. Tune in weeknights at 8 and 10 ET on CNN.
Questions or comments? Send an email
Want to know more? Go behind the scenes with AC361°


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Juvenile Rheumatoid Arthritis
What is juvenile rheumatoid arthritis?
Juvenile rheumatoid arthritis (JRA) is a form of arthritis in children ages 16 or younger that causes inflammation and stiffness of joints for more than six weeks. Unlike adult rheumatoid arthritis, which is chronic and lasts a lifetime, children often outgrow juvenile rheumatoid arthritis. However, the disease can affect bone development in the growing child.
The disease can be classified into three categories based on the number of and which joints are involved, the symptoms present and their duration, and the presence of specific antibodies produced by the immune system. These three variables often help doctors determine the progression of JRA and include the following:
Pauciarticular. This form of JRA affects about 50 percent of children with this disease, involving four joints or fewer. Large joints, such as the knees, ankles, or elbows are typically affected.
Polyarticular. Nearly 30 to 40 percent of children with JRA are affected by this type of the disease, which affects five or more joints. Polyarticular disease is more serious and tends to affect the small joints, such as the hands and feet, and often on both sides of the body.
Systemic. Systemic onset JRA (also called Still's disease) is the most serious, but least common form of the disease, affecting 10 to 15 percent of children with JRA. It affects one or more joints and causes inflammation of internal organs, including the heart, liver, spleen, and lymph nodes.
What causes juvenile rheumatoid arthritis?
Like adult rheumatoid arthritis, JRA is an autoimmune disease, which means the body's immune system attacks its own healthy cells and tissues.
JRA is considered to be a multifactorial condition. Multifactorial inheritance means that many factors are involved in causing a health problem. The factors are usually both genetic and environmental, where a combination of genes from both parents, in addition to unknown environmental factors, produce the trait or condition. Often one gender (either males or females) is affected more frequently than the other in multifactorial traits. Multifactorial traits do recur in families because they are partly caused by genes.
A group of genes on chromosome 6 codes for the HLA antigens play a major role in susceptibility and resistance to disease. Specific HLA antigens influence the development of many common disorders. Some of these disorders, like JRA, are autoimmune related and inherited in a multifactorial manner. When a child has the specific HLA antigen type associated with the disease, he or she is thought to have an increased chance to develop the disorder. The HLA antigen associated with JRA is called DR4. Children with the DR4 HLA antigen are thought to have an increased chance (or genetic susceptibility) to develop JRA; however, it is important to understand that a child without this antigen may also develop JRA. This means HLA antigen testing is not diagnostic or accurate for prediction of the condition. Females are affected with JRA more often than males.
What are the symptoms of juvenile rheumatoid arthritis?
Symptoms of juvenile rheumatoid arthritis may appear during episodes (flare-ups) or may be chronic and continuous. The following are the most common symptoms of juvenile rheumatoid arthritis. However, each child may experience symptoms differently. Symptoms may include:
Swollen, stiff, and painful joints, especially in the morning or after a nap (joints in the knees, hands, and feet are most commonly affected)
High fever and rash, if systemic juvenile rheumatoid arthritis
Swollen lymph nodes, if systemic juvenile rheumatoid arthritis
Eye inflammation
Warmth and redness in a joint
Decreased use of one or more particular joints
Decreased appetite, poor weight gain, and slow growth
Symptoms of juvenile rheumatoid arthritis may resemble other medical conditions or problems. Always consult your child's doctor for a diagnosis.
How is juvenile rheumatoid arthritis diagnosed?
In addition to a complete medical history and physical examination your child's doctor will obtain a complete prenatal and birth history of your child and ask if your child has had any recent colds or other infections.
Currently, there is no diagnostic test that definitively tells that a child has JRA. Diagnosis of juvenile rheumatoid arthritis is usually confirmed based on the presence of the following:
Reported symptoms. Joint inflammation usually must be present for at least six weeks, continuously.
Laboratory tests. Laboratory tests, such as certain blood tests, can help rule out other conditions and help determine the type of juvenile rheumatoid arthritis present. Tests may include:
Checking for the presence of antinuclear antibodies (ANA) and IgM rheumatoid factor (RF)
Blood tests and other laboratory tests, including:
Antinuclear antibody (ANA) and other antibody tests. These tests measure blood levels of antibodies, which are often present in persons with rheumatic disease.
Arthrocentesis (also called joint aspiration). A procedure that involves obtaining a sample of synovial fluid in the joint for examination by inserting a thin, hollow needle into the joint and removing the fluid with a syringe.
Complement. A blood test that measures the level of complement, a group of proteins in the blood. Low levels of complement in the blood are associated with immune disorders.
Complete blood count (CBC). A measurement of size, number, and maturity of different blood cells in a specific volume of blood.
Creatinine. A blood test to evaluate for underlying kidney disease.
Erythrocyte sedimentation rate (ESR or sed rate). A measurement of how quickly red blood cells fall to the bottom of a test tube. When swelling and inflammation are present, the blood's proteins clump together and become heavier than normal. Thus, when measured, they fall and settle faster at the bottom of the test tube. Generally, the faster the blood cells fall, the more severe the inflammation.
Hematocrit. This measures the number of red blood cells present in a sample of blood. Low levels of red blood cells (anemia) are common in people with inflammatory arthritis and rheumatic diseases.
Rheumatoid factor (RF). This detects whether rheumatoid factor is present in the blood (an antibody found in the blood of most, but not all, people who have rheumatoid arthritis, as well as other rheumatic diseases).
Urinalysis. Testing of a urine sample for protein, red blood cells, white blood cells, or casts to indicate kidney disease associated with several rheumatic diseases.
White blood cell count (WBC). This measures the number of white blood cells in the blood (increased levels of white blood cells may indicate an infection, while decreased levels may indicate certain rheumatic diseases or reaction to medication).
Imaging tests, to show the extent of damage to the bones, may include the following:
X-ray. A diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
Computed tomography scan (also called a CT or CAT scan). A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays.
Magnetic resonance imaging (MRI). A diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.
Bone scan. A nuclear radiology study of the bones.
Treatment for juvenile rheumatoid arthritis
The goal of treatment for juvenile rheumatoid arthritis is to maintain a normal activity level for your child. Specific treatment for juvenile rheumatoid arthritis will be determined by your child's doctor based on:
Your child's overall health and medical history
Extent of the condition
Your child's tolerance for specific medications, procedures, and therapies
Expectation for the course of the disease
Your opinion or preference
Treatment may include:
Nonsteroidal anti-inflammatory medications, NSAIDs, (to relieve symptoms)
Disease-modifying anti-rheumatic medications (to slow the progress of the disease, such as methotrexate)
Biologics, drugs designed to interfere with your body's inflammatory response, such as etanercept, infliximab, adalimumab, abatacept, and anakinra. These are used if there is no response to other therapies.
Corticosteroids (to reduce inflammation and control severe symptoms)
Physical therapy (to improve and maintain muscle and joint function)
Occupational therapy (to improve ability to perform activities of daily living)
Assessment of nutritional status by a nutritionist and ongoing, if necessary, nutritional guidance (to ensure adequate nutritional intake for your child whose appetite may be adversely affected by the disease process itself or some medications used for treatment)
Regular eye exams to detect early changes of eye inflammations
Patient education (to help decrease the frequency and severity of flare-ups and prevent complications), including educational topics such as:
Exercise and weight control
Adequate rest
How to use large joints rather than small joints to move or carry things