The Lipid Intensive Drug Therapy for Sepsis Phase II Pilot Clinical Trial.

OBJECTIVES: Low cholesterol levels in early sepsis patients are associated with mortality. We sought to test if IV lipid emulsion administration to sepsis patients with low cholesterol levels would prevent a decline or increase total cholesterol levels at 48 hours. DESIGN: Phase II, adaptive, randomized pilot clinical trial powered for 48 patients. SETTING: Emergency department or ICU of an academic medical center. PATIENTS: Sepsis patients (first 24 hr) with Sequential Organ Failure Assessment greater than or equal to 4 or shock. INTERVENTIONS: Patients meeting study criteria, including screening total cholesterol levels less than or equal to 100 mg/dL or high-density lipoprotein cholesterol (HDL-C) + low-density lipoprotein cholesterol (LDL-C) less than or equal to 70 mg/dL, were randomized to receive one of three doses of lipid emulsion administered twice in 48 hours or no drug (controls). The primary endpoint was a change in serum total cholesterol (48 hr - enrollment) between groups. MEASUREMENTS AND MAIN RESULTS: Forty-nine patients were enrolled and randomized. Two patients randomized to lipid emulsion were withdrawn before drug administration. Data for 24 control patients and 23 lipid emulsion patients were analyzed. The mean change in total cholesterol from enrollment to 48 hours was not different between groups and was 5 mg/dL ( sd 20) for lipid emulsion patients, and 2 mg/dL ( sd 18) for control patients ( p = 0.62). The mean changes in HDL-C and LDL-C were similar between groups. Mean change in triglycerides was elevated in lipid emulsion patients (61 mg/dL, sd 87) compared with controls (20 mg/dL, sd 70, p = 0.086). The 48-hour change in SOFA score was -2 (interquartile range [IQR] -4, -1) for control patients and -2 (IQR -3, 0) for lipid emulsion patients ( p = 0.46). CONCLUSIONS: Administration of IV lipid emulsion to early sepsis patients with low cholesterol levels did not influence change in cholesterol levels from enrollment to 48 hours.

Cannabis Use and Inhalational Anesthesia Administration in Older Adults: A Propensity Matched Retrospective Cohort Study.

BACKGROUND: Cannabis use is associated with higher intravenous anesthetic administration. Similar data regarding inhalational anesthetics are limited. With rising cannabis use prevalence, understanding any potential relationship with inhalational anesthetic dosing is crucial. We compared average intraoperative isoflurane/sevoflurane minimum alveolar concentration equivalents between older adults with and without cannabis use. METHODS: The electronic health records of 22,476 surgical patients ≥65 years old at the University of Florida Health System between 2018-2020 were reviewed. The primary exposure was cannabis use within 60 days of surgery, determined via i) a previously published natural language processing algorithm applied to unstructured notes and ii) structured data, including International Classification of Disease codes for cannabis use disorders and poisoning by cannabis, laboratory cannabinoids screening results, and RxNorm codes. The primary outcome was the intraoperative time-weighted average of isoflurane/sevoflurane minimum alveolar concentration equivalents at one-minute resolution. No a priori minimally clinically important difference was established. Patients demonstrating cannabis use were matched 4:1 to non-cannabis use controls using a propensity score. RESULTS: Among 5,118 meeting inclusion criteria, 1,340 patients (268 cannabis users and 1,072 nonusers) remained after propensity score matching. The median and interquartile range (IQR) age was 69 (67, 73) years; 872 (65.0%) were male, and 1,143 (85.3%) were non-Hispanic White. The median (IQR) anesthesia duration was 175 (118, 268) minutes. After matching, all baseline characteristics were well-balanced by exposure. Cannabis users had statistically significantly higher average minimum alveolar concentrations than nonusers [mean±SD: 0.58±0.23 versus 0.54±0.22, respectively; mean difference=0.04; 95% confidence limits, 0.01 to 0.06; p=0.020]. CONCLUSION: Cannabis use was associated with administering statistically significantly higher inhalational anesthetic minimum alveolar concentration equivalents in older adults, but the clinical significance of this difference is unclear. These data do not support the hypothesis that cannabis users require clinically meaningfully higher inhalational anesthetics doses.

The effect of social pension on health-related quality of life of the rural older people: a panel study from China.

BACKGROUND: Social pensions, social assistance systems for older people in rural areas, have been put into place in many nations and have positively impacted health. The long-term health consequences of social pension programs in China are uncertain. The aim of this study is to evaluate the long-term health consequences of the new rural social pension (NRSP) for the rural older people in China. METHODS: Based on the 2011 and 2018 China Health and Retirement Longitudinal Study, we compared the scores on eight Health-Related Quality of Life (HRQoL) subscales of the rural older people before and after participation in the NRSP. The propensity score matching and difference-in-difference methods were used in data analysis. We also conducted a heterogeneity analysis for subgroups with different characteristics and pension enrolment times. RESULTS: The NRSP significantly enhanced scores on physical functioning, role-physical, and self-rated mental health of old rural participants by 1.90 (p < 0.01), 2.05 (p < 0.01), and 2.93 (p < 0.05), respectively. After excluding newly enrolled individuals, the beneficial health effects of the NRSP remained significant. There were no significant changes due to NRSP in the other five scores on the HRQoL subscale of the rural older people. The NRSP had more health benefits for older people in underdeveloped areas without formal schooling. CONCLUSIONS: The NRSP reduced health disparities and had long-term benefits on the physical and mental health of the rural older people. We suggest continuously expanding the NRSP throughout rural China and further improving the social support system to enhance the overall quality of life of the rural older people. Comparable social pension programs aimed at underprivileged groups could also be conducted in other low- or middle-income nations.

Rationale and Design for the BLOCK-SAH Study (Pterygopalatine Fossa Block as an Opioid-Sparing Treatment for Acute Headache in Aneurysmal Subarachnoid Hemorrhage): A Phase II, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial with a Sequential Parallel Comparison Design.

BACKGROUND: Acute post-subarachnoid hemorrhage (SAH) headaches are common and severe. Management strategies for post-SAH headaches are limited, with heavy reliance on opioids, and pain control is overall poor. Pterygopalatine fossa (PPF) nerve blocks have shown promising results in treatment of acute headache, including our preliminary and published experience with PPF-blocks for refractory post-SAH headache during hospitalization. The BLOCK-SAH trial was designed to assess the efficacy and safety of bilateral PPF-blocks in awake patients with severe headaches from aneurysmal SAH who require opioids for pain control and are able to verbalize pain scores. METHODS: BLOCK-SAH is a phase II, multicenter, randomized, double-blinded, placebo-controlled clinical trial using the sequential parallel comparison design (SPCD), followed by an open-label phase. RESULTS: Across 12 sites in the United States, 195 eligible study participants will be randomized into three groups to receive bilateral active or placebo PPF-injections for 2 consecutive days with periprocedural monitoring of intracranial arterial mean flow velocities with transcranial Doppler, according to SPCD (group 1: active block followed by placebo; group 2: placebo followed by active block; group 3: placebo followed by placebo). PPF-injections will be delivered under ultrasound guidance and will comprise 5-mL injectates of 20 mg of ropivacaine plus 4 mg of dexamethasone (active PPF-block) or saline solution (placebo PPF-injection). CONCLUSIONS: The trial has a primary efficacy end point (oral morphine equivalent/day use within 24 h after each PPF-injection), a primary safety end point (incidence of radiographic vasospasm at 48 h from first PPF-injection), and a primary tolerability end point (rate of acceptance of second PPF-injection following the first PPF-injection). BLOCK-SAH will inform the design of a phase III trial to establish the efficacy of PPF-block, accounting for different headache phenotypes.

Increased odds for COVID-19 infection among individuals with periodontal disease.

OBJECTIVES: Periodontal disease has been linked to multiple systemic conditions, but the relationship with COVID-19 still needs to be elucidated. We hypothesized that periodontal disease may be associated with COVID-19 infection. MATERIALS AND METHODS: This study utilized cross-sectional data to establish the strength of the association between periodontal disease and COVID-19 infection. The University of Florida Health Center's i2b2 patient's registry was used to generate patient counts through ICD-10 diagnostic codes. Univariate descriptive statistics of the patient population and logistic regression to estimate odds ratios of associations between periodontal disease and COVID-19 infection were used for analysis. RESULTS: Patients with periodontal disease were 4.4 times more likely to be positively diagnosed with COVID-19 than patients without PD. Associations remained similar and robust (P value < 0.0001) after adjustment for age (OR = 4.34; 95% CI, 3.68-5.09), gender (OR = 4.46; 95% CI, 3.79-5.23), and smoking status (OR = 4.77; 95% CI, 4.04-5.59). Associations were smaller but remained robust (P value < 0.0001) after adjusting for race (OR = 2.83; 95% CI, 2.40-3.32), obesity (OR = 2.53; 95% CI, 2.14-2.98), diabetes (OR = 3.32; 95% CI, 2.81-3.90), and cardiovascular disease (OR = 2.68; 95% CI, 2.27-3.14). CONCLUSIONS: Periodontal disease is significantly associated with increased odds for COVID-19 infection. CLINICAL RELEVANCE: With the caveat of a cross-sectional study design, these results suggest that periodontal disease may increase the odds for COVID-19 infection.

Diffusion Magnetic Resonance Imaging Detects Progression in Parkinson's Disease: A Placebo-Controlled Trial of Rasagiline.

BACKGROUND: Rasagiline has received attention as a potential disease-modifying therapy for Parkinson's disease (PD). Whether rasagiline is disease modifying remains in question. OBJECTIVE: The main objective of this study was to determine whether rasagiline has disease-modifying effects in PD over 1 year. Secondarily we evaluated two diffusion magnetic resonance imaging pulse sequences to determine the best sequence to measure disease progression. METHODS: This prospective, randomized, double-blind, placebo-controlled trial assessed the effects of rasagiline administered at 1 mg/day over 12 months in early-stage PD. The primary outcome was 1-year change in free-water accumulation in posterior substantia nigra (pSN) measured using two diffusion magnetic resonance imaging pulse sequences, one with a repetition time (TR) of 2500 ms (short TR; n = 90) and one with a TR of 6400 ms (long TR; n = 75). Secondary clinical outcomes also were assessed. RESULTS: Absolute change in pSN free-water accumulation was not significantly different between groups (short TR: P = 0.346; long TR: P = 0.228). No significant differences were found in any secondary clinical outcomes between groups. Long TR, but not short TR, data show pSN free-water increased significantly over 1 year (P = 0.025). Movement Disorder Society Unified Parkinson's Disease Rating Scale testing of motor function, Part III increased significantly over 1 year (P = 0.009), and baseline free-water in the pSN correlated with the 1-year change in Movement Disorder Society Unified Parkinson's Disease Rating Scale testing of motor function, Part III (P = 0.004) and 1-year change in bradykinesia score (P = 0.044). CONCLUSIONS: We found no evidence that 1 mg/day rasagiline has a disease-modifying effect in PD over 1 year. We found pSN free-water increased over 1 year, and baseline free-water relates to clinical motor progression, demonstrating the importance of diffusion imaging parameters for detecting and predicting PD progression. © 2021 International Parkinson and Movement Disorder Society.

Efficacy of BCG for non-muscle invasive bladder cancer following nephroureterectomy for upper tract urothelial carcinoma.

PURPOSE: To evaluate the efficacy of intravesical (IVe) Bacillus Calmette-Guerin (BCG) to treat non-muscle invasive bladder cancer (NMIBC) recurrences in patients who have previously undergone nephroureterectomy for upper tract urothelial carcinoma (UTUC). METHODS: We performed a single institution retrospective review of patients who underwent nephroureterectomy for UTUC from 2009 to 2021. Patients who subsequently developed NMIBC treated with transurethral resection followed by IVe BCG were included in the study group. A control cohort was formed by retrospective review of patents with primary NMIBC treated with BCG during the same period. Patients in the control cohort were matched by stage of bladder cancer at a 2:1 ratio of control to study subjects. Demographic data, pathology of bladder tumors prior to and following BCG, use of maintenance BCG (mBCG), time to recurrence, time to progression, progression to cystectomy, and progression to metastatic disease were collected on all patients. Descriptive statistics were utilized to compare the 2 groups. The primary outcome was progression to muscle invasive disease. Secondary outcomes included intravesical recurrence free survival, disease free survival, and progression to metastatic disease. Univariable and multivariable logistic regression analysis was performed to elucidate independent variables associated with bladder tumor recurrence. Multivariable Cox regression analysis was used to assess the impact of prior UTUC on time to bladder tumor recurrence. RESULTS: One-hundred and ninety-one patients underwent nephroureterectomy at our institution from 2009 to 2021 for UTUC. Twenty-five patients were identified to have subsequently developed NMIBC recurrences treated with inductions BCG. The control group was comprised of 50 patients with primary NMIBC matched by stage of bladder cancer for which BCG was indicated in the study group. Median (interquartile range [IQR]) follow-up was significantly longer in the control group relative to the study group (64.8 [50.1-85.6] vs 25 months [17-35]; P = 0.001). There were no significant differences in demographics between the study and control groups. The rate of progression to muscle invasive disease was 17% vs 0% in the study group and control group respectively (P = 0.0521). History of UTUC was associated with increased risk of intravesical bladder tumor recurrence post BCG on multivariable analysis (HR 2.5; P = 0.017) and Kaplan Meier survival analysis (P = 0.039). The mean time to bladder tumor recurrence after treatment with BCG was significantly worse in the study group at (7.9 vs. 23.9 months; P = 0.0322). Similarly, the rate of progression to metastatic disease was worse in the study group (24% vs 2%; P = 0.0047). Overall disease-free survival was also noted to be significantly worse on Kaplan Meier survival analysis in the study group (P = 0.0074). No statistically significant differences in the stage grade of bladder tumor recurrence, grade of bladder tumor recurrence, or rate of progression to cystectomy were identified. CONCLUSIONS: Our study suggests reduced efficacy of BCG for NMIBC in patients with a history of UTUC. Patients in this population should be counseled accordingly. Research into alternative treatments for bladder tumor recurrence and more aggressive prophylactic regimens after nephroureterectomy for prevention of bladder tumor recurrence in this population is encouraged.

Characterizing Referrals to Professional Health Monitoring Programs for Unprofessional Sexual Behavior.

Concerns about sexual misconduct by health care professionals have been highlighted by recent high-profile cases. Professional health monitoring programs (PHPs) offer an additional layer of protection when health care professionals with a history of unprofessional sexual behavior (USB) return to practice; however, little is known about the characteristics or outcomes of clinicians referred to a PHP because of USB. Data were extracted from over 35 years of PHP records involving USB-related referrals (N = 570). The majority of cases were deemed ineligible for PHP monitoring and handled by other entities (e.g., licensing board, legal system). Of the 232 monitored cases (46.84 ± 9.42 years; 95.7% male), most were physicians (n = 156, 67.2%), with 75.9 percent of monitored cases involving USB with at least one patient. Most (74.9%) PHP monitoring outcomes were classified as "successful" or "very successful." Only three individuals (1.3%) who completed their monitoring were rereferred to the PHP. Monitored professionals exhibited less severe USB and were less likely to experience legal or disciplinary consequences (57.3% versus 69.8%, Cramer's V = .174, p < .0001) compared with unmonitored professionals. Findings enhance transparency of the PHP process and highlight its utility in safely returning clinicians to practice. Results may inform policies to prevent USB by health care professionals.

Cannabis use and acute postoperative pain outcomes in older adults: a propensity matched retrospective cohort study.

INTRODUCTION: Cannabis use is increasing among older adults, but its impact on postoperative pain outcomes remains unclear in this population. We examined the association between cannabis use and postoperative pain levels and opioid doses within 24 hours of surgery. METHODS: We conducted a propensity score-matched retrospective cohort study using electronic health records data of 22 476 older surgical patients with at least 24-hour hospital stays at University of Florida Health between 2018 and 2020. Of the original cohort, 2577 patients were eligible for propensity-score matching (1:3 cannabis user: non-user). Cannabis use status was determined via natural language processing of clinical notes within 60 days of surgery and structured data. The primary outcomes were average Defense and Veterans Pain Rating Scale (DVPRS) score and total oral morphine equivalents (OME) within 24 hours of surgery. RESULTS: 504 patients were included (126 cannabis users and 378 non-users). The median (IQR) age was 69 (65-72) years; 295 (58.53%) were male, and 442 (87.70%) were non-Hispanic white. Baseline characteristics were well balanced. Cannabis users had significantly higher average DVPRS scores (median (IQR): 4.68 (2.71-5.96) vs 3.88 (2.33, 5.17); difference=0.80; 95% confidence limit (CL), 0.19 to 1.36; p=0.01) and total OME (median (IQR): 42.50 (15.00-60.00) mg vs 30.00 (7.50-60.00) mg; difference=12.5 mg; 95% CL, 3.80 mg to 21.20 mg; p=0.02) than non-users within 24 hours of surgery. DISCUSSION: This study showed that cannabis use in older adults was associated with increased postoperative pain levels and opioid doses.

Analysis of Internal Dermatology Matches Following the COVID-19 Pandemic.

Dermatology has long been recognized as a highly competitive field within medicine, with extremely limited spots available for aspiring dermatologists to secure residencies across the United States. We sought to evaluate the trends and factors influencing the match process in dermatology residencies, particularly given the changes brought on by the COVID-19 pandemic. Using data from publicly available match lists and regional categorizations, we studied the rates of internal and regional matches for dermatology applicants in the postpandemic era (2022-2023) compared with prepandemic statistics. Overall, the research sheds light on the evolving dynamics of dermatology residency matching in response to pandemic-induced changes and applicant preferences.

Monitoring and management of hypertriglyceridemia in extremely low birth weight neonates receiving intravenous lipid emulsions: A national survey.

AIM: To assess the practice variation of defining, monitoring and managing hypertriglyceridemia (HTG) in extremely low birth weight neonates receiving intravenous lipid emulsions (IVLE). METHODS: An 8-question survey created via the web survey site Qualtrics was distributed to neonatologists, neonatal nurse practitioners and fellows within the Section of Neonatal-Perinatal Medicine email directory list in the United States and Canada. Survey results were obtained between August and September 2022. RESULTS: There were 249 respondents from approximately 4000 members within the Section of Neonatal-Perinatal Medicine. Responses were documented as a frequency (percentage) with a margin of error of plus or minus 6.2 %. Most respondents were neonatologists, individuals practicing for >10 years and reported a unit-based policy for IVLE initiation and advancement. The definitions of HTG varied among respondents, with the majority (42.7 %) reporting a defining threshold of >200 mg/dL. Nineteen percent of respondents reported not routinely monitoring serum triglyceride concentrations with variable triglyceride monitoring intervals reported by other survey respondents. Regarding elevated triglyceride concentrations, 19.0 % reported decreasing the IVLE rate and checking triglyceride concentrations until normalization; 14.6 % reported IVLE discontinuation and monitoring triglyceride concentrations until normalization; 61.9 % reported using a combination of the above practices; and 4.4 % reported individualized practices for IVLE management with elevated triglyceride concentrations. CONCLUSION: This survey demonstrates a high variation in defining, monitoring and managing HTG in extremely low birth weight neonates and emphasizes the need for studies to better guide this practice.

Impact of Biopsy Attempts, Race, and Access on Time to Initiation of Treatment for Pancreatic Cancer.

BACKGROUND: Biopsy of suspected pancreatic cancer (PDAC) in surgical candidates is informative however not always necessary. Biopsies impact treatment options as histological diagnosis are presently required for neo-adjuvant therapy, but not surgical resection. We explored the impact of pursuing tissue diagnosis by endoscopic ultrasound (EUS) biopsy on time to treatment in patients with resectable and borderline resectable PDAC. METHODS: A retrospective review of surgical patients with ultimately proven PDAC was performed (2011-2021). Milestone dates (cancer suspected, biopsy(ies), surgical or neo-adjuvant treatment) were collected. Mann-Whitney-Wilcoxon tests, Pearson's chi-squared tests, Fisher's exact tests, linear regressions, and Cox proportional hazard models were used for data analysis. RESULTS: Among 131 resectable and 58 borderline resectable patients, the borderline resectable group underwent more biopsies (1.2 vs 0.7, p < 0.0001), were more likely to undergo biopsy at tertiary care centers (67.2% vs 30.5%, p < 0.0001), and trended toward longer time to treatment (49 vs 44 days, p = 0.070). Significant increases in days to treatment were seen in patients with Black race (29 days, p = 0.0002) and Medicare insurance (22 days, p = 0.038) and no biopsies at a tertiary care center (10 days, p = 0.039). After adjusting for covariates, additional biopsies significantly delayed treatment (1 biopsy: 21 days, p = 0.0001; 2 biopsies: 44 days, p < 0.0001; 3 biopsies: 68 days, p < 0.0001). CONCLUSIONS: EUS biopsy significantly impacts time between suspicion and treatment of PDAC. This may be exacerbated by clinical practices increasingly favoring neo-adjuvant therapy that necessitates biopsy-proven disease. Time to treatment may also be impacted by access to tertiary centers and racial disparities.

Prescribing patterns of SGLT-2 inhibitors for patients with heart failure: A two-center analysis.

Background: Sodium glucose co-transporter 2 inhibitors (SGLT2i) have been proven to reduce the combined risk of cardiovascular death and hospitalizations in patients with heart failure (HF), irrespective of the presence or absence of diabetes. Despite class 1 and class 2A recommendations for their usage in HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) respectively by the American College of Cardiology, their prescription rate has remained low. Objective: The aim of this study is to analyze SGLT2i prescription patterns at two academic institutions, with the goal of identifying barriers to implementation. Design: A two-center retrospective analysis was conducted on patients ≥18 years old with a diagnosis of heart failure who were admitted to one of two hospital systems between 5/1/21 and 5/31/22. Patients with an eGFR ≥20 mL/min/1.73m2 and BNP ≥ 100 pg/mL were included. Results: SGLT2i was prescribed in only 19 out of 1081 HFpEF patients (1.8 %) and 51 out of 1596 HFrEF patients (3.2 %). A majority of SGLT2i prescriptions for the HFpEF population came from general medicine services (57.9 %) after obtaining approval from a cardiologist, which was required at our institutions. Adverse effects such as hypoglycemia and urinary tract infections were not significantly associated with SGLT2i use. Conclusions: Despite proven benefits of this class of medications as witnessed in large-scale clinical trials, the implementation of this drug class continues to be low.

Training Medical-Diagnosis Neural Networks on the Cloud with Privacy-Sensitive Patient Data from Multiple Clients.

Artificial neural networks (ANNs) are changing the paradigm in medical diagnosis. However, it remains an open problem how to outsource the model training operations to the cloud while protecting the privacy of distributed patient data. Homomorphic encryption suffers from high overhead over data independently encrypted from numerous sources, differential privacy introduces a high level of noise which drastically increases the number of patient records needed to train a model, while federated learning requires all participants to perform synchronized local training that counters our goal of outsourcing all training operations to the cloud. This paper proposes to use matrix masking for outsourcing all model training operations to the cloud with privacy protection. After outsourcing their masked data to the cloud, the clients do not need to coordinate and perform any local training operations. The accuracy of the models trained by the cloud from the masked data is comparable to the accuracy of the optimal benchmark models that are trained directly from the original raw data. Our results are confirmed by experimental studies on privacy-preserving cloud training of medical-diagnosis neural network models based on real-world Alzheimer's disease data and Parkinson's disease data.

Impact of ß-blockers on survival outcomes in patients with unresectable hepatocellular carcinoma.

Background: ß-blockers (BBs) have shown promise in improving overall survival (OS) in patients with breast, ovarian, pancreatic and lung cancer. However, few studies have evaluated the impact of BBs on unresectable hepatocellular carcinoma (HCC). Methods: The authors compared clinical data and outcomes between unresectable HCC patients based on whether they were prescribed BBs. Results: There was significantly decreased disease progression in the BB group compared with the non-BB group (22.8 vs 28.0%; p < 0.05). No difference was seen in OS or progression-free survival between groups. Those specifically on selective BBs had improved OS (hazard ratio: 0.75; 95% CI: 0.61-0.94; p = 0.01) and progression-free survival (hazard ratio: 0.66; 95% CI: 0.45-0.96; p = 0.03) compared with non-BB patients. Conclusion: Although the authors' study did not demonstrate that BBs improve OS in HCC, it did show decreased disease progression among patients with HCC who were taking BBs compared with those who were not.

American Physical Therapy Association Clinical Practice Guideline Implementation for Neck and Low Back Pain in Outpatient Physical Therapy: A Nonrandomized, Cross-sectional Stepped-Wedge Pilot Study.

OBJECTIVE: To determine whether a multifaceted implementation strategy for American Physical Therapy Association neck and low back pain clinical practice guidelines (CPGs) was associated with changes in clinician and patient outcomes. DESIGN: Cross-sectional stepped-wedge pilot study. METHODS: Physical therapy clinics (n = 9) were allocated to 1 of 4 clusters that varied by CPG implementation timing. Clinics crossed over from usual care (control) to CPG implementation (intervention) every 8 weeks and ended with a 24-week follow-up period. Implementation outcomes were measured at the clinician (perspectives and behaviors) and patient (pain and disability outcomes) levels. Descriptive statistics were used to summarize clinician perspectives and behaviors. Generalized linear mixed models were used to analyze patient-level outcomes data (pain and disability) and total number of physical therapy visits. RESULTS: Improvements in several clinician perspectives about CPGs were observed 8 weeks after training and sustained at 16 weeks (P<.05), although it is unclear whether these changes were meaningful. Training on CPGs was relevant to physical therapists and more acceptable at 16 weeks (P<.05). In a random sample (n = 764/1994, 38.3%), the overall rate of CPG classification was 65.0% (n = 497/764), and CPG intervention concordance was 71.2% (n = 354/497). Implementation of a CPG was not associated with final pain and disability scores (P>.05) but was associated with an approximate increase of 8% in total visits. CONCLUSION: Our multifaceted implementation strategy was associated with statistical changes in clinician perspectives and behaviors, but not in patient outcomes. J Orthop Sports Phys Ther 2022;52(2):113-123. doi:10.2519/jospt.2022.10545.

A randomized clinical trial of burst vs. spaced physical therapy for Parkinsons disease.

INTRODUCTION: The optimal timing for physical therapy (PT) delivery in Parkinson's disease (PD) is unknown. Our objective was to determine whether spacing physical therapy visits over a longer period of time is beneficial for maintenance of physical function in PD. METHODS: A single center, single-blinded, randomized controlled trial of PD participants. Participants (n = 30) were randomized to either burst (two PT sessions weekly for 6 weeks) or spaced (one PT session every 2 weeks for 6 months) PT. 11 participants in each arm completed the study and were analyzed. The primary outcome measure was the Timed Up and Go (TUG) test at baseline and 6 months. The burst group had an additional outcome measure timepoint at the completion of PT at 6 weeks. RESULTS: Neither group achieved a minimal clinically significant benefit in the TUG score (3.5s) at 6 months. The spaced PT TUG scores were maintained when comparing baseline (7.8 ± 1.5s) and 6 month timepoints (7.8 ± 2.6s, p = 0.594). The burst group TUG scores comparing baseline (9.8 ± 3.8s) to 6 weeks (9.1 ± 3.0s) also was maintained (p = 0.365). The burst group worsened, however, when measuring the period from 6 weeks to 6 months (12.1 ± 7.6s, p = 0.034). CONCLUSIONS: The spaced PT group had stability of the TUG mobility measure at 6 months, while the burst group had a significant worsening once PT was discontinued after 6 weeks. It is feasible to test these approaches in a future larger comparative effectiveness study.

The Alzheimer-E. coli Axis: What Can We Learn from an Electronic Health Record Platform.

BACKGROUND: Alzheimer's disease (AD) is a neurodegenerative disease with unclear etiology. Recent studies have demonstrated a potential role for gut microbiome. There is, however, a significant dearth in epidemiological correlation between gut bacteria and AD. OBJECTIVE: To investigate the association between Escherichia coli (E. coli) infection and AD. METHODS: Counts of patients with ICD 10 diagnoses of AD, E. coli, urinary tract infection, and comorbidities were retrieved from the electronic health records at the University of Florida Health Center. RESULTS: The relative risk for AD with a previous event of E. coli was 5.17 (95%CI 4.0786 to 6.5446, p < 0.0001). In the unadjusted association, patients with E. coli infection had odds ratio (OR) of 20.83 to have AD (95%CI, 17.7-24.34; p < 0.0001); after adjusting for gender (OR = 12.71; 95%CI, 10.82-14.83; p < 0.0001), race (OR = 13.97; 95%CI, 11.84-16.36; p < 0.0001), age group (OR = 11.51; 95%CI, 9.73-13.54; p < 0.0001), diabetes (OR = 9.23; 95%CI, 7.79-10.87; p < 0.0001), stroke (OR = 5.31; 95%CI, 4.47-6.28; p < 0.0001), and hypertension (OR = 4.55; 95%CI, 3.86-5.32; p < 0.0001). CONCLUSION: These results should be taken cautiously. This retrospective cross-sectional study cannot infer causality and had used aggregate data that did not allow simultaneous adjustments of covariates. Future studies are warranted to investigate the link between gut bacteria and AD.