Bacterial diversity and geomicrobiology of Winter Wonderland ice cave, Utah, USA.

The Winter Wonderland ice cave, located at an elevation of 3140 m above sea level in the Uinta Mountains of northern Utah, USA, maintains a constant sub-zero temperature. Seasonal snowmelt and rain enter the cave, freeze on the surface of the existing ice, and contribute to a 3-m-thick layered ice mass. This ice mass contains organic matter and cryogenic cave carbonates (CCCs) that date back centuries. In this study, samples of ice, liquid water, and exposed CCCs were collected to examine the bacterial communities within the cave and to determine if these communities vary spatially and between sample types. Flow cytometry showed that cell counts are an order of magnitude higher in liquid water samples than in ice. Epifluorescence microscopy and scanning electron microscopy imaging revealed potential coccoid and bacillus microbial morphologies in water samples and putative cells or calcite spherules in the CCCs. The diversity of bacteria associated with soil, identified through sequence-based analysis, supports the hypothesis that water enters the cave by filtering through soil and bedrock. A differential abundance of bacterial taxa was observed between sample types, with the greatest diversity found in CCCs. This supports a geomicrobiological framework where microbes aggregate in the water, sink into a concentrated layer, and precipitate out of the ice with the CCCs, thereby reducing the cell counts in the ice. These CCCs may provide essential nutrients for the bacteria or could themselves be products of biomineralization.

Possible eucynodont (Synapsida: Cynodontia) tracks from a lacustrine facies in the Lower Jurassic Moenave Formation of southwestern Utah.

Eight fossil tetrapod footprints from lake-shore deposits in the Lower Jurassic Moenave Formation at the St. George Dinosaur Discovery Site (SGDS) in southwestern Utah cannot be assigned to the prevalent dinosaurian (Anomoepus, Eubrontes, Gigandipus, Grallator, Kayentapus) or crocodyliform (Batrachopus) ichnotaxa at the site. The tridactyl and tetradactyl footprints are incomplete, consisting of digit- and digit-tip-only imprints. Seven of the eight are likely pes prints; the remaining specimen is a possible manus print. The pes prints have digit imprint morphologies and similar anterior projections and divarication angles to those of Brasilichnium, an ichnotaxon found primarily in eolian paleoenvironments attributed to eucynodont synapsids. Although their incompleteness prevents clear referral to Brasilichnium, the SGDS tracks nevertheless suggest a eucynodont track maker and thus represent a rare, Early Mesozoic occurrence of such tracks outside of an eolian paleoenvironment.

Wood-Ljungdahl pathway encoding anaerobes facilitate low-cost primary production in hypersaline sediments at Great Salt Lake, Utah.

Little is known of primary production in dark hypersaline ecosystems despite the prevalence of such environments on Earth today and throughout its geologic history. Here, we generated and analyzed metagenome-assembled genomes (MAGs) organized as operational taxonomic units (OTUs) from three depth intervals along a 30-cm sediment core from the north arm of Great Salt Lake, Utah. The sediments and associated porewaters were saturated with NaCl, exhibited redox gradients with depth, and harbored nitrogen-depleted organic carbon. Metabolic predictions of MAGs representing 36 total OTUs recovered from the core indicated that communities transitioned from aerobic and heterotrophic at the surface to anaerobic and autotrophic at depth. Dark CO2 fixation was detected in sediments and the primary mode of autotrophy was predicted to be via the Wood-Ljungdahl pathway. This included novel hydrogenotrophic acetogens affiliated with the bacterial class Candidatus Bipolaricaulia. Minor populations were dependent on the Calvin cycle and the reverse tricarboxylic acid cycle, including in a novel Thermoplasmatota MAG. These results are interpreted to reflect the favorability of and selectability for populations that operate the lowest energy requiring CO2-fixation pathway known, the Wood-Ljungdahl pathway, in anoxic and hypersaline conditions that together impart a higher energy demand on cells.

Lung Cancer Screening Before and After a Multifaceted Electronic Health Record Intervention: A Nonrandomized Controlled Trial.

Importance: Lung cancer is the deadliest cancer in the US. Early-stage lung cancer detection with lung cancer screening (LCS) through low-dose computed tomography (LDCT) improves outcomes. Objective: To assess the association of a multifaceted clinical decision support intervention with rates of identification and completion of recommended LCS-related services. Design, Setting, and Participants: This nonrandomized controlled trial used an interrupted time series design, including 3 study periods from August 24, 2019, to April 27, 2022: baseline (12 months), period 1 (11 months), and period 2 (9 months). Outcome changes were reported as shifts in the outcome level at the beginning of each period and changes in monthly trend (ie, slope). The study was conducted at primary care and pulmonary clinics at a health care system headquartered in Salt Lake City, Utah, among patients aged 55 to 80 years who had smoked 30 pack-years or more and were current smokers or had quit smoking in the past 15 years. Data were analyzed from September 2023 through February 2024. Interventions: Interventions in period 1 included clinician-facing preventive care reminders, an electronic health record-integrated shared decision-making tool, and narrative LCS guidance provided in the LDCT ordering screen. Interventions in period 2 included the same clinician-facing interventions and patient-facing reminders for LCS discussion and LCS. Main Outcome and Measure: The primary outcome was LCS care gap closure, defined as the identification and completion of recommended care services. LCS care gap closure could be achieved through LDCT completion, other chest CT completion, or LCS shared decision-making. Results: The study included 1865 patients (median [IQR] age, 64 [60-70] years; 759 female [40.7%]). The clinician-facing intervention (period 1) was not associated with changes in level but was associated with an increase in slope of 2.6 percentage points (95% CI, 2.4-2.7 percentage points) per month in care gap closure through any means and 1.6 percentage points (95% CI, 1.4-1.8 percentage points) per month in closure through LDCT. In period 2, introduction of patient-facing reminders was associated with an immediate increase in care gap closure (2.3 percentage points; 95% CI, 1.0-3.6 percentage points) and closure through LDCT (2.4 percentage points; 95% CI, 0.9-3.9 percentage points) but was not associated with an increase in slope. The overall care gap closure rate was 175 of 1104 patients (15.9%) at the end of the baseline period vs 588 of 1255 patients (46.9%) at the end of period 2. Conclusions and Relevance: In this study, a multifaceted intervention was associated with an improvement in LCS care gap closure. Trial Registration: ClinicalTrials.gov Identifier: NCT04498052.

Ambulatory antibiotic prescription rates for acute respiratory infection rebound two years after the start of the COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, acute respiratory infection (ARI) antibiotic prescribing in ambulatory care markedly decreased. It is unclear if antibiotic prescription rates will remain lowered. METHODS: We used trend analyses of antibiotics prescribed during and after the first wave of COVID-19 to determine whether ARI antibiotic prescribing rates in ambulatory care have remained suppressed compared to pre-COVID-19 levels. Retrospective data was used from patients with ARI or UTI diagnosis code(s) for their encounter from 298 primary care and 66 urgent care practices within four academic health systems in New York, Wisconsin, and Utah between January 2017 and June 2022. The primary measures included antibiotic prescriptions per 100 non-COVID ARI encounters, encounter volume, prescribing trends, and change from expected trend. RESULTS: At baseline, during and after the first wave, the overall ARI antibiotic prescribing rates were 54.7, 38.5, and 54.7 prescriptions per 100 encounters, respectively. ARI antibiotic prescription rates saw a statistically significant decline after COVID-19 onset (step change -15.2, 95% CI: -19.6 to -4.8). During the first wave, encounter volume decreased 29.4% and, after the first wave, remained decreased by 188%. After the first wave, ARI antibiotic prescription rates were no longer significantly suppressed from baseline (step change 0.01, 95% CI: -6.3 to 6.2). There was no significant difference between UTI antibiotic prescription rates at baseline versus the end of the observation period. CONCLUSIONS: The decline in ARI antibiotic prescribing observed after the onset of COVID-19 was temporary, not mirrored in UTI antibiotic prescribing, and does not represent a long-term change in clinician prescribing behaviors. During a period of heightened awareness of a viral cause of ARI, a substantial and clinically meaningful decrease in clinician antibiotic prescribing was observed. Future efforts in antibiotic stewardship may benefit from continued study of factors leading to this reduction and rebound in prescribing rates.

Physical Activity Among Utah Cancer Survivors: Analysis From a Population-Based Statewide Survey.

BACKGROUND: Regular physical activity improves cancer survivors' health-related quality of life and physical function. We estimated the proportion of Utah cancer survivors meeting U.S. Department of Health and Human Services guidelines for weekly physical activity (aerobic plus strength exercise) and identify sociodemographic, cancer, and health-related factors associated with meeting guidelines. METHODS: Survivors randomly sampled from Utah Cancer Registry records were surveyed from 2018 to 2022 to ascertain physical activity. We calculated the percent of survivors meeting guidelines and conducted logistic regression to assess predictors of meeting guidelines. Analyses were weighted to account for complex survey sample design and nonresponse and age adjusted. RESULTS: Among Utah cancer survivors, 20.7% (95% CI, 18.5%-23.2%) met guidelines for both aerobic activity and strength exercise. 22.4% reported no aerobic exercise in a typical week, and 59.4% reported no strength exercise. Survivors 75 or older were less likely to meet physical activity guidelines than those under 55 (adjusted odds ratio: 0.40; 95% CI, 0.25-0.65). Survivors with a bachelor's degree or higher were more likely to meet physical activity guidelines than those without a college degree. Individuals with poorer overall health were less likely to report sufficient physical activity. Individuals treated with both chemotherapy and radiation had decreased odds of meeting guidelines compared to no treatment (adjusted odds ratio: 0.54; 95% CI, 0.29-0.99). CONCLUSIONS: Most Utah cancer survivors, and particularly those who received multiple modes of adjuvant treatment, are not participating in sufficient physical activity to improve longevity and quality of life after cancer.

Japanese Yew (Taxus) poisoning of wild ungulates in Utah during the winter of 2022-2023.

Taxus is a genus of coniferous shrubs and trees, commonly known as the yews, in the family Taxaceae. All species of yew contain taxine alkaloids, which are ascribed as the toxic principles. Anecdotally, free ranging ruminants such as antelope, deer, elk, and moose have been regarded as tolerant to yew. Herein several cases of intoxication of deer, elk, and moose by yew from the state of Utah in the winter of 2022-2023 are documented. Ingestion of yew was documented by three means among the poisoned cervids; plant fragments consistent with yew were visually observed in the rumen contents, chemical analysis, and subsequent detection of the taxines from rumen and liver contents, and identification of exact sequence variants identified as Taxus species from DNA metabarcoding. Undoubtedly, the record snowfall in Utah during the winter of 2022-2023 contributed to these poisonings.

Shiga Toxin-Producing Escherichia coli O157:H7 Illness Outbreak Associated with Untreated, Pressurized, Municipal Irrigation Water - Utah, 2023.

During July-September 2023, an outbreak of Shiga toxin-producing Escherichia coli O157:H7 illness among children in city A, Utah, caused 13 confirmed illnesses; seven patients were hospitalized, including two with hemolytic uremic syndrome. Local, state, and federal public health partners investigating the outbreak linked the illnesses to untreated, pressurized, municipal irrigation water (UPMIW) exposure in city A; 12 of 13 ill children reported playing in or drinking UPMIW. Clinical isolates were genetically highly related to one another and to environmental isolates from multiple locations within city A's UPMIW system. Microbial source tracking, a method to indicate possible contamination sources, identified birds and ruminants as potential sources of fecal contamination of UPMIW. Public health and city A officials issued multiple press releases regarding the outbreak reminding residents that UPMIW is not intended for drinking or recreation. Public education and UPMIW management and operations interventions, including assessing and mitigating potential contamination sources, covering UPMIW sources and reservoirs, indicating UPMIW lines and spigots with a designated color, and providing conspicuous signage to communicate risk and intended use might help prevent future UPMIW-associated illnesses.

Characteristics of a transgender and gender-diverse patient population in Utah: Use of electronic health records to advance clinical and health equity research.

Transgender and gender-diverse (TGD) people, individuals whose gender identity differs from their sex assigned at birth, face unique challenges in accessing gender-affirming care and often experience disparities in a variety of health outcomes. Clinical research on TGD health is limited by a lack of standardization on how to best identify these individuals. The objective of this retrospective cohort analysis was to accurately identify and describe TGD adults and their use of gender-affirming care from 2003-2023 in a healthcare system in Utah, United States. International Classification of Disease (ICD)-9 and 10 codes and surgical procedure codes, along with sexual orientation and gender identity data were used to develop a dataset of 4,587 TGD adults. During this time frame, 2,985 adults received gender-affirming hormone therapy (GAHT) and/or gender-affirming surgery (GAS) within one healthcare system. There was no significant difference in race or ethnicity between TGD adults who received GAHT and/or GAS compared to TGD adults who did not receive such care. TGD adults who received GAHT and/or GAS were more likely to have commercial insurance coverage, and adults from rural communities were underrepresented. Patients seeking estradiol-based GAHT tended to be older than those seeking testosterone-based GAHT. The first GAS occurred in 2013, and uptake of GAS have doubled since 2018. This study provides a methodology to identify and examine TGD patients in other health systems and offers insights into emerging trends and access to gender-affirming care.

Leadership Development in Graduate Medical Education: A Pilot Study of Implementation of a Validated Self-assessment Instrument.

BACKGROUND AND OBJECTIVES: Graduate medical education programs need leadership assessments and curricula to engage residents and advance their leadership skills. The Foundational Healthcare Leadership Self-assessment (FHLS) is a validated 21-item self-assessment of leadership skills residents need to be effective team leaders in health care settings. It generates a composite score along five foundational leadership domains: accountability, collaboration, communication, team management, and self-management. Our objective was to determine whether a leadership curriculum, using the FHLS as an educational tool to support self-assessment, self-directed learning, and reflective practice, promotes self-awareness and engagement in leadership development. METHODS: We conducted a qualitative pilot study in the University of Utah Family Medicine Residency Program, integrating the FHLS into our residency's longitudinal leadership curriculum using coaching, self-directed learning, and reflective practice. Family medicine residents completed the FHLS prior to their leadership rotation. Faculty met with each resident during their rotation using a coaching paradigm based on data from the FHLS to inform leadership self-awareness. Residents identified a leadership domain for self-improvement, selected resources for self-study, and submitted a written reflection. We conducted qualitative content analysis on the reflections for evidence of self-awareness and engagement in leadership development. RESULTS: Residents completed 27 leadership rotations between May 2019 and April 2020, generating 21 reflections. Qualitative content analysis of resident reflections grouped by FHLS leadership domains identified evidence of impact on the residents' leadership development. CONCLUSIONS: This qualitative pilot study supports the usefulness of the FHLS within a residency leadership curriculum to promote self-awareness and engagement in leadership development.

Drink then drive away: The effects of lowering the blood alcohol concentration in Utah.

In March of 2017 Utah announced its intent to lower the legal blood alcohol content (BAC) for driving from 0.08 to 0.05 g/dL. However, this change did not take effect until 2019. We employ a difference-in- differences strategy on Utah counties using neighboring states as controls to test whether this policy change significantly affected the number of traffic accidents or the severity of those accidents. Results show the policy appears to temporarily decrease the total number of accidents, limited primarily to property damage- only accidents. We believe these results may be partially explained by drivers who, after the policy is enacted, avoid reporting property damage-only accidents if possible. Using insurance claims data, we show there is no corresponding fall in insurance claims or payouts suggesting that the fall in total accidents likely comes from under-reporting.

Assessing Contraceptive Switching and Discontinuation Over 3 Years in the HER Salt Lake Study.

OBJECTIVE: To assess contraceptive switching and discontinuation among participants enrolled in a contraceptive access project over 3 years and to identify variables associated with contraceptive change. METHODS: The HER Salt Lake study enrolled individuals between 2015 and 2017 from four clinics in Salt Lake County into a prospective, longitudinal cohort. All participants were able to switch or discontinue at no cost (between March 2016 and March 2020). We collected eight follow-up surveys over 3 years after enrollment. Each survey wave included questions about method use in the previous 4 weeks. We categorized participants in three ways, allowing for time-varying outcomes by wave: 1) those who reported using the same method as previous wave (continuers), 2) those who reported using a different method from previous wave (switchers), and 3) those who reported using no contraceptive method at that wave (discontinuers). We report the frequency of outcomes and conducted multinomial regression models assessing predictors of switching and discontinuation. RESULTS: Among 4,289 participants included in this analysis, 2,179 (50.8%) reported at least one instance of switching or discontinuation, and 2,110 (49.1%) reported continuing with their baseline method at the end of the study. Those reporting method change (switching or discontinuing) reported an average of 1.93 change events over the study follow-up period (range 1-8). Among those reporting any method change, 522 participants (23.9%) reporting at least one instance of both switching and discontinuation. Among those reporting any instance of discontinuation (n=966), 498 (51.6%) never reported uptake of a subsequent method. Among those who did report a subsequent method (n=468), 210 (44.8%) reported restarting a previously used method, and 258 (55.1%) reported starting a new method. Although we identified overlap among variables associated with switching and discontinuation, other predictors were discordant between switching and discontinuation. CONCLUSION: New contraceptive users commonly switch and discontinue methods. User behavior is associated with certain demographic characteristics and pregnancy planning. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT02734199.

Pharmaceutical messianism and the politics of COVID-19 in the United States.

Throughout the COVID-19 pandemic, public officials in the United States - from the President to governors, mayors, lawmakers, and even school district commissioners - touted unproven treatments for COVID-19 alongside, and sometimes as opposed to, mask and vaccine mandates. Utilising the framework of 'pharmaceutical messianism', our article focuses on three such cures - hydroxychloroquine, ivermectin, and monoclonal antibodies - to explore how pharmaceuticals were mobilised within politicised pandemic discourses. Using the states of Utah, Texas, and Florida as illustrative examples, we make the case for paying attention to pharmaceutical messianism at the subnational and local levels, which can very well determine pandemic responses and outcomes in contexts such as the US where subnational governments have wide autonomy. Moreover, we argue that aside from the affordability of the treatments being studied and the heterodox knowledge claiming their efficacy, the widespread uptake of these cures was also informed by popular medical (including immunological) knowledge, pre-existing attitudes toward 'orthodox' measures like vaccines and masks, and mistrust toward authorities and institutions identified with the 'medical establishment'. Taken together, our case studies affirm the recurrent nature of pharmaceutical messianism in times of health crises - while also refining the concept and exposing its limitations.

Obesity-Preventive Behaviors and Improvements in Depression among Diverse Utah Women Receiving Coaching from Community Health Workers.

OBJECTIVES: This study evaluated how high versus low-intensity community wellness coaching and health behaviors were associated with changes in depression screen results over one year. METHODS: This was an analysis of secondary data collected in a 12-month obesity-related community health worker (CHW) program for 485 Utah women of color. Depression screen (Patient Health Questionnaire-2 score ³3) and self-reported fruit/vegetable consumption and physical activity (FV/PA) were recorded quarterly. Associations between FV/PA and changes in depression screen over time were evaluated in multivariable models. RESULTS: Positive depression screen prevalence declined over 12 months (21.7% to 9.5%) with no difference between study arms. Overall, FV ³5 times/day (AOR=1.5; 95% CI 1.0-2.2), any PA (AOR=3.1; 95% CI 1.5-6.4), and muscle strengthening activities (AOR=1.13; 95% CI 1.01-1.26) were associated with improved depression screen results over time. CONCLUSION: These results indicate value in addressing and evaluating depression in obesity-related interventions in underserved communities.

A Case Report on Product Rotation to Manage Severe Lysinibacillus sphaericus Resistance in Culex pipiens from Salt Lake City, Utah.

The Salt Lake City Mosquito Abatement District (SLCMAD) detected a 20,000-fold resistance to Lysinibacillus sphaericus (Lsph) in Culex pipiens occurring in catch basins of Salt Lake City during 2016. In response, SLCMAD suspended use of Lsph and rotated use of spinosyn and s-methoprene products for the next three years. At the end of the third year, Lsph was evaluated again and efficacy similar to susceptible colony strains. During the second year of Lsph use, technicians observed lack of control of larvae at some urban sites. Bioassays performed during 2021 showed recurrence of some resistance to Lsph to varying degrees across SLCMAD urban areas. The rapidity with which resistant phenotypes reemerged clarifies that SLCMAD cannot in the near future rely on repeated use of Lsph, even after suspending use for three years and using within-season product rotations. Prior reports in other research groups have found long-term selection to Lsph, as is the case at SLCMAD, to not regress in spite of halting use of the products. However, our findings offer some optimism that regression may be relatively quick. More operational review is needed, and future work should characterize resistance alleles in field populations. Collectively, there is a lack of concrete data supporting the prevailing assumptions from adjacent industries that were adopted into mosquito abatement. We provide this short note as additional guidance for mosquito and vector control districts weighing options to remediate Lsph resistance.

Developing semiochemical repellents for protecting Picea from Dendroctonus rufipennis (Coleoptera: Curculionidae) in Alaska and Utah, USA.

Spruce beetle, Dendroctonus rufipennis (Kirby) (Coleoptera: Curculionidae), is the most destructive pest of mature spruce (Picea) in western North America. Recent outbreaks in Alaska and other western US states highlight the need for tools to protect Picea from D. rufipennis. The primary antiaggregation pheromone of D. rufipennis (3-methylcyclohex-2-en-1-one, MCH) and various combinations of potential repellents (1-octen-3-ol, exo-brevicomin, endo-brevicomin, ipsdienol, ipsenol, limonene, and verbenone) were tested for their ability to disrupt the response of D. rufipennis to attractant-baited multiple-funnel traps. Two assays were conducted on the Kenai Peninsula, Alaska, in June and July 2021. All treatments significantly reduced the mean number of D. rufipennis caught compared to the baited control. No other significant differences were observed among treatments. Informed by these and other data, tree protection studies were established in Lutz spruce, Picea × lutzii, on the Kenai Peninsula in 2022 and in Engelmann spruce, Pi. engelmannii, in the Uinta Mountains, Utah, in 2021. All experimental trees were baited with frontalin. Repellent treatments included MCH (SPLAT MCH, ISCA Inc., Riverside, CA, USA) and at least 1 additional repellent combination. In Alaska, all treatments significantly reduced colonization (strip attacks + mass attacks) and mortality of individually treated Pi. × lutzii and all Picea within 11.3-m radius of each treated Pi. × lutzii compared to the control. In Utah, all treatments except for SPLAT MCH + octenol significantly reduced colonization compared to the control. Only SPLAT MCH + Acer kairomone blend (AKB) and SPLAT MCH + octenol reduced Pi. engelmannii mortality compared to the control. SPLAT MCH + AKB and SPLAT MCH + acetophenone and green leaf volatiles (PLUS) were the most effective across both studies. The implications of these and other results to the development of an effective semiochemical repellent for D. rufipennis are discussed.

Impact of Local Tailoring on Acute Stroke Care in 21 Disparate Emergency Departments: A Prospective Stepped Wedge Type III Hybrid Effectiveness-Implementation Study.

BACKGROUND: Faster delivery of tPA (tissue-type plasminogen activator) results in better health outcomes for eligible patients with stroke. Standardization of stroke protocols in emergency departments (EDs) has been difficult, especially in nonstroke centers. We measured the effectiveness of a centrally led implementation strategy with local site tailoring to sustain adherence to an acute stroke protocol to improve door-to-needle (DTN) times across disparate EDs in a multihospital health system. METHODS: Prospective, type III hybrid effectiveness-implementation cohort study measuring performance at 21 EDs in Utah and Idaho (stroke centers [4]/nonstroke centers [17]) from January 2018 to February 2020 using a nonrandomized stepped-wedge design, monthly repeated site measures and multilevel hierarchical modeling. Each site received the implementation strategies in 1 of 6 steps providing control and intervention data. Co-primary outcomes were percentage of DTN times ≤60 minutes and median DTN time. Secondary outcomes included percentage of door-to-activation of neurological consult times ≤10 minutes and clinical effectiveness outcomes. Results were stratified between stroke and nonstroke centers. RESULTS: A total of 855 474 ED patient encounters occurred with 5325 code stroke activations (median age, 69 [IQR, 56-79] years; 51.8% female patients]. Percentage of door-to-activation times ≤10 minutes increased from 47.5% to 59.9% (adjusted odds ratio, 1.93 [95% CI, 1.40-2.67]). A total of 615 patients received tPA of ≤3 hours from symptom onset (median age, 71 [IQR, 58-80] years; 49.6% female patients). The percentage of DTN times ≤60 minutes increased from 72.5% to 86.1% (adjusted odds ratio, 3.38, [95% CI, 1.47-7.78]; stroke centers (77.4%-90.0%); nonstroke centers [59.3%-72.1%]). Median DTN time declined from 46 to 38 minutes (adjusted median difference, -9.68 [95% CI, -17.17 to -2.20]; stroke centers [41-35 minutes]; nonstroke centers [55-52 minutes]). No differences were observed in clinical effectiveness outcomes. CONCLUSIONS: A centrally led implementation strategy with local site tailoring led to faster delivery of tPA across disparate EDs in a multihospital system with no change in clinical effectiveness outcomes including rates of complication. Disparities in performance persisted between stroke and nonstroke centers.

Utah flouts FDA with new placental stem cell law.

Measure declares that patients can be given unapproved treatments.