Hendrick Medical Center

Background: Environmental screening and mapping (ESM) tools can characterize the spatial distribution of environmental hazards and their effects, health status, and demographics of communities. For communities impacted by environmental injustices, ESM tools can play an important role in identifying areas facing cumulative impacts (CI). Methods: We identified 36 state and federal ESM tools to analyze. Map layers/indicators were organized by subcategories within nine broad categories. A framework was used to assess tools: number and variety of indicators and layers included; types of geospatial options available to view data; presence and type of qualitative data included; and type of methodology used for creating indices. Results: A total of 197 subcategories were identified. The most common subcategories used across tools were race/ethnicity ( n = 31), income/poverty ( n = 31), and designation for priority or EJ areas ( n = 29). Few tools included layers for structural racism, qualitative data, and those relevant to rural communities. Most tools ( n = 32) utilized composite measures or thresholds to identify impacted areas, often at the census tract level. Discussion: To ensure tools accurately reflect communities’ lived experiences, community engagement is essential. Tools should incorporate qualitative data, expand the use of indicators relevant to rural communities, offer differing geospatial units to view data, and incorporate measures of structural racism and inequity. While ESM tool indices can help identify impacted areas, limitations still exist. However, the use of ESM tools to address CI has great promise. Conclusion: Enhancing ESM tools for environmental decision making can support community-led and government actions to address CI and promote environmental justice.

Fluorescence-guided surgery aims to improve intraoperative identification of vital structures. Rizedisben is a myelin-binding fluorophore that fluoresces in the blue light (370-425 nm) spectrum to improve intraoperative nerve identification. To determine the optimal safe and clinically effective dose of rizedisben for sustained intraoperative fluorescence of nerve structures. A single-arm, open-label, phase 1 study was conducted in patients undergoing robot-assisted laparoscopic radical prostatectomy (RALP) at an urban academic cancer center in New York City between January 2023 and October 2024. Using a dose escalation design, increasing doses of rizedisben were administered after safety was assessed at each level until a clinically effective dose was determined. The obturator nerve served as the reference nerve for measuring fluorescence intensity. Eligible patients were 18 years old and older, diagnosed with prostate cancer, and scheduled for RALP. Patients were recruited in preoperative clinic visits once deemed eligible for the study. Those with prior pelvic surgery or radiation, known central or peripheral nervous system disease, current use of neurotoxic medications, recent exposure to phototoxic drugs, or serious kidney or liver dysfunction were excluded. Rizedisben was intravenously administered intraoperatively 30 minutes prior to visualization of the obturator nerve. Safety was assessed through 45 postoperative days. Fluorescence was measured via subjective intraoperative scoring and by post hoc objective image analysis. Clinically effective dose was defined as achieving sustained fluorescence of the obturator nerve in 3 or more of 5 patients in 2 consecutive cohorts, provided fewer than 20% of patients experienced grade 2 or greater toxicity. Sustained fluorescence was defined as moderate or better fluorescence for 90 minutes or longer. At the clinically effective dose, fluorescence assessments of the neurovascular bundles were included. Thirty-eight patients (median [IQR] age, 61.5 [57.8-66.3] years) enrolled in and completed the trial. Dosing was escalated from 0.25 to 3.0 mg/kg. There was 1 grade 2 adverse event (rash) possibly attributable to rizedisben. Sustained fluorescence of the obturator nerve was achieved in all patients at 3.0 mg/kg. Prostate neurovascular bundles demonstrated evidence of fluorescence in 8 of 9 (89%) patients at 3.0 mg/kg. In this phase 1 trial of rizedisben, the 3.0-mg/kg dose was shown to be generally well tolerated and clinically effective. At this dose, there was excellent sustained fluorescence of the obturator nerves, and the neurovascular bundles were visualized in 8 of 9 patients. Based on these data, we are designing phase 2 studies with rizedisben for additional indications. ClinicalTrials.gov Identifier: NCT04983862.

Background It is unclear how back squat depth influences muscle activation and should be considered when designing strength training programs. Current evidence suggests this relationship is population-specific and should be examined in different populations to optimize strength training outcomes. This study examined the effect of different squat depths on muscle activation in college football players. Methods Sixteen Division II college football players performed back squat at three depths (C1 = 65°, C2 = 90°, and C3 = 115° knee flexion). During the descent and ascent phases, five-trial averages of mean gluteus maximus (GM), semitendinosus (ST), biceps femoris (BF), vastus medialis (VM), and vastus lateralis (VL) activation were calculated. Phase-specific differences were examined by calculating one-way repeated analyses of variance (α=0.05) and Bonferroni-corrected paired t-tests for post-hoc comparisons. Results Compared to C1, activation increased during C2 and C3 for the VM, VL, and BF during the descent and ascent phases. Additionally, during ascent, the greatest VM, VL, and BF activation occured during C3. Semitendinosus activation increased during C2 and C3 compared to C1 during the ascent phase, but it was not affected during the descent phase. Similarly, no GM activation changes were observed in either phase. Conclusions These findings indicate back squat depth influence on muscle activation is phase- and muscle-specific and should be considered when designing strength training programs for college football players.

Purpose: Competency-based education and creation of profession-based entrustable professional activities are current trends in physical therapist (PT) education. The purpose of this project is to determine the current entry-level PT competencies for cardiovascular & pulmonary (CVP) physical therapy. Methods: The Academy of Cardiovascular & Pulmonary Physical Therapy Competency Task Force was established to update and expand previous competencies. A mixed method approach of Subject Matter Expert (SME) consensus (modified Delphi process) and a broader survey process was used to develop these entry-level competencies. With SME guidance, a modified version of the levels of competence, None-to-Proficient, was adopted based on previous competency work by the American Council of Academic Physical Therapy. Results: Twenty-nine SME members engaged in the consensus process, and 268, 194, 305, and 222 respondents completed the 4 surveys, respectively. Six hundred fifty-one competency items were rated across most Commission on the Accreditation of Physical Therapy Education Standard 7 Curriculum areas, following the patient–client management model. Conclusions: These competencies establish specific expected levels of knowledge, skills, and behaviors essential for entry-level CVP PT practice. Adopting these competencies will help lay the groundwork for future competency-based PT education and aid in the development of the physical therapy profession's core entrustable professional activities.

Competency-based education (CBE) is an emerging topic within physical therapy (PT). It has emerged to assure all stakeholders that physical therapist education program graduates are proficient in the requisite knowledge, skills, and behaviors (KSBs) essential for entry-level practice. Competencies have existed within cardiovascular and pulmonary (CVP) PT since 1980, updated in 2008, and most recently updated in 2022. This article discusses how individuals should apply the 2022 CVP competencies to clinical practice and education. The 2022 CVP competencies were developed using a modified mixed-method Delphi approach. These competencies set a level of proficiency for KSBs used within entry-level CVP PT practice following the patient-client management model. The position put forward in this article describes how and why multiple stakeholder groups should apply these entry-level competencies specifically for graduates of physical therapist education programs who are entering practice (entry level). The competencies provide a more detailed description of expected proficiency for entry-level CVP PT practice than currently available documents. These competencies may form the basis for developing entrustable professional activities (EPAs). The establishment of entry-level competencies is essential for use by multiple stakeholders to inform physical therapist curriculum, provide clinical instructors with a reference for expected levels of proficiency during final student clinical experiences, guide content on the Federation of State Boards of PT national licensure examination, and prepare employers to provide needed continued professional development, based on the clinical environment. These competencies lend themselves to the future development of EPAs in the PT profession for CVP PT.

There is limited evidence identifying best practices to promote competency of accurate assignment of the Emergency Severity Index (ESI) acuity level to patients who present to the emergency department (ED) triage. Triage-trained nurses do not receive competency training in an ESI triage tool. A retrospective chart review of 150 patients was completed to evaluate mistriage rates before and after triage-trained nurses completed an ESI competency assessment. The retrospective chart review showed no statistically significant difference in mistriage from pre- to postintervention ( P = .8535). Implementation of an ESI annual competency assessment aligns well with an emerging theme in the literature that ED nurses should be provided with ongoing education that reinforces knowledge and implementation of ESI triaging.

Introduction:Time of medication delivery from the onset of illness is one factor that determines disease outcomes. In this study, we aimed to reduce the average time from admission to the first dose of antibiotic by at least 30% and increase the percentage of neonates receiving the first antibiotic dose within 1 hour of neonatal intensive care unit arrival to 50% over 12 months in asymptomatic neonates 34 weeks and older estimated gestational age with exposure to maternal chorioamnionitis as a sample population.Method:This study involved 135 infants 34 weeks and older gestational age exposed to chorioamnionitis. We documented the demographic characteristics of mothers and infants. We monitored time to the administration of the first dose of antibiotics through multiple plan-do-study-act cycles. We identified barriers to timely antibiotic administration and targeted them with multipronged interventions in plan-do-study-act cycles. Process measures were displayed monthly using X-bar/S control charts and P charts. We applied established rules for detecting a special cause.Results:We reduced the meantime to the first dose of antibiotics from 130 to 78 minutes (40% reduction). The percentage of infants who received the first antibiotic dose within 60 minutes rose from 5.8% to 36.3% during the study period. Special cause improvement was seen in all process measures. The most significant improvement seen was in the time to obtain a blood culture and the interval between intravenous access placement and antibiotic delivery.Conclusion:Multipronged interventions can help improve timely medication delivery to neonates in the neonatal intensive care unit in this example of infants exposed to chorioamnionitis.

Background:Significant geographical variations exist in amputation rates and utilization of diagnostic and therapeutic vascular procedures before lower extremity amputations in the United States. The purpose of this study was to evaluate the rates of diagnostic and therapeutic vascular procedures in the year prior to amputation in a contemporary population and correlate with pathological findings of the amputation specimens.Methods:A retrospective analysis was conducted of non-traumatic amputations from 2011 to 2017 at a rural community hospital. We reviewed the proportion of patients undergoing diagnostic (ankle brachial index with duplex ultrasound, computerized tomography angiogram and invasive angiogram) and therapeutic (endovascular and surgical revascularization) vascular procedures in the year prior to amputation. Prevalence of tissue viability and osteomyelitis were evaluated in all amputated specimens and atherosclerotic vascular disease (ASVD) was evaluated in major amputations. We also analyzed primary amputation rates among different subgroups.Results:698 patients were included with 248 (36%) major amputations and 450 (64%) minor amputations. Any diagnostic procedure was performed in 59% of the major amputations and 49% of the minor amputations (P = 0.01). Any therapeutic revascularization procedure was performed in 34% of the major amputations and 28% of the minor amputations (P = 0.08). The pathology of major amputation specimens revealed severe ASVD in 57% and mild-moderate ASVD in 27% of specimens. Tissue viability was significantly higher in major amputations (90% vs 30%, P = 0.04) and osteomyelitis was significantly higher in minor amputations (50% vs 14%, P = 0.03). Primary amputations were performed in 66% of major amputations, 72% of minor amputations, 81% with mild to moderate ASVD and 54% with severe ASVD.Conclusion:Diagnostic and therapeutic vascular procedures appear under-utilized for patients undergoing lower extremity amputations at a rural community hospital. ASVD rates and tissue viability imply that revascularization could be of significant benefit to avoid major amputation.

Parking is a serious issue in many urban areas, especially those experiencing rapid population growth. To address this problem, some cities have implemented demand-responsive pricing programs, where parking prices vary depending on the occupancy rate in a previous period. Yet, few empirical studies have rigorously evaluated these programs, though they have the potential to improve turnover and much needed parking availability in growing cities with limited infrastructure. In this study, we investigate the impacts of SFpark, a demand-responsive pricing parking program in San Francisco that began in 2011. We focus on metered, on-street parking and exploit the timing of SFpark as a natural experiment. We observe effects on three important aspects of urban transportation: parking availability, transit bus ridership and congestion. The timing of this program is plausibly exogenous to factors that affect these outcomes of interest since it is based on bureaucratic decision-making, so endogeneity is less of a concern. We generate a novel panel data set by merging detailed parking occupancy and meter rate data with micro-level transit bus ridership information at the bus stop-bus shift level. Results show that SFpark led to more areas meeting the target occupancy range of 60-80%. We also find heterogeneous effects on transit ridership and show an increase in meter rates is associated with a modest increase in ridership, suggesting people are substituting between transit and non-transit travel and that meter rates factor into mode choice. Finally, we find SFpark reduced congestion, specifically decreasing lane occupancy and increasing vehicle speed. These results have important implications for transportation policy as cities continue to expand and implement demand-responsive pricing programs globally.