Inpatient Rehabilitation Quality of Care From the Patient's Perspective: Effect of Data Collection Timing and Patient Characteristics.

OBJECTIVE: To compare, by collection time and patient characteristics, inpatient rehabilitation quality measure scores calculated using patient-reported data. DESIGN: Cohort study of rehabilitation inpatients with neurologic conditions who reported their experience of care and pain status at discharge and 1month after discharge. SETTING: Two inpatient rehabilitation facilities (IRFs). PARTICIPANTS: Patients with neurologic conditions (N=391). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We calculated 18 quality measure scores using participants' responses to 55 experience of care and health status questions addressing communication, support and encouragement, care coordination, discharge information, goals, new medications, responsiveness of staff, cleanliness, quietness, pain management, care transitions, overall hospital rating, willingness to recommend, and pain. RESULTS: Of the 391 participants reporting at discharge, 277 (71%) also reported postdischarge after multiple attempts by e-mail, mail, and telephone. Discharge experience of care quality scores ranged from 25% (responsiveness of hospital staff) to 75% (willingness to recommend hospital); corresponding postdischarge scores were 32% to 87%, respectively. Five of the 16 experience of care quality scores increased significantly between discharge and postdischarge. The percentage of participants reporting high pain levels at discharge did not change across time periods. Patients with less education, older age, higher motor and cognitive function, and those who were not Hispanic or black had more favorable quality measure scores. CONCLUSION: Patients' experience of care responses tended to be more favorable after discharge compared to discharge, suggesting that survey timing is important. Responses were more favorable for patients with selected characteristics, suggesting the possible need for risk adjustment if patient-reported quality measure scores are compared across IRFs.

A noncytolytic α toxin recombinant protein protects turkeys against Clostridium septicum challenge.

Clostridium septicum and its associated cytolytic α toxin, along with several other clostridial species, has been implicated as the causative agent of gangrenous dermatitis. A recombinant noncytolytic C. septicum α toxin (NCAT) peptide was developed for use as a vaccine and demonstrated to be safe at concentrations as high as 1 mg/ml. NCAT, used as a purified antigen, partially purified antigen, or in combination with native antigens, was compared to salt-fractionated α toxin combined with denatured C septicum bacteria (native) in a vaccination trial. Three-day-old poults were placed into one of five groups and received two, 0.2-ml vaccinations 5 wk apart. Subcutaneous challenge with 3.2 x 10(7) log phase C. septicum resulted in 78% to 95% of the vaccinated birds surviving challenge compared to 48% of sham-injected controls. By ELISA analysis on NCAT-coated plates, birds receiving vaccines containing the recombinant NCAT peptide showed significantly higher blood serum antibody concentrations than did birds receiving vaccines containing native antigens or alum controls. Additionally, high levels of maternally transferred antibodies reactive to NCAT-purified antigens found in the pre-immune sera from naive 3-day-old poults suggest that the tertiary structure of the NCAT peptide has a high homology to the native protein structure. In conclusion, our study showed that the use of a vaccine comprised of a noncytolytic recombinant α toxin peptide antigen provided clinical protection equal to the use of vaccines formulated with inactivated native proteins at a reduced overall cost.

The design, implementation, and operational management of a comprehensive quality management program to support national telehealth networks.

The Veterans Health Administration (VHA) is a large integrated healthcare system with a mission to care for over 5.6 million Veteran patients annually. VHA, like other healthcare organizations, is challenged with providing access to care to those it serves when they live at a distance from a physical site of care. VHA has embraced telehealth as a way of delivering care at a distance and increase access to specialty care services. Since 2003 VHA has developed large national telehealth networks that provided care to 497,342 patients in fiscal year 2012, who received 1,429,424 episodes of care, and is recognized as a national leader in this field. To ensure the safety and effectiveness of its telehealth networks in their delivery of care VHA has implemented a dedicated quality management (QM) program for telehealth. QM data for telehealth are reviewed at 3-month intervals, and the procedures and processes in place to support telehealth in VHA are assessed biannually in an internal accreditation process called "Telehealth Conditions of Participation." This collegial, nonadversarial process has ensured that all designated telehealth programs meet minimal standards and disseminate best practice. As a result of VHA's QM program, telehealth services in VHA meet consistently high clinical outcomes and have received no adverse Joint Commission citations. The Joint Commission regularly assesses patients managed via telehealth under its tracer methodology reviews.

Passport, a native Tc1 transposon from flatfish, is functionally active in vertebrate cells.

The Tc1/mariner family of DNA transposons is widespread across fungal, plant and animal kingdoms, and thought to contribute to the evolution of their host genomes. To date, an active Tc1 transposon has not been identified within the native genome of a vertebrate. We demonstrate that Passport, a native transposon isolated from a fish (Pleuronectes platessa), is active in a variety of vertebrate cells. In transposition assays, we found that the Passport transposon system improved stable cellular transgenesis by 40-fold, has an apparent preference for insertion into genes, and is subject to overproduction inhibition like other Tc1 elements. Passport represents the first vertebrate Tc1 element described as both natively intact and functionally active, and given its restricted phylogenetic distribution, may be contemporaneously active. The Passport transposon system thus complements the available genetic tools for the manipulation of vertebrate genomes, and may provide a unique system for studying the infiltration of vertebrate genomes by Tc1 elements.

Home telehealth: patient satisfaction, program functions, and challenges for the care coordinator.

Home telehealth programs can enhance older adults' access to care, but eliciting accurate information regarding program effectiveness is challenging because patients are reluctant to criticize. This study sought accurate patient perspectives about both benefits and challenges of the Veterans Health Administration's rapidly expanding care coordination/home telehealth program. Patients who completed the standard 8-item satisfaction survey were subsequently interviewed, and the transcripts were content analyzed to identify program functions most salient to patients and program components most challenging for patients. Interviews generally supported patients' high survey ratings but also revealed some challenges that the survey did not capture. Program functions most salient to patients were providing access, educating or instructing, and monitoring or tracking. However, patients were frustrated by equipment problems as well as care coordinator inaccessibility and slow response. Gathering detailed information about patient perceptions of health care delivery is important so challenges can be addressed to meet patients' expectations.

Virtual Reality Is Sexist: But It Does Not Have to Be.

The aim of this study was to assess what drives gender-based differences in the experience of cybersickness within virtual environments. In general, those who have studied cybersickness (i.e., motion sickness associated with virtual reality [VR] exposure), oftentimes report that females are more susceptible than males. As there are many individual factors that could contribute to gender differences, understanding the biggest drivers could help point to solutions. Two experiments were conducted in which males and females were exposed for 20 min to a virtual rollercoaster. In the first experiment, individual factors that may contribute to cybersickness were assessed via self-report, body measurements, and surveys. Cybersickness was measured via the simulator sickness questionnaire and physiological sensor data. Interpupillary distance (IPD) non-fit was found to be the primary driver of gender differences in cybersickness, with motion sickness susceptibility identified as a secondary driver. Females whose IPD could not be properly fit to the VR headset and had a high motion sickness history suffered the most cybersickness and did not fully recover within 1 h post exposure. A follow-on experiment demonstrated that when females could properly fit their IPD to the VR headset, they experienced cybersickness in a manner similar to males, with high cybersickness immediately upon cessation of VR exposure but recovery within 1 h post exposure. Taken together, the results suggest that gender differences in cybersickness may be largely contingent on whether or not the VR display can be fit to the IPD of the user; with a substantially greater proportion of females unable to achieve a good fit. VR displays may need to be redesigned to have a wider IPD adjustable range in order to reduce cybersickness rates, especially among females.

A method for the rapid isolation of virus from cultured cells.

A simple and efficient collection method using hypotonic burst to isolate virions from infected cultured cells is described. Distilled water treatment of avian metapneumovirus (AMPV)-infected cells with thorough mixing and repeated pipeting was considerably faster for virion collection in avian cells compared to the widely used freeze-thaw (F-T) method (30 min vs. 3-4 h). This method was also more effective for virion collection. The total number of virions recovered from AMPV-infected immortal turkey turbinate cells by the novel water lysis method was 3-fold higher than by the F-T method. This simple water lysis method can be applied to virion collection for other RNA viruses such as the paramyxoviruses that are used to infect cultured cells.

Species-specific deletion of the viral attachment glycoprotein of avian metapneumovirus.

The avian metapneumovirus (AMPV) genome encodes the fusion (F), small hydrophobic (SH), and attachment glycoprotein (G) as envelope glycoproteins. The F and G proteins mainly function to allow viral entry into host cells during the early steps of the virus life cycle. The highly variable AMPV G protein is a major determinant for distinguishing virus subtypes. Sequence analysis was used to determine if any differences between avian or mammalian cell propagated subtype C AMPV could be detected for the 1.8kb G gene. As a result, the complete 1.8kb G gene was found to be present when AMPV was propagated in our immortal turkey turbinate (TT-1) cell line regardless of passage number. Surprisingly, AMPV propagated for 15 or more passages in mammalian Vero cells revealed an essentially deleted G gene in the viral genome, resulting in no G gene mRNA expression. Although the Vero cell propagated AMPV genome contained a small 122 nucleotide fragment of the G gene, no other mRNA variants were detected from either mammalian or avian propagated AMPV. The G gene truncation might be caused by cellular molecular mechanisms that are species-specific. The lack of viral gene deletions suggests that avian cell propagated AMPV will provide a better alternative host for live recombinant vaccine development based on a reverse genetics system.

Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions.

Between July 2003 and December 2007, the Veterans Health Administration (VHA) introduced a national home telehealth program, Care Coordination/Home Telehealth (CCHT). Its purpose was to coordinate the care of veteran patients with chronic conditions and avoid their unnecessary admission to long-term institutional care. Demographic changes in the veteran population necessitate VHA increase its noninstitutional care (NIC) services 100% above its 2007 level to provide care for 110,000 NIC patients by 2011. By 2011, CCHT will meet 50% of VHA's anticipated NIC provision. CCHT involves the systematic implementation of health informatics, home telehealth, and disease management technologies. It helps patients live independently at home. Between 2003 and 2007, the census figure (point prevalence) for VHA CCHT patients increased from 2,000 to 31,570 (1,500% growth). CCHT is now a routine NIC service provided by VHA to support veteran patients with chronic conditions as they age. CCHT patients are predominantly male (95%) and aged 65 years or older. Strict criteria determine patient eligibility for enrollment into the program and VHA internally assesses how well its CCHT programs meet standardized clinical, technology, and managerial requirements. VHA has trained 5,000 staff to provide CCHT. Routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients shows the benefits of a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrolment into the program. The cost of CCHT is $1,600 per patient per annum, substantially less than other NIC programs and nursing home care. VHA's experience is that an enterprise-wide home telehealth implementation is an appropriate and cost-effective way of managing chronic care patients in both urban and rural settings.

Assessing the need for developing a comprehensive content-validated pressure ulcer guideline.

Healthcare professionals need evidence-based strategies and guidelines for care to optimize pressure ulcer prevention and management. Differences among pressure ulcer guidelines confuse caregivers, reducing consistency of care. To assess the need for a comprehensive content-validated guideline document, the Association for the Advancement of Wound Care Guideline Subcommittee evaluated current pressure ulcer guideline recommendations by compiling 10 pressure ulcer-specific guidelines existing before June 2008 on the National Guideline Clearinghouse website along with the National Pressure Ulcer Advisory Panel (draft), European Pressure Ulcer Advisory Panel (draft), and Wound Healing Society guidelines. Steps for each aspect of pressure ulcer management were compiled and inconsistent recommendations identified. Currently available pressure ulcer guidelines were found to differ in definitions, aspects of care, validation, evidence criteria, and procedural recommendations, potentially affecting consistency and quality of all aspects of pressure ulcer management, including diagnosis, prevention, treatment, and outcomes measurement. To address these inconsistencies, a comprehensive list of Pressure Ulcer Care Initiative (PUCI) steps was prepared for content validation and posted on www.aawconline.org, enabling healthcare professionals interested in improving the consistency and quality of pressure ulcer prevention and care to participate in this process. All steps with a content validity index > 0.75 (rated clinically relevant by survey respondents) and/or with A-level standardized clinical evidence support will be included in the comprehensive PUCI guideline. Content validation of recommendations is an important first step to improving the consistency of pressure ulcer care.

Feasibility of Collecting Patient-Reported Outcomes for Inpatient Rehabilitation Quality Reporting.

OBJECTIVE: To evaluate rehabilitation inpatients' willingness and ability to complete patient-reported outcomes (PROs) and the burden of completion on patients and staff. DATA SOURCES/STUDY SETTING: Two inpatient rehabilitation facilities. STUDY DESIGN: Patients with neurological disorders were assigned randomly to receive a nominal monetary incentive during or 1 month after the stay. DATA COLLECTION: Patients responded using a tablet computer or paper. PRINCIPAL FINDINGS: Of the 1,055 admissions, 74 percent were eligible, and 51 percent of eligible patients completed the survey. Most answered without assistance. A majority completed the survey 1 month after discharge; incentive timing was unrelated to postdischarge completion. Half of the 285 follow-up respondents required at least two reminder calls. CONCLUSIONS: Collection of PROs from rehabilitation patients is feasible. Results inform policy makers regarding feasibility of PRO data in evaluating rehabilitation quality.

Using PROMIS Pain Interference Items to Improve Quality Measurement in Inpatient Rehabilitation Facilities.

OBJECTIVE: To evaluate the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference items for use in a quality measure and to compare the resulting quality score, along with internal reliability and validity, to a similar item set in the Minimum Data Set Version 3.0 (MDS). DESIGN: Cross-sectional, observational study. SETTING: One freestanding inpatient rehabilitation facility (IRF) and one large hospital-based IRF. PARTICIPANTS: Patients with neurologic disorders. Of 1055 consecutive admissions, 26% were excluded based on clinician-determined cognitive impairment or emotional distress. Of the remainder, 50% consented and completed the survey near the end of their IRF stay (N = 391). Of these, more than half (57%) reported pain over the last day (n = 224). MEASUREMENTS: Psychometric statistics and quality scores were computed from a 55-question survey, including the MDS and PROMIS pain interference items. RESULTS: Estimates for internal reliability were higher for the PROMIS 2-item scale compared to the MDS: Cronbach α (0.86 vs 0.48) and interitem correlations (0.75 vs 0.31). The PROMIS-2 items were better able to detect differences in patients with mild and severe pain intensity (Cohen d = 1.57) relative to the corresponding MDS items (Cohen d = 0.81). Two quality scores based on the PROMIS-2 items, reflecting low and high levels of pain interference, showed 46% or 12% of patients meeting these thresholds. This compared to a 30% rate when patients were classified by the MDS as experiencing pain interference. CONCLUSIONS: PROMIS pain interference items appear to be more internally consistent than similar MDS items. The graded PROMIS items permit the creation of multiple quality scores, showing predictable overlap with corresponding MDS quality scores. Because PROMIS items provide finer distinctions, they allow greater latitude in reporting quality scores. We recommend further study of pain interference scores across IRFs to improve their reliability and validity.

Enzymatic engineering of the porcine genome with transposons and recombinases.

BACKGROUND: Swine is an important agricultural commodity and biomedical model. Manipulation of the pig genome provides opportunity to improve production efficiency, enhance disease resistance, and add value to swine products. Genetic engineering can also expand the utility of pigs for modeling human disease, developing clinical treatment methodologies, or donating tissues for xenotransplantation. Realizing the full potential of pig genetic engineering requires translation of the complete repertoire of genetic tools currently employed in smaller model organisms to practical use in pigs. RESULTS: Application of transposon and recombinase technologies for manipulation of the swine genome requires characterization of their activity in pig cells. We tested four transposon systems- Sleeping Beauty, Tol2, piggyBac, and Passport in cultured porcine cells. Transposons increased the efficiency of DNA integration up to 28-fold above background and provided for precise delivery of 1 to 15 transgenes per cell. Both Cre and Flp recombinase were functional in pig cells as measured by their ability to remove a positive-negative selection cassette from 16 independent clones and over 20 independent genomic locations. We also demonstrated a Cre-dependent genetic switch capable of eliminating an intervening positive-negative selection cassette and activating GFP expression from episomal and genome-resident transposons. CONCLUSION: We have demonstrated for the first time that transposons and recombinases are capable of mobilizing DNA into and out of the porcine genome in a precise and efficient manner. This study provides the basis for developing transposon and recombinase based tools for genetic engineering of the swine genome.

Establishment of an immortal turkey turbinate cell line suitable for avian metapneumovirus propagation.

Until recently, there has not been a homologous avian cellular substrate which could continuously produce high titer avian metapneumovirus (AMPV); development of such a cell line should provide an excellent model system for studying AMPV infection. We have established a non-tumorigenic immortal turkey turbinate cell line (TT-1) to propagate sufficiently high AMPV titers. Currently, immortal TT-1 cells are growing continuously at 1.2-1.4 population doublings per day and are at passage 160. Kinetic analysis suggests that AMPV can infect and replicate more rapidly in TT-1 compared to Vero cells, although both cell types undergo apoptosis upon infection. The non-tumorigenic, reverse transcriptase negative TT-1 cell line can serve as an excellent homologous cellular substrate for virus propagation.

Comparison of avian cell substrates for propagating subtype C avian metapneumovirus.

Avian metapneumovirus (AMPV) is a respiratory viral pathogen that causes turkey rhinotracheitis (TRT) or swollen head syndrome (SHS) in chickens. AMPV was first isolated in South Africa during the early 1970s and has subsequently spread worldwide during the 1980s to include Europe, Asia, and South America. In 1996, a genetically distinct AMPV subgroup C was isolated in the US following an outbreak of TRT. Vero cells are currently the best available substrate for AMPV propagation but are of non-avian origin. A number of different avian cell substrates have been compared to determine which is the most suitable for the propagation of AMPV to sufficiently high titers. Of the cell substrates tested, primary turkey turbinate and kidney and chicken kidney cells produced titers equal to or greater than Vero cells. Turkey turbinate and kidney epithelial cells that were life-span extended by the ectopic expression of human telomerase catalytic subunit (HTERT) initially displayed AMPV titers comparable to Vero cell controls, but declined in virus production with increased passage in culture. Interestingly, plaques emanating from Vero propagated virus were relatively small and dispersed, when analyzed by immunofluorescent assays (IFA), while both turkey turbinate and kidney cell propagated AMPV produced larger plaques. Even with these differences, there were no changes in the predicted amino acid sequences of the nucleocapsid (N) and phosphoprotein (P) genes of AMPV propagated in either turkey turbinate or Vero host cells. However, the fusion (F) gene showed 11 amino acid differences (98.7% identity) between the two host cell types. These results suggest that AMPV propagated in homologous avian cellular substrates may produce more infectious virus with possibly more effective fusion activity, compared to Vero cell propagation.

I don't need a degree to know how to be a good nurse.

I recently returned home after caring for a patient who had been neither shaved nor adequately fed for 12 days. I returned home to a daughter who had been refused entry to do a nursing degree at university because her grades were not ABB. I didn't need a degree to ask my patient if he normally had a beard, to encourage him to order breakfast or to find out that he didn't want to be any trouble and, due to a fractured arm, could not feed or shave himself.

Expression profiles of p53-, p16(INK4a)-, and telomere-regulating genes in replicative senescent primary human, mouse, and chicken fibroblast cells.

Replicative senescence is known to be an intrinsic mechanism in determining the finite life span of in vitro cultured cells. Since this process is recognized as an evolutionarily conserved mechanism from yeast to mammalian cells, we compared the senescence-associated genetic alterations in the p53, p16(INK4a), and telomere regulatory pathways using replicative senescent human, mouse, and chicken fibroblast cells. Normal human diploid fibroblast (HDF; WI38) and chicken embryonic fibroblast (CEF) cells were shown to have a more extended in vitro proliferative potential than their mouse embryonic fibroblast (MEF) counterpart. In contrast to the HDF and CEF cells, MEF cells were shown to express telomerase mRNA and maintain telomerase activity throughout their in vitro life span. Functional p53 activity was shown to increase in the replicative senescent HDF and CEF cells, but not in replicative senescent MEF cells. On the other hand, there was a gradual elevation of p16(INK4a) expression with increased cell passages which reached a maximum in replicative senescent MEF cells. Taken together, the present study demonstrates that the p53, p16(INK4a), and telomere regulatory functions may be differentially regulated during replicative senescence in human, mouse, and chicken fibroblast cells.

Events in the immortalizing process of primary human mammary epithelial cells by the catalytic subunit of human telomerase.

The in vitro immortalization of primary human mammary epithelial (HME) cells solely by the exogenous introduction of the catalytic subunit of human telomerase (hTERT) has been achieved. Early passage hTERT-transfected HME (T-HME) cells continuously decreased the length and density of telomeres even in the presence of telomerase activity, with a significant number of cells staining positive for senescence-associated beta-galactosidase (SA-beta-gal). Subsequently, with the increase in cell passages, the copy number of the exogenously transfected hTERT gene and the percentage of SA-beta-gal positive cells were found to decrease. Eventually, a single copy of the exogenous hTERT gene was observed in the relatively later passage T-HME cells in which telomere length was elongated and stabilized without obvious activation of endogenous hTERT and c-Myc expression. In T-HME cells, the expression of two p53 regulated genes p21(WAF) and HDM2 increased (as in primary senescent HME cells), and was found to be further elevated as the function of p53 was activated by treatment with DNA-damaging agents. p16(INK4a) was shown to be significantly higher in the primary senescent HME and the early passage T-HME cells when compared with the primary presenescent HME cells, with a dramatic repression of p16(INK4a) observed in the later passage T-HME cells. In addition, the expression of E2F1 and its transcription factor activity were found to be significantly higher in the later passage T-HME cells when compared with the earlier passage T-HME cells. Together, our results indicate that in vitro immortalization in HME cells may require the activation of the function of telomerase and other genetic alterations such as the spontaneous loss of p16(INK4a) expression.