An Inter-Institutional External Peer-Review Process to Evaluate Educators at Schools of Veterinary Medicine.

Despite its fundamental importance, the educational mission of most schools of veterinary medicine receives far less recognition and support than the missions of research and discovery. This disparity is evident in promotion and tenure processes. Despite the frequent assertion that education is every college's core mission, there is a broad consensus that faculty are promoted primarily on the basis of meeting expectations relative to publications and grant funding. This expectation is evident in the promotion packets faculty are expected to produce and the criteria by which those packets are reviewed. Among the outcomes is increasing difficulty in hiring and retaining faculty, including young clinicians and basic scientists who are drawn to academic institutions because of the opportunity to teach. The Regional Teaching Academy (RTA) of the West Region Consortium of Colleges of Veterinary Medicine initiated an inter-institutional collaboration to address the most important obstacles to recognizing and rewarding teaching in its five member colleges. Working from the medical education literature, the RTA developed an Educator's Promotion Dossier, workshops to train promotion applicants, and an external review process. Initial use has shown that the reviews are efficient and complete. Administrators have expressed strong support for the product, a letter of external review that is returned to a promotion applicant's home institution. The overall result is an evidence-based, structured process by which teaching-intensive faculty can more fully document their achievements in teaching and educational leadership and a more rigorous external review process by which member colleges can assess quality, impact, and scholarly approach.

An Inter-Institutional Collaboration to "Make Teaching Matter": The Teaching Academy of the Consortium of West Region Colleges of Veterinary Medicine.

Veterinary medical education is a relatively small community with limited numbers of institutions, people, and resources widely dispersed geographically. The problems faced, however, are large-and not very different from the problems faced by (human) medical education. As part of an effort to share resources and build a community of practice around common issues, five colleges in the westernmost region of the United States came together to form a regional inter-institutional consortium. This article describes the processes by which the consortium was formed and the initiation of its first collaborative endeavor, an inter-institutional medical/biomedical teaching academy (the Regional Teaching Academy, or RTA). We report outcomes, including the successful launch of three RTA initiatives, and the strategies that have been considered key to the academy's success. These include strong support from the consortium deans, including an ongoing financial commitment, a dedicated part-time Executive Coordinator, regular face-to-face meetings that supplement virtual meetings, an organization-wide biennial conference, an effective organizational structure, and a core group of dedicated leaders and RTA Fellows. The western consortium and RTA share these processes, insights, and outcomes to provide a model upon which other colleges of veterinary medicine can build to further leverage inter-institutional collaboration.

The equine CD1 gene family is the largest and most diverse yet identified.

The CD1 family is a group of non-polymorphic MHC class I-like molecules that present lipid-based antigens to T cells. Previous work in our laboratory demonstrated that cytotoxic T lymphocytes from immune adult horses recognize lipids from the cell wall of an important equine pathogen, Rhodococcus equi. These findings suggest an important role for the equine CD1 antigen presentation system in protective immune responses to microbial pathogens in the horse. In this study, we characterized and mapped the equine CD1 gene cluster. The equine genome was found to contain 13 complete CD1 genes; seven genes were classified as homologues of human CD1a, two CD1b, one CD1c, one CD1d, and two CD1e, making it the largest CD1 family to date. All but one of the eqCD1 molecules were expressed in all antigen-presenting cells investigated. The major amino acid differences between equine CD1 isoforms are located in the predicted antigen binding site, suggesting that a variety of lipid antigens can be presented. R. equi survives and replicates within professional phagocytes by arresting phagosome maturation between the early endosome and late phagosome. Based on the absence of a tyrosine sorting motif in all eqCD1a, CD1a molecules are predicted to co-localize with R. equi in the early endosome. Here, they could acquire lipid antigen and present it to T lymphocytes. The extraordinarily large number of CD1 molecules in the horse may reflect their crucial role in immunity to R. equi.

A Review of the Design and Implementation of a Hybrid Cardiac Rehabilitation Program: AN EXPANDING OPPORTUNITY FOR OPTIMIZING CARDIOVASCULAR CARE.

PURPOSE: This review describes the considerations for the design and implementation of a hybrid cardiac rehabilitation (HYCR) program, a patient-individualized combination of facility-based cardiac rehabilitation (FBCR) with virtual cardiac rehabilitation (CR) and/or remote CR. REVIEW METHODS: To help meet the goal of the Millions Hearts Initiative to increase CR participation to 70% by 2022, a targeted review of the literature was conducted to identify studies pertinent to the practical design and implementation of an HYCR program. Areas focused upon included the current use of HYCR, exercise programming considerations (eligibility and safety, exercise prescription, and patient monitoring), program assessments and outcomes, patient education, step-by-step instructions for billing and insurance reimbursement, patient and provider engagement strategies, and special considerations. SUMMARY: A FBCR is the first choice for patient participation in CR, as it is supported by an extensive evidence base demonstrating effectiveness in decreasing cardiac and overall mortality, as well as improving functional capacity and quality of life. However, to attain the CR participation rate goal of 70% set by the Million Hearts Initiative, CR programming will need to be expanded beyond the confines of FBCR. In particular, HYCR programs will be necessary to supplement FBCR and will be particularly useful for the many patients with geographic or work-related barriers to participation in an FBCR program. Research is ongoing and needed to develop optimal programming for HYCR.

Identification of Rhodococcus equi lipids recognized by host cytotoxic T lymphocytes.

Immune adult horses have CD8(+) cytotoxic T lymphocytes (CTLs) that recognize and lyse Rhodococcus equi-infected cells in an equine lymphocyte alloantigen (ELA)-A [classical major histocompatibility complex (MHC) class I]-unrestricted fashion. As protein antigens are MHC class I-restricted, the lack of restriction suggests that the bacterial antigens being recognized by the host are not proteins. The goals of this study were to test the hypothesis that these CTLs recognize unique R. equi cell-wall lipids related to mycobacterial lipids. Initial experiments showed that treatment of soluble R. equi antigen with broadly reactive proteases did not significantly diminish the ability of the antigen to stimulate R. equi-specific CTLs. R. equi-specific CTLs were also shown to lyse target cells (equine macrophages) pulsed with an R. equi lipid extract. Analysis of the R. equi lipid by TLC and MS (MALDI-TOF and ES) indicated that the extracted antigen consisted of three primary fractions: trehalose monomycolate (TMM), trehalose dimycolate (TDM) and cardiolipin (CL). ELA-A-mismatched cells pulsed with purified TMM and CL, but not the TDM fraction, were recognized and lysed by R. equi-specific CTLs. Because of their role in immune clearance and pathogenesis, transcription of the cytokines gamma interferon (IFN-gamma) and interleukin-4 (IL-4) was also measured in response to R. equi lipids by using real-time PCR; elevated IFN-gamma, but not IL-4, was associated with host clearance of the bacteria. The whole-cell R. equi lipid and all three R. equi lipid fractions resulted in marked increases in IFN-gamma transcription, but no increase in IL-4 transcription. Together, these data support the hypothesis that immune recognition of unique lipids in the bacterial cell wall is an important component of the protective immune response to R. equi. The results also identify potential lipid antigens not previously shown to be recognized by CTLs in an important, naturally occurring actinomycete bacterial pathogen.

ACO Status Associated with Reports of Meals on Wheels in Hospitals in 2017.

Hospitals' approaches to increased value may include taking part in payment programs, such as those relating to accountable care organizations (ACOs), and addressing social determinants of health. We conduct a cross-sectional study using 2017 American Hospital Association Annual Survey and Area Health Resource File data to examine hospitals that are in ACOs and offer Meals on Wheels. Of 3,992 hospitals in 2017, 27.4% took part in only ACOs, 8.4% took part in Meals on Wheels only, and 11.2% were part of both. In adjusted models, hospitals in ACOs had 1.94 higher odds of having Meals on Wheels programs compared with hospitals not in ACOs (95% CI 1.58-2.38). In an exploratory analysis, we found no associations between 30-day inpatient Medicare costs and ACO status or Meals on Wheels. Some hospital strategies to increase value may extend beyond traditional medical care to social services.

Rash decisions can be life-saving: a case of disseminated histoplasmosis in an immunocompromised patient.

Histoplasmosis is the most prevalent endemic mycosis in the United States with the highest incidence in the Mississippi and Ohio River Valleys. Most infections are asymptomatic or self-limited. However, in immunocompromised patients, severe and progressive disseminated infection can occur. In our patient, evaluation of her cutaneous lesions was critical in making the diagnosis of acute-disseminated histoplasmosis. Because clinical manifestations of disseminated histoplasmosis can vary widely, early recognition of this infection is challenging. This case highlights the importance of considering histoplasmosis in immunocompromised patients since the untreated disease can be fatal.

Serum antibodies against human albumin in critically ill and healthy dogs.

OBJECTIVE: To characterize the magnitude and duration of the antibody response against human albumin (HA) in critically ill and healthy dogs. DESIGN: Cohort and cross-sectional study. ANIMALS: Fourteen critically ill dogs that received 25% HA as part of their treatment protocol, 2 healthy dogs with no known previous exposure to HA that received 2 infusions of 25% HA (positive control dogs), and 47 healthy dogs and 21 critically ill dogs with no known exposure to HA (negative control dogs). PROCEDURES: An ELISA to detect IgG against HA was developed. Serum samples were obtained from the critically ill dogs prior to infusion of HA, at the time of hospital discharge, and 4 to 6 weeks and 6 months after HA administration. Serum samples were obtained at 2- to 4-week intervals from both positive control dogs for 101 weeks. A single serum sample was obtained from each of the negative control dogs. RESULTS: All 14 critically ill dogs developed serum IgG against HA. Peak antibody response was detected 4 to 6 weeks after HA administration. In both positive control dogs, IgG against HA was detected 10 days after HA administration and continued past 97 weeks. The peak antibody response was detected at 3 weeks in 1 dog and at 9 weeks in the other. Five of the 68 (7%) negative control dogs had a positive antibody response. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that dogs developed a pronounced IgG response following exposure to HA and that some dogs with no history of HA administration were positive for anti-HA IgG.

HCAHPS Scores and Community Factors.

The objective was to examine associations between patient experience, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and the sociodemographic, cultural, and access-to-care factors of the surrounding community. Using an empty model, this study found that 27% of the variation in HCAHPS scores was at the level of the county in which the hospital was located. The county factors examined explained about half of this county-level variation. Among community factors most strongly associated with increased HCAHPS scores were higher numbers of primary care physicians per capita, fewer specialists per capita, and smaller percentages of African Americans and Hispanics in the county. A number of community factors beyond the hospitalization experience may influence HCAHPS scores. As HCAHPS gains importance as a measure of quality of care and is linked to higher payments over time, it will be essential to understand the possible effects of community factors.

Adverse reactions suggestive of type III hypersensitivity in six healthy dogs given human albumin.

CASE DESCRIPTION: 6 healthy dogs given human albumin solution as part of a study were examined following development of an immediate hypersensitivity reaction (1 dog) and signs suggestive of a type III hypersensitivity reaction (all 6 dogs). CLINICAL FINDINGS: All 6 dogs were healthy prior to administration of human albumin solution. One dog developed signs of an immediate hypersensitivity reaction, characterized by vomiting and facial edema, during administration of human albumin solution. All 6 dogs developed signs of a delayed adverse reaction 5 to 13 days after administration of human albumin solution. Initial clinical signs included lethargy, lameness, edema, cutaneous lesions indicative of vasculitis, vomiting, and inappetance. TREATMENT AND OUTCOME: In the dog with signs of immediate hypersensitivity, signs resolved after administration of human albumin solution was discontinued and diphenhydramine was administered. Supportive treatment was provided after dogs developed signs of a delayed adverse reaction. Four dogs recovered, but 2 dogs died despite treatment. All 6 dogs were found to have antihuman albumin antibodies. There was no evidence of contamination of the human albumin solution. CLINICAL RELEVANCE: Findings suggest that administration of human albumin solution in healthy dogs with normal serum albumin concentrations may result in signs of a type III hypersensitivity reaction.

The Relationship of Engagement in Improvement Practices to Outcome Measures in Large-Scale Quality Improvement Initiatives.

Hospital engagement networks (HENs) are part of the largest health care improvement initiative ever undertaken. This article explores whether engagement in improvement activities within a HEN affected quality measures. Data were drawn from 1174 acute care hospitals. A composite quality score was created from 10 targeted topic area measures multiplied by the number of qualifying topics. Scores improved from 5.4 (SD = 6.8) at baseline to 4.6 (5.9) at remeasurement; P < .0001. Hospitals with higher baseline scores demonstrated greater improvement ( P < .0001) than hospitals with lower baseline scores. Hospitals with larger Medicaid populations ( P = .023) and micropolitan ( P = .034) hospitals tended to have greater improvement, whereas hospitals in the West ( P = .0009) did not improve as much as hospitals in other regions. After adjusting for hospital characteristics, hospitals with improvement champions ( P = .008), a higher level of engagement with their state association ( P = .001), and more leadership involvement ( P = .005) in HEN demonstrated greater improvement.

Getting the board on board: Engaging hospital boards in quality and patient safety.

BACKGROUND: Transformational change in health care calls on hospital boards of trustees to engage in quality ata level that has never been asked before. Yet little research has been conducted regarding the role of hospital governance in quality. METHODS: Interviews were conducted with chief executive officers (CEOs) and board chairpersons from aconvenient sample of 30 hospitals, representing 14 states across the United States. The interviews were 30 to 45 minutes in length and included approximately 30 questions that were open-ended and ratings based. RESULTS: The level of knowledge of landmark Institute of Medicine (IOM) quality reports among CEOs and board chairs was remarkably low. Conversely, board chairs and CEOs were well attuned to public reporting of quality information. There were significant differences between the CEOs' perception of the level of knowledge of their board chairs and the board chairs' self-perception. There was a mild association between board engagement in quality and hospital performance asdefined by their rates in their composite measure of heart failure, heart attack, and pneumonia. DISCUSSION: The engagement of hospital boards inquality can be enhanced by (1) increasing education on quality to increase the board's quality literacy; (2) improving the framing of an agenda for quality; (3) more quality planning, focus, and incentives for leadership and governance for quality improvement; and (4) greater focus on the patients. Implementing these steps can improve a hospital's overall performance.

Assessing Community Quality of Health Care.

OBJECTIVE: To determine the agreement of measures of care in different settings-hospitals, nursing homes (NHs), and home health agencies (HHAs)-and identify communities with high-quality care in all settings. DATA SOURCES/STUDY SETTING: Publicly available quality measures for hospitals, NHs, and HHAs, linked to hospital service areas (HSAs). STUDY DESIGN: We constructed composite quality measures for hospitals, HHAs, and nursing homes. We used these measures to identify HSAs with exceptionally high- or low-quality of care across all settings, or only high hospital quality, and compared these with respect to sociodemographic and health system factors. PRINCIPAL FINDINGS: We identified three dimensions of hospital quality, four HHA dimensions, and two NH dimensions; these were poorly correlated across the three care settings. HSAs that ranked high on all dimensions had more general practitioners per capita, and fewer specialists per capita, than HSAs that ranked highly on only the hospital measures. CONCLUSION: Higher quality hospital, HHA, and NH care are not correlated at the regional level; regions where all dimensions of care are high differ systematically from regions which score well on only hospital measures and from those which score well on none.

Patient and family engagement: a survey of US hospital practices.

BACKGROUND: Patient and family engagement (PFE) in healthcare is an important element of the transforming healthcare system; however, the prevalence of various PFE practices in the USA is not known. OBJECTIVE: We report on a survey of hospitals in the USA regarding their PFE practices during 2013-2014. RESULTS: The response rate was 42%, with 1457 acute care hospitals completing the survey. We constructed 25 items to summarise the responses regarding key practices, which fell into three broad categories: (1) organisational practices, (2) bedside practices and (3) access to information and shared decision-making. We found a wide range of scores across hospitals. Selected findings include: 86% of hospitals had a policy for unrestricted visitor access in at least some units; 68% encouraged patients/families to participate in shift-change reports; 67% had formal policies for disclosing and apologising for errors; and 38% had a patient and family advisory council. The most commonly reported barrier to increased PFE was 'competing organisational priorities'. SUMMARY: Our findings indicate that there is a large variation in hospital implementation of PFE practices, with competing organisational priorities being the most commonly identified barrier to adoption.

ATLes: the strategic application of Web-based technology to address learning objectives and enhance classroom discussion in a veterinary pathology course.

A case-based program called ATLes (Adaptive Teaching and Learning Environments) was designed for use in a systemic pathology course and implemented over a four-year period. Second-year veterinary students working in small collaborative learning groups used the program prior to their weekly pathology laboratory. The goals of ATLes were to better address specific learning objectives in the course (notably the appreciation of pathophysiology), to solve previously identified problems associated with information overload and information sorting that commonly occur as part of discovery-based processes, and to enhance classroom discussion. The program was also designed to model and allow students to practice the problem-oriented approach to clinical cases, thereby enabling them to study pathology in a relevant clinical context. Features included opportunities for students to obtain additional information on the case by requesting specific laboratory tests and/or diagnostic procedures. However, students were also required to justify their diagnostic plans and to provide mechanistic analyses. The use of ATLes met most of these objectives. Student acceptance was high, and students favorably reviewed the online ''Content Links'' that made useful information more readily accessible and level appropriate. Students came to the lab better prepared to engage in an in-depth and high-quality discussion and were better able to connect clinical problems to underlying changes in tissue (lesions). However, many students indicated that the required time on task prior to lab might have been excessive relative to what they thought they learned. The classroom discussion, although improved, was not elevated to the expected level-most likely reflecting other missing elements of the learning environment, including the existing student culture and the students' current discussion skills. This article briefly discusses the lessons learned from ATLes and how similar case-based exercises might be combined with other approaches to enhance and enliven classroom discussions in the veterinary curriculum.

In contrast to other species, α-Galactosylceramide (α-GalCer) is not an immunostimulatory NKT cell agonist in horses.

α-GalCer is a potent immunomodulatory molecule that is presented to NKT cells via the CD1 antigen-presenting system. We hypothesized that when used as an adjuvant α-GalCer would induce protective immune responses against Rhodococcus equi, an important pathogen of young horses. Here we demonstrate that the equine CD1d molecule shares most features found in CD1d from other species and has a suitable lipid-binding groove for presenting glycolipids to NKT cells. However, equine CTL stimulated with α-GalCer failed to kill cells infected with R. equi, and α-GalCer did not increase killing by CTL co-stimulated with R. equi antigen. Likewise, α-GalCer did not induce the lymphoproliferation of equine PBMC or increase the proliferation of R. equi-stimulated cells. Intradermal injection of α-GalCer in horses did not increase the recruitment of lymphocytes or cytokine production. Furthermore, α-GalCer-loaded CD1d tetramers, which have been shown to be broadly cross-reactive, did not bind equine lymphocytes. Altogether, our results demonstrate that in contrast to previously described species, horses are unable to respond to α-GalCer. This raises questions about the capabilities and function of NKT cells and other lipid-specific T lymphocytes in horses.

Community factors and hospital readmission rates.

OBJECTIVE: To examine the relationship between community factors and hospital readmission rates. DATA SOURCES/STUDY SETTING: We examined all hospitals with publicly reported 30-day readmission rates for patients discharged during July 1, 2007, to June 30, 2010, with acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PN). We linked these to publicly available county data from the Area Resource File, the Census, Nursing Home Compare, and the Neilsen PopFacts datasets. STUDY DESIGN: We used hierarchical linear models to assess the effect of county demographic, access to care, and nursing home quality characteristics on the pooled 30-day risk-standardized readmission rate. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: The study sample included 4,073 hospitals. Fifty-eight percent of national variation in hospital readmission rates was explained by the county in which the hospital was located. In multivariable analysis, a number of county characteristics were found to be independently associated with higher readmission rates, the strongest associations being for measures of access to care. These county characteristics explained almost half of the total variation across counties. CONCLUSIONS: Community factors, as measured by county characteristics, explain a substantial amount of variation in hospital readmission rates.

Variation in infection prevention practices in dialysis facilities: results from the national opportunity to improve infection control in ESRD (End-Stage Renal Disease) project.

OBJECTIVE To observe patient care across hemodialysis facilities enrolled in the National Opportunity to Improve Infection Control in ESRD (end-stage renal disease) (NOTICE) project in order to evaluate adherence to evidence-based practices aimed at prevention of infection. SETTING AND PARTICIPANTS Thirty-four hemodialysis facilities were randomly selected from among 772 facilities in 4 end-stage renal disease participating networks. Facility selection was stratified on dialysis organization affiliation, size, socioeconomic status, and urban/rural status. MEASUREMENTS Trained infection control evaluators used an infection control worksheet to observe 73 distinct infection control practices at the hemodialysis facilities, from October 1, 2011, through January 31, 2012. RESULTS There was considerable variation in infection control practices across enrolled facilities. Overall adherence to recommended practices was 68% (range, 45%-92%) across all facilities. Overall adherence to expected hand hygiene practice was 72% (range, 10%-100%). Compliance to hand hygiene before and after procedures was high; however, during procedures hand hygiene compliance averaged 58%. Use of chlorhexidine as the specific agent for exit site care was 19% overall but varied from 0% to 35% by facility type. The 8 checklists varied in the frequency of perfect performance from 0% for meeting every item on the checklist for disinfection practices to 22% on the arteriovenous access practices at initiation. CONCLUSIONS Our findings suggest that there are many areas for improvement in hand hygiene and other infection prevention practices in end-stage renal disease. These NOTICE project findings will help inform the development of a larger quality improvement initiative at dialysis facilities.

Organization, transcription, and expression of rhoptry associated protein genes in the Babesia bigemina rap-1 locus.

The Babesia bigemina rap-1 gene locus contains five tandemly arranged copies of rap-1a genes. However, the size of the locus, as defined by conserved, unrelated orfs at the 5' and 3' ends, suggests that additional genes may be present. In this study, we identified all additional genes in the locus and characterized their pattern of expression in merozoites. The rap-1a genes are separated by 3.38-kbp intergenic (IG) regions, each of which contains an identical copy of a related gene designated rap-1b. One additional copy of rap-1b and one copy of another related gene designated rap-1c is present in the 3' end of the locus. Common sequence features that define the Babesia rap-1 family are present in rap-1b and rap-1c, but otherwise these genes average only 27% identity to rap-1a. Homologues of the rap-1b and rap-1c genes identified in diverse B. bigemina strains have a high degree of predicted amino acid sequence conservation (averaging >90%), with the largest number of changes in the carboxyl end of RAP-1c. We tested whether all rap-1 genes in the locus are co-transcribed in merozoites using RT-PCR, Northern blots, and quantitative real-time PCR. Rap-1a genes produce the most abundant transcripts of the family, while rap-1b transcripts are the least abundant despite the large number of gene copies. Similar patterns of transcription were observed whether merozoites were obtained from in vitro cultures or in vivo infection. Immunoblot analysis of merozoites revealed the expected RAP-1a expression but failed to detect expressed RAP-1b and RAP-1c, indicating that expression of the rap-1 genes is regulated both at the transcriptional and translational levels.

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

BACKGROUND: Several studies demonstrating that central line-associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections. METHODS: We conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented. RESULTS: A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16-18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50-0.65) at 16-18 months after implementation. CONCLUSION: Coincident with the implementation of the national "On the CUSP: Stop BSI" program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.