Research on the Translation and Implementation of Stepping On in Three Wisconsin Communities.

OBJECTIVE: Falls are a leading cause of injury death. Stepping On is a fall prevention program developed in Australia and shown to reduce falls by up to 31%. The original program was implemented in a community setting, by an occupational therapist, and included a home visit. The purpose of this study was to examine aspects of the translation and implementation of Stepping On in three community settings in Wisconsin. METHODS: The investigative team identified four research questions to understand the spread and use of the program, as well as to determine whether critical components of the program could be modified to maximize use in community practice. The team evaluated program uptake, participant reach, program feasibility, program acceptability, and program fidelity by varying the implementation setting and components of Stepping On. Implementation setting included type of host organization, rural versus urban location, health versus non-health background of leaders, and whether a phone call could replace the home visit. A mixed methodology of surveys and interviews completed by site managers, leaders, guest experts, participants, and content expert observations for program fidelity during classes was used. RESULTS: The study identified implementation challenges that varied by setting, including securing a physical therapist for the class and needing more time to recruit participants. There were no implementation differences between rural and urban locations. Potential differences emerged in program fidelity between health and non-health professional leaders, although fidelity was high overall with both. Home visits identified more home hazards than did phone calls and were perceived as of greater benefit to participants, but at 1 year no differences were apparent in uptake of strategies discussed in home versus phone visits. CONCLUSION: Adaptations to the program to increase implementation include using a leader who is a non-health professional, and omitting the home visit. Our research demonstrated that a non-health professional leader can conduct Stepping On with adequate fidelity, however non-health professional leaders may benefit from increased training in certain aspects of Stepping On. A phone call may be substituted for the home visit, although short-term benefits are greater with the home visit.

Modified Delphi Consensus to Suggest Key Elements of Stepping On Falls Prevention Program.

Falls among older adults result in substantial morbidity and mortality. Community-based programs have been shown to decrease the rate of falls. In 2007, the Centers for Disease Control and Prevention funded a research study to determine how to successfully disseminate the evidence-based fall prevention program (Stepping On) in the community setting. As the first step for this study, a panel of subject matter experts was convened to suggest which parts of the Stepping On fall prevention program were considered key elements, which could not be modified by implementers. METHODS: Older adult fall prevention experts from the US, Canada, and Australia participated in a modified Delphi technique process to suggest key program elements of Stepping On. Forty-four experts were invited to ensure that the panel of experts would consist of equal numbers of physical therapists, occupational therapists, geriatricians, exercise scientists, and public health researchers. Consensus was determined by percent of agreement among panelists. A Rasch analysis of item fit was conducted to explore the degree of diversity and/or homogeneity of responses across our panelists. RESULTS: The Rasch analysis of the 19 panelists using fit statistics shows there was a reasonable and sufficient range of diverse perspectives (Infit MnSQ 1.01, Z score -0.1, Outfit MnSQ 0.96, Z score -0.2 with a separation of 4.89). Consensus was achieved that these elements were key: 17 of 18 adult learning elements, 11 of 22 programming, 12 of 15 exercise, 7 of 8 upgrading exercises, 2 of 4 peer co-leader's role, and all of the home visits, booster sessions, group leader's role, and background and training of group leader elements. The top five key elements were: (1) use plain language, (2) develop trust, (3) engage people in what is meaningful and contextual for them, (4) train participants for cues in self-monitoring quality of exercises, and (5) group leader learns about exercises and understands how to progress them. DISCUSSION: The Delphi consensus process suggested key elements related to Stepping On program delivery. These elements were considered essential to program effectiveness. Findings from this study laid the foundation for translation of Stepping On for broad US dissemination.

Improving Fidelity of Translation of the Stepping On Falls Prevention Program through Root Cause Analysis.

BACKGROUND: Fidelity monitoring is essential with implementation of complex health interventions, but there is little description of how to use results of fidelity monitoring to improve the draft program package prior to widespread dissemination. Root cause analysis (RCA) provides a systematic approach to identifying underlying causes and devising solutions to prevent errors in complex processes. Its use has not been described in implementation science. METHODS: Stepping On (SO) is a small group, community-based intervention that has been shown to reduce falls by 31%. To prepare SO for widespread U.S. dissemination, we conducted a pilot of the draft program package, monitoring the seven SO sessions for fidelity of program delivery and assessing participant receipt and enactment through participant interviews after the workshop. Lapses to fidelity in program delivery, receipt, and enactment were identified. We performed a RCA to identify underlying causes of, and solutions to, such lapses, with the goal of preventing fidelity lapses with widespread dissemination. RESULTS: Lapses to fidelity in program delivery were in the domains of group leader's role, use of adult learning principles, and introducing and upgrading the exercises. Lapses in fidelity of participant receipt and enactment included lack of knowledge about balance exercises and reduced adherence to frequency of exercise practice and advancement of exercise. Root causes related to leader training and background, site characteristics and capacity, and participant frailty and expectations prior to starting the program. The RCA resulted in changes to the program manual, the training program, and training manual for new leaders, and to the methods for and criteria for participant and leader recruitment. A Site Implementation Guide was created to provide information to sites interested in the program. CONCLUSION: Disseminating complex interventions can be done more smoothly by first using a systematic quality improvement technique, such as the RCA, to identify how lapses in fidelity occur during the earliest stages of implementation. This technique can also help bring about solutions to these lapses of fidelity prior to widespread dissemination across multiple domain lapses.

Genomic sequences of a low passage herpes simplex virus 2 clinical isolate and its plaque-purified derivative strain.

Herpes simplex virus 2 is an important human pathogen as the causative agent of genital herpes, neonatal herpes, and increased risk of HIV acquisition and transmission. Nevertheless, the only genomic sequence that has been completed is the attenuated HSV-2 HG52 laboratory strain. In this study we defined the genomic sequence of the HSV-2 SD90e low passage clinical isolate and a plaque-purified derivative, SD90-3P. We found minimal sequence differences between SD90e and SD90-3P. However, in comparisons with the HSV-2 HG52 reference genome sequence, the SD90e genome ORFs contained numerous point mutations, 13 insertions/deletions (indels), and 9 short compensatory frameshifts. The indels were true sequence differences, but the compensatory frameshifts were likely sequence errors in the original HG52 sequence. Because HG52 virus is less virulent than other HSV-2 strains and may not be representative of wildtype HSV-2 strains, we propose that the HSV-2 SD90e genome serve as the new HSV-2 reference genome.

Declining cognition and falls: role of risky performance of everyday mobility activities.

BACKGROUND: Declining cognition is a risk factor for falls among older adults. The extent to which impaired judgment in performance of daily activities increases fall risk is unclear. OBJECTIVE: The aim of this study was to determine whether engagement in mobility activities in a risky manner explains the association between declining cognition and rate of falls. DESIGN: This study was a secondary analysis of baseline and prospective data from older adults enrolled in the intervention arm of a randomized clinical trial. METHODS: Two hundred forty-five community-dwelling older adults (79% female; mean age=79 years, SD=8.0) who were at risk for falls received physical, cognitive, and functional evaluations. Cognition was assessed with the Short Portable Mental Status Questionnaire (SPMSQ). Using interview and in-home assessment data, physical therapists determined whether participants were at risk for falls when performing mobility-related activities of daily living (ADL) and instrumental ADL (IADL). Falls were measured prospectively for 1 year using monthly falls diaries. RESULTS: Declining cognition was associated with increased number of mobility activities designated as risky (1.5% of mobility activities performed in a risky manner per SPMSQ point) and with increased rate of falls (rate ratio=1.16 for each unit change in SPMSQ score). Risky performance of mobility activities mediated the relationship between cognition and rate of falls. LIMITATIONS: Risk assessment was based on the clinical judgment of experienced physical therapists. Cognition was measured with a relatively insensitive instrument, and only selected mobility activities were evaluated. CONCLUSIONS: Engagement in mobility ADL and IADL tasks in a risky manner emerged as a link between declining cognition and increased number of falls, suggesting a mechanism through which the rate of falls may increase. Specifically, declining cognition is associated with performance of mobility activities in an unsafe manner, thereby increasing the risk for falls.

High-quality draft genome sequences of 28 Enterococcus sp. isolates.

The enterococci are low-GC Gram-positive bacteria that have emerged as leading causes of hospital-acquired infection. They are also commensals of the gastrointestinal tract of healthy humans and most other animals with gastrointestinal flora and are important for food fermentations. Here we report the availability of draft genome sequences for 28 enterococcal strains of diverse origin, including the species Enterococcus faecalis, E. faecium, E. casseliflavus, and E. gallinarum.

Kenosha County falls prevention study: a randomized, controlled trial of an intermediate-intensity, community-based multifactorial falls intervention.

OBJECTIVES: To decrease the rate of falls in high-risk community-dwelling older adults. DESIGN: Randomized, controlled trial. SETTING: Community-based. PARTICIPANTS: Three hundred forty-nine adults aged 65 and older with two falls in the previous year or one fall in the previous 2 years with injury or balance problems. INTERVENTION: Subjects received two in-home visits from a trained nurse or physical therapist who assessed falls risk factors using an algorithm. The intervention consisted of recommendations to the subject and their primary physician, referrals to physical therapy and other providers, 11 monthly telephone calls, and a balance exercise plan. Control subjects received a home safety assessment. MEASUREMENTS: The primary outcome was rate of falls per year in the community. Secondary outcomes included all-cause hospitalizations and nursing home admissions per year. RESULTS: There was no difference in rate of falls between the intervention and control groups (rate ratio (RR)=0.81, P=.27). Nursing home days were fewer in the intervention group (10.3 vs 20.5 days, P=.04). Intervention subjects with a Mini-Mental State Examination (MMSE) score of 27 or less had a lower rate of falls (RR=0.55; P=.05) and, if they lived with someone, had fewer hospitalizations (RR=0.44, P=.05), nursing home admissions (RR=0.15, P=.003), and nursing home days (7.5 vs 58.2, P=.008). CONCLUSION: This multifactorial intervention did not decrease falls in at-risk community-living adults but did decrease nursing home utilization. There was evidence of efficacy in the subgroup who had an MMSE score of 27 or less and lived with a caregiver, but validation is required.

Effects of vestibular and balance rehabilitation on sensory organization and dizziness handicap.

This retrospective study was undertaken to assess balance recovery and dizziness handicap in 32 patients after a vestibular and balance rehabilitation program. Outcomes were compared between 12 patients with peripheral vestibular disorders and 20 patients with central or mixed balance disorders. The patients were tested with posturography (sensory organization test [SOT]) and the Dizziness Handicap Inventory (DHI) before and after their therapy program. The vestibular SOT, composite SOT, and functional DHI scores obtained before and after exercise were significantly improved in both the peripheral and central groups. The visual SOT mean scores obtained before and after therapy were significantly different only for the group with central or mixed vestibular disorders. Changes in SOT scores were not directly correlated with changes in DHI scores. Outcome measures of vestibular rehabilitation protocols confirmed objective and subjective improvement of balance and dizziness handicap in patients with peripheral and central vestibular disorders.

Outcomes after rehabilitation for adults with balance dysfunction.

OBJECTIVES: To assess balance, dynamic gait, and dynamic visual acuity outcomes after a vestibular and balance rehabilitation program and to determine which variables were significantly associated with improved balance and ambulation. DESIGN: Retrospective case series. SETTING: Outpatient setting at a tertiary care facility. PARTICIPANTS: Twenty patients who were seen for vestibular and balance therapy between July 1999 and June 2000. INTERVENTIONS: A customized exercise program was developed for each patient according to the results of the assessment and included the following interventions, as indicated: gaze stabilization, balance and gait training, and habituation exercises. MAIN OUTCOME MEASURES: The Dynamic Gait Index (DGI), Berg Balance Scale (BBS), Dynamic Visual Acuity Test (DVAT), and computerized post urography (Sensory Organization Test [SOT]). RESULTS: The mean change scores for the DGI showed significant improvement for both patients with peripheral vestibular dysfunction and patients with central balance disorders. For the central balance disorders group, the BBS score also showed significant improvement. No difference was noted for pretherapy and posttherapy SOT scores between groups. The total group appeared to show an average improvement of more than 2 lines on the visual acuity chart on the clinical DVAT. Patients who were 66 years or older were 1.5 times more likely to score less than 20 on the DGI, and those whose pretherapy vertical dynamic visual acuity was 20/80 or worse were 1.3 times more likely to score less than 20 on the DGI. CONCLUSIONS: Patients showed functional improvements in balance, visual acuity, and gait stability after balance and vestibular physical therapy. Age and pretherapy vertical dynamic visual acuity score influenced dynamic gait outcome after a balance rehabilitation program.

Outcomes in vestibular ablative procedures.

OBJECTIVE: To assess dizziness handicap and postural recovery in 17 patients undergoing a vestibular ablative procedure. STUDY DESIGN: Outcomes were compared between nine patients who underwent selective vestibular neurectomy and eight patients who underwent a transmastoid labyrinthectomy. SETTING: Patients underwent ablative procedures at a tertiary care facility. METHODS: Patients were tested with posturography (sensory organization test [SOT]) and the Dizziness Handicap Inventory (DHI) before and 4 to 5 weeks after their procedure. RESULTS: The mean change scores for each of the DHI subscales and the total DHI score showed significant improvement for the labyrinthectomy group. For the neurectomy group, only the emotional DHI subscale change score showed significant improvement. No difference was noted between preprocedure and postprocedure SOT scores for either group. The results indicated that the largest proportion of significant correlations existed between DHI and the somatosensory and vestibular subtests of platform posturography. In regression analyses, a model with age (p = 0.04) and vestibular score (p = 0.001) fitted the data well and explained 52.9% of the variance. Persons who were less than 69 years old were three times more likely to report persistent episodes of dizziness after the ablative procedure, and those who had neurectomies were 2.3 times more likely to report episodes of dizziness than those who underwent transmastoid labyrinthectomy. CONCLUSION: Dizziness handicap after an ablative procedure is influenced by the type of procedure (labyrinthectomy versus neurectomy), age, and preoperative vestibular score on the SOT. Preoperative vestibular SOT score is highly associated with the emotional, physical, and functional domains of perceived handicap and quality of life after the surgery.

A 50-kb plasmid rich in mobile gene sequences isolated from a marine micrococcus.

A 50,709-bp cryptic plasmid isolated from a marine Micrococcus has been sequenced and found to contain a number of putative mobile genetic elements. The coding regions for 11 putative transposases comprise approximately 17% of the total plasmid sequence. The majority of these transposases are located within a 13-kb cluster which includes a 1553-bp direct repeat consisting of a duplicated pair of transposase genes. The remaining putative ORFs showed similarity to a variety of proteins, the most notable being spider silk.