Human amnion mesenchymal cells are pro-inflammatory when activated by the Toll-like receptor 2/6 ligand, macrophage-activating lipoprotein-2.

INTRODUCTION: Infection accounts for over 40% of preterm premature rupture of the fetal membranes (PPROM), a major cause of preterm birth. Toll-like receptors (TLR) play key roles in pathogen surveillance but their expression and function in amnion mesenchymal cells (AMC) is unclear. The aims of this study were to determine the expression of all TLR isoforms and the effect of macrophage-activating lipoprotein-2 (MALP-2), derived from a common pathogen involved in PPROM, on human AMC. METHODS: AMC were isolated from normal, term amnion from repeat cesarean section. Semi-quantitative RT-PCR, immunocytochemistry, immunohistochemistry and western blotting were used to detect TLR isoform expression. Immunocytochemistry of NF-κB p65, pro-inflammatory cytokine secretion (ELISA), MTT assay, LDH assay, immunoblotting of cytosolic cytochrome c and cleaved caspase-3, and expression of 84 microRNAs by Qiagen miRNA PCR array were used to determine the functional effect of MALP-2 on AMC. RESULTS: TLR1-10 was detected in AMC, and protein expression of TLR2, 4, and 6 were confirmed. MALP-2 induced nuclear translocation of p65, reaching significance after 45 min (ANOVA, P < 0.05). MALP-2 did not cause apoptosis but did lead to significant secretion of IL-4, IL-6, and IL-8 (P < 0.05, 0.01, 0.001, respectively) and significant changes in miRNA-320a and miRNA-18a (P < 0.05). DISCUSSION: These results suggest that AMC elicit a pro-inflammatory response following stimulation with the known TLR2/6 ligand MALP-2. This data supports the idea that AMC express the innate immune system receptors that could help with immune surveillance during infection and contribute to inflammatory responses that lead to PPROM.

The relationship of California's Medicaid reimbursement system to nurse staffing levels.

BACKGROUND: Policy initiatives at the Federal and state level are aimed at increasing staffing in nursing homes. These include direct staffing standards, public reporting, and financial incentives. OBJECTIVE: To examine the impact of California's Medicaid reimbursement for nursing homes which includes incentives directed at staffing. RESEARCH DESIGN: Two-stage limited-information maximum-likelihood regressions were used to model the relationship between staffing [registered nurses (RNs), licensed practical nurses, and certified nursing assistants hours per resident day] and the Medicaid payment rate, accounting for the specific structure of the payment system, endogeneity of payment and case-mix, and controlling for facility and market characteristics. SAMPLE: A total of 927 California free-standing nursing homes in 2006. MEASURES: The model included facility characteristics (case-mix, size, ownership, and chain affiliation), market competition and excess demand, labor supply and wages, unemployment, and female employment. The instrumental variable for Medicaid reimbursement was the peer group payment rate for 7 geographical market areas, and the instrumental variables for resident case-mix were the average county revenues for professional therapy establishments and the percent of county population aged 65 and over. RESULTS: Consistent with the rate incentives and rational expectation behavior, expected nursing home reimbursement rates in 2008 were associated with increased RN staffing levels in 2006 but had no relationship with licensed practical nurse and certified nursing assistant staffing. The effect was estimated at 2 minutes per $10 increase in rate. CONCLUSIONS: The incentives in the Medicaid system impacted only RN staffing suggesting the need to improve the state's rate setting methodology.

Staffing characteristics, turnover rates, and quality of resident care in nursing facilities.

Despite substantial spending and considerable regulatory oversight, the quality of care provided to residents in the nation's nursing facilities is inadequate, and strategies to address this problem are needed. Staffing characteristics are important predictors of quality in nursing facilities, and the relationship between staffing and various quality measures fluctuates across studies and in analyses that account for the effects of market, resident, and organizational characteristics. However and even with such variations, it is has generally been concluded that higher staffing levels, less turnover, and higher retention rates are associated with an array of improved resident and facility outcomes. This article synthesizes literature, including published reports, expert opinion, and peer reviewed studies, on staffing levels, turnover, and quality of care in nursing homes. The findings were used to develop three staffing interventions that need to be further evaluated in an effort to improve the quality of care in nursing facilities.

Discharge planning, nursing home placement, and the Internet.

BACKGROUND: Effective discharge planning and well-coordinated case management related to nursing home (NH) placement are key services in acute-care hospitals. OBJECTIVES: (1) identify the individuals and important factors involved in the discharge planning process; (2) describe the types/sources of information used by discharge planners to recommend specific nursing homes for patients and families; and (3) determine which methods are used to evaluate the quality of US nursing homes (NHs). METHODS: Descriptive study, with a convenience sample of 41 discharge planners and case managers from California acute-care hospitals. RESULTS: This study found that patients, families, friends, and physicians are all involved in the discharge planning process along with discharge planners and/or case managers. Discharge planners/case managers were generally concerned about NH bed availability, geographic location, and financial considerations. Although the discharge planners and case managers were able to articulate important indicators of quality in NHs, such information was not routinely considered during discharge planning activities. CONCLUSIONS: Discharge planners and case managers need to play a more central role in the decision-making process related to the selection of a NH, especially because decisions are time-limited and can benefit from a well-planned discharge planning program that uses a variety of data on quality and costs. The widespread use of Internet-based information sources can be expanded to aid this process.

Case study: development of and stakeholder responses to a nursing home consumer information system.

California Nursing Home Search (www.calnhs.org), launched in October 2002, provides information about nursing home quality to a broad range of stakeholders. This case study discusses the process of developing a consumer-oriented nursing home Web site and presents an analysis of postlaunch responses from a number of sources (i.e., media, outreach, Web site use, correspondence, meetings, interviews) to determine the impact of the site and how it can be improved and used as an example. Consumers found the Web site valuable, but some needed clarification on navigation. Providers had complaints about the use of quality ratings and concerns about public availability of the data. Most discharge planners and care managers do not use Internet resources to find facilities. Feedback, modifications, updates, and outreach are needed on a continuous basis to ensure the site is a helpful tool for all stakeholders.

Nursing indicators of quality in nursing homes. A Web-based approach.

This article is an examination of websites providing consumer information about nursing home quality of care, including existing federal and state websites and a new comprehensive website designed for California nursing homes. The article focuses on research and information related to nursing indicators of quality used for the California nursing home website. It includes staffing levels (e.g., hours, types, turnover rates), financial indicators (e.g., direct care expenditures, wages, benefits), and complaints and deficiencies. Overall, nursing indicators of quality are a major approach for evaluating nursing home quality and can be used by nurses, consumers, and advocates.

Federal and state nursing facility websites: just what the consumer needs?

Since the introduction of the Medicare Nursing Home Compare website in 1999, some states have begun to develop their own websites to help consumers compare nursing facilities (NFs). This article presents a brief conceptual framework for the type of information needed for an Internet-based information system and analyzes existing federal and state NF websites, using data collected from a survey completed in 2002. Twenty-four states and the District of Columbia have a variety of information on NFs, similar to the information on the Medicare website. Information on characteristics and deficiencies of a facility is the most commonly available, but a few states have data on ownership, staffing indicators, quality indicators, complaints, and enforcement actions. Other types of data, such as resident characteristics, staff turnover rates, and financial indicators, are generally not available. Although many states are making progress toward providing consumers with information, there are gaps that exist, which if filled, could provide consumers with a better tool for facility selection and monitoring the quality of care.