Journal articles on the topic 'Hospital in the Home (HITH) Program (Vic )'

There is a question surrounding the funding of Hospital in the Home (HITH) as to whether the allocation policy was driven by customer service preference or was largely a financial imperative. HITH has the capacity to increase the throughput and therefore the efficiency of acute care facilities which is attractive to Government and Health Service Managers. There is insufficient evidence to indicate that this is true in all circumstances. Hospital in the Home is a desirable and safe option for some clients. Hospital in the Home has the potential to provide a more cost effective mode of delivery of acute care than hospital facilities. However, there is a need for identification of which clients, with which conditions and care needs, will benefit from being part of a HITH program in emotional, health and financial terms. Health professionals are still grappling with the impact that HITH has on their roles and relationships with other health care providers. More qualitative and quantitative research needs to be undertaken to identify the best models of HITH in both organisational and financial tems, and its impact on the wellbeing of clients and carers.

Objective The aim of this study was to identify whether the Hospital in the Home (HITH) program was taken up equitably by eligible patients in relation to their age, sex, country of birth, place of residence and primary diagnosis. Methods This study presents results of a descriptive analysis of the administrative records of 3552 people with specific conditions who met the study criteria of potential eligibility to HITH and resided within the health district boundary. Results Systematic differences were found for participation in HITH and in-patient care according to sex, language spoken at home and socioeconomic status based on place of residence. This suggests that people from higher socioeconomic backgrounds who speak English at home were more likely to participate in and benefit from HITH. Tailored interventions were identified as a potential way to reduce the gap in access to quality health care for women and people who speak a language other than English at home. If HITH is the optimum treatment available, then these differences could be considered potentially avoidable and unfair. Conclusion Data analysis through an equity lens can effectively identify who is accessing health services and who is missing out. Further analysis is required to understand patient and system barriers to accessing HITH. What is known about the topic? Advances in medical and surgical treatments and pharmaceuticals reduce the need for in-patient hospitalisation. For some conditions, home-based treatment is safer, cheaper and preferable to the patient and carers, particularly some older people who may experience deteriorating cognitive and physical functioning related to hospitalisation. It is well known that health and access to health care is not equally distributed in society. What does this paper add? This study represents the first effort to quantitatively evaluate differences in patterns of participation in HITH related to socioeconomic and language characteristics. There are underutilised opportunities for improved participation in HITH by identifying who is not accessing programs at a comparable rate and therefore not benefitting from optimal health services. By exploring why this may be occurring at an individual and system level, we can be more informed to address these reasons and achieve better health and social outcomes. What are the implications for practitioners? It is important to consider both consumer and service provider views in shaping current and future service models. Comprehensive assessment of support needs to participate in HITH for patients and carers, as well as communicating potential benefits in ways patients understand, can improve participation and satisfaction, reduce health costs and improve health outcomes.

Worldwide, there has been a shift in health care delivery, with an increasing emphasis on avoiding hospital admissions and providing treatment such as intravenous antibiotics for patients at home, using peripherally inserted central catheters (PICCs). However, there is inadequate data to demonstrate if rates of PICC failure are similar for hospital inpatients, currently understood to be between 7% and 36%, than those cared for at home. The objective of this study was to identify prevalence, dwell time, and complications associated with PICCs in the home setting. This single-center, retrospective cohort study of adults treated by the “Hospital in the Home” (HITH) program in Queensland, was conducted between June 1, 2017 and June 15, 2018. Clinical data were collected for patient and PICC characteristics. Variables were described as frequencies and proportions, means and standard deviations, or medians and interquartile ranges. In total, 304 patients treated by HITH during this timeframe, and 164 (54%) patients with 181 PICCs were included in this study. These patients were predominately male (n = 105, 64%), with a mean age of 54 years. The most common reason for admission was a wound infection and/or bone infection (n = 120, 33%). Most PICCs were single lumen (n = 120; 67%), inserted in the basilic vein (n = 137; 80%) by nurses (n = 122; 67%). Peripherally inserted central catheter failure occurred in 10% (n = 19); the most common complications were dislodgement (n = 9; 5%) and thrombosis (n = 4; 2%). There were no confirmed catheter-related blood stream infections. Peripherally inserted central catheter failure rates are similar between hospitalized inpatients and those cared for at home.

Abstract Background Adoption of outpatient parenteral antibiotic therapy (OPAT) is accelerating due to proven safety and value, but experience in safety-net settings remains limited, especially in those with history of illicit drug use. Emerging reports from safety-net settings have featured OPAT delivered in nursing facilities, respite care centers, and infusion centers (including some persons who inject drugs [PWID]), but literature is sparse on home-based OPAT for vulnerable patients. In a new home antibiotics program at San Francisco General Hospital, we sought to describe early safety and efficacy outcomes among adults without active injection drug use but with high rates of substance use and comorbid illnesses. Methods We conducted a cohort study of patients discharged from a large urban county medical center and enrolled in an outpatient IV antibiotics program from September 2017 to January 2019. We collected demographic and clinical data and computed outcomes of safety (30- and 90-day readmission for infection, vascular access complications, and death) and efficacy (completion of antibiotic therapy). Results Overall, 47 courses of antibiotics were given to 45 patients. Of these, 39/47 (83%) of antibiotic courses were administered in a residential setting, and 8/47 (17%) via the hospital outpatient infusion center. Comorbid conditions were common, including 9/45 (20%) with hepatitis B/C and 8/45 (18%) with HIV (Table 1). Present or prior illicit drug use was seen in 17/45 patients (38%), including recent or active illicit drug use in 11/45 (24%) (Table 1). Most common indications for antibiotics were osteomyelitis and bacteremia (Table 2). Efficacy in the OPAT program was high: overall, 44/47 (94%) courses of outpatient IV antibiotics were completed, and the 30-day and 90-day readmission rates were 13% and 20% respectively, with zero 30-day readmissions related to OPAT (Table 3). Conclusion An OPAT program embedded within a safety net hospital system delivering care in patients’ homes had high completion rate and low readmission rate, despite patients’ high prevalence of underlying comorbid conditions and noninjection illicit drug use. Home-based OPAT should be considered for broader adoption in safety-net hospital systems. Disclosures All authors: No reported disclosures.

Background: Patients undergoing colorectal surgery are vulnerable during their transition from hospital to home and require increased support following discharge from hospital. Study objectives were to perform an initial assessment of patient uptake, outcomes, and satisfaction with an integrated discharge monitoring system called Home to Stay. Methods: The intervention was an integrated discharge monitoring system that uses a mobile app platform. Patients downloaded the app prior to discharge from hospital and received a Daily Health Check day #1 to #14, #21, and #30. Patient responses’ were accessed by the health-care team via secure web site, and extreme responses were “flagged” to indicate that a follow-up telephone call was necessary. Primary outcomes were patient uptake, Quality of Recovery scores and satisfaction with the program. Secondary outcomes were 30-day emergency room (ER) visits and readmissions. Results: One hundred and thirty-two patients were invited to participate and 106 accepted. Of these, 93 used the app at least once. The mean overall score on the Quality of Recovery Scale increased significantly from day 1 to day 14. Patient satisfaction with the app was high, with 92% of patients reporting overall satisfaction as good or excellent. The 30-day readmission rate was 6% and was lower than the 30-day readmission rate of 18% reported for the 4 months prior to the start of the study. Conclusions: The Home to Stay Program to support patients at home after colorectal surgery is feasible with high patient uptake and satisfaction. This program has the potential to reduce 30-day readmissions, however further studies are required.

This examination seeks to determine the influence of proximal density to nurse education resources (nursing schools) on nursing home care quality outcomes in Alabama. Motivated by the social network theory, which highlights the influence of relational closeness on shared resources and values, we hypothesize that nursing homes that have higher levels of nursing education resources within a close proximity will exhibit significantly higher nursing home quality outcomes. As proximal density to nurse education resources increases, the opportunity for nursing homes to build closer, stronger ties increase, leading to higher quality outcomes. We examine this hypothesis via ordered logistic regressions of proximal density measures developed through geographic information systems (GIS) software, nurse education resource data from Johnson & Johnson’s Campaign for Nursing’s Future (n = 37), and nursing home quality outcome data from Centers for Medicare and Medicaid Services’s (CMS) Nursing Home Compare from 2016 (n = 226). The results find that increases in proximal density to nurse education resources have a negative and significant association with nursing home quality outcomes in Alabama. Additional sensitivity analysis, which examines the degree to which the nature of this relationship is sensitive to health care facilities’ location in high-density areas, is offered and confirms principal findings. Because nursing programs generally have stronger ties with hospitals, the findings suggest that the nursing homes in areas with higher nurse education resources may actually face greater competition for nurses.

15 Background: We previously demonstrated that Huntsman at Home (HH), a novel oncology hospital at home program, was associated with reduced healthcare utilization and costs. HH was also linked to shorter hospital stays and fewer emergency room (ER) visits. In this study, we sought to understand the impact of HH in specific patient subgroups. Methods: We compared outcomes among 169 patients consecutively admitted to HH against 198 usual care patients. Five dichotomous subgroups were created based upon patient a) sex b) age c) area level median income d) Charlson Comorbidity Index (CCI), and e) current use of systemic therapy (ST). Outcomes included 30-day costs, unplanned hospitalizations (UH), length of hospital stays, and ER visits. HH and usual care were compared via inverse propensity weighted regression models. Treatment propensities were estimated via random forests based on age, race, stage, cancer site, presence of metastases, CCI, and area level median income.Results: The between group difference favoring HH achieved statistical significance (p < 0.05) for at least two out of the four outcomes in each subgroup except for patients with higher comorbid illnesses. While HH participants did not always experience statistically better outcomes than usual care, none of the outcomes examined favored usual care for any subgroup. Sex. Female and male HH patients experienced fewer UH and lower costs than usual care. Male HH patients also had shorter hospital stays and fewer ED visits. Age. When stratifying age at 65 years, older HH patients experienced fewer days in the hospital and fewer UH. Younger HH patients had lower costs, and fewer UH and ED visits. Area level Income. All outcomes were better for high and low income HH patients compared to usual care except for ED visits among those with low income. CCI. Among those with a low CCI score, all four outcomes were better among HH patients. In contrast, differences between groups with higher comorbid illness did not achieve statistical significance for any outcome. Systemic Therapy. HH participants on ST experienced shorter hospital stays and fewer UH compared to usual care. Among those not on ST, HH patients experienced lower costs, and fewer UH and ED admissions. Conclusions: In this exploratory analysis, we found that the utilization and cost benefit associated with HH was robust, favoring better outcomes in each subgroup including lower 30-day costs, shorter hospital length of stay and fewer unplanned hospitalizations or ER visits. While medically complex patients may not receive similar benefit from HH as other subgroups, no outcomes favored patients managed by usual care. Taken together, this suggests that health care utilization and cost reductions associated with HH occur across multiple subgroups, but patients with high comorbidity may require additional intervention to realize lower utilization and costs.

A metropolitan hospital system has developed and implemented a transition-of-care program focusing on patients with mental illnesses and high risk for hospital readmissions or emergency department visits. Currently, the transition period between care settings creates a state of vulnerability for patients and their caregivers. Poor care coordination negatively affects patient outcomes and results in a major economic burden. Patients with mental illnesses are particularly sensitive to transition-of-care issues including confusion about which medications to start and stop. This program aims to design, implement, and evaluate interventions to improve care transitions at 3 hospitals for individuals with a primary or secondary psychiatric diagnosis. In the inpatient setting, the clinical pharmacist, nurse practitioners, and social workers collaborate to identify medication-related problems. After patients are discharged from the hospital, nurse practitioners, the clinical pharmacist, and educators follow up with patients for 30 days via home health aide visits and telephone calls. Evidence-based tools and assessments are used to drive the program's interventions. From June 2014 to September 2014, 770 patients were identified as high risk. Readmissions data are pending. The patient outcomes data will fill the gap in the literature with essential information on transition-of-care issues within the mental health population. This program has implications to affect health care policy because it uses multiple evidence-based practices with the ultimate goal of decreasing economic burden for health systems and patients. New pharmacist roles in transition of care may emerge from this program.

Abstract Background Staphylococcus aureus (SA) and Gram-negative bacilli (GNB) bacteremia often require prolonged treatment courses due to high morbidity and mortality risk. Outpatient parenteral antibiotic therapy (OPAT) has emerged as a preferred delivery method. Few data have been published regarding the follow-up and adverse event rates among OPAT patients. We describe outcomes in patients with SA or GNB bacteremia transitioning from an academic medical center to home infusion, prompting the implementation of the Parenteral ANtimicrobial therapy Transitions to Home Infusion Review (PANTHIR) program. Methods A retrospective chart review of adult patients with SA or GNB bacteremia at the University of Minnesota Medical Center requiring home infusion represent a 26-month period. Baseline outcomes, including 30-day hospital readmissions and adverse drug events (ADEs), were calculated. The PANTHIR program was launched as an interdisciplinary collaborative with an infectious diseases (ID) provider, pharmacists, and home infusion specialists. Core program elements include inpatient identification, ID pharmacist review, care plan documentation and communication, and OPAT program measures. Results The retrospective cohort included 69 patients. 23.2% experienced a hospitalization within 30 days of discharge and 26.1% experienced an ADE (Table 1). The mean duration of therapy was 22 days. No patient received aminoglycosides and one required vancomycin. A primary goal was to improve the continuity of care for potentially life-threatening bacteremia during the vulnerable inpatient to outpatient transition. Electronic health record functionality allowed for creation of an OPAT navigator for infectious diseases (ID) pharmacist transition plan documentation, electronic communication with designated provider and home infusion pharmacist, and retrieval of focal data points for ongoing program evaluation. 28 patients have been enrolled in the PANTHIR program with outcomes data collection underway. Table 1. Retrospective data among University of Minnesota Medical Center patients hospitalized with SA or GNB bacteremia requiring home infusion on discharge. Conclusion Hospital readmission rates and ADEs are frequent among patients with SA or GNB bacteremia requiring OPAT via home infusion. An ID pharmacist-directed program in collaboration with an ID provider is feasible for OPAT transitions and may serve as a roadmap for other institutions. Disclosures Dana Simonson, PharmD, BCPS, Janssen (Advisor or Review Panel member, Other Financial or Material Support, Webinar Series Speaker Fall 2019)

Objective: To evaluate the Grand-Aides Program for patients with type 2 diabetes mellitus (T2DM) according to the variables of body weight, blood pressure, medication adherence, and hospital consultation and readmissions.Methods: Patients ages 18 years or older with a past medical history of T2DM, hypertension (HTN), and/or obesity and who were recently seen in the emergency department (ED) or recently admitted to the hospital were eligible to enroll in the Grand-Aides Program. Eligible patients were identified after hospital or ED discharge and were asked to enroll in the in-home based program from March 2016 through June 2018. In-home visit protocol was defined prior to patient enrollment with intense in-home visits during the first weeks of enrollment followed by monthly visits for the duration of enrollment in the program. In-home visit frequency was adjusted on as needed basis so that patients at higher risk for ED visits or hospitalization were seen more frequently. In-home visits were performed by trained Grand-Aide who for the purpose of this study was a certified nursing assistant (CNA). The Grand-Aide underwent eighty hours of didactic training which included visit protocols, visit schedules, and data collection. The one-on-one in-home patient with every visit were supervised by a registered nurse (RN) or nurse practitioner (NP) via video or telephone contact near the conclusion of the visit. Active patients at the University of Virginia Family Medicine clinic were eligible for enrollment. Fifty-seven patients with T2DM worked with Grand-Aides for three months and an additional forty-eight T2DM patients worked with Grand-Aides for twelve months. Emergency department visits, all 30-day hospital readmissions, as well as blood pressure readings, medication adherence, weights, and glycated hemoglobin (HbA1c) were compared with the prior twelve months.Results: Systolic (p < .001) and diastolic (p < .01) blood pressures decreased (p < .01) at 1 year. At baseline 56 percent of the patients had a systolic blood pressure of >130 mmHg despite treatment; after 12 months, 48 percent of these were < 130. In those whose baseline diastolic blood pressure was > 90 mmHg, 100 percent had diastolic blood pressure < 90 mmHg at 1 year. Medication adherence by ARMS test at 1 year was 94 percent. Despite trending downward, weight and HbA1c did not change significantly. In the preceding, 58 percent had at least one ED visit, which was reduced by 50 percent (p < .01) with Grand-Aides; 30-day all-cause readmissions reduced by 50 percent to 6.3 percent. Conclusions: The Grand-Aides program was associated with a significant change in blood pressure control, high medication adherence and reductions in ED visits and readmissions that compare favorably with published comparative data. For systems “at risk” for preventable increased health care expense burden, the Grand-Aides program can result in significant savings.

Abstract Background: The Acute Life Interventions Goals & Needs Program (ALIGN) at the Mount Sinai Hospital in New York City aims to work closely with high risk geriatric patients for short term intensive management of acute medical and social issues. Quantitative measures for determining success of the program is comparing emergency room visits and hospitalizations prior to and after enrollment with ALIGN. The Community Paramedicine service allows a paramedic, the ALIGN provider, and an emergency room physician to assess and triage patients in their home via video conference thereby avoiding ED visits for non-urgent services. Method: We reviewed the utilization of the Community Paramedicine service (from July 2017-February 2020) and its impact on ALIGN’s efforts to reduce unnecessary ED visits and hospitalizations. Results: 36 patients were evaluated with the Community Paramedicine service (from July 2017-February 2020). 19 or 52.8% avoided an ED visit and 17 or 47.2% were transported to the ED. 12 or 70.6% were admitted to the hospital of those that were transported to the ED initially. Top reasons for transport to ED included generalized weakness, acute mental status change (AMS), and shortness of breath (SOB). Conclusions: A Community Paramedicine program utilized by a high risk geriatrics team like ALIGN is effective in reducing ED visits and hospitalizations for the elderly population who incur greater expenses to the health care system and traditionally have poorer health outcomes.

This study aims to analyze the description of Procurement of Nursing Management Information System at Home Visit Telenursing application at RS. M.Yunus Bengkulu. Design research that researchers use modify the theory of research (R) and development (D). The development of telenursing technology based on BAN (body area network) technology can provide realtime monitoring results and connect with WSN (wireless sensor network) transmission through integration with end user devices (laptop) which design and implementation can be used in rural and remote areas. The result of the study is the design of the program system that has the advantage of being able to be used to transmit medical data of the patient, the main complaint, the type of illness he feels (mild, moderate and severe), visualization of data in image, sound and text, even video, can be used as health detector digital-based patients via video mail, and family medical history with multimedia medical records techniques that are connected to the health center of M. Yusuf Bengkulu Hospital. Direct research was piloted to the nurse to gain a nurse's understanding of the use of telenursing. The conclusion of this research is the enthusiasm of nurses in accepting new challenge in providing telenursing service is very high, it can impact on ability to improve effective communication between nurse and patient. Keywords: Home Visit Telenursing, Development, SIM

Background: Transitions of care (TOC) points are those where patient outcomes can be affected, especially patients at high risk for medication errors. Pharmacist-led postdischarge telephone counseling positively affects patient outcomes, though challenges exist relating to successful patient contact. Objective: The objective of this study was to develop and evaluate a discharge education service bridging the inpatient and outpatient setting to increase successful patient contact points during the TOC process from hospital to home. Methods: This prospective, single-centered observational study examined the impact of a discharge medication education program on successful telephone follow-up contact. The primary outcome was the percentage of high-risk patients educated at hospital discharge who were successfully reached via follow-up telephone contact within 2 business days of discharge. Secondary end points included hospital readmission rates and patient survey responses. Results: A total of 50 patients were included in the initial evaluation of this service; 78% of patients were successfully contacted within 2 business days after discharge, an increase from a 20% success rate prior to service implementation. At follow-up telephone calls, patients reported taking an average of 16 medications. The 30-day readmission rate was 10% for patients receiving this service, compared with 19% prior to implementation. When asked if they understood the medication component of their care and if they found the TOC service to be satisfactory, 100% and 96% of patients strongly agreed or agreed with these statements, respectively, and none disagreed. Conclusion and Relevance: This service demonstrates how pharmacists can interact with a high-risk population and increase contact points to optimize care at crucial health care transition points.

Abstract Objective Research has shown effectiveness of nonremoval of the spoon and physical guidance in increasing consumption and decreasing inappropriate mealtime behavior. The side deposit has been used to treat passive refusal in 2 studies (1 in a highly specialized hospital setting) using lower manipulated-texture foods on an infant gum brush. Methods We extended the literature by using regular texture bites of food with a finger prompt and side deposit (placing bites inside the side of the child’s mouth via the cheek) in an intensive home-based program setting in Australia, demonstrating that attention and tangible treatments alone were ineffective prior, fading the tangible treatment, showing caregiver training, and following up. 2 male children with autism spectrum disorder (with texture/variety selectivity; one with liquid dependence) participated in their homes. We used a reversal design to replicate effectiveness of the side deposit added to a treatment package. Results For both participants, we observed a &gt;98% decrease in latency to acceptance, a 100% decrease in inappropriate mealtime behavior, and a 100% increase in consumption with the side deposit added. Variety was increased to over 85 regular texture foods. 100% of admission goals were met. Caregivers were trained to high procedural integrity and the protocol was generalized to school and the community. Gains maintained to 3 and 1.5 years. Conclusion This is important work in adding to the literature and support for the side deposit and expanding to regular texture, as well as replicating and extending empirically supported treatments for feeding internationally to the home setting.

Abstract Background The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic threatened to oversaturate hospitals worldwide, necessitating rapid patient discharge to preserve capacity for the most severe cases. This need, as well as the high risk of SARS-CoV-2 transmission, led many hospitals to implement remote patient monitoring (RPM) programs for SARS-CoV-2 positive patients in an effort to provide care that was safe and preserve scarce resources. Objective The aim of this study is to provide an integrative review of peer-reviewed literature on different RPM programs that were implemented for SARS-CoV-2 positive patients including their strengths and challenges. Methods A search was conducted for peer reviewed literature using PubMed, CINAHL, OVID, and Google Scholar. Peer-reviewed studies written in English or Spanish and published between 2019 and 2021 on RPM of SARS-CoV-2-positive patients were considered. Information was extracted according to a qualitative content analysis method, informed by the Comparison of Mobile Patient Monitoring Systems Framework. Results Of 57 retrieved articles, 10 publications were included. The sample sizes ranged from 75 to 48,290 and the monitoring length ranged from 7 to 30 days. Information regarding the comparison framework was summarized. Main strengths of using RPM for SARS-CoV-2 positive patients was participant acceptance, feasibility, safety, and resource conservation. Main limitations were the lack of information on patient data security measures, robust outcomes testing, and identification of the most effective biomarkers to track SARS-CoV-2 decompensation. Conclusion Different RPM programs for SARS-CoV-2 were implemented, from sending home participants with a pulse oximeter and collecting readings via call to modifying existing mobile applications and sending holistic health questionnaires to participants. This review determined that RPM is beneficial to SARS-CoV-2 positive patients; however, its effectiveness can be improved by further research. Mainly, identifying what patient data are most effective at tracking SARS-CoV-2 decompensation by utilizing advanced technology already in the market.

Objective The aim of Queen Elizabeth II Jubilee Hospital (QEII) redesign project (QEII United) was to enhance timely access to an inpatient bed and maximise opportunities to value add during the inpatient episode of care. Methods A tripartite relationship between the hospital team, system manager and external consultants. The team, QEII United, was formed to ‘diagnose, solve and implement’ change under the unifying metaphorical banner of a football team. A marketing strategy and communication plan targeted the key ‘players’ and outlined the ‘game plan’. Baseline data were collected, analysed and reported in keeping with key aims. Strategies for systems improvement implementation were attached to key performance indicators (KPIs). Results Thematic KPIs were developed to embed internal process change to reflect the contributions made towards the National Emergency Access Target (NEAT) at each stage of the patient journey. As such, access block of under 20%, morning discharge rates of 50% before midday, reduced length of stay for selected elective orthopaedic and general medical diagnostic related groupings (DRGs; i.e. relative stay index ≤1) and hospital in the home (HITH) utilisation rates 1.5% of all admissions were all met. Key to sustainability was the transfer of clinical redesign skills to hospital staff and the fostering of emergent ground up leadership. Conclusions QEII United’s success has been underpinned by the development of themed solution areas developed by the hospital staff themselves. Robust baseline data analysis used in combination with nationally available benchmarking data provided a quantitative starting point for the work. The collaborative elements of the program re-energised the hospital team, who were kept informed by targeted communications, to establish quick wins and build trust and momentum for the more challenging areas. What is known about the topic? Clinical redesign is now commonly used to understand, define and improve those clinical processes that underpin the patient journey across the continuum of care. Different industry models exist and have been extended for use in healthcare settings to involve, engage and educate staff with the primary focus of providing the best possible patient care, in an effective and efficient manner. What does this paper add? The clinical redesign process outlined in this paper is instructive in its use of the metaphorical team. Team philosophy, composition and functionality was built up using the vernacular of a football competition. In this way, organisational learning and capability building occurred within empowered local action teams, across the ‘season’ to effect changes at all points of the patient journey. What are the implications for practitioners? The implications for practitioners are to fully understand the breadth of issues before deciding upon focus areas for improvement. Resistance to change is inevitable and there are a number of ways to mitigate this and create a sense of purpose within the broader clinical group by structuring teams across traditional reporting lines. Collaboration is crucial in keeping lines of communication open and the use of data and patient feedback is very instructive.

AbstractThe purpose of the study was to develop a smoking cessation online service (SCOS) for cigarette smokers. The SCOS website was developed via Flash Professional® program version 9.0 with software that included Mozilla™, Java®, and Windows™. Twenty-five volunteers accessed SCOS. Five trained hospital pharmacists were responsible for the online counselling service. Most volunteers were males with a history of smoking of at least ten years, were aged between 21 to 30 years, and were in the low income bracket. Twenty-five per cent of the volunteers stated that they were ready to quit smoking. The most common method of smoking cessation was to give up smoking at once (48%). Results showed that attitudes towards smoking perceptions were positively high with a mean score of 28.52 out of 30. Volunteers also stated they thought SCOS was interesting and useful. They liked the functions of the program as well as its benefits. Recommendations included the extension of the study into different areas, the continuation of SCOS as an alternative for quitting smoking and the evaluation of the effectiveness of SCOS alongside current methods of smoking cessation, such as face-to-face counselling, home visits and phone calls.

Background: 5% of the population over 65 is on oral anticoagulant therapy. The indications for anticoagulation therapy are wide, not limited to but including treatment of arterial and venous thrombosis, and primary stroke prophylaxis is patients with atrial fibrillation and mechanical cardiac valves. While new oral anticoagulants not requiring monitoring are being more widely prescribed, vitamin K antagonists (VKA) are still being used for many patients in whom the novel agents are contra-indicated (renal failure), not available (funding), or patient/physician preference. Most patients on VKA have their family physicians manage their oral anticoagulants. On average, the time in therapeutic range achieved by family physicians is low (50-55%). There is also a number of patients who have no family physician and are either taking VKA without monitoring, or are having their anticoagulants monitored routinely though emergency room physicians/visits. The Ottawa Hospital (TOH) anticoagulation management service is an e-health solution that offers patients world beating time in therapeutic range (TIR). TOH uses a pharmacy managed DAWN software package (computer-assisted warfarin dosing program). Maintaining patients in therapeutic range for a high percentage of time (greater than 70%) can reduce the risk or recurrent thrombosis (venous or arterial) from under-anticoagulation and the risk of bleeding complications from over-anticoagulation. Well managed VKA therapy has also been suggested to be as safe as therapy with novel oral anticoagulants in some subgroup analysis of studies investigating the novel oral anticoagulants. Objectives/Methods: The purpose of this study was to bring the benefits of the TOH experience to provide a Regional Anticoagulation Management Service across a wide region of eastern Ontario, Canada. This service includes remote blood testing (at a lab near the patient’s home), integrated LIS link to a computerized dosing system (possible through a commercial lab partnership), and communication of dosing and testing instructions via interactive voice recognition (IVRS), email, or live (pharmacist/pharmacist assistant). We administered a patient satisfaction survey to a sample of 111 patients enrolled in the service as well as reported TIR for patients enrolled in our service during the study period (2009-2011). Results: At the beginning of the study, 1400 patients were enrolled in the program. After 2 years, the number has increased to by 66% to 2325. The average TIR for patients in the program as of October 2011 was 76.3% (overall), 77.8% (IVRS), 76.8% (email), and 73.3% (live). The patient satisfaction survey demonstrated that 94% patients prefer VKA anticoagulation monitoring through TOH service compared to their previous experience. 84% patients either satisfied or very satisfied with VKA anticoagulation care through TOH service (compared to 53% satisfaction with anticoagulant care prior to enrolling in our program). Conclusions: The TOH model of anticoagulation management service results in excellent VKA monitoring (high TIR) for a large number of patients across a wide geographical area, as well as a high level of patient satisfaction. This service allows for the safe and efficient management of VKAs in patients in whom VKA therapy is indicated. Disclosures No relevant conflicts of interest to declare.

Background Access to exercise for cancer survivors is poor despite global recognition of its benefits. Telerehabilitation may overcome barriers to exercise for cancer survivors but is not routinely offered. Objective Following the rapid implementation of an exercise-based telerehabilitation program in response to COVID-19, a process evaluation was conducted to understand the impact on patients, staff, and the health service with the aim of informing future program development. Methods A mixed methods evaluation was completed for a telerehabilitation program for cancer survivors admitted between March and December 2020. Interviews were conducted with patients and staff involved in implementation. Routinely collected hospital data (adverse events, referrals, admissions, wait time, attendance, physical activity, and quality of life) were also assessed. Patients received an 8-week telerehabilitation intervention including one-on-one health coaching via telehealth, online group exercise and education, information portal, and home exercise prescription. Quantitative data were reported descriptively, and qualitative interview data were coded and mapped to the Proctor model for implementation research. Results The telerehabilitation program received 175 new referrals over 8 months. Of those eligible, 123 of 150 (82%) commenced the study. There were no major adverse events. Adherence to health coaching was high (674/843, 80% of scheduled sessions), but participation in online group exercise classes was low (n=36, 29%). Patients improved their self-reported physical activity levels by a median of 110 minutes per week (IQR 90-401) by program completion. Patients were satisfied with telerehabilitation, but clinicians reported a mixed experience of pride in rapid care delivery contrasting with loss of personal connections. The average health service cost per patient was Aus $1104 (US $790). Conclusions Telerehabilitation is safe, feasible, and improved outcomes for cancer survivors. Learnings from this study may inform the ongoing implementation of cancer telerehabilitation.

99 Background: Inpatient palliative care (PC) teams have increased their presence over the past decade, with over 90% of hospitals having access to PC specialists. However, such growth has not been mirrored in the outpatient setting; this is relevant for patients living far from major medical centers. Memorial Sloan Kettering Cancer Center (MSK) has expanded its ambulatory care footprint beyond New York City (NYC) to sites where PC is not currently available. To address the need for PC delivery to a geographically dispersed patient population, we developed a clinical initiative utilizing telemedicine technology. Methods: The Telemedicine Palliative Care Program (TPCP) was initiated after planning with multiple stakeholders, including clinical, legal, billing, compliance, ambulatory care, information systems, and scheduling departments. The TPCP provides PC consultation and management of patients via a “hub-and-spoke” model, whereby PC specialists are located at the main campus in NYC and patients are scheduled to be seen at one of six regional ambulatory cancer sites within a 50-mile radius. Regional ambulatory sites have video teleconference rooms equipped with Cisco (San Jose, CA) TelePresence MX300 hardware and Jabber software allowing for secure, high fidelity, real-time video communication with clinicians at the main campus who use iPads installed with Jabber software during their consultation sessions. Results: The TPCP is currently active at two regional sites in New York and New Jersey. Patient satisfaction, perception of quality of care, and patient outcomes will be measured. Preliminary results indicate that both patients and providers find this clinical program to be an extremely valuable experience. Conclusions: The technologic infrastructure is now available to deliver telemedicine-enabled PC for cancer patients in a geographically distributed model. Our early experience suggests that our program will help enable the convenient delivery of concurrent PC to cancer patients across a wide geographic area. This innovative clinical initiative has the potential to enable all MSK patients to access high-quality palliative care in a geography-agnostic manner, and eventually deliver such care to patients in their homes.

Abstract Background: VOCs are the hallmark of SCD and can lead to serious complications and organ damage. P-selectin, a cell adhesion protein, plays a central role in the multicellular interactions that can lead to VOCs. Crizanlizumab, a first-in-class humanized monoclonal antibody that targets P-selectin, is approved in several regions to prevent/reduce VOC burden for patients (pts) with SCD aged ≥16 years. Pts in some countries can obtain early access to crizanlizumab before health authority approval via a MAP (NCT03720626); first pt enrolled in June 2018. Aim: To describe the proportions of pts with 0 home- or 0 healthcare-managed VOCs after 6 months of treatment with crizanlizumab in the MAP (in countries where publication of these data is allowed). Methods: The MAP was designed to provide access to crizanlizumab for SCD pts with serious or life-threatening disease for which no comparable or satisfactory alternative to crizanlizumab was available as treatment in their country. Other eligibility criteria included: aged 16-70 years (18-70 years in Italy); history of VOCs as assessed by the treating physician (including recurrent VOCs while receiving hydroxyurea [HU], L-glutamine or other therapies); and not eligible for a crizanlizumab clinical trial. At baseline, treating physicians were asked about their pts' disease burden in the 12 months prior to requesting access to crizanlizumab (eg frequency of home- or healthcare-managed VOCs and opioid use for VOC management). The proportions of pts with 0 home- or 0 healthcare-managed VOCs after 6 months of treatment with crizanlizumab are described overall and stratified by SCD genotype and history of HU use. Results: Treating physicians made requests for initial access to crizanlizumab for 146 pts eligible for this analysis. Most of these pts were from Brazil (n=105; 72%), with the remainder residing in Italy, Spain, Israel, Canada, Portugal and Switzerland. Of the 144 pts with baseline data (missing, n=2), 142 (99%) had ≥1 home-managed VOC (median [interquartile range; IQR] of 6 [4‒8.5] VOCs) and 137 (95%) had ≥1 healthcare-managed VOC (median [IQR] of 3 [2‒5] VOCs) in the 12 months before entry into the MAP. Opioids were taken for VOC management by 92% of pts in the 12 months prior to baseline (n=132/144); the most common was morphine (n=57/132; 43%). As of June 2021, 102 of the 146 pts with initial requests had received crizanlizumab for ≥6 months and had resupply requests submitted by their physicians. For these 102 pts, median (IQR) age was 33 (25-40) years, 62% were female, 47% were of African American ethnicity, the genotype was HbSS in 79%, and a history of HU use was reported in 45% of these pts. Eleven pts (5%) discontinued crizanlizumab during the 6 months of treatment reported in this analysis. Of the 102 pts with data available 6 months post-crizanlizumab initiation, 46 (45%) reported 0 home-managed VOCs (median [IQR] of 1 [0‒2] VOC) and 62 (61%) reported 0 healthcare-managed VOCs (median [IQR] of 0 [0‒1] VOCs) during this time period. The proportions of pts with 0 home- or 0 healthcare-managed VOCs after 6 months of treatment with crizanlizumab stratified by SCD genotype and history of HU use are shown in Figure 1. Clinicians participating in the MAP anecdotally reported improvement in certain clinical complications (eg leg ulcers and priapism), reduced frequency of hospitalizations, shorter lengths of hospital stay and reduced use of opioids in some pts after crizanlizumab treatment. Adverse events were consistent with those reported in other crizanlizumab studies. Limitations: The difference in time periods for which data are available (ie 12 months for baseline data vs 6 months for post-treatment initiation data) precludes a comparison of data pre- and post-initiation of crizanlizumab in this analysis. Information about HU use was not provided for all pts, therefore the proportion of pts with a history of HU use in this analysis could be higher than reported. Conclusion: Pts participating in the crizanlizumab MAP had a high burden of home- and healthcare-managed VOCs at baseline despite many pts reporting a history of HU use; almost all required opioids for VOC management. Findings from this analysis looking at the proportion of pts with 0 home- or 0 healthcare-managed VOCs after 6 months of treatment with crizanlizumab are promising, although additional data with ≥12 months of exposure are required to compare VOC burden on treatment with that reported here at baseline. Figure 1 Figure 1. Disclosures Cançado: Novartis: Consultancy. Colombatti: NovoNordisk: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding; bluebird bio: Membership on an entity's Board of Directors or advisory committees, Research Funding; Forma Therapeutics: Membership on an entity's Board of Directors or advisory committees. Quarta: Novartis: Membership on an entity's Board of Directors or advisory committees, Other: collaboration relationships for Advisory boards, Webinar events, editorial projects; Speaker at conferences; Celgene: Other: collaboration relationships for Advisory boards, Webinar events, editorial projects; Sanofi - Genzyme: Membership on an entity's Board of Directors or advisory committees, Other: collaboration relationships for Advisory boards, Webinar events, editorial projects; Speaker at conferences; Blue Bird Bio: Other: collaboration relationships for Advisory boards, Webinar events, editorial projects; Takeda: Other: collaboration relationships for Advisory boards, Webinar events, editorial projects; speaker at conferences; Bristol Meyer Squibb: Membership on an entity's Board of Directors or advisory committees, Other: Speaker at conferences. DeBonnett: Novartis Pharmaceuticals Corporation: Current Employment. Soliman: Novartis: Current Employment. Sarkar: Novartis: Current Employment. Pinto: Novartis: Consultancy; Global Blood therapeutics (GBT): Consultancy; EMS, Brazil: Consultancy.

Background Youth with cerebral palsy do not have enjoyable, accessible, and scalable exercise options that can empower them to independently maintain their cardiometabolic health. Objective The primary aim is to examine the preliminary efficacy of a 12-week home-based virtual reality tele-exergaming intervention on several indicators of cardiometabolic health in youth with cerebral palsy compared to the wait list control. A secondary aim is to describe feasibility metrics, namely, recruitment, retention, and adherence rates; perceived enjoyment; intervention safety; and management issues. The tertiary aim is to generate a theory that reveals critical behavioral mechanisms of adherence to tele-exergaming. Methods In this parallel group design randomized controlled trial, 34 inactive youths with cerebral palsy are randomly allocated to one of two groups: a group that immediately receives 12 weeks of virtual reality exergaming with tele–physical education or a wait list control group that undergoes their habitual activity for 12 weeks. Participants are recruited from a Children’s Hospital and community network. At baseline (week 0), week 6, and week 12, high sensitivity C-reactive protein and blood insulin, hemoglobin A1c, triglycerides, cholesterol, and pressure are measured by the youth and a caregiver at home using a blood spot test kit and blood pressure cuff. They will also self-measure their lung function and body weight using a peak flow meter and bathroom scale, respectively. Collections are supervised by research staff via videoconference. Changes in outcomes are compared between and within groups using exploratory statistical analyses and descriptive statistics. At postintervention or dropout, participants will undergo semistructured interviews to identify behavioral mechanisms that underly participation. Results Recruitment procedures started in June 2022. All data are expected to be collected by October 2023. Full trial results are expected to be published by February 2024. Secondary analyses of data will be subsequently published. Conclusions This trial tests an innovative serious exergaming virtual reality program that includes a completely remote enrollment, assessment, and intervention tele-protocol. The knowledge obtained will inform the development of a larger effectiveness trial for improving the health and well-being of youth with cerebral palsy. Trial Registration ClinicalTrials.gov NCT05336227; https://clinicaltrials.gov/ct2/show/NCT05336227 International Registered Report Identifier (IRRID) PRR1-10.2196/40708

Abstract Background Optimizing patients’ total hip and knee arthroplasty (THA/TKA) experience is as crucial for providing high quality care as improving safety and clinical effectiveness. Yet, little evidence is available on patient experience in standard-inpatient and enhanced recovery after surgery (ERAS)-outpatient programs. Therefore, this study aimed to gain a more in-depth understanding of the patient experience of ERAS-outpatient programs in comparison to standard-inpatient programs. Methods We conducted a convergent mixed methods study of 48 consecutive patients who experienced both standard-inpatient and ERAS-outpatient THA/TKA contralaterally. A reflective thematic analysis was conducted based on data collected via a questionnaire. Bivariate correlations between the patient experience and patients’ characteristics, clinical outcomes and care components satisfaction were performed. Then, the quantitative and qualitative data were integrated together. Results The theme Support makes the difference for better and for worse was identified by patients as crucial to their experience in both joint replacement programs. On the other hand, patients identified 3 themes distinguishing their ERAS-outpatient from their standard-inpatient experience: 1) Minimizing inconvenience, 2) Home sweet home and 3) Returning to normal function and activities. Potential optimization expressed by patients were to receive more preoperative information, additional postoperative rehabilitation sessions, and ensuring better coherence of care between hospital and home care teams. Weak to moderate positive and statistically significant correlations were found between patients’ THA/TKA experience and satisfaction with pain management, hospital stay, postoperative recovery, home care, and overall results (rs = + [0.36–0.66], p-value < 0.01). Conclusion Whatever the perioperative program, the key to improving patients’ THA/TKA experience lies in improving support throughout the care episode. However, compared to standard-inpatient care, the ERAS-outpatient program improves patients’ experience by providing dedicated support in postoperative care, reducing postoperative inconvenience, optimizing pain management, returning home sooner, and recovering and regaining function sooner. Patients’ THA/TKA experience could further be enhanced by optimizing the information provided to the patient, the rehabilitation program and the coherence between care teams.

Introduction Telemedicine serves as a viable option during the COVID-19 pandemic to provide in-home care, maintain home isolation precautions, reduce unnecessary healthcare exposures, and de-burden hospitals. Methods We created a novel telemedicine program to closely monitor patients infected with SARS-CoV-2 (COVID-19) at home. Adult patients with COVID-19 were enrolled in the program at the time of documented infection. Patients were followed by a team of providers via telephone or video visits at frequent intervals until resolution of their acute illness. Additionally, patients were stratified into high-risk and low-risk categories based on demographics and underlying comorbidities. The primary outcome was hospitalization after enrollment in the home monitoring program, including 30 days after discharge from the program. Results Over a 3.5-month period, 1128 patients met criteria for enrollment in the home monitoring program. 30.7% were risk stratified as high risk for poor outcomes based on their comorbidities and age. Of the 1128 patients, 6.2% required hospitalization and 1.2% required ICU admission during the outcome period. Hospitalization was more frequent in patients identified as high risk (14.2% vs 2.7%, P < 0.001). Discussion Enrollment in a home monitoring program appears to be an effective and sustainable modality for the ambulatory management of COVID-19.

Abstract Patient compliance with medical recommendations and monitoring of the cardiovascular system parameters after discharge from the hospital are important in the postoperative period. Material and methods The program of remote home monitoring of patients after cardiac surgery was created and is used in clinical practice of the department of surgical treatment of interactive pathology. First of all, we analyzed the capabilities of apps for mobile phones, ECG monitoring devices, and blood pressure monitors with the ability to remotely reset data via Bluetooth which are available in Russia. In accordance with the requirements of the high-tech clinic, the following applications were selected: MediSafe (control of drug therapy), MedMBP (control of blood pressure), Ritmer (ECG monitoring), MiFit (a step tracker). In the follow-up program 25 patients (15 men, 10 women) were included. The average age is 59±11 years (min-29, max-91). Performed interventions: 7 patients underwent RFA, 6-valve replacement with a mechanical prosthesis, 2-valve replacement with a bioprosthesis, 7-CABG, 5-PCI. The patients gave their voluntary consent to participation, confirmed their readiness and ability to use apps and devices. The initial psychological status and the quality of life were assessed using the SF 36 and HADS questionnaires. All patients were given a tonometer for BP measuring, an ECG device and a step tracker to evaluate physical activity. According to the protocol, patients measure BP and ECG daily or additionally if they feel worse; using the mobile app, they note the taken medications. All data are sent to the server and analysis by the doctor. The doctor reviews the received indicators every day and, if necessary, contacts the patient to discuss treatment tactics. Results For today the follow-up period is 3 months. During this period, 96% of patients strictly follow the program protocol. One patient has difficulties when using the ECG recorder, does not regularly follow the recommendations for drug therapy, which requires an individual approach. Based on the monitoring results, correction of antihypertensive therapy was necessary in 40% of cases, antiarrhythmic therapy-in 20%. In one case, a sinus node weakness syndrome was detected, and the patient was called to the hospital for the pacemaker implantation. Conclusion The remote monitoring program is an effective and promising tool for monitoring patients after discharge from the hospital. It is clear that the results obtained from more patients and after a longer follow-up period would be more informative. However, the intermediate initial result indicates the necessity and effectiveness of this program. Funding Acknowledgement Type of funding sources: None. Figure 1

Abstract Background Diabetes is a progressive condition requiring long-term medical care and self-management. The ineffective transition from hospital to community or home health care may result in poor glycemic control and increase the risk of serious diabetes-related complications. In China, the most common transitional care model is home visits or telephone interventions led by a single healthcare setting, with a lack of cooperation between specialists and primary care, which leads to inadequate service and discontinuous care. Thus, an integrated hospital-community-home (i-HCH) transitional care program was developed to promote hospital and community cooperation and provide comprehensive and continuous medical care for type 2 diabetes mellitus (T2DM) via mobile health (mHealth) technology. Methods This protocol is for a multicenter randomized controlled trial in T2DM patients. Hospitalized patients diagnosed with T2DM who meet the eligibility criteria will be recruited. The patients will be randomly allocated to either the intervention or the control group and receive the i-HCH transitional care or usual transitional care intervention. The change in glycated hemoglobin is the primary outcome. Secondary outcome measures are blood pressure, lipids (total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein), body mass index, self-management skills, quality of life, diabetes knowledge, transitional care satisfaction and the rate of readmission. The follow-up period of this study is six months. Discussion The study will enhance the cooperation between local hospitals and communities for diabetes transitional care. Research on the effectiveness of diabetes outcomes will have potentially significant implications for chronic disease patients, family members, health caregivers and policymakers. Trial registration Chinese Clinical Trial Registry ChiCTR1900023861: June 15, 2019.

Background: Stroke patients are at high risk for complications and hospital readmissions, ranging from 6.5% to 24.3% 30 days post-discharge. Evidence-based interventions for prevention of stroke readmissions are not clearly defined and surveillance data for transitions of care (TOC) are lacking. The Michigan Coverdell Stroke Registry is conducting surveillance to understand the current processes in order to assist hospitals to develop, implement and evaluate strategies to improve stroke TOC. Methods: Data were collected from 395 cases from three hospitals from October 2013 to March 2014. Stroke nurses at each hospital collected data on selected transition of care elements via a combination of follow-up phone calls and chart review at different time intervals within 30 days of hospital discharge. Patients who died in-hospital or were discharged to a skilled nursing facility were excluded. Results: Of the 395 cases, 357 (90.3%) of patients had a recorded history of high blood pressure. A total of 19.0% (N=68) were not monitoring BP at home, 45.1% (N=161) were, and 35.9% (N=68) had an unknown monitoring status. Among patients living at the time of follow up, 61.8% (N=240) were recorded as taking a medication post discharge. Only about half of patients who were taking medications responded as having understood how to take them, why they were taking them, and what to do when they ran out. Of note, a large proportion of the data was missing for each of those questions (44.6%, 45.8%, and 45.4% respectively). A total of 149 patients were referred for follow-up at the time of the post-discharge call. Conclusions/Discussion: TOC surveillance is a key component in the development and implementations of strategies to strengthen and evaluate the effectiveness of stroke care including: secondary adherence to prevention measures, patient/caregiver understanding of patient education, and hospital readmissions for complications following stroke. The data suggest that an there are opportunities to improve how patients are prepared for hospital discharge including teaching to monitor and report BP readings and prepare to manage medications after discharge. To our knowledge, this is the first multi-hospital stroke TOC surveillance program currently collecting data.

Objective: Shortage of general neurosurgery and specialized neurotrauma care in low resource settings is a critical setback in the national surgical plans of low and middle-income countries (LMIC). Neurotrauma fellowship programs typically exist in high-income countries (HIC), where surgeons who fulfill the requirements for positions regularly stay to practice. Due to this issue, neurosurgery residents and medical students from LMICs do not have regular access to this kind of specialized training and knowledge-hubs. The objective of this paper is to present the results of a recently established neurotrauma fellowship program for neurosurgeons of LMICs in the framework of global neurosurgery collaborations, including the involvement of specialized parallel education for neurosurgery residents and medical students.Methods: The Global Neurotrauma Fellowship (GNTF) program was inaugurated in 2015 by a multi-institutional collaboration between a HIC and an LMIC. The course organizers designed it to be a 12-month program based on adapted neurotrauma international competencies with the academic support of the Barrow Neurological Institute at Phoenix Children's Hospital and Meditech Foundation in Colombia. Since 2018, additional support from the UK, National Institute of Health Research (NIHR) Global Health Research in Neurotrauma Project from the University of Cambridge enhanced the infrastructure of the program, adding a research component in global neurosurgery and system science.Results: Eight fellows from Brazil, Venezuela, Cuba, Pakistan, and Colombia have been trained and certified via the fellowship program. The integration of international competencies and exposure to different systems of care in high-income and low-income environments creates a unique environment for training within a global neurosurgery framework. Additionally, 18 residents (Venezuela, Colombia, Ecuador, Peru, Cuba, Germany, Spain, and the USA), and ten medical students (the United Kingdom, USA, Australia, and Colombia) have also participated in elective rotations of neurotrauma and critical care during the time of the fellowship program, as well as in research projects as part of an established global surgery initiative.Conclusion: We have shown that it is possible to establish a neurotrauma fellowship program in an LMIC based on the structure of HIC formal training programs. Adaptation of the international competencies focusing on neurotrauma care in low resource settings and maintaining international mentoring and academic support will allow the participants to return to practice in their home-based countries.

Abstract Background Opioid use disorder poses a significant public health risk. Persons who inject drugs (PWID) suffer from high mortality and morbidity secondary to serious infectious diseases, often requiring prolonged courses of outpatient parenteral antibiotics. The goal of this study was to determine the outcomes of PWID discharged to home or to a skilled nursing or rehabilitation facility (SNF/rehab) with parenteral antibiotic treatment under an outpatient parenteral antimicrobial therapy (OPAT) program. Methods This is a retrospective observational study. The study population was identified via hospital and OPAT databases using substance use disorder diagnoses and confirmed through chart review. The study population included hospitalized PWID with injection drug use in the preceding 2 years who were discharged between 2010 and 2015 to complete at least 2 weeks of parenteral antibiotics and monitored by the OPAT program. Retrospective chart review was used to describe patient characteristics and outcomes. Results Fifty-two patients met inclusion criteria, 21 of whom were discharged to home and 31 were discharged to a SNF/rehab. Of the patients discharged to home, 17 (81%) completed their planned antibiotic courses without complication. Twenty (64%) patients discharged to a SNF/rehab completed the antibiotic courses without complication. Six (11%) patients had line infections, 6 (11%) had injection drug use relapse, and 12 (23%) required readmission. Conclusions Persons who inject drugs discharged home were not more likely to have complications than those discharged to a SNF/rehab. Home OPAT may be a safe discharge option in carefully selected patients.

Abstract Background Hypertrophic cardiomyopathy (HCM) is the most common hereditary heart disease, and its diagnosis is often associated with limited physical activity. Little is known about cardiac rehabilitation programs for patients with HCM. Therefore the novel hybrid cardiac telerehabilitation (HCTR) model consisting of hospital-based rehabilitation and home-based telemonitored rehabilitation might be an option to improve physical capacity in patients with HCM. Purpose To evaluate the safety, effectiveness and adherence to HCTR in patients with HCM without the left ventricle (LV) outflow tract obstruction and preserved LV ejection fraction. Methods The study group comprised 60 patients with HCM (51.1±13.3 years; NYHA II-III; LV ejection fraction 66.1±6.9%). Patients were randomised (1:1) to either HCTR program (hospital-based rehabilitation [1 month] based on cycloergometer training and home-based telemonitored rehabilitation [2 months] based on Nordic walking, five times a week, at 40–70% of maximal estimated heart rate) - training group (TG), or to a control group (CG). All patients had implantable cardioverter-defibrillator. In order to perform home-based telemonitored rehabilitation, a special device was used which enabled patients to: (1) do Nordic walking training according to a preprogrammed plan, (2) record and send electrocardiograms (ECGs) via mobile phone network to the monitoring centre. The moments of automatic ECGs registration were pre-set and coordinated with exercise training. The effectiveness of HCTR was assessed by changes - delta (Δ) in duration (t) of the workload, peak oxygen consumption (pVO2) in cardiopulmonary exercise test, 6-minute walking test distance (6-MWT) as a result of comparing t (s), pVO2 (ml/kg/min), 6-MWT (m) from the beginning and the end of the program. Results Safety of HCTR. Neither death nor other serious adverse events occurred during HCTR. We did not observe any ICDs intervention during the HCTR. Effectiveness of HCTR: Within-group analysis: t, pVO2, 6-MWT increased significantly in TG: t 657±183 vs 766±181 (p&lt;0.001), pVO2 19.2±5.0 vs 20.6±4.9 (p=0.007), 6-MWT 445±88 vs 551±77 (p&lt;0.001). In the untrained CG, the unfavourable results were observed: 695±198 vs 717±187 (p=0.114), pVO2 21.2±5.1 vs 21.1±5.6 (p=0.723), 6-MWT 512±83 vs 536±84 (p=0.061). Between-group analysis: The differences between TG and CG were statistically significant: in Δt (p&lt;0.001); ΔpVO2 (p=0.012); Δ6-MWT (p&lt;0.001). Adherence to HCTR: In TG 28 patients (93%) completed the HCTR program. Two patients did no undergo HCTR because of personal issues. Conclusion Hybrid cardiac telerehabilitation in patients with HCM without the left ventricle (LV) outflow tract obstruction and preserved LV ejection fraction is safe and effective. The adherence to HCTR is high. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Statutory work in The Cardinal Stefan Wyszyński National Institute of Cardiology in Warsaw, Poland

Abstract Background Hypertrophic cardiomyopathy (HCM) is the most common hereditary heart disease, and its diagnosis is often associated with limited physical activity. Little is known about cardiac rehabilitation programs for patients with HCM. Therefore the novel hybrid cardiac telerehabilitation (HCTR) model consisting of hospital-based rehabilitation and home-based telemonitored rehabilitation might be an option to improve physical capacity in patients with HCM. Purpose To evaluate the safety, effectiveness and adherence to HCTR in patients with HCM without the left ventricle (LV) outflow tract obstruction and preserved LV ejection fraction. Methods The study group comprised 60 patients with HCM (51.1±13.3 years; NYHA II-III; LV ejection fraction 66.1±6.9%). Patients were randomised (1:1) to either HCTR program (hospital-based rehabilitation [1 month] based on cycloergometer training and home-based telemonitored rehabilitation [2 months] based on Nordic walking, five times a week, at 40–70% of maximal estimated heart rate) - training group (TG), or to a control group (CG). All patients had implantable cardioverter-defibrillator. In order to perform home-based telemonitored rehabilitation, a special device was used which enabled patients to: (1) do Nordic walking training according to a preprogrammed plan, (2) record and send electrocardiograms (ECGs) via mobile phone network to the monitoring centre. The moments of automatic ECGs registration were pre-set and coordinated with exercise training. The effectiveness of HCTR was assessed by changes - delta (Δ) in duration (t) of the workload, peak oxygen consumption (pVO2) in cardiopulmonary exercise test, 6-minute walking test distance (6-MWT) as a result of comparing t (s), pVO2 (ml/kg/min), 6-MWT (m) from the beginning and the end of the program. Results Safety of HCTR. Neither death nor other serious adverse events occurred during HCTR. We did not observe any ICDs intervention during the HCTR. Effectiveness of HCTR: Within-group analysis: t, pVO2, 6-MWT increased significantly in TG: t 657±183 vs 766±181 (p&lt;0.001), pVO2 19.2±5.0 vs 20.6±4.9 (p=0.007), 6-MWT 445±88 vs 551±77 (p&lt;0.001). In the untrained CG, the unfavourable results were observed: 695±198 vs 717±187 (p=0.114), pVO2 21.2±5.1 vs 21.1±5.6 (p=0.723), 6-MWT 512±83 vs 536±84 (p=0.061). Between-group analysis: The differences between TG and CG were statistically significant: in Δt (p&lt;0.001); ΔpVO2 (p=0.012); Δ6-MWT (p&lt;0.001). Adherence to HCTR: In TG 28 patients (93%) completed the HCTR program. Two patients did no undergo HCTR because of personal issues. Conclusion Hybrid cardiac telerehabilitation in patients with HCM without the left ventricle (LV) outflow tract obstruction and preserved LV ejection fraction is safe and effective. The adherence to HCTR is high. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Statutory work in The Cardinal Stefan Wyszyński National Institute of Cardiology in Warsaw, Poland

Background: Readmission rates are high for patients with cardiovascular disease, particularly heart failure (HF) and acute coronary syndrome (ACS). Telephone calls by clinical staff have had mixed effects. We aim to evaluate the degree of implementation and the effect of a quality improvement initiative using a simplified post-discharge phone call by administrative assistants. Methods: Clinical data were retrospectively reviewed at a single urban public hospital. From January through October 2012 all patient discharged home from inpatient cardiology services (intervention group, n=1034 discharges) were identified. Within 7 days, administrative assistants contacted patients via telephone and queried regarding (1) medication compliance, (2) awareness of follow-up appointments and (3) if clinician contact is requested. Outcome events were defined as readmissions (for any cause) within 30 days to the same hospital and are reported as patients experiencing readmission, and total readmissions. A comparison group of all patients discharged home from inpatient cardiology services from January through October 2010 (n=746) were selected as controls (no phone calls). Categorical data were compared in a univariate fashion using the Chi Square test. Statistical significance is defined as p<.05. Results: Of the 1034 discharge events in the intervention group, 620 (60.0%) had phone calls attempted. Of those, 419 (67.6%) were directly contacted. Patients were statistically different with respect to language, ethnicity and insurance status. Of the patients called, 48 (7.7%) reported medication abnormalities, 13 (2.1%) did not understand their follow-up and 38 (6.1%) had a question for a clinician. The rates of patients experiencing events was not statistically different (132 [17.7%] vs. 156 [15.1%], OR 0.85, p=.14). Total readmissions were significantly reduced (157[21.0%] vs. 179 [17.3%], OR 0.82, p=.047). Pre-specified subgroups of ACS and HF patients showed a trend towards decreased re-admissions but were not statistically significant. Conclusion: A simplified post-discharge telephone call strategy is associated with a trend towards reduced hospital readmissions for cardiology patients. Further refinements are needed to improve program implementation.

Introduction: India has a high burden of young-onset heart failure owing to an increased incidence of ischemic heart disease(IHD) in young and older adults (<60 years). Hypertension affects 207 million adults in India; less than 20% have controlled blood pressure. Cardiac rehabilitation (CR) effectively improves outcomes in patients with heart failure but is very scarce; there is only one spot for every 360 IHD patients/year, with more than 3 million CR spaces needed each year. Methods: Virtual cardiac rehabilitation is administered via a mobile application, Numen Health. This is a physician-led program delivered by a multi-disciplinary team of experts. The experts provide multi-faceted interventions for IHD patients, targeting increased medication adherence, behavior changes, reinforced lifestyle modification, blood pressure control through diet, exercise, and building mental resilience with continued care post-hospital discharge. Results: Between April 2021 and March 2022, 42 patients with low ejection fraction (LVEF<45%) heart failure registered on the program. They represented nearly 10% of 426 IHD patients who had joined the program. Over a median duration of 90 days, target blood pressure control was achieved in 39/42 (93%). Zero hospital re-admissions were encountered; 17/42(40%) achieved improved cardiac and exercise tolerance compared to baseline exercise tolerance time. It had increased from 15 minutes to 30 minutes, 200% from baseline. The median MET score on day 90 was 13 (9-17). Physical activity duration per week increased; to 90 minutes on average; It had risen from the ability to do for <5 minutes at baseline. Medication adherence and clinical follow-up were 100% of the prescribed. A self-rated satisfaction scale scored the program at 90 - 95 /100 on day 30 by all. Conclusions: Virtual Cardiac Rehabilitation in India is feasible and possibly effective in delivering integrated CR services at home. Numen health shows promise in bridging the gap of negligent CR services across India.

Background: Non-interventional large-scale research on patients with stroke requires the use of data sources ensuring access to large populations with clinically detailed and longitudinally available real-world healthcare information. We linked the Paul Coverdell National Acute Stroke Program registry (PCNASP) to commercial longitudinal claims data to assess long-term medication adherence post discharge. Methods: All ischemic stroke (IS) admissions in PCNASP between 2008-2015 were considered for linkage to longitudinal patient claims records from a commercial health insurer using a probabilistic algorithm. We assessed the linkage quality via the percentage of unique records among the linked subset, evaluated the representativeness of the linked population via standardized differences (SD), and described medical history, stroke severity and disability, and patterns of medication use before and after the stroke hospitalization among linked patients. Results: The linkage produced uniqueness equal to 99.1%. Overall, we linked 5,644 out of 104,540 patients with an IS hospitalization in claims data. Linked patients were similar to unlinked except for mean age (69.7 vs 72.5 yr, SD 0.23) and % home discharge (59.8 vs. 52.2, SD 0.14) with mild strokes (median NIHSS 3). Medication information from the PCNASP registry often differed from claims-based out-of-hospital drug utilization patterns, particularly after discharge, with prescriptions at discharge largely overestimating the real-world use of medications as measured by filled prescriptions. (Table) Conclusions: In a large cohort of hospitalized IS patients, high-quality probabilistic linkage between the PCNASP stroke registry and commercial claims data is feasible. Differences between predicted and actual post discharge medication utilization highlight the challenges of assuming long-term medication adherence based on discharge prescriptions. Further research is warranted.

Abstract Funding Acknowledgements Type of funding sources: None. Background As COVID-19 pandemic continues, using technologies within cardiac rehabilitation facilitates access to care and reduces the frequency of direct contact with vulnerable cardiac patients. We aimed to assess the feasibility of technology-assisted interventions in hybrid cardiac rehabilitation (TecHCR) and preliminarily evaluate its effects on patients with coronary heart disease (CHD). Methods Between February 2021 to May 2021, a total of 28 patients with CHD were recruited and randomised to receive a 12-week TecHCR programme (n = 14) or a 12-week conventional, centre-based programme (n = 14). The TecHCR group received three center-based, supervised exercise training sessions. Participants were instructed to wear a fitness tracker watch for exercise self-monitoring at home environment, and the exercise data were shared through a web-based application for remote monitoring by the intervener. Participants received six audio-visual educational videos via a messaging application and a weekly video/telephone call follow-up. Self- Efficacy for Exercise (ESE), Health Promoting Lifestyle Profile II (HPLP II), Hospital Anxiety and Depression Scale (HADS), exercise capacity and cardiovascular health outcomes were assessed at baseline and at 12th week on completion of the programme. Generalised estimating equations analysis was conducted to compare the outcomes between groups. Results Out of 28 participants (56.46±12.98 years old; 1 female), 67.9% had percutaneous coronary intervention and 28.6% had coronary bypass grafting surgery. Among 14 participants in the TecHCR group, three dropped out due to: 1) fear to attend face-to-face supervised exercise training during high daily COVID-19 cases; 2) infected with COVID-19 and 3) found a job in overseas. Eleven participants in the TecHCR group attended all video/telephone call sessions, nine participants completed 3 supervised exercise training sessions and nine participants adhered to the weekly exercise recommendations. No treatment-related adverse events were reported. TecHCR was non-inferior to conventional, centre-based program on exercise self-efficacy, exercise capacity and cardiovascular health outcomes. TecHCR group showed significantly greater improvement in health-promoting behavior when compared with the control group (p =0.013) at post-intervention. Conclusion This pilot study demonstrated the feasibility in recruitment and implementation of TecHCR as an alternative delivery mode and could enhance health-promoting behavior among patients with CHD. Implications The TecHCR program provides accessible interventions to patients without frequent visits to the outpatient centre. A full-scale randomised controlled trial is needed to confirm the effectiveness of TecHCR.

I sat alone on the beach under the shade of a big umbrella. My husband, Bill, and our three children were in the condo taking a break from the Florida sunshine. Dreamily, I gazed at the vast Gulf of Mexico, the brilliant blue sky stretching endlessly above. I was sitting about 50 feet from the surf, but I couldn't actually see the waves hitting the beach; I was almost blind. It was a windy day in late May and I loved feeling the ocean breeze sweeping over me. I imagined I could hear the waves crashing onto the surf, but the sound was only a memory. I was totally deaf. Although I had a cochlear implant and could hear the waves, the cry of sea gulls, and many other sounds with the technology, I wasn't wearing it at the moment and everything I heard was in my mind. As a child, my understanding of speech was better and my vision was clearer. My diagnosis was optic atrophy at age 5 and my vision gradually degenerated over the years. For unknown reasons, nerve damage caused hearing loss and during my teens, my hearing grew worse and worse until by the time I was ready for college, I was profoundly deaf. I chose to attend Gallaudet University because my high school teachers and my parents felt I would receive better services as a deaf and blind student. I feel it was a very good decision; when I entered Gallaudet, it was like entering a new and exhilarating world. Before attending Gallaudet, while I struggled to cope with hearing loss combined with severely low vision, my world grew smaller and smaller, not being able to communicate efficiently with others. At Gallaudet, I suddenly found I could communicate with almost anybody I met on campus using sign language. Thus, my self-confidence and independence grew as I proceeded to get a college education.It wasn't an easy route to follow. I didn't know Braille at the time and depended on using a CCTV (closed captioned television) electronic aid which magnified text, enabling me to read all my college books. I also relied on the assistance of a class aid who interpreted all my teachers' lectures and class discussions because I was unable to see people's signing unless they signed right in front of my face. It was slow going and often frustrating, trying to keep involved socially and keeping up with my coursework but when I was 13 years old, my vision specialist teacher who had worked with me from 5th grade until I graduated from high school, wrote a note for me saying, "Anything worthwhile seldom comes easy." The phrase stuck in my mind and I tried to follow this philosophy. In 1989 after 7 years of persistence, I graduated with a Bachelor's of Arts degree in psychology. With the B.A. in hand and having developed good communication skills with deaf and deaf-blind people using sign language and ASL (American Sign Language), I was ready to face the world. But I wasn't exactly ready; I knew I wanted a professional job working with deaf-blind people and the way to get there was to earn a master's degree. I applied for admission into Gallaudet's graduate school and was accepted into the vocational rehabilitation counselling program. While I thoroughly enjoyed graduate school experience, I got to work with my class mates one-on-one more often and there were a lot more hands-on activities, it became obvious to me that I wasn't prepared for graduate school. I needed to learn Braille and how to use Braille technology; my vision had worsened a lot since starting college. In addition, I needed a break from school and needed to gain experience in the working world. After completing one and a half years and earning 15 credit hours in the master's program, I left Gallaudet and found a job in Baltimore, Maryland.The job was with a new program for adults who were visually and hearing impaired and mentally disabled. My job was assisting the clients with independent living and work related skills. Most of the other staff were deaf, communicating via ASL. By then, I was skilled using tactile signing, putting my hand on the back of the signer's hand to follow movements by touch, and I made friends with co-workers. I felt grown up and independent working full-time, living in my own apartment, using the subway train and bus to travel to and from work. I didn't have any serious problems living on my own. There was a supermarket up the road to which I could walk or ride a bus. But I needed a taxi ride back to the apartment when I had more groceries than I could carry. I would leave a sign I made out of cardboard and wrote my address in big black numbers, on my apartment door to help the driver find my place. I used a white cane and upon moving to Baltimore, an Orientation and Mobility (O and M) teacher who worked with blind people, showing them how to travel in the city, taught me the route to my work place using the subway and bus. Thus, I was independent and knew my way to work as well as to a nearby shopping mall. One day as I stood on the subway station platform holding my white cane, waiting for my train, the opposite train pulled in. As I stood watching passengers hurrying to board, knowing my train would arrive soon on the other side, a woman ran up to me and started pulling my arm. I handed her my notebook and black marker I used for communicating with people in the public, telling her I couldn't hear and would she please write in large print? She frantically scribbled something, but I couldn't read the note. She then gave me back the pen and pad, grabbed my arm again and started pulling me towards the train. I refused to budge, gesturing towards the opposite tracks, clearly indicating I was waiting for the other train. Finally, she let go, dashed into the train before the doors closed. I watched the train pull away, sadly reflecting that some people who wanted to help, just didn't understand how to approach disabled people. As a deaf-blind traveller, it was my duty to help educate the general public how to assist disabled persons in a humane way. After I established my new life for a few months, Bill was offered a position in the same program and moved to Baltimore to join me. He had worked at the Helen Keller National Centre in New York where I met him while doing a summer internship there three years before. I was thrilled when he got the job working beside me and we got to know each other on a daily basis. We had been dating since we met although I was in college and he was working and living in New York and then Cleveland, Ohio. Bill being hearing and sighted, was skilled in sign language and communication techniques with deaf-blind people. He had a wonderful attitude towards disabled people and made me feel like a normal person who was capable of doing things. We shared a lot and were very comfortable with each other. After nearly six months together in Baltimore, we married in May 1992, several weeks before my 28th birthday.After our first year of marriage living in Maryland, Bill and I moved to Little Rock, Arkansas. We wanted to live closer to my family and parents, Ron and Judy Cummings, who lived in Poplar Bluff, Missouri, 176 miles north of Little Rock. I wanted to go back to school and entered the deaf education program at the University of Arkansas at Little Rock with the goal of becoming a teacher for deaf-blind students. I never dreamed I would have a deaf-blind child of my own one day. My vision and hearing loss were caused by nerve damage and no one else in my family nor Bill's had a similar disability.I was pregnant with our first child when I entered UALR. In spite of my growing belly, I enjoyed the teacher training experience. I worked with a deaf-blind 12-year-old student and her teacher at the Arkansas School for the Deaf; observed two energetic four-year-olds in the pre-school program. But when my son, Joe was born in June 1994, my world changed once again. School became less important and motherhood became the ultimate. As a deaf-blind person, I wanted to be the best mom within my abilities.I decided that establishing good communication with my child was an important aspect of being a deaf-blind mom. Bill was in full agreement and we would set Joe on the kitchen table in his infant carrier, reciting together in sign language, "The three Bears". I could see Joe's tiny fists and feet wave excitedly in the air as he watched us signing children's stories. I would encourage Joe to hold my fingers while I signed to him, trying to establish a tactile signing relationship. But he was almost two years old when he finally understood that he needed to sign into my hands. We were sitting at the table and I had a bag of cookies. I refused to give him one until he made the sign for "cookie" in my hand. I quickly rewarded him with a cookie and he got three or four each time he made the sign in my hand. Today at 16, Joe is an expert finger speller and can effectively communicate with me and his younger deaf-blind brother, Ben.When Joe was two and a half, I decided to explore a cochlear implant. It was 1996 and we were living in Poplar Bluff by then. My cousin, who was studying audiology, told me that people using cochlear implants were able to understand sound so well they didn't need good vision. I made an appointment with the St. Louis cochlear implant program and after being evaluated, I decided to go ahead. I am glad I have a cochlear implant. After months of practice I learned to use the new sound and was eventually able to understand many environmental sounds. I never regained the ability of understanding speech, though, but I could hear people's voices very clearly, the sound of laughter, birds singing, and many more. Being able to hear my children's voices is especially wonderful, even when they get noisy and I get a headache. That fall I went to Leader Dogs School for the Blind (LDSB) where I met Milo, a large yellow Labrador retriever. At LDSB I learned how to care for and work with a dog guide. Having Milo as my companion and guide was like stepping into another new and wonderful world of independence. With Milo, I could walk briskly and feel secure. Milo was a big help as a deaf-blind mom, too. With Milo's guiding help, it was wonderful following my children while they rode tricycles or bikes and the whole family enjoyed going out for walks together. Our second son, Ben, was born in February 1999. He was a perfectly healthy little boy and Bill and I were looking forward to raising two sons. Joe was four and a half years old when Ben was born and was fascinated in his new brother. But when Ben was 5 months old, he was diagnosed with Langerhans Cell Histiocytosis (LCH), a rare childhood disease and in some cases, fatal. It was a long, scary road we followed as Ben received treatment at the children's hospital in St. Louis which involved making the 150 mile trip almost weekly for chemotherapy and doctor check-ups. Through it all, Ben was a happy little boy, in spite of the terrible rash that affected his scalp and diaper area, a symptom of LCH. Bill and I knew that we had to do everything possible to help Ben. When he was a year old, his condition seemed stable enough for me to feel comfortable leaving my family for two months to study Braille and learn new technology skills at a program in Kansas City. My vision had deteriorated to a point where I could no longer use a CCTV.Bill's mom, Marie Reid, who lived in Cleveland, Ohio, made a special trip to stay at our home in Poplar Bluff to help Bill with the boys while I was gone. I was successful at the program, learning Braille, making a change from magnification to Braille technology. Upon returning home, I began looking for a job and found employment as a deaf-blind specialist in a new project in Mississippi. The job was in Tupelo and we moved to northern Mississippi, settling into a new life. We transferred Ben's treatment to St. Judes Children's hospital located in Memphis, 94 miles west of Tupelo. I went to work and Bill stayed home with the boys, which worked well. When Ben had to go to St. Judes every three weeks for chemotherapy, Bill was able to drive him. The treatment was successful, the rash had disappeared and there were no traces of LCH in Ben's blood tests. But when he was almost 3 years old, he was diagnosed with optic atrophy, the same eye disease I suffered from and an audiologist detected signs of inner ear hearing loss.Shocked at the news that our little son would grow up legally blind and perhaps become deaf, Bill and I had to rethink our future. We knew we wanted Ben to have a good life and as a deaf-blind child, he needed quality services. We chose to move to Pittsburgh, Pennsylvania because I knew there were good services for deaf-blind people and I could function independently as a stay-home mom. In addition, Cleveland, Ohio, where Marie Reid and several of Bill's siblings lived, was a two hour's drive from Pittsburgh and living near family was important to us. With regret, I left my job opportunity and new friends and we re-located to Pittsburgh. We lived on a quiet street near Squirrel Hill and enrolled Joe into a near-by Catholic school. Ben received excellent early intervention services through the Pittsburgh public school, beginning Braille, using a white cane and tactile signing. The Pennsylvania services for the blind generously purchased a wonderful computer system and Braille display for me to use at home. I was able to communicate with Joe's and Ben's teachers and other contacts using e-mail. Ben's Braille teacher provided us with several print/Braille books which I read to the boys while Ben touched the tactile pictures. I made friends in the deaf and deaf-blind community and our family attended social events. Besides the social benefits of a deaf community, Pittsburgh offered a wonderful interpreting service and I was able to take Ben to doctor appointments knowing an interpreter would meet me at the hospital to assist with communication. I also found people who were willing to help me as volunteer SSPs (support Service Providers), persons whose role is to assist a deaf-blind person in any way, such as shopping, going to the bank, etc. Thus, I was able to function quite independently while Bill worked. Perhaps Bill and I were a bit crazy; after all, we had enough on our plate with a deaf-blind son and a deaf-blind mom, but love is a mysterious thing. In October 2003, Tim was born and our family was complete. Having two school-aged children and a baby on my hands was too much for me to handle alone. Bill was working and busy with culinary arts school. We realized we needed more help with the children, plus the high cost of living in the city was a struggle for us. We decided for the family's best interest, it would be better to move back to Poplar Bluff. After Joe and Ben were out of school in June, my mom flew out to Pittsburgh to escort them back to her home while Bill finished his externship for his culinary arts degree and in the late summer of 2004, we packed up our apartment, said good-bye to Pittsburgh, and drove to Missouri. The move was a good decision in many ways. Poplar Bluff, a rural town in south-eastern Missouri, has been my hometown since I was 10 years old. My extended family live there and the boys are thriving growing up among their cousins. Ben is receiving Braille and sign language services at public school and reads Braille faster than me!While both Bill and I are deeply satisfied knowing our children are happy, we have made personal sacrifices. Bill has given up his career satisfaction as a professional cook, needing to help look after the children and house. I have given up the benefits of city life such as interpreting and SSP services, not to mention the social benefits of a deaf community. But the children's well-being comes first, and I have found ways to fulfil my needs by getting involved with on-line groups for deaf-blind people, including writers and poets. I have taken a great interest in writing, especially children's stories and hope to establish a career as a writer. While I work on my computer, Bill keeps busy engaging the boys in various projects. They have built a screened-in tree house in the backyard where Ben and Tim like to sleep during warm summer nights.“It's almost 5 o'clock," Bill signed into my hand, rousing me from my thoughts. Time to prepare for our homeward journey the next day to Poplar Bluff, Missouri.Christy and Family

IntroductionIn July 1997, the Mackay campus of Central Queensland University hosted a conference with the theme Regional Australia: Visions of Mackay. It was the first academic conference to be held at the young campus, and its aim was to provide an opportunity for academics, business people, government officials, and other interested parties to discuss their visions for the development of Mackay, a regional community of 75,000 people situated on the Central Queensland coast (Danaher). I delivered a presentation at that conference and authored a chapter in the book that emerged from its proceedings. The chapter entitled “Mackay Online” explored the potential impact that the Internet could have on the Mackay region, particularly in the areas of regional business, education, health, and entertainment (Pace). Two decades later, how does the reality compare with that vision?Broadband BluesAt the time of the Visions of Mackay conference, public commercial use of the Internet was in its infancy. Many Internet services and technologies that users take for granted today were uncommon or non-existent then. Examples include online video, video-conferencing, Voice over Internet Protocol (VoIP), blogs, social media, peer-to-peer file sharing, payment gateways, content management systems, wireless data communications, smartphones, mobile applications, and tablet computers. In 1997, most users connected to the Internet using slow dial-up modems with speeds ranging from 28.8 Kbps to 33.6 Kbps. 56 Kbps modems had just become available. Lamenting these slow data transmission speeds, I looked forward to a time when widespread availability of high-bandwidth networks would allow the Internet’s services to “expand to include electronic commerce, home entertainment and desktop video-conferencing” (Pace 103). Although that future eventually arrived, I incorrectly anticipated how it would arrive.In 1997, Optus and Telstra were engaged in the rollout of hybrid fibre coaxial (HFC) networks in Sydney, Melbourne, and Brisbane for the Optus Vision and Foxtel pay TV services (Meredith). These HFC networks had a large amount of unused bandwidth, which both Telstra and Optus planned to use to provide broadband Internet services. Telstra's Big Pond Cable broadband service was already available to approximately one million households in Sydney and Melbourne (Taylor), and Optus was considering extending its cable network into regional Australia through partnerships with smaller regional telecommunications companies (Lewis). These promising developments seemed to point the way forward to a future high-bandwidth network, but that was not the case. A short time after the Visions of Mackay conference, Telstra and Optus ceased the rollout of their HFC networks in response to the invention of Asynchronous Digital Subscriber Line (ADSL), a technology that increases the bandwidth of copper wire and enables Internet connections of up to 6 Mbps over the existing phone network. ADSL was significantly faster than a dial-up service, it was broadly available to homes and businesses across the country, and it did not require enormous investment in infrastructure. However, ADSL could not offer speeds anywhere near the 27 Mbps of the HFC networks. When it came to broadband provision, Australia seemed destined to continue playing catch-up with the rest of the world. According to data from the Organisation for Economic Cooperation and Development (OECD), in 2009 Australia ranked 18th in the world for broadband penetration, with 24.1 percent of Australians having a fixed-line broadband subscription. Statistics like these eventually prompted the federal government to commit to the deployment of a National Broadband Network (NBN). In 2009, the Kevin Rudd Government announced that the NBN would combine fibre-to-the-premises (FTTP), fixed wireless, and satellite technologies to deliver Internet speeds of up to 100 Mbps to 90 percent of Australian homes, schools, and workplaces (Rudd).The rollout of the NBN in Mackay commenced in 2013 and continued, suburb by suburb, until its completion in 2017 (Frost, “Mackay”; Garvey). The rollout was anything but smooth. After a change of government in 2013, the NBN was redesigned to reduce costs. A mixed copper/optical technology known as fibre-to-the-node (FTTN) replaced FTTP as the preferred approach for providing most NBN connections. The resulting connection speeds were significantly slower than the 100 Mbps that was originally proposed. Many Mackay premises could only achieve a maximum speed of 40 Mbps, which led to some overcharging by Internet service providers, and subsequent compensation for failing to deliver services they had promised (“Optus”). Some Mackay residents even complained that their new NBN connections were slower than their former ADSL connections. NBN Co representatives claimed that the problems were due to “service providers not buying enough space in the network to provide the service they had promised to customers” (“Telcos”). Unsurprisingly, the number of complaints about the NBN that were lodged with the Telecommunications Industry Ombudsman skyrocketed during the last six months of 2017. Queensland complaints increased by approximately 40 percent when compared with the same period during the previous year (“Qld”).Despite the challenges presented by infrastructure limitations, the rollout of the NBN was a boost for the Mackay region. For some rural residents, it meant having reliable Internet access for the first time. Frost, for example, reports on the experiences of a Mackay couple who could not get an ADSL service at their rural home because it was too far away from the nearest telephone exchange. Unreliable 3G mobile broadband was the only option for operating their air-conditioning business. All of that changed with the arrival of the NBN. “It’s so fast we can run a number of things at the same time”, the couple reported (“NBN”).Networking the NationOne factor that contributed to the uptake of Internet services in the Mackay region after the Visions of Mackay conference was the Australian Government’s Networking the Nation (NTN) program. When the national telecommunications carrier Telstra was partially privatised in 1997, and further sold in 1999, proceeds from the sale were used to fund an ambitious communications infrastructure program named Networking the Nation (Department of Communications, Information Technology and the Arts). The program funded projects that improved the availability, accessibility, affordability, and use of communications facilities and services throughout regional Australia. Eligibility for funding was limited to not-for-profit organisations, including local councils, regional development organisations, community groups, local government associations, and state and territory governments.In 1998, the Mackay region received $930,000 in Networking the Nation funding for Mackay Regionlink, a project that aimed to provide equitable community access to online services, skills development for local residents, an affordable online presence for local business and community organisations, and increased external awareness of the Mackay region (Jewell et al.). One element of the project was a training program that provided basic Internet skills to 2,168 people across the region over a period of two years. A second element of the project involved the establishment of 20 public Internet access centres in locations throughout the region, such as libraries, community centres, and tourist information centres. The centres provided free Internet access to users and encouraged local participation and skill development. More than 9,200 users were recorded in these centres during the first year of the project, and the facilities remained active until 2006. A third element of the project was a regional web portal that provided a free easily-updated online presence for community organisations. The project aimed to have every business and community group in the Mackay region represented on the website, with hosting fees for the business web pages funding its ongoing operation and development. More than 6,000 organisations were listed on the site, and the project remained financially viable until 2005.The availability, affordability and use of communications facilities and services in Mackay increased significantly during the period of the Regionlink project. Changes in technology, services, markets, competition, and many other factors contributed to this increase, so it is difficult to ascertain the extent to which Mackay Regionlink fostered those outcomes. However, the large number of people who participated in the Regionlink training program and made use of the public Internet access centres, suggests that the project had a positive influence on digital literacy in the Mackay region.The Impact on BusinessThe Internet has transformed regional business for both consumers and business owners alike since the Visions of Mackay conference. When Mackay residents made a purchase in 1997, their choice of suppliers was limited to a few local businesses. Today they can shop online in a global market. Security concerns were initially a major obstacle to the growth of electronic commerce. Consumers were slow to adopt the Internet as a place for doing business, fearing that their credit card details would be vulnerable to hackers once they were placed online. After observing the efforts that finance and software companies were making to eliminate those obstacles, I anticipated that it would only be a matter of time before online transactions became commonplace:Consumers seeking a particular product will be able to quickly find the names of suitable suppliers around the world, compare their prices, and place an order with the one that can deliver the product at the cheapest price. (Pace 106)This expectation was soon fulfilled by the arrival of online payment systems such as PayPal in 1998, and online shopping services such as eBay in 1997. eBay is a global online auction and shopping website where individuals and businesses buy and sell goods and services worldwide. The eBay service is free to use for buyers, but sellers are charged modest fees when they make a sale. It exemplifies the notion of “friction-free capitalism” articulated by Gates (157).In 1997, regional Australian business owners were largely sceptical about the potential benefits the Internet could bring to their businesses. Only 11 percent of Australian businesses had some form of web presence, and less than 35 percent of those early adopters felt that their website was significant to their business (Department of Industry, Science and Tourism). Anticipating the significant opportunities that the Internet offered Mackay businesses to compete in new markets, I recommended that they work “towards the goal of providing products and services that meet the needs of international consumers as well as local ones” (107). In the two decades that have passed since that time, many Mackay businesses have been doing just that. One prime example is Big on Shoes (bigonshoes.com.au), a retailer of ladies’ shoes from sizes five to fifteen (Plane). Big on Shoes has physical shopfronts in Mackay and Moranbah, an online store that has been operating since 2009, and more than 12,000 followers on Facebook. This speciality store caters for women who have traditionally been unable to find shoes in their size. As the store’s customer base has grown within Australia and internationally, an unexpected transgender market has also emerged. In 2018 Big on Shoes was one of 30 regional businesses featured in the first Facebook and Instagram Annual Gift Guide, and it continues to build on its strengths (Cureton).The Impact on HealthThe growth of the Internet has improved the availability of specialist health services for people in the Mackay region. Traditionally, access to surgical services in Mackay has been much more limited than in metropolitan areas because of the shortage of specialists willing to practise in regional areas (Green). In 2003, a senior informant from the Royal Australasian College of Surgeons bluntly described the Central Queensland region from Mackay to Gladstone as “a black hole in terms of surgery” (Birrell et al. 15). In 1997 I anticipated that, although the Internet would never completely replace a visit to a local doctor or hospital, it would provide tools that improve the availability of specialist medical services for people living in regional areas. Using these tools, doctors would be able to “analyse medical images captured from patients living in remote locations” and “diagnose patients at a distance” (Pace 108).These expectations have been realised in the form of Queensland Health’s Telehealth initiative, which permits medical specialists in Brisbane and Townsville to conduct consultations with patients at the Mackay Base Hospital using video-conference technology. Telehealth reduces the need for patients to travel for specialist advice, and it provides health professionals with access to peer support. Averill (7), for example, reports on the experience of a breast cancer patient at the Mackay Base Hospital who was able to participate in a drug trial with a Townsville oncologist through the Telehealth network. Mackay health professionals organised the patient’s scans, administered blood tests, and checked her lymph nodes, blood pressure and weight. Townsville health professionals then used this information to advise the Mackay team about her ongoing treatment. The patient expressed appreciation that the service allowed her to avoid the lengthy round-trip to Townsville. Prior to being offered the Telehealth option, she had refused to participate in the trial because “the trip was just too much of a stumbling block” (Averill 7).The Impact on Media and EntertainmentThe field of media and entertainment is another aspect of regional life that has been reshaped by the Internet since the Visions of Mackay conference. Most of these changes have been equally apparent in both regional and metropolitan areas. Over the past decade, the way individuals consume media has been transformed by new online services offering user-generated video, video-on-demand, and catch-up TV. These developments were among the changes I anticipated in 1997:The convergence of television and the Internet will stimulate the creation of new services such as video-on-demand. Today television is a synchronous media—programs are usually viewed while they are being broadcast. When high-quality video can be transmitted over the information superhighway, users will be able to watch what they want, when and where they like. […] Newly released movies will continue to be rented, but probably not from stores. Instead, consumers will shop on the information superhighway for movies that can be delivered on demand.In the mid-2000s, free online video-sharing services such as YouTube and Vimeo began to emerge. These websites allow users to freely upload, view, share, comment on, and curate online videos. Subscription-based streaming services such as Netflix and Amazon Prime have also become increasingly popular since that time. These services offer online streaming of a library of films and television programs for a fee of less than 20 dollars per month. Computers, smart TVs, Blu-ray players, game consoles, mobile phones, tablets, and other devices provide a multitude of ways of accessing streaming services. Some of these devices cost less than 100 dollars, while higher-end electronic devices include the capability as a bundled feature. Netflix became available in Mackay at the time of its Australian launch in 2015. The growth of streaming services greatly reduced the demand for video rental shops in the region, and all closed down as a result. The last remaining video rental store in Mackay closed its doors in 2018 after trading for 26 years (“Last”).Some of the most dramatic transformations that have occurred the field of media and entertainment were not anticipated in 1997. The rise of mobile technology, including wireless data communications, smartphones, mobile applications, and tablet computers, was largely unforeseen at that time. Some Internet luminaries such as Vinton Cerf expected that mobile access to the Internet via laptop computers would become commonplace (Lange), but this view did not encompass the evolution of smartphones, and it was not widely held. Similarly, the rise of social media services and the impact they have had on the way people share content and communicate was generally unexpected. In some respects, these phenomena resemble the Black Swan events described by Nassim Nicholas Taleb (xvii)—surprising events with a major effect that are often inappropriately rationalised after the fact. They remind us of how difficult it is to predict the future media landscape by extrapolating from things we know, while failing to take into consideration what we do not know.The Challenge for MackayIn 1997, when exploring the potential impact that the Internet could have on the Mackay region, I identified a special challenge that the community faced if it wanted to be competitive in this new environment:The region has traditionally prospered from industries that control physical resources such as coal, sugar and tourism, but over the last two decades there has been a global ‘shift away from physical assets and towards information as the principal driver of wealth creation’ (Petre and Harrington 1996). The risk for Mackay is that its residents may be inclined to believe that wealth can only be created by means of industries that control physical assets. The community must realise that its value-added information is at least as precious as its abundant natural resources. (110)The Mackay region has not responded well to this challenge, as evidenced by measures such as the Knowledge City Index (KCI), a collection of six indicators that assess how well a city is positioned to grow and advance in today’s technology-driven, knowledge-based economy. A 2017 study used the KCI to conduct a comparative analysis of 25 Australian cities (Pratchett, Hu, Walsh, and Tuli). Mackay rated reasonably well in the areas of Income and Digital Access. But the city’s ratings were “very limited across all the other measures of the KCI”: Knowledge Capacity, Knowledge Mobility, Knowledge Industries and Smart Work (44).The need to be competitive in a technology-driven, knowledge-based economy is likely to become even more pressing in the years ahead. The 2017 World Energy Outlook Report estimated that China’s coal use is likely to have peaked in 2013 amid a rapid shift toward renewable energy, which means that demand for Mackay’s coal will continue to decline (International Energy Agency). The sugar industry is in crisis, finding itself unable to diversify its revenue base or increase production enough to offset falling global sugar prices (Rynne). The region’s biggest tourism drawcard, the Great Barrier Reef, continues to be degraded by mass coral bleaching events and ongoing threats posed by climate change and poor water quality (Great Barrier Reef Marine Park Authority). All of these developments have disturbing implications for Mackay’s regional economy and its reliance on coal, sugar, and tourism. Diversifying the local economy through the introduction of new knowledge industries would be one way of preparing the Mackay region for the impact of new technologies and the economic challenges that lie ahead.ReferencesAverill, Zizi. “Webcam Consultations.” Daily Mercury 22 Nov. 2018: 7.Birrell, Bob, Lesleyanne Hawthorne, and Virginia Rapson. The Outlook for Surgical Services in Australasia. Melbourne: Monash University Centre for Population and Urban Research, 2003.Cureton, Aidan. “Big Shoes, Big Ideas.” Daily Mercury 8 Dec. 2018: 12.Danaher, Geoff. Ed. Visions of Mackay: Conference Papers. Rockhampton: Central Queensland UP, 1998.Department of Communications, Information Technology and the Arts. Networking the Nation: Evaluation of Outcomes and Impacts. Canberra: Australian Government, 2005.Department of Industry, Science and Tourism. Electronic Commerce in Australia. Canberra: Australian Government, 1998.Frost, Pamela. “Mackay Is Up with Switch to Speed to NBN.” Daily Mercury 15 Aug. 2013: 8.———. “NBN Boost to Business.” Daily Mercury 29 Oct. 2013: 3.Gates, Bill. The Road Ahead. New York: Viking Penguin, 1995.Garvey, Cas. “NBN Rollout Hit, Miss in Mackay.” Daily Mercury 11 Jul. 2017: 6.Great Barrier Reef Marine Park Authority. Reef Blueprint: Great Barrier Reef Blueprint for Resilience. Townsville: Great Barrier Reef Marine Park Authority, 2017.Green, Anthony. “Surgical Services and Referrals in Rural and Remote Australia.” Medical Journal of Australia 177.2 (2002): 110–11.International Energy Agency. World Energy Outlook 2017. France: IEA Publications, 2017.Jewell, Roderick, Mary O’Flynn, Fiorella De Cindio, and Margaret Cameron. “RCM and MRL—A Reflection on Two Approaches to Constructing Communication Memory.” Constructing and Sharing Memory: Community Informatics, Identity and Empowerment. Eds. Larry Stillman and Graeme Johanson. Newcastle: Cambridge Scholars Publishing, 2007. 73–86.Lange, Larry. “The Internet: Where’s It All Going?” Information Week 17 Jul. 1995: 30.“Last Man Standing Shuts Doors after 26 Years of Trade.” Daily Mercury 28 Aug. 2018: 7.Lewis, Steve. “Optus Plans to Share Cost Burden.” Australian Financial Review 22 May 1997: 26.Meredith, Helen. “Time Short for Cable Modem.” Australian Financial Review 10 Apr. 1997: 42Nassim Nicholas Taleb. The Black Swan: The Impact of the Highly Improbable. New York: Random House, 2007.“Optus Offers Comp for Slow NBN.” Daily Mercury 10 Nov. 2017: 15.Organisation for Economic Cooperation and Development. “Fixed Broadband Subscriptions.” OECD Data, n.d. <https://data.oecd.org/broadband/fixed-broadband-subscriptions.htm>.Pace, Steven. “Mackay Online.” Visions of Mackay: Conference Papers. Ed. Geoff Danaher. Rockhampton: Central Queensland University Press, 1998. 111–19.Petre, Daniel and David Harrington. The Clever Country? Australia’s Digital Future. Sydney: Lansdown Publishing, 1996.Plane, Melanie. “A Shoe-In for Big Success.” Daily Mercury 9 Sep. 2017: 6.Pratchett, Lawrence, Richard Hu, Michael Walsh, and Sajeda Tuli. The Knowledge City Index: A Tale of 25 Cities in Australia. Canberra: University of Canberra neXus Research Centre, 2017.“Qld Customers NB-uN Happy Complaints about NBN Service Double in 12 Months.” Daily Mercury 17 Apr. 2018: 1.Rudd, Kevin. “Media Release: New National Broadband Network.” Parliament of Australia Press Release, 7 Apr. 2009 <https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id:"media/pressrel/PS8T6">.Rynne, David. “Revitalising the Sugar Industry.” Sugar Policy Insights Feb. 2019: 2–3.Taylor, Emma. “A Dip in the Pond.” Sydney Morning Herald 16 Aug. 1997: 12.“Telcos and NBN Co in a Crisis.” Daily Mercury 27 Jul. 2017: 6.

On the morning of Thursday, 4 May 2006, the United States House Permanent Select Committee on Intelligence held an open hearing entitled “Terrorist Use of the Internet.” The Intelligence committee meeting was scheduled to take place in Room 1302 of the Longworth Office Building, a Depression-era structure with a neoclassical façade. Because of a dysfunctional elevator, some of the congressional representatives were late to the meeting. During the testimony about the newest political applications for cutting-edge digital technology, the microphones periodically malfunctioned, and witnesses complained of “technical problems” several times. By the end of the day it seemed that what was to be remembered about the hearing was the shocking revelation that terrorists were using videogames to recruit young jihadists. The Associated Press wrote a short, restrained article about the hearing that only mentioned “computer games and recruitment videos” in passing. Eager to have their version of the news item picked up, Reuters made videogames the focus of their coverage with a headline that announced, “Islamists Using US Videogames in Youth Appeal.” Like a game of telephone, as the Reuters videogame story was quickly re-run by several Internet news services, each iteration of the title seemed less true to the exact language of the original. One Internet news service changed the headline to “Islamic militants recruit using U.S. video games.” Fox News re-titled the story again to emphasise that this alert about technological manipulation was coming from recognised specialists in the anti-terrorism surveillance field: “Experts: Islamic Militants Customizing Violent Video Games.” As the story circulated, the body of the article remained largely unchanged, in which the Reuters reporter described the digital materials from Islamic extremists that were shown at the congressional hearing. During the segment that apparently most captured the attention of the wire service reporters, eerie music played as an English-speaking narrator condemned the “infidel” and declared that he had “put a jihad” on them, as aerial shots moved over 3D computer-generated images of flaming oil facilities and mosques covered with geometric designs. Suddenly, this menacing voice-over was interrupted by an explosion, as a virtual rocket was launched into a simulated military helicopter. The Reuters reporter shared this dystopian vision from cyberspace with Western audiences by quoting directly from the chilling commentary and describing a dissonant montage of images and remixed sound. “I was just a boy when the infidels came to my village in Blackhawk helicopters,” a narrator’s voice said as the screen flashed between images of street-level gunfights, explosions and helicopter assaults. Then came a recording of President George W. Bush’s September 16, 2001, statement: “This crusade, this war on terrorism, is going to take a while.” It was edited to repeat the word “crusade,” which Muslims often define as an attack on Islam by Christianity. According to the news reports, the key piece of evidence before Congress seemed to be a film by “SonicJihad” of recorded videogame play, which – according to the experts – was widely distributed online. Much of the clip takes place from the point of view of a first-person shooter, seen as if through the eyes of an armed insurgent, but the viewer also periodically sees third-person action in which the player appears as a running figure wearing a red-and-white checked keffiyeh, who dashes toward the screen with a rocket launcher balanced on his shoulder. Significantly, another of the player’s hand-held weapons is a detonator that triggers remote blasts. As jaunty music plays, helicopters, tanks, and armoured vehicles burst into smoke and flame. Finally, at the triumphant ending of the video, a green and white flag bearing a crescent is hoisted aloft into the sky to signify victory by Islamic forces. To explain the existence of this digital alternative history in which jihadists could be conquerors, the Reuters story described the deviousness of the country’s terrorist opponents, who were now apparently modifying popular videogames through their wizardry and inserting anti-American, pro-insurgency content into U.S.-made consumer technology. One of the latest video games modified by militants is the popular “Battlefield 2” from leading video game publisher, Electronic Arts Inc of Redwood City, California. Jeff Brown, a spokesman for Electronic Arts, said enthusiasts often write software modifications, known as “mods,” to video games. “Millions of people create mods on games around the world,” he said. “We have absolutely no control over them. It’s like drawing a mustache on a picture.” Although the Electronic Arts executive dismissed the activities of modders as a “mustache on a picture” that could only be considered little more than childish vandalism of their off-the-shelf corporate product, others saw a more serious form of criminality at work. Testifying experts and the legislators listening on the committee used the video to call for greater Internet surveillance efforts and electronic counter-measures. Within twenty-four hours of the sensationalistic news breaking, however, a group of Battlefield 2 fans was crowing about the idiocy of reporters. The game play footage wasn’t from a high-tech modification of the software by Islamic extremists; it had been posted on a Planet Battlefield forum the previous December of 2005 by a game fan who had cut together regular game play with a Bush remix and a parody snippet of the soundtrack from the 2004 hit comedy film Team America. The voice describing the Black Hawk helicopters was the voice of Trey Parker of South Park cartoon fame, and – much to Parker’s amusement – even the mention of “goats screaming” did not clue spectators in to the fact of a comic source. Ironically, the moment in the movie from which the sound clip is excerpted is one about intelligence gathering. As an agent of Team America, a fictional elite U.S. commando squad, the hero of the film’s all-puppet cast, Gary Johnston, is impersonating a jihadist radical inside a hostile Egyptian tavern that is modelled on the cantina scene from Star Wars. Additional laughs come from the fact that agent Johnston is accepted by the menacing terrorist cell as “Hakmed,” despite the fact that he utters a series of improbable clichés made up of incoherent stereotypes about life in the Middle East while dressed up in a disguise made up of shoe polish and a turban from a bathroom towel. The man behind the “SonicJihad” pseudonym turned out to be a twenty-five-year-old hospital administrator named Samir, and what reporters and representatives saw was nothing more exotic than game play from an add-on expansion pack of Battlefield 2, which – like other versions of the game – allows first-person shooter play from the position of the opponent as a standard feature. While SonicJihad initially joined his fellow gamers in ridiculing the mainstream media, he also expressed astonishment and outrage about a larger politics of reception. In one interview he argued that the media illiteracy of Reuters potentially enabled a whole series of category errors, in which harmless gamers could be demonised as terrorists. It wasn’t intended for the purpose what it was portrayed to be by the media. So no I don’t regret making a funny video . . . why should I? The only thing I regret is thinking that news from Reuters was objective and always right. The least they could do is some online research before publishing this. If they label me al-Qaeda just for making this silly video, that makes you think, what is this al-Qaeda? And is everything al-Qaeda? Although Sonic Jihad dismissed his own work as “silly” or “funny,” he expected considerably more from a credible news agency like Reuters: “objective” reporting, “online research,” and fact-checking before “publishing.” Within the week, almost all of the salient details in the Reuters story were revealed to be incorrect. SonicJihad’s film was not made by terrorists or for terrorists: it was not created by “Islamic militants” for “Muslim youths.” The videogame it depicted had not been modified by a “tech-savvy militant” with advanced programming skills. Of course, what is most extraordinary about this story isn’t just that Reuters merely got its facts wrong; it is that a self-identified “parody” video was shown to the august House Intelligence Committee by a team of well-paid “experts” from the Science Applications International Corporation (SAIC), a major contractor with the federal government, as key evidence of terrorist recruitment techniques and abuse of digital networks. Moreover, this story of media illiteracy unfolded in the context of a fundamental Constitutional debate about domestic surveillance via communications technology and the further regulation of digital content by lawmakers. Furthermore, the transcripts of the actual hearing showed that much more than simple gullibility or technological ignorance was in play. Based on their exchanges in the public record, elected representatives and government experts appear to be keenly aware that the digital discourses of an emerging information culture might be challenging their authority and that of the longstanding institutions of knowledge and power with which they are affiliated. These hearings can be seen as representative of a larger historical moment in which emphatic declarations about prohibiting specific practices in digital culture have come to occupy a prominent place at the podium, news desk, or official Web portal. This environment of cultural reaction can be used to explain why policy makers’ reaction to terrorists’ use of networked communication and digital media actually tells us more about our own American ideologies about technology and rhetoric in a contemporary information environment. When the experts come forward at the Sonic Jihad hearing to “walk us through the media and some of the products,” they present digital artefacts of an information economy that mirrors many of the features of our own consumption of objects of electronic discourse, which seem dangerously easy to copy and distribute and thus also create confusion about their intended meanings, audiences, and purposes. From this one hearing we can see how the reception of many new digital genres plays out in the public sphere of legislative discourse. Web pages, videogames, and Weblogs are mentioned specifically in the transcript. The main architecture of the witnesses’ presentation to the committee is organised according to the rhetorical conventions of a PowerPoint presentation. Moreover, the arguments made by expert witnesses about the relationship of orality to literacy or of public to private communications in new media are highly relevant to how we might understand other important digital genres, such as electronic mail or text messaging. The hearing also invites consideration of privacy, intellectual property, and digital “rights,” because moral values about freedom and ownership are alluded to by many of the elected representatives present, albeit often through the looking glass of user behaviours imagined as radically Other. For example, terrorists are described as “modders” and “hackers” who subvert those who properly create, own, legitimate, and regulate intellectual property. To explain embarrassing leaks of infinitely replicable digital files, witness Ron Roughead says, “We’re not even sure that they don’t even hack into the kinds of spaces that hold photographs in order to get pictures that our forces have taken.” Another witness, Undersecretary of Defense for Policy and International Affairs, Peter Rodman claims that “any video game that comes out, as soon as the code is released, they will modify it and change the game for their needs.” Thus, the implication of these witnesses’ testimony is that the release of code into the public domain can contribute to political subversion, much as covert intrusion into computer networks by stealthy hackers can. However, the witnesses from the Pentagon and from the government contractor SAIC often present a contradictory image of the supposed terrorists in the hearing transcripts. Sometimes the enemy is depicted as an organisation of technological masterminds, capable of manipulating the computer code of unwitting Americans and snatching their rightful intellectual property away; sometimes those from the opposing forces are depicted as pre-modern and even sub-literate political innocents. In contrast, the congressional representatives seem to focus on similarities when comparing the work of “terrorists” to the everyday digital practices of their constituents and even of themselves. According to the transcripts of this open hearing, legislators on both sides of the aisle express anxiety about domestic patterns of Internet reception. Even the legislators’ own Web pages are potentially disruptive electronic artefacts, particularly when the demands of digital labour interfere with their duties as lawmakers. Although the subject of the hearing is ostensibly terrorist Websites, Representative Anna Eshoo (D-California) bemoans the difficulty of maintaining her own official congressional site. As she observes, “So we are – as members, I think we’re very sensitive about what’s on our Website, and if I retained what I had on my Website three years ago, I’d be out of business. So we know that they have to be renewed. They go up, they go down, they’re rebuilt, they’re – you know, the message is targeted to the future.” In their questions, lawmakers identify Weblogs (blogs) as a particular area of concern as a destabilising alternative to authoritative print sources of information from established institutions. Representative Alcee Hastings (D-Florida) compares the polluting power of insurgent bloggers to that of influential online muckrakers from the American political Right. Hastings complains of “garbage on our regular mainstream news that comes from blog sites.” Representative Heather Wilson (R-New Mexico) attempts to project a media-savvy persona by bringing up the “phenomenon of blogging” in conjunction with her questions about jihadist Websites in which she notes how Internet traffic can be magnified by cooperative ventures among groups of ideologically like-minded content-providers: “These Websites, and particularly the most active ones, are they cross-linked? And do they have kind of hot links to your other favorite sites on them?” At one point Representative Wilson asks witness Rodman if he knows “of your 100 hottest sites where the Webmasters are educated? What nationality they are? Where they’re getting their money from?” In her questions, Wilson implicitly acknowledges that Web work reflects influences from pedagogical communities, economic networks of the exchange of capital, and even potentially the specific ideologies of nation-states. It is perhaps indicative of the government contractors’ anachronistic worldview that the witness is unable to answer Wilson’s question. He explains that his agency focuses on the physical location of the server or ISP rather than the social backgrounds of the individuals who might be manufacturing objectionable digital texts. The premise behind the contractors’ working method – surveilling the technical apparatus not the social network – may be related to other beliefs expressed by government witnesses, such as the supposition that jihadist Websites are collectively produced and spontaneously emerge from the indigenous, traditional, tribal culture, instead of assuming that Iraqi insurgents have analogous beliefs, practices, and technological awareness to those in first-world countries. The residual subtexts in the witnesses’ conjectures about competing cultures of orality and literacy may tell us something about a reactionary rhetoric around videogames and digital culture more generally. According to the experts before Congress, the Middle Eastern audience for these videogames and Websites is limited by its membership in a pre-literate society that is only capable of abortive cultural production without access to knowledge that is archived in printed codices. Sometimes the witnesses before Congress seem to be unintentionally channelling the ideas of the late literacy theorist Walter Ong about the “secondary orality” associated with talky electronic media such as television, radio, audio recording, or telephone communication. Later followers of Ong extend this concept of secondary orality to hypertext, hypermedia, e-mail, and blogs, because they similarly share features of both speech and written discourse. Although Ong’s disciples celebrate this vibrant reconnection to a mythic, communal past of what Kathleen Welch calls “electric rhetoric,” the defence industry consultants express their profound state of alarm at the potentially dangerous and subversive character of this hybrid form of communication. The concept of an “oral tradition” is first introduced by the expert witnesses in the context of modern marketing and product distribution: “The Internet is used for a variety of things – command and control,” one witness states. “One of the things that’s missed frequently is how and – how effective the adversary is at using the Internet to distribute product. They’re using that distribution network as a modern form of oral tradition, if you will.” Thus, although the Internet can be deployed for hierarchical “command and control” activities, it also functions as a highly efficient peer-to-peer distributed network for disseminating the commodity of information. Throughout the hearings, the witnesses imply that unregulated lateral communication among social actors who are not authorised to speak for nation-states or to produce legitimated expert discourses is potentially destabilising to political order. Witness Eric Michael describes the “oral tradition” and the conventions of communal life in the Middle East to emphasise the primacy of speech in the collective discursive practices of this alien population: “I’d like to point your attention to the media types and the fact that the oral tradition is listed as most important. The other media listed support that. And the significance of the oral tradition is more than just – it’s the medium by which, once it comes off the Internet, it is transferred.” The experts go on to claim that this “oral tradition” can contaminate other media because it functions as “rumor,” the traditional bane of the stately discourse of military leaders since the classical era. The oral tradition now also has an aspect of rumor. A[n] event takes place. There is an explosion in a city. Rumor is that the United States Air Force dropped a bomb and is doing indiscriminate killing. This ends up being discussed on the street. It ends up showing up in a Friday sermon in a mosque or in another religious institution. It then gets recycled into written materials. Media picks up the story and broadcasts it, at which point it’s now a fact. In this particular case that we were telling you about, it showed up on a network television, and their propaganda continues to go back to this false initial report on network television and continue to reiterate that it’s a fact, even though the United States government has proven that it was not a fact, even though the network has since recanted the broadcast. In this example, many-to-many discussion on the “street” is formalised into a one-to many “sermon” and then further stylised using technology in a one-to-many broadcast on “network television” in which “propaganda” that is “false” can no longer be disputed. This “oral tradition” is like digital media, because elements of discourse can be infinitely copied or “recycled,” and it is designed to “reiterate” content. In this hearing, the word “rhetoric” is associated with destructive counter-cultural forces by the witnesses who reiterate cultural truisms dating back to Plato and the Gorgias. For example, witness Eric Michael initially presents “rhetoric” as the use of culturally specific and hence untranslatable figures of speech, but he quickly moves to an outright castigation of the entire communicative mode. “Rhetoric,” he tells us, is designed to “distort the truth,” because it is a “selective” assembly or a “distortion.” Rhetoric is also at odds with reason, because it appeals to “emotion” and a romanticised Weltanschauung oriented around discourses of “struggle.” The film by SonicJihad is chosen as the final clip by the witnesses before Congress, because it allegedly combines many different types of emotional appeal, and thus it conveniently ties together all of the themes that the witnesses present to the legislators about unreliable oral or rhetorical sources in the Middle East: And there you see how all these products are linked together. And you can see where the games are set to psychologically condition you to go kill coalition forces. You can see how they use humor. You can see how the entire campaign is carefully crafted to first evoke an emotion and then to evoke a response and to direct that response in the direction that they want. Jihadist digital products, especially videogames, are effective means of manipulation, the witnesses argue, because they employ multiple channels of persuasion and carefully sequenced and integrated subliminal messages. To understand the larger cultural conversation of the hearing, it is important to keep in mind that the related argument that “games” can “psychologically condition” players to be predisposed to violence is one that was important in other congressional hearings of the period, as well one that played a role in bills and resolutions that were passed by the full body of the legislative branch. In the witness’s testimony an appeal to anti-game sympathies at home is combined with a critique of a closed anti-democratic system abroad in which the circuits of rhetorical production and their composite metonymic chains are described as those that command specific, unvarying, robotic responses. This sharp criticism of the artful use of a presentation style that is “crafted” is ironic, given that the witnesses’ “compilation” of jihadist digital material is staged in the form of a carefully structured PowerPoint presentation, one that is paced to a well-rehearsed rhythm of “slide, please” or “next slide” in the transcript. The transcript also reveals that the members of the House Intelligence Committee were not the original audience for the witnesses’ PowerPoint presentation. Rather, when it was first created by SAIC, this “expert” presentation was designed for training purposes for the troops on the ground, who would be facing the challenges of deployment in hostile terrain. According to the witnesses, having the slide show showcased before Congress was something of an afterthought. Nonetheless, Congressman Tiahrt (R-KN) is so impressed with the rhetorical mastery of the consultants that he tries to appropriate it. As Tiarht puts it, “I’d like to get a copy of that slide sometime.” From the hearing we also learn that the terrorists’ Websites are threatening precisely because they manifest a polymorphously perverse geometry of expansion. For example, one SAIC witness before the House Committee compares the replication and elaboration of digital material online to a “spiderweb.” Like Representative Eshoo’s site, he also notes that the terrorists’ sites go “up” and “down,” but the consultant is left to speculate about whether or not there is any “central coordination” to serve as an organising principle and to explain the persistence and consistency of messages despite the apparent lack of a single authorial ethos to offer a stable, humanised, point of reference. In the hearing, the oft-cited solution to the problem created by the hybridity and iterability of digital rhetoric appears to be “public diplomacy.” Both consultants and lawmakers seem to agree that the damaging messages of the insurgents must be countered with U.S. sanctioned information, and thus the phrase “public diplomacy” appears in the hearing seven times. However, witness Roughhead complains that the protean “oral tradition” and what Henry Jenkins has called the “transmedia” character of digital culture, which often crosses several platforms of traditional print, projection, or broadcast media, stymies their best rhetorical efforts: “I think the point that we’ve tried to make in the briefing is that wherever there’s Internet availability at all, they can then download these – these programs and put them onto compact discs, DVDs, or post them into posters, and provide them to a greater range of people in the oral tradition that they’ve grown up in. And so they only need a few Internet sites in order to distribute and disseminate the message.” Of course, to maintain their share of the government market, the Science Applications International Corporation also employs practices of publicity and promotion through the Internet and digital media. They use HTML Web pages for these purposes, as well as PowerPoint presentations and online video. The rhetoric of the Website of SAIC emphasises their motto “From Science to Solutions.” After a short Flash film about how SAIC scientists and engineers solve “complex technical problems,” the visitor is taken to the home page of the firm that re-emphasises their central message about expertise. The maps, uniforms, and specialised tools and equipment that are depicted in these opening Web pages reinforce an ethos of professional specialisation that is able to respond to multiple threats posed by the “global war on terror.” By 26 June 2006, the incident finally was being described as a “Pentagon Snafu” by ABC News. From the opening of reporter Jake Tapper’s investigative Webcast, established government institutions were put on the spot: “So, how much does the Pentagon know about videogames? Well, when it came to a recent appearance before Congress, apparently not enough.” Indeed, the very language about “experts” that was highlighted in the earlier coverage is repeated by Tapper in mockery, with the significant exception of “independent expert” Ian Bogost of the Georgia Institute of Technology. If the Pentagon and SAIC deride the legitimacy of rhetoric as a cultural practice, Bogost occupies himself with its defence. In his recent book Persuasive Games: The Expressive Power of Videogames, Bogost draws upon the authority of the “2,500 year history of rhetoric” to argue that videogames represent a significant development in that cultural narrative. Given that Bogost and his Watercooler Games Weblog co-editor Gonzalo Frasca were actively involved in the detective work that exposed the depth of professional incompetence involved in the government’s line-up of witnesses, it is appropriate that Bogost is given the final words in the ABC exposé. As Bogost says, “We should be deeply bothered by this. We should really be questioning the kind of advice that Congress is getting.” Bogost may be right that Congress received terrible counsel on that day, but a close reading of the transcript reveals that elected officials were much more than passive listeners: in fact they were lively participants in a cultural conversation about regulating digital media. After looking at the actual language of these exchanges, it seems that the persuasiveness of the misinformation from the Pentagon and SAIC had as much to do with lawmakers’ preconceived anxieties about practices of computer-mediated communication close to home as it did with the contradictory stereotypes that were presented to them about Internet practices abroad. In other words, lawmakers found themselves looking into a fun house mirror that distorted what should have been familiar artefacts of American popular culture because it was precisely what they wanted to see. 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