The quality of the quality indicator of pain derived from the minimum data set

OBJECTIVE: To examine facility variation in data quality of the level of pain documented in the minimum data set (MDS) as a function of level of hospice enrollment in nursing homes (NHs). DATA SOURCE: Clinical assessments on 3,469 nonhospice residents from 178 NHs were merged with On-line Survey Certification and Reporting data of 2000, Medicare Claims data of 2000 and the MDS of 2000-2002. STUDY DESIGN: Using the same assessment protocol, NH staff and study nurses independently assessed 3,469 nonhospice residents. Study nurses' assessments being gold standard, we quantified and compared quality of NH staff's pain rating across NHs with high, medium, or low hospice use. Multilevel models were built to assess the effect of NH hospice use levels on the occurrence of false positive (FP) and false negative (FN) errors in NH-rated "severe pain." PRINCIPAL FINDINGS: Of 178 NHs, 25 had medium and 41 high hospice use. NHs with higher hospice use had lower sensitivities. In multilevel analysis, we found a significant facility-level variation in the probability of FP and FN errors in facility-rated "severe pain." Resident characteristics only explained 4 and 0 percent of the facility variation in FP and FN, respectively; characteristics and locations (state) of NHs further explained 53 and 52 percent of the variance. After controlling for resident and NH characteristics, staff in NHs with medium or high hospice use were less likely to have FP or FN errors in their MDS documentation of pain than were staff in NHs with low or no hospice use. CONCLUSIONS: The examination of data quality of pooled MDS data from multiple NHs is insufficient. Multilevel analysis is needed to elucidate sources of heterogeneity in the quality of MDS data across NHs. Facility characteristics, e.g., hospice use or NH location, are systematically associated with overrated/underrated pain and may bias pain quality indicator (QI) comparisons. To ensure the integrity of QI comparison in the NH setting, the government may need to institute regular audits of MDS data quality.     

Biodistribution and persistence of an MVA-vectored candidate HIV vaccine in SIV-infected rhesus macaques and SCID mice

Recombinant modified vaccinia virus Ankara (MVA) is together with a few other attenuated viral vectors on the forefront of human immunodeficiency virus type 1 (HIV-1) vaccine development. As such, MVA-vectored vaccines are likely to be administered into immunocompromized individuals. Here, we demonstrated in a good laboratory practice study safety and biological clearance of candidate HIV-1 vaccine MVA.HIVA in simian immunodeficiency virus (SIV)-infected rhesus macaques and mice with a severe combined immunodeficiency (SCID) following an intradermal vaccine administration. In SIV-infected macaques, MVA.HIVA DNA was undetectable by nested PCR 6 weeks after dosing. In SCID mice, the MVA.HIVA vaccine was well tolerated and a positive PCR signal was only observed at the site of injection 49 days after dosing in four out of six mice, but even these sites were negative by day 81 post-injection. Therefore, the MVA.HIVA vaccine is considered safe for application in phase I clinical trials in HIV-1-infected human subjects. These results also contribute to the confidence of using MVA as a smallpox vaccine.     

A comparative analysis of communication about sex, health and sexual health in India and South Africa: Implications for HIV prevention

This paper provides a comparative analysis of modes of dialogue, non-verbal communication and embodied action relating to sex and health in two contrasting countries-India and South Africa-which have the world's two most heavily HIV-affected populations (in terms of numbers of people living with HIV). Drawing on material derived from multiple studies, including ethnographic and other forms of qualitative and multi-disciplinary research, the paper identifies commonalities as well as differences in communication relating to sex and sexual health in these diverse settings. The paper considers: first, how and by whom sex is and is not talked about, in public discourse and private conversation; second, how sexual intention and desire are communicated through indirect, non-verbal means in everyday life; and third, how references to sexuality and the sexual body re-enter within a more explicit set of indigenous discourses about health (rather than 'sexual health' per se), such as semen loss in India and womb 'dirtiness' in South Africa. The concluding section reflects on the implications of a comparative analysis such as this for current policy emphases on the importance of promoting verbal communication skills as part of 'life skills' for HIV prevention.     

Study design I

This is the first of a series of articles that will describe the different types of study design; considerations when choosing a study design; and the advantages and disadvantages of each type of study. This first article explains the importance of choosing an appropriate design and the decisions to be made when doing so.     

Short report: Phylogenetic relationships of the anthropophilic Plasmodium falciparum malaria vectors in Africa

Malaria kills more than one million people a year, and understanding the historical association between its most notorious causative agent, Plasmodium falciparum, and its mosquito vectors is important in fighting the disease. We present a phylogenetic analysis of a number of species within the mosquito subgenus Cellia based on a selection of mitochondrial and nuclear genes. Although some of these relationships have been estimated in other studies, generally few species were included and/or statistical support at many nodes was low. Here we include two additional species of anthropophilic P. falciparum malaria vectors and reanalyze these relationships using a Bayesian method that allows us to simultaneously incorporate different models of evolution. We report data that indicate a paraphyletic relationship between five anthropophilic African mosquito vectors. Such a relationship suggests that these species can serve as independent natural experiments for anopheline immunologic responses to regular, prolonged contact with P. falciparum.     

Differential introgression of chromsomal regions between Anopheles gambiae and An. arabiensis

Evidence for introgression between Anopheles gambiae and An. arabiensis has accumulated for some time. We examined the fate of introgressed DNA directly, using microsatellite markers located throughout the genome. Introgressed X chromosomes were removed within two generations. Furthermore, substantial differences in introgressive capacity between the two autosomes were found. After introgression from An. arabiensis into An. gambiae, most introgressed alleles at third chromosome markers, particularly those on 3R, decreased steadily, indicating selection against them. No such pattern was observed for 2L markers and several 2R markers. The frequency of introgressed alleles on 2L were close to the original frequency even after 19 generations, whereas only two 2R markers showed a modest decrease. Even though limited information was available on the reciprocal cross, the pattern appears to be identical. Although the decrease in frequency of the introgressed X chromosome can be attributed to the presence of sterility and inviability effects, the variation in introgressive capacity of the autosomes does not appear to be explained by the presence of inversion polymorphisms, or regions causing hybrid sterility and inviability. These results can have some important implications for the spread of insecticide resistance and the control of these vector populations via the release of transgenic mosquitoes.     

Spinal blockade of TNF blocks spinal nerve ligation-induced increases in spinal P-p38

Although research on DNIC has revealed the inhibitory effect occurring between two remote pain stimuli, the interrelation between two adjacent painful stimuli has not yet been characterized. In the present study, we used a sample of 40 healthy volunteers to examine the effect of 30-s immersion of the fingers in water of 1 °C, as a conditioning stimulus, on pain intensities produced by conditioned mechanical punctuate stimuli, applied both adjacent and contralateral to the cooled area. There was a significant decrease in mechanical pain intensities from 17.23 ± 2.39 at baseline to 12.45 ± 2.39 when stimulating immediately after the cold immersion at an adjacent site, and from 20.00 ± 2.39 to 15.08 ± 2.39 at remote sites (F = 20.02, p < 0.0001). A significant positive correlation between the extent of pain reduction in the cooled and in the uncooled hand was found (r_s = 0.59, p = 0.0001). The extent of pain reduction following cooling in the cooled and in the uncooled hand was also found to be similar for males and for females (p = 0.63). It is concluded that under the conditions of this experiment, EA affects heterotopic and homotopic regions similarly and without gender differences.