Assessment of level of care: implications of interrater reliability on health policy.

In Wisconsin, level-of-care assessments are used to set Medicaid reimbursement and determine nursing home eligibility. This study examined three methods of assessing level of care: 1) the Wisconsin quality assurance project (QAP) method, based on observations of patients, patient records, and staff interviews; 2) the Wisconsin standard (STD) method, based primarily on a clinical record review; and, 3) an adaptation of New York's "DMS-I," a checklist with numerical weights used to set level of care. Results address interrater reliability, the agreement between assessments by research teams and actual levels of care set by the State, and the implications that agreement has for reimbursement.     

Treatment of malignant gliomas in adults with BCNU plus metronidazole

Summary Twenty-six adult patients with astrocytomas were treated with BCNU (1,3-bis(2-chloroethyl)-1-nitrosourea) 180–240 mg/m² 1.V. every 6–9 weeks, with metronidazole 1.5 g/m² p. o. 12 h and 1 h before BCNU and again 6 h and 24 h after BCNU. Of twenty-two evaluable patients, 9 (41%) responded with evidence of reduced tumor size on CT scan, 3 (14%) stabilized and 10 (45%) failed. Patients with no prior chemotherapy or radiotherapy, good performance. status, low grade tumors, and age 50 years had the highest response rates, although differences were not statistically significant. Median survival and duration of response have not been reached with a median follow-up time of ten months. Hematological toxicity was dose-limiting and was probably not augmented by the metronidazole. There was one death from infection that was possibly drug-related. Gastrointestinal toxicity was substantial, and was probably increased by the metronidazole.While the combination of BCNU and metronidazole were tolerable, the response rate seen was no higher than that noted for BCNU alone, and further studies using this dose-schedule are not recommended in astrocytomas.Presented at the 13th International Congress of Chemotherapy, Vienna Austria, August 1983.     

Variability in surface antigen expression of human breast epithelial cells cultured from normal breast, normal tissue peripheral to breast carcinomas, and breast carcinomas

Single-cell heterogeneity and variability in expression of several surface antigens on human mammary epithelial cells in short-term culture were studied with immunofluorescence techniques, using polyclonal and monoclonal antibodies. The cultures, derived from normal breast, a fibroadenoma, a gynecomastia, normal breast tissue peripheral to breast carcinomas, and breast carcinomas and their metastases, were studied after one passage in vitro. The percentage of positive cells varied considerably from one tissue sample to another in all categories from normal to malignant, although there was an overall trend toward a decreasing percentage of positive cells of malignant tissues. The relative antigen content varied 3- to 8-fold among individual samples of cells from normal, peripheral, and carcinoma tissue, while the mean values in the three categories were similar. The single-cell variability in relative antigen content was considerable in all individual samples of normal, peripheral, and carcinoma tissues, as reflected in the high coefficients of variation. However, the coefficients of variation were significantly higher for cells from carcinoma and peripheral tissues [69 +/- 10% (S.E.) and 75 +/- 9%, respectively] than for cells from normal breast (48 +/- 5%). By analyzing in clonal colonies the appearance of quantitative variants in expression of a specific surface antigen, detected with a monoclonal antibody, the carcinoma cells were found to have a 10-fold higher rate of phenotypic variability (mean, 1.21 X 10(-2)/cell/generation) than did cells from normal breast (mean, 0.119 X 10(-2)) and one gynecomastia (0.045 X 10(-2)). Mammary epithelial cells from apparently "normal" tissue peripheral to a carcinoma had an intermediate rate of phenotypic variability (mean, 0.310 X 10(-2)) that was significantly higher than that of the normal tissue.     

Infection Control Citations in Nursing Homes: Compliance and Geographic Variability

ObjectivesTo report the initial compliance with new infection control regulations and geographic disparities in nursing homes (NHs) in the United States.DesignRetrospective cohort study from November 27, 2017 to November 27, 2019.Setting and ParticipantsIn total, 14,894 NHs in the continental United States comprising 26,201 inspections and 176,841 deficiencies.MethodsWe measured the cumulative incidence of receiving F880: Infection Prevention and Control deficiencies, geographic variability of F880 citations across the United States, and the scope and severity of the infection control deficiencies.ResultsA total of 6164 NHs (41%) in the continental United States received 1 deficiency for F880, and 2300 NHs (15%) were cited more than once during the 2-year period. Geographic variation was evident for F880 deficiencies, ranging from 20% of NHs in North Carolina to 79% of NHs in West Virginia. Between 0% (Vermont) and 33% (Michigan) of states’ NHs were cited multiple times over 2 years. Facilities receiving 2 or more F880 deficiencies were more reliant on Medicaid, for-profit, and served more acute residents. Infection Prevention and Control deficiencies were of similar severity but of greater scope in NHs that were cited multiple times.Conclusions and ImplicationsAs the coronavirus disease 2019 pandemic challenges hospitals with an increased surge of patients from the community, NHs will be asked to accept convalescing patients who were previously infected with the virus. NHs will need to rely on infection control practices to mitigate the effects of the virus in their facilities. Particular attention to NHs that have fared poorly with repeat infection control practices deficiencies might be a good first step to improving care overall and preventing downstream morbidity and mortality among the highest-risk patients.     

Prevalence and Correlates of Sexual Violence Experienced by Young Adult Black Men Who Have Sex with Men

Archives of Sexual Behavior - Men who have sex with men (MSM) experience high prevalence of sexual violence (SV), and SV has well-documented effects on health. Research gaps are especially evident...     

The peril and promise of sensitivity in eating disorders

Differential susceptibility, a reconceptualization of the diathesis-stress model of psychopathology, describes gene–environment interactions that reflect individual differences in responsiveness to environmental influences, both detrimental and beneficial. This model has been described metaphorically by the classification of orchids, which thrive under optimal care but wither under adverse conditions, and dandelions, which weather broad environmental circumstances but are less responsive to careful cultivation. Etiological research in the field of eating disorders has largely focused on the identification of specific behavioral phenotypes, temperamental traits, genotypes and neurobiological processes that confer risk. In this article, we propose that these putative vulnerability factors represent phenotypes and endophenotypes of a genetic predisposition towards environmental sensitivity. We assert that this sensitivity not only transmits eating disorder risk but also confers resilience, depending on the circumstances. In particular, we propose that differential susceptibility can be used as a framework to organize disparate temperamental and neurobiological findings and their complex interplay with various developmental, environmental and sociocultural influences to increase eating disorder risk and treatment responsiveness. Finally, we assert that viewed through the lens of differential susceptibility, sensitivity can be leveraged to refine our interventions and develop novel treatment and prevention strategies to support favorable outcomes for individuals with eating disorders.     

Altered impedance during pigment aggregation in<Emphasis Type="Italic">Xenopus laevis</Emphasis> melanophores

Melanophores are dark-brown pigment cells located in the skin of amphibia, fish and many invertebrates. The skin colour of these organisms is regulated by the translocation of pigment organelles, and the pigment distribution can be altered by external stimuli. The ability to change colour in response to stimuli makes these cells of interest for biosensing applications. It was investigated whether pigment aggregation in Xenopus laevis melanophores can be detected by impedance measurements performed in transparent microvials. The results show that cell attachment, cell spreading and pigment aggregation all resulted in impedance changes, seen particularly at the highest frequency tested (10 kHz). The mechanisms behind the impedance changes were investigated by the addition of latrunculin or melatonin, both of which cause pigment aggregation. The latrunculin-induced aggregation was associated with cell area decrease and filamentous actin (F-actin) breakdown, processes that can influence the impedance. Lack of F-actin breakdown and an increase in cell area during melatonin-induced aggregation suggest that some other intracellular process also contributes to the impedance decrease seen for melatonin. It was shown that impedance measurements reflect not only cell attachment and cell spreading, but also intracellular events.     

Characterization of "neo-dermis" formation beneath cultured human epidermal autografts transplanted on muscle fascia.

Cultured human keratinocyte autografts were transplanted to burn wounds that had been completely excised down to muscle fascia such that all cutaneous elements were removed from the wounds. Healing autografts were biopsied from days 6-153 in five patients, and the "neo-dermis" beneath the autografts was examined by immunofluorescent staining using antibody probes to connective tissue molecules, by histochemical staining for elastin fibers, and by electron microscopy. We found that the neo-dermis contained most of the major connective tissue elements early in the post-transplantation period. However, regardless of the time examined, there was a paucity of elastin fibers and poor organization of linkin (microthread-like fibers) in the neo-dermis beneath autografts. The perturbations of these connective tissue components in the neo-dermis may play a role in the poor recoil and elastic properties of burn wounds treated with autografts.     

The Pharmacokinetics of Recombinant Human Relaxin in Nonpregnant Women After Intravenous,Intravaginal, and Intracervical Administration

The pharmacokinetics of recombinant human relaxin (rhRlx) after intravenous (iv) bolus administration and the absorption of rhRlx after intracervical or intravaginal administration were determined in nonpregnant women. The study was conducted in two parts. In part I, 25 women received 0.01 mg/kg rhRlx iv. After a minimum 7-day washout period, these women were dosed intracervically (n = 10) or intravaginally (n = 15) with 0.75 or 1.5 mg rhRlx, respectively, in 3% methylcellulose gel. Part II was a double-blind, randomized, three-way crossover study in 26 women. At 1-month intervals, each woman received one of three intravaginal treatments consisting of 0 (placebo), 1, or 6 mg rhRlx in 3% methylcellulose gel. The serum concentrations of relaxin following iv administration were described as the sum of three exponentials. The mean (±SD) initial, intermediate, and terminal half-lives were 0.09 ± 0.04, 0.72 ± 0.11, and 4.6 ± 1.2 hr, respectively. Most of the area under the curve was associated with the intermediate half-life. The weight-normalized clearance was 170 ± 50 mL/hr/kg. The observed peak concentration was 98 ± 29 ng/mL, and the weight-normalized initial volume of distribution was 78 ± 40 mL/kg, which is approximately equivalent to the serum volume. If central compartment elimination was assumed, the volume of distribution at steady state (V _ss/W) was 280 ± 100 mL/kg, which is approximately equivalent to extracellular fluid volume. V _ss/W could be as large as 1300 ± 400 mL/kg without this assumption. After intravaginal administration of the placebo gel, endogenous relaxin concentrations were evident (i.e., 20 pg/mL) in 9 of the 26 women (maximum concentrations, 23–234 pg/mL). A similar proportion of women (approximately 35–40%) exhibited measurable serum concentrations of relaxin following intravaginal rhRlx treatment; this proportion increased to 90% following intracervical rhRlx treatment. For both routes of administration, the maximum serum concentrations of relaxin were usually within the range of values observed for endogenous relaxin, suggesting that the absorption of rhRlx was minimal.     

Comparison of the costs of compliance with nutrition education messages to improve the diets of Bangladeshi breastfeeding mothers and weaning-age children

Local market prices in rural Bangladesh were used to compute the costs of filling the nutrient gaps between actual intakes and safe nutrient requirements, and the costs of compliance with nutrition messages, for 78 lactating mothers and 61 weaning-age breastfed children. (The gap is the difference between the requirement and the amount of nutrient consumed.) To fill the mother's energy gap of approximately 1050 kcal (4393 kJ) would cost an additional 21% of the daily wage, or almost double the value of food she was presently eating. Given social reality, these costs would probably be much greater, as the mother would also need to increase the allocation of food to other household members. The weaning-age children's energy gap could theoretically be closed for less than one-third of the cost of improving the mothers' diets, or about 8% of the daily wage. The increase in food intake equivalent to 2% of the daily wage actually achieved through nutrition education resulted in a significant improvement in child weight gain, though not ideal. These findings suggest that, in the absence of programs which reduce economic barriers, it is economically feasible for families to close the nutrient gaps for weaning-age breastfed children in Bangladesh, but not for lactating women. Thus, education to improve women's diets should be incorporated into programs that make these improvements affordable, whereas education to improve weaning-age children's diets can be implemented with or without other program supports.