bluuebunny/crossref_metadata_2025 huggingface dataset:
A Two-Stage Method for the Study of Cultural Bias in the Diagnosis of Schizophrenia in African Americans
Authors: Whaley Arthur L.
Published: April 2004

Reasons for diagnostic bias in psychiatric evaluations of African Americans fall into two basic categories: clinician bias, which is the lack of adherence to diagnostic criteria during psychiatric evaluations, and cultural bias, which is true ethnic/racial differences in symptom expression being overlooked or misinterpreted by diagnosticians. The ideal method of studying cultural biases in the psychiatric diagnosis of African Americans is a two-stage procedure with the first stage controlling for clinician bias and the second stage addressing cultural bias. This study evaluated a two-stage procedure that first considers clinician bias by a structured clinical interview followed by a best estimate diagnosis by a mental health clinician who is a cultural expert. The method was developed and evaluated for its reliability and validity in the Culturally Sensitive Diagnostic Interview Research Project. Data from 24 psychiatric inpatients were used to evaluate this diagnostic approach. Several hypotheses were tested, but not all were supported.
Establishment Growth in Small Cities and Towns
Authors: Gabe Todd M.
Published: April 2004

This article examines the effects of local industry agglomeration on establishment growth and employee earnings in Maine manufacturing and nonmanufacturing businesses. Empirical results reveal a positive relationship between an establishment’s 1996 to 1999 employment growth rate and the industry location quotient, measured at the two-digit standard industry classification (SIC) level in 129 municipalities and the three-digit SIC level in 16 counties. The results also indicate that industry agglomeration has a positive effect on the wages paid by an establishment relative to the U.S. industry average. In Maine municipalities, an increase in industry agglomeration is found to be a more powerful stimulant to establishment growth than a comparable increase in population size. On the other hand, an increase inmunicipality size has a relatively larger effect on establishment wages than a comparable increase in local industry agglomeration.
Anti-Semitism in Europe before the Holocaust
Authors: Brustein William I. , King Ryan D.
Published: April 2004

It is commonly accepted that the years 1899–1939 represent a highpoint in anti-Semitism in western societies. What factors account for the wave of extraordinary anti-Semitism after 1899? Was the rise of anti-Semitism between 1899 and the Holocaust uneven? Did anti-Semitism vary in content and intensity across societies? Did Germans embrace anti-Semitism differently from French, Italian, Romanian, and British citizens? Data drawn from the annual volumes of the American Jewish Year Book are used to examine these questions systematically. Pooled time-series analyses suggest that variation in anti-Semitism over time and across countries was largely a function of economic conditions and Jewish immigration, and to a limited extent of the rise of leftist parties.
Religious Denomination and Party Choice in Western Europe: A Comparative Longitudinal Study from Eight Countries, 1970–97
Authors: Knutsen Oddbjørn
Published: April 2004

In this article, the impact of religious denomination on party choice is studied in eight western European countries from the early 1970s to the late 1990s. The research problems are (1) to examine the strength of the correlation between party choice and religious denomination over time, and (2) to analyze which political parties those who are affiliated and those who are unaffiliated to a religious community vote for, and how this has changed over time. The denominational cleavage varies considerably in strength in the eight countries. It is strongest in the Catholic and religiously mixed countries of Continental Europe. There is stability in the correlation between party choice and religious denomination in most countries. The main polarization involves, to a large degree, voters for parties on the left versus voters for parties on the right. It varies considerably, however, as to which parties on the left and the right have voters who contribute comparatively to polarization. Green parties are making inroads among the unaffiliated sections of the population. This changes the polarization caused by religious denomination in the sense that denominational differences become smaller for some other parties, first and foremost, the socialist and the communist parties.
Governance and Bureaucracy in Singapore: Contemporary Reforms and Implications
Authors: Shamsul Haque M.
Published: April 2004

In recent decades, there have been substantial reforms in governance and administration based on neoliberal assumptions, market-driven policies, and neo-managerial principles. These contemporary reforms aimed at reinventing government and restructuring the state began in a few advanced capitalist nations, and gradually became a global model affecting countries around the world, including the interventionist developmental states in Asia. This article examines the case of Singapore in terms of the recent trends of reform in its public governance and explores the major local and global factors shaping this reform agenda. It also briefly considers the implications of these changes for the state, bureaucracy, and people in Singapore.
Organizing International Politics: Sovereignty and Open Systems
Authors: Ansell Christopher K. , Weber Steven
Published: April 2004

Changes in the meaning of sovereignty are at the center of intersecting discussions between comparative and international politics. This article uses open-system perspectives from organization theory to move beyond arguments over the erosion or resilience of sovereignty, toward more substantive questions about the nature of the boundaries of political actors, and to frame the possibility that changes in world politics are constituting new actors whose relationships would follow logics different from those ascribed to sovereign states.
The Fate of Sustainable Development Under Neo-Liberal Regimes in Developing Countries
Authors: Haque M. Shamsul
Published: April 2004

Due to an enhanced global environmental awareness reinforced by dramatic environmental events, international conferences on the environment and development, as well as academic research and publications, have increasingly shifted the developmental discourse toward the concept of “sustainable development.” In developing countries, however, the realization of the notion of sustainable development has come under challenge due to the emergence of neo-liberal regimes and their pro-market policies. The current article addresses the following issues in this context: the origin, meaning, and problems of sustainable development; the major features and policy orientations of neo-liberal regimes in developing countries; and the critical implications of neo-liberal policies for the environment and development. The article also offers some recommendations with a view to overcoming the contemporary challenges to sustainability and ensuring a more genuine and effective mode of sustainable development.
Goods, Games, and Institutions
Authors: Aggarwal Vinod K. , Dupont Cédric
Published: April 2004

International institutions can help to overcome the problem of supplying goods that are difficult to restrict in terms of consumption. Yet the links between the characteristics of goods, the nature of strategic interaction between actors, and the effectiveness or need for international institutions have not been systematically treated. This article tries to remedy this gap by providing a systematic analysis of the problem of the provision of two types of goods—public goods and common pool resources (CPRs). It starts by examining the characteristics of these goods, and then derives some simple game structures that correspond to different assumptions about the costs and benefits of these goods and variations in actors’ capabilities. It then discusses the links between games and institutional solutions. In doing this, the authors are able to encompass previous analytical work and open up new avenues for empirical studies of collective action.
Sister Act VI: Venus and Serena Williams at Indian Wells: “Sincere Fictions” and White Racism
Authors: Spencer Nancy E.
Published: April 2004

Venus and Serena Williams’ dominance of professional women’s tennis at the dawn of the 21st century may well signify progress in a sport that typically privileges Whiteness. What happened at Indian Wells, California, in the spring of 2001 suggests otherwise. After advancing to the semifinals where they were scheduled to meet, Venus defaulted to Serena and thus incurred the wrath of fans at Indian Wells. Two days later, when Venus and her father Richard entered the stadium to watch Serena play, they encountered boos and racist epithets. Similar to other “racialized incidents” that occurred in the United States during the 1990s, the episode at Indian Wells signals the continuance of racism in the new millennium. Although contemporary terms have shifted from “scientific racism” to “cultural racism” and “commodity racism,” the underlying dynamics of White racism persist.
European Bank Lending to the UK SME Sector
Authors: Berry Aidan , Grant Paul , Jarvis Robin
Published: April 2004

The relationship between UK SMEs and their bankers has been the subject of considerable debate over the years. The literature suggests that one area of concern is UK banks adopting a security-based approach to lending to SMEs. The literature also suggests that European banks ‘do it differently’. Given the considerable number of overseas financial institutions operating in the UK, the research reported here aimed to find out whether European banks in the UK were lending to UK SMEs and, if they were, what approach they adopted to lending practice. The data for the research study was collected via interviews with the bankers concerned using the methodology previously adopted by Berry et al. (1993b). The study found that only 10 European banks were active in lending to UK SMEs and that these European banks adopted a mixture of approaches to SME lending. The implications of this are that the European banks are unlikely to provide the sort of influence that was apparent from the US banks in the 1970s and 1980s in the large corporate lending sector, either by way of any real competition to the UK banks in the SME sector of lending or through indirect influence via different approaches to lending practice.
Fluoxetine Dose-Increment Related Akathisia in Depression: Implications for Clinical Care, Recognition and Management of Selective Serotonin Reuptake Inhibitor-Induced Akathisia
Authors: Hansen Lars
Published: April 2004

We report the case of a 22-year-old woman presenting major depressive episode with severe akathisia after an increase in fluoxetine. The patient developed severe restlessness andde novosuicidal ideation approximately 1 week after the dosage of fluoxetine was doubled, 1 year on from when the drug was first introduced. This case illustrates the importance of being alert to movement disorders in patients treated with selective serotonin reuptake inhibitors. The clinical implications are discussed. A management strategy based on the evidence in the existing literature is suggested.
Outcome Measurement in Pharmacological Trials: Validity of the Routine Assessment of Patient Progress (RAPP)
Authors: Ehmann T. S. , Kragelj T. , Higgs E. , Flynn S. W. , Altman S. , Smith G. N. , Honer W. G. , Macewan G. W.
Published: April 2004

The assessment of outcomes after treatment with antipsychotic medication is fundamental to clinical care and research. The Routine Assessment of Patient Progress (RAPP) is a reliable multidimensional scale that employs nurses’ ratings of symptoms and functioning in psychiatric inpatients. The present study sought to extend validity evidence for the RAPP by examining its ability to reflect changes associated with treatment by antipsychotic medications. The use of a different sample in this study also provided the opportunity to replicate earlier validity data collected on the original set of patients. Ninety-seven separate trials were conducted, involving 65 consecutive admissions to a unit that specializes in the assessment and treatment of patients with long standing severe psychiatric disorders. The RAPP, along with the Positive and Negative Syndrome Scale and global measures of severity, were administered at baseline and at the end of each trial. Both factor scores and clinically-derived subscales were analysed for sensitivity to change. Patients were globally rated as improved, unchanged or worsened at the end of the medication trial. Results indicated that the RAPP factor, clinical scale and total scores compared favourably to other outcome measures in patients rated as improved or worse. In patients rated as unchanged, RAPP scores displayed significantly less change than did the PANSS scores. These findings support the validity of the RAPP as an outcome measure in treatment trials.
Chronic Cannabis Abuse Raises Nerve Growth Factor Serum Concentrations in Drug-Naive Schizophrenic Patients
Authors: Jockers-ScherüBl Maria C. , Matthies Uta , Danker-Hopfe Heidi , Lang Undine E. , Mahlberg Richard , Hellweg Rainer
Published: April 2004

Long-term cannabis abuse may increase the risk of schizophrenia. Nerve growth factor (NGF) is a pleiotropic neurotrophic protein that is implicated in development, protection and regeneration of NFG-sensitive neurones. We tested the hypothesis that damage to neuronal cells in schizophrenia is precipitated by the consumption of cannabis and other neurotoxic substances, resulting in raised NGF serum concentrations and a younger age for disease onset. The NGF serum levels of 109 consecutive drug-naive schizophrenic patients were measured and compared with those of healthy controls. The results were correlated with the long-term intake of cannabis and other illegal drugs. Mean (± SD) NGF serum levels of 61 control persons (33.1 ± 31.0 pg/ml) and 76 schizophrenics who did not consume illegal drugs (26.3 ± 19.5 pg/ml) did not differ significantly. Schizophrenic patients with regular cannabis intake (> 0.5 g on average per day for at least 2 years) had significantly raised NGF serum levels of 412.9 ± 288.4 pg/ml (n = 21) compared to controls and schizophrenic patients not consuming cannabis (p < 0.001). In schizophrenic patients who abused not only cannabis, but also additional substances, NGF concentrations were as high as 2336.2 ± 1711.4 pg/ml (n = 12). On average, heavy cannabis consumers suffered their first episode of schizophrenia 3.5 years (n = 21) earlier than schizophrenic patients who abstained from cannabis. These results indicate that cannabis is a possible risk factor for the development of schizophrenia. This might be reflected in the raised NGF-serum concentrations when both schizophrenia and long-term cannabis abuse prevail.
Ziprasidone in Huntington’s Disease: The First Case Reports
Authors: Bonelli Raphael M. , Mayr Brigitte M. , Niederwieser Gerald , Reisecker Franz , Kapfhammer Hans-Peter
Published: April 2004

Huntington’s disease (HD) is a relentlessly progressive neuropsychiatric disorder with an underlying autosomal dominantly inherited genetic defect. Classical antipsychotics (i.e. phenothiazines or butyrophenones) are the most used medication to reduce the (probably dopamine-born) choreiform hyperkinesias. Ziprasidone is the latest of a new class of atypical antipsychotics; it has not been studied so far in this indication. We report three genetically confirmed HD patients who improved significantly in several categories of the motor scale of the Unified HD Rating Scale.
Discontinuation Symptoms Associated with Nefazodone
Authors: Tamam Lut , Ozpoyraz Nurgul
Published: April 2004

We present a patient who developed discontinuation symptoms following abrupt cessation of nefazodone. Three days after the first appearance of the discontinuation symptoms (i.e. 5 days after cessation of the drug), all symptoms resolved spontaneously without a need for intervention. This case report emphasizes the importance of gradual discontinuation of serotonergic drugs to avoid any consequent unpleasant discontinuation symptoms.
The Barnes Akathisia Rating Scale–Revisited
Authors: Barnes Thomas R. E.
Published: April 2004

Akathisia is a syndrome of motor restlessness, principally seen in association with antipsychotic medication. It is characterized by a subjective experience of mental unease and the urge to move, and manifests physically as particular patterns of restless movement. This review focuses on the signs and symptoms of the condition, and its diagnosis and assessment using the Barnes Akathisia Rating Scale. This scale was generated 15 years ago, and was derived from the findings of studies exploring the clinical features of antipsychotic-induced akathisia. Subsequently, its validity and reliability have been established, and it has been used extensively in clinical studies worldwide.
Correlation of Hyperforin Content of Hypericum Perforatum(St John’s Wort) Extracts with Their Effects On Alcohol Drinking in C57Bl/6J Mice: A Preliminary Study
Authors: Wright C. W. , Gott M. , Grayson B. , Smith A. G. , Sunter A. , Neill J. C. , Hanna M.
Published: April 2004

Extracts of the herb St John’s Wort have been shown to reduce alcohol intake in alcohol-preferring rats, but it is not known which of the constituent(s) are responsible for this effect. In this study, the effect of a crude methanolic extract ofHypericum perforatum(negligible hyperforin content) on alcohol drinking in C57BL/6J alcohol-preferring mice was compared with that of a hyperforin-rich extract (45% hyperforin) prepared by extracting the herb with supercritical carbon dioxide. The dose of the hyperforin-rich extract required to significantly reduce 10% ethanol intake (5 mg/kg) was 125-fold less than that required for the crude extract (625 mg/kg), and was comparable to the dose of fluoxetine (10 mg/kg) required to produce a similar effect. None of these agents significantly affected water intake. These results suggest that the effects of H. perforatumextracts on alcohol drinking behaviour are due to the hyperforin content of the herb rather than to other, more polar constituents. Hyperforin is an unstable compound and this study also highlights the effect of different methods of extract preparation on hyperforin content.
The Application of the Principles of Clinical Drug Development to Pharmacological Challenge Tests of the Serotonergic System
Authors: Gijsman H. J. , Cohen A. F. , Van Gerven J. M. A
Published: April 2004

Pharmacological challenge tests of the serotonergic system have extensively been used during the past 20 years and new tests are in development. It is of crucial importance to standardize challenge tests to ascertain that observed variability is due to the state of the challenged system and not caused by variability of the test itself. This is even more important now that challenge tests increasingly are used in complex studies (e.g. in combination with neuroimaging and in large population studies with repeated tests over time). The Guideline for Good Clinical Practice may be of great help in the standardization of these tests. This is a recently developed guideline for pharmaceutical drug-development, which increasingly is used as a reference for all research in humans. To exemplify the possible usefulness of this approach, we apply it to meta-chlorophenylpiperazine, one of the most commonly used drugs in serotonergic challenge tests. We conclude that much can be learned from the development of this particular challenge. In the discussion, we address general issues that emerged from this review and their relevance to the development of future challenge tests.
Simultaneous Depletion of Serotonin and Catecholamines Impairs Sustained Attention in Healthy Female Subjects without Affecting Learning and Memory
Authors: Matrenza Cathy , Hughes Jay-Maree , Kemp Andrew H. , Wesnes Keith A. , Harrison Ben J. , Nathan Pradeep J.
Published: April 2004

Monoamine neurotransmitters, serotonin, noradrenaline and dopamine modulate many important cognitive processes such as attention, learning and memory. While the selective effects of serotonin and catecholamine depletion on such processes have been investigated, the effects of simultaneous depletion of these monoamines on cognition remain unclear. This is of particular interest given that multiple neurotransmitter abnormalities have been implicated in many psychiatric disorders. The aim of the current study was to examine the effects of lowered brain monoamine function on cognitive performance, using the technique of amino acid precursor depletion. The study was a double-blind, placebo-controlled design in which 20 healthy female subjects were tested under a combined monoamine depletion condition (CMD) and a balanced control condition (B). Cognitive testing was conducted at baseline and 5 h post-depletion. The CMD condition relative to the B condition resulted in deficits in digit vigilance (accuracy and reaction time), a measure of sustained attention. There were no effects on measures of learning and memory or psychomotor function. These findings suggest that simultaneously depleting the availability of brain serotonin and catecholamines in healthy female subjects selectively impairs sustained attention, without affecting other cognitive domains.
Repeated administration with δ9- tetrahydrocannabinol regulates µ-opioid receptor density in the rat brain
Authors: Corchero Javier , Oliva José M. , García-Lecumberri Carmen , Martin Sonsoles , Ambrosio Emilio , Manzanares Jorge
Published: April 2004

Several studies have demonstrated reciprocal, as well as synergistic interactions between cannabinoid and opioid systems. The aim of this study was to explore the time-related effects of repeated administration of δ9-tetrahydrocannabinol on µ-opioid receptor autoradiography in various brain regions of the rat. To this aim, the effects of δ9-tetrahydrocannabinol (δ9-THC, 5 mg/kg/day; i.p.) were examined after 1, 3, 7 and 14 days of repeated administration on regions containing µ-opioid receptors: (i) forebrain [caudate-putamen, nucleus accumbens (core and shell) and piriform cortex]; (ii) amygdala (medial pars and cortical posteromedial pars), hypothalamus (ventromedial and dorsomedial nuclei, zona incerta), hippocampal regions (CA1, CA2, CA3, dentate girus), hindbrain (substantia nigra and ventral tegmental area); and (iii) thalamus, including 12 thalamic nuclei. In most of these regions, repeated cannabinoid administration increases µ-opioid receptor density; however, the onset, degree of magnitude reached and time-related effects produced by administration with δ9-tetrahydrocannabinol are dependent upon the brain region examined. It appears that the major increase in µ-opioid receptor density occurs 1 and 3 days after δ9-THC administration. In some regions, this increase is maintained and, for most of the brain areas examined, this effect is no longer significant by 14 days of administration, suggesting tolerance to cannabinoid treatment. Taken together, the results of this study suggest that cannabinoids produce a time-related differential responsiveness in µ-opioid receptor density in several brain areas that may be relevant to an understanding of the alterations associated with cannabinoid exposure.
Influence of Nicotine Gum on Acute Cravings for Cigarettes
Authors: Davies G. M. , Willner P. , James D. L. , Morgan M. J.
Published: April 2004

Reviews of nicotine gum trials generally confirm the efficacy of this substitute in smoking cessation. However, little research has considered the efficacy of nicotine gum as a method for alleviating acute cravings in situations where smokers are not permitted to smoke. The aim of the present study was to evaluate the efficacy of nicotine gum in alleviating acute cravings for cigarettes using the subjective multi-dimensional Questionnaire of Smoking Urges (QSU) and the objective progressive ratio (PR) measures of craving. Forty-five regular smokers participated in a double-blind placebo-controlled trial. All participants were required to abstain from cigarettes for a period of 4 h. Fifteen of the participants were required to chew nicotine gum, 15 were required to chew placebo gum and 15 received no intervention during this abstinence period. All participants then completed the QSU, PR and mood and anxiety questionnaires. The results revealed that participants who had been in either of the gum conditions reported significantly lower QSU factor 1 and factor 2 craving scores after 4 h abstinence than those who had received no intervention. Although a significant partial correlation between QSU factor 1 and 2 scores and the number of reinforcers earned under the PR procedure was observed, the results revealed no significant difference between groups on measures of PR performance or mood and anxiety. Both nicotine and placebo gum are equally effective at reducing acute cravings for cigarettes.
Mirtazapine Improves Alcohol Detoxification
Authors: Liappas J. , Paparrigopoulos T. , Malitas P. , Tzavellas E. , Christodoulou G.
Published: April 2004

The objective of the present study was to determine whether a combined psychotherapeutic–psychopharmacological (with mirtazapine) treatment of collateral anxiety and depressive symptomatology during the post-withdrawal phase of alcoholism facilitates the process of alcohol detoxification, which is a decisive stage in the treatment of alcohol-dependent individuals. For that purpose, the rate of remission of anxiety and depressive symptoms over a 4-week detoxification period was evaluated between two groups: the first group followed a standard detoxification protocol ( n = 33) and the second group was assigned to mirtazapine in addition to standard treatment ( n= 35). A marked reduction of anxiety and depressive symptoms was demonstrated in both groups. However, patients on mirtazapine improved more and at a faster rate compared to controls. Thus, mirtazapine, used adjunctively to short-term psychotherapy, may help the detoxification process by minimizing physical and subjective discomfort. Consequently, it may improve patient compliance in alcohol detoxification programs and facilitate the initial phase treatment of alcohol abuse dependence.
Incidences of New Prescribing by British Child and Adolescent Psychiatrists: a Prospective Study Over 12 Months
Authors: Clark Andrew F.
Published: April 2004

Little is known about the epidemiology of pharmacotherapy in the treatment of child psychiatric disorder. This study reports on the systematic prospective collection of instances of new prescribing by child and adolescent mental health services serving a population of approximately four million people in North West England. Diagnostic and demographic information regarding new prescribing by child and adolescent mental health services within Greater Manchester and Lancashire was systematically collected prospectively over two 6-month periods between 2000 and 2002. Within the 12 months studied, there were 845 instances of a drug being newly prescribed to a child or adolescent in the treatment of a psychiatric disorder. In total, 48 different drugs were prescribed for 25 different diagnoses. The eight most commonly prescribed drugs were methylphenidate, methylphenidate/placebo trial, paroxetine, fluoxetine, risperidone, imipramine, dexamphetamine and melatonin, accounting for 73% of all prescribing. There was marked variation between services in the amount of prescribing with significant correlation between prescription of stimulants and prescription of selective serotonin reuptake inhibitor antidepressants. Prescription of medications in the treatment of child psychiatric disorder has become a significant part of child and adolescent mental health practice. However, the evidence base underpinning this usage remains limited, and further high quality therapeutic clinical trials are urgently needed.
Atypical antipsychotic drugs and tardive dyskinesia: relevance of D2 receptor affinity
Authors: Bressan Rodrigo A. , Jones Hugh M. , Pilowsky Lyn S.
Published: April 2004

Evidence suggests atypical antipsychotic treatment is associated with a lower incidence of tardive dyskinesia (TD) than typical antipsychotic drugs, and is a potential antidyskinetic treatment. We present the case of a middle-aged woman never previously exposed to antipsychotic treatment who developed TD after 6 months of olanzapine monotherapy. Substitution of quetiapine for olanzapine alleviated her TD symptoms. The case demonstrates that atypical antipsychotic drugs have different effects in relation to TD. Potential psychopharmacological mechanisms explaining these differences are discussed, highlighting the importance of D2 receptor occupancy by atypical antipsychotic drugs for TD.
Measurement of Health Preferences among Patients with Tuberculous Infection and Disease
Authors: Dion Marie-Josée , Tousignant Pierre , Bourbeau Jean , Menzies Dick , Schwartzman Kevin
Published: April 2004

Health preferences have not previously been investigated among patients with tuberculous infection or disease. The authors assessed the reliability of visual analogue scale (VAS) and standard gamble (SG) measurements in this patient population. Participants were interviewed 3 times in English or French, at weekly intervals. They evaluated their own health status, as well as 3 marker health states, derived by consensus among tuberculosis (TB) practitioners. For the VAS, health states were assigned a duration of 6 months, whereas for the SG, the duration was 10 years. One hundred eighty-six potentially eligible individuals were identified from the TB clinic database of the Montreal Chest Institute. One hundred twelve (60%) were successfully located; of these, 106 were confirmed eligible. Sixty-seven (63%) agreed to participate, and 50 completed all study measurements (25 treated for latent TB, 17 treated for active TB, and 8 with previous active TB); 38 out of 50 were foreign-born. Intraclass correlation coefficients for the marker states were 0.57 to 0.81 for the VAS, and 0.75 to 0.87 for the SG. For respondents’ own health, the coefficients were 0.60 and 0.87, respectively. Median VAS scores for respondents’ own health were 85.0 to 88.0 for the 3 interviews, whereas the median utility score was 97.5 for all 3. Administration of the visual analogue scale and standard gamble instruments appeared reliable in a selected group of tuberculosis patients. Major barriers to recruitment were language and mobility in this largely foreign-born population.
Variation in Average Costs among Federally Sponsored State-Organized Cancer Detection Programs: Economies of Scale?
Authors: Mansley Edward C. , Duñet Diane O. , May Daniel S. , Chattopadhyay Sajal K. , Mckenna Matthew T.
Published: April 2004

Background

Societal cost-effectiveness analysis and its variants help decision makers achieve an efficient allocation of resources across the set of all possible health interventions. Sometimes, however, decision makers are focused instead on the efficient allocation of resources within a particular intervention program that has already been implemented. This is especially true when the intervention is being delivered at several different sites. An analysis of average cost across program sites may help program officials to maximize the health benefits that can be achieved with limited resources. In this article, the authors present such an analysis, with special attention paid to the possible existence and implications of economies of scale.

Methods

Focusing on federally sponsored, state-organized cancer detection programs, the authors modeled 19 state programs as productive processes and examined their average costs over a 2- to 5-year period of operation. They considered 3 alternative definitions of output: women served, screens performed, and conditions detected. Average federal costs and average total costs were estimated for each grant period. Multivariate regression analysis was used to help explain the variation in average costs.

Results

The average cost estimates were distributed in a skewed pattern with the majority of observations falling close to the median and substantially below the mean. For all measures considered, average cost decreased as output expanded. This inverse relationship between average cost and output level persisted even after controlling for the effects of other predictors, suggesting the possible existence of economies of scale.

Discussion

The potential existence of economies of scale calls into question the assumption of a constant average cost frequently made in economic analyses of proposed public health programs. It also implies that a) differences in output level should be taken into account when comparing operating efficiency across program sites; b) conclusions from societal cost-effectiveness analyses may depend on the level of output at which the programs are evaluated; c) cost projections could be inaccurate if they do not take into account the decrease in average cost that occurs as output expands; and d) gains might be possible if similar programs with limited output potential are integrated, perhaps through cost sharing.
Modeling the Public Health Response to Bioterrorism: Using Discrete Event Simulation to Design Antibiotic Distribution Centers
Authors: Hupert Nathaniel , Mushlin Alvin I. , Callahan Mark A.
Published: April 2004

Background

Post-exposure prophylaxis is a critical component of the public health response to bioterrorism. Computer simulation modeling may assist in designing antibiotic distribution centers for this task.

Methods

The authors used discrete event simulation modeling to determine staffing levels for entry screening, triage, medical evaluation, and drug dispensing stations in a hypothetical antibiotic distribution center operating in low, medium, and high disease prevalence bioterrorism response scenarios. Patient arrival rates and processing times were based on prior mass prophylaxis campaigns. Multiple sensitivity analyses examined the relationship between average staff utilization rate (UR) (i.e., percentage of time occupied in patient contact) and capacity of the model to handle surge arrivals.

Results

Distribution center operation required from 93 staff for the low-prevalence scenario to 111 staff for the high-prevalence scenario to process approximately 1000 people per hour within the baseline model assumptions. Excess capacity to process surge arrivals approximated (1-UR) for triage staffing.

Conclusions

Discrete event simulation modeling is a useful tool in developing the public health infrastructure for bioterrorism response. Live exercises to validate the assumptions and outcomes presented here may improve preparedness to respond to bioterrorism.
Variations in Risk Attitude across Race, Gender, and Education
Authors: Rosen Allison B. , Tsai Jerry S. , Downs Stephen M.
Published: April 2004

Background. Significant disparities in health care utilization exist across gender and race. Little is known about the patient-specific factors that may contribute to this variation. This study examined variations in risk attitude across major sociodemographic groups.Methods. A survey elicited utility measures for health states under risk-insensitive and risksensitive conditions (time tradeoff and standard gamble methods, respectively). Risk attitude was modeled assuming constant proportional risk posture, thus the utility function used was a power function. A multivariable linear regression model was used to examine the relationship between risk attitude and sociodemographic factors.Results.Of the 62 study subjects, the mean age was 47.6 years, 47% were female, and 33% were African American. Overall, 37% of respondents-were decidedly risk averse, 37% moderately risk averse, 15% moderately risk seeking, and 11% decidedly risk seeking. Significant predictors of increasing risk aversion in multivariate modeling were white race (P < 0.01) and lower education (P < 0.05). Women also tended to be more risk averse (P = 0.07).Conclusions.This study found significant differences in risk attitude across race and educational status, with a smaller difference across gender. Further research is needed to validate these findings and clarify their contribution to racial and gender variations in health care utilization and their future role in decision and cost-effectiveness analyses.
A Comparison of the Health Utilities Indices Mark 2 and Mark 3 in Type 2 Diabetes
Authors: Maddigan Sheri L. , Feeny David H. , Johnson Jeffrey A.
Published: April 2004

Purpose. Past research into health-related quality of life (HRQL) in diabetes using preference-based measures, such as the Health Utilities Index Mark 2 (HUI2) or the Health Utilities Index Mark 3 (HUI3), is sparse. Important differences between the HUI2 and HUI3 could lead to differences in their abilities to capture HRQL deficits in type 2 diabetes. This analysis compared the extent to which the HUI2 and HUI3 detect differences associated with varying levels of disease severity or advancement in type 2 diabetes. Methods. This analysis was conducted as part of using baseline, crosssectional data from a larger, prospective, controlled study of an intervention to improve care for individualswith type 2 diabetes in ruralcommunities in Alberta, Canada. The HUI2 and HUI3were self-administered to 372 community-dwelling individuals with type 2 diabetes. Results. Relative to HUI2 scores, larger differences in overall HUI3 scores were seen forcomparisons for individuals presumed to have more advanced disease. The pain attribute of the HUI3 categorized a larger proportion of individuals as moderately to severely impaired (41.5% v. 24.2%,P < 0.001), as did the emotion attribute (20.5% v. 7.7%,P < 0.001). For individuals with negative overall HUI3 scores, differences between overall HUI2 and HUI3 scores persisted after rescaling (mean difference = 0.33,P = 0.009). Conclusions. The greater range of possibl e scores on the HUI3, its relative ability to assess the utility of states worse than dead, and its relative superiority in discriminating moderate to severe impairment from mild or no impairment might favor its use over the HUI2 in type 2 diabetes.
When Is It Worth Introducing a Quality Improvement Program? A Mathematical Model
Authors: Gandjour Afschin , Lauterbach Karl Wilhelm
Published: April 2004

Quality improvement programs must compete with other health care interventions for limited health care resources. The goal of the research presented here was to develop a model that portrays the mathematical relationship between the size of a quality deficit caused by the noncompliance of health professionals and the cost-effectiveness of a quality improvement program. The model allows the determination of the minimum size of a quality deficit for which it is worth introducinga quality improvement program. If a quality improvement program has already been implemented, the model can be used to define the quality threshold beyond which a reduction in quality becomes economically unattractive. An example consideringthe reduction of underuse in depression treatment demonstrates that an intervention with a favorable cost-effectiveness ratio may become economically unattractive once the costs for the implementation effort are considered.
The Use of Fixed-and Random-Effects Models for Classifying Hospitals as Mortality Outliers: A Monte Carlo Assessment
Authors: Austin Peter C. , Alter David A. , Tu Jack V.
Published: April 2004

Background. There is an increasing movement towards the release of hospital “report-cards.” However, there is a paucity of research into the abilities of the different methods to correctly classify hospitals as performance outliers.Objective.To examine the ability of risk-adjusted mortality rates computed using conventional logistic regression and random-effects logistic regression models to correctly identify hospitals that have higher than acceptable mortality.Research Design.Monte Carlo simulations.Measures.Sensitivity, specificity, and positive predictive value of a classification as a high-outlier for identifying hospitals with higher than acceptable mortality rates.Results.When the distribution of hospital-specific log-odds of death was normal, random-effects models had greater specificity and positive predictive value than fixed-effects models. However, fixed-effects models had greater sensitivity than random-effects models.Conclusions.Researchers and policy makers need to carefully consider the balance between false positives and false negatives when choosing statistical models for determining which hospitals have higher than acceptablemortality in performance profiling.
What Is the Least Costly Strategy to Evaluate Cervical Abnormalities in Rural Women? Comparing Telemedicine, Local Practitioners, and Expert Physicians
Authors: Bishai David M. , Ferris Daron G. , Litaker Mark S.
Published: April 2004

Objective. This study establishes the least costly strategy for evaluation of rural women in need of colposcopy among 3 alternatives: telemedicine, local practitioners, and referral experts. Methods. Women in rural Georgia who needed colposcopy were examined by an expert colposcopist on site, by a local practitioner, and by a distant expert colposcopist linked by telemedicine. Independent determinations of biopsy intent were used to model the differing biopsy costs of the 3 methods. Record reviewdetermined the average total cost of telemedicine. Reports of average cost in year 2000 dollars from societal perspective include medical costs and pain and suffering due to additional biopsies and curettage, telemedicine costs, and costs of potential diagnostic delay for a 1-year time horizon. Results: From the societal perspective in the baseline case, the average cost per patient evaluated was $270 for patients seen by referral experts. The cost was $38 less (e.g., $232) for patients seen by local practitioners, and $35 more (e.g., $305) for patients seen by telemedicine. From the societal perspective, local practitioners were less costly than referral experts because of lower travel costs for patients, but from the medical perspective, their average cost was $32 higher than referral experts because they performed more biopsies and curettage procedures than experts. Telemedicine assistance would have lowered the number of biopsies performed by local practitioners, but as of year 2000 the costs of this technology could not be justified by the savings. Conclusion. From the societal perspective, local practitioners performing colposcopy are the least costly way to evaluate cervical abnormalities in rural patients with substantial time and travel costs.
A Comparison of Narrative and Table Formats for Presenting Hypothetical Health States to Patients with Gastrointestinal or Pulmonary Disease
Authors: Schünemann Holger J. , Ståhl Elisabeth , Austin Peggy , Akl Elie , Armstrong David , Guyatt Gordon H.
Published: April 2004

Traditionally, quality-of-life researchers describe states of health for patients to rate either in narrative form or in table form, but evidence about which format patients prefer is limited. The authors performed 2 randomized studies to test whether patients prefer the table or narrative format and whether the format of presentation influences how patients rate health states. Approximately three-fourths of patients with gastrointestinal disease or chronic airflow limitation preferred the table format. There were no differences in patients’ ratings of 3 described health states or of their own health. Investigators should consider using the table presentation for describing health states to subjects who are not familiar with these states of health.
Influence of Clinical and Economical Factors on the Expert Rating of Appropriateness of Preoperative Use of Recombinant Erythropoietin in Elective Orthopedic Surgery Patients
Authors: Taffé Patrick , Burnand Bernard , Wietlisbach Vincent , Vader John-Paul
Published: April 2004

To evaluate the relative impact of clinical factors and health care environment resources on the expert ratings of appropriateness of preoperative erythropoietin in elective orthopedic surgery, the authors analyzed 6905 individual votes on 496 clinical scenarios from 14 experts, applying a multivariate logistic model. Sixty-six percent of the indications were appropriate when resource constraints (RC) were not considered and 53% when they were, resulting in a drop in the median vote of 2 points on a 9-point scale (P < 0.05). Initial hemoglobin level, expected perioperative blood loss, and RC were by far the most significant contributors to the model (P < 0.01), but other factors (i.e., clinical specialty of the expert, prior history of transfusion reactions, patient age, cardiovascular disease, anemia of chronic disease) also contributed significantly (P< 0.01). For assessing appropriateness of care, this study confirms the need for detailed clinical scenarios and a multidisciplinary panel carefully selected to reflect those involved in the interventions under consideration.
“Is 28% Good or Bad?” Evaluability and Preference Reversals in Health Care Decisions
Authors: Zikmund-Fisher Brian J. , Fagerlin Angela , Ubel Peter A.
Published: April 2004

Choices of health care providers can become inconsistent when people lack sufficient context to assess the value of available information. In a series of surveys, general population samples were randomized to read descriptions of either 2 possible health care providers or a single provider. Some information about providers was easy to consider (e.g., travel time), but some was difficult to interpret without additional context (e.g., success rates). Ratings of the described health care providers varied significantly by whether options were evaluated independently or concurrently. For example, one fertility clinic (33% success rate, 15 min away) was rated higher than a 2nd (40% success rate, 45 min away) when each clinic was considered separately (7.1 v. 6.2, P = 0.046), but preferences reversed in joint evaluation (5.9 v. 6.7, P = 0.051). The results suggest that clinicians and developers of patient information materials alike should consider information evaluability when deciding how to present health care options to patients.
The Consumer Price Index and Consumer Well-Being: Developing a Fair Measure
Authors: Samli A. Coskun
Published: April 2004

This article explores the far-reaching implications of the Consumer Price Index (CPI) on the consumer well-being. There has been much debate recently regarding the CPI. It has been claimed that it exaggerates the realities of the economic conditions in favor of the poor. However, the author, by construct ing two CPIs, one for the rich and one for the poor, maintains that, on the contrary, the current CPI does not fairly reflectthe economic conditions that the poor are facing. If anything, it understates the cost of living for the poor. Thus, having only one representative national CPI is not quite fair. The article proposes at least one price index for the rich and one for the poor.
From Schizophrenia to Pseudostupidity
Authors: Harris Max , Levan Donald , Lane Robert C.
Published: April 2004

This paper seeks to showthe impact of reconceptualization of a clinical case and the consequent change in therapeutic practice. It explores the shift in conceptualization from “schizophrenia” to “pseudostupidity” using Freud’s idea of the “wish not to know.” The wish not to know is a hysterical reaction to primal scene and other early traumas (usually sexual) in which the child is so traumatized by the exposure and abuse that she develops a style of cognition of “not knowing” not only in relation to the traumas but to life in general. Her communication tended to be characterized by her previous therapists as “thought disordered” and was seen as indicative of schizophrenia. After reconceptualization the latest therapist began to attend to the issues of psuedostupidity with the result of a major lessening of her “thought disorder.”