How expectations affect reference point formation: an experimental investigation

This paper addresses two major topics concerning the role of expectations in the formation of reference points. First, we show that when expectations are present, they have a significant impact on reference point formation. Second, we find that decision-makers employ expected values when forming reference points (integrated mechanism) as opposed to single possible outcomes (segregated mechanism). Despite the importance of reference points in prospect theory, to date, there is no standard method of examining these. We develop a new experimental design that employs an indirect approach and extends an existing direct approach. Our findings are consistent across the two approaches.

Fostering sustainable urban development in Nakuru, Kenya Rift Valley

The town of Nakuru—Kenya's fourth largest town—lies in a unique setting in the Great Rift Valley. Recent developments on the Menengai Crater, the Mau Escarpment, and the Bahati Highlands exemplify the impacts of poorly planned urban growth on mountain ecosystems. The Nakuru Local Urban Observatory (LUO) project was initiated by the Municipal Council of Nakuru in January 2003, in collaboration with the Centre for Development and Environment (CDE) of the University of Berne and the Intermediate Technology Development Group (ITDG), and with funding from the Swiss Agency for Development and Cooperation (SDC). The project aims to provide a framework for sustainable urban development practices by building technical skills and improving participation by local stakeholders in decision-making processes. The potentials of information technology (IT) are being tapped to provide up-to-date information to decision-makers and democratize access to information, in order to improve public participation. The overall objective is to find ways of achieving better urban management in order to mitigate non-sustainable development trends in the town and its surroundings.

Do clinicians understand the size of treatment effects? A randomized survey across 8 countries.

BACKGROUND Meta-analyses of continuous outcomes typically provide enough information for decision-makers to evaluate the extent to which chance can explain apparent differences between interventions. The interpretation of the magnitude of these differences - from trivial to large - can, however, be challenging. We investigated clinicians' understanding and perceptions of usefulness of 6 statistical formats for presenting continuous outcomes from meta-analyses (standardized mean difference, minimal important difference units, mean difference in natural units, ratio of means, relative risk and risk difference). METHODS We invited 610 staff and trainees in internal medicine and family medicine programs in 8 countries to participate. Paper-based, self-administered questionnaires presented summary estimates of hypothetical interventions versus placebo for chronic pain. The estimates showed either a small or a large effect for each of the 6 statistical formats for presenting continuous outcomes. Questions addressed participants' understanding of the magnitude of treatment effects and their perception of the usefulness of the presentation format. We randomly assigned participants 1 of 4 versions of the questionnaire, each with a different effect size (large or small) and presentation order for the 6 formats (1 to 6, or 6 to 1). RESULTS Overall, 531 (87.0%) of the clinicians responded. Respondents best understood risk difference, followed by relative risk and ratio of means. Similarly, they perceived the dichotomous presentation of continuous outcomes (relative risk and risk difference) to be most useful. Presenting results as a standardized mean difference, the longest standing and most widely used approach, was poorly understood and perceived as least useful. INTERPRETATION None of the presentation formats were well understood or perceived as extremely useful. Clinicians best understood the dichotomous presentations of continuous outcomes and perceived them to be the most useful. Further initiatives to help clinicians better grasp the magnitude of the treatment effect are needed.

Ethical considerations for a global concept of sustainable land use

The paper gives an overview of current land husbandry problems in different agro-ecological zones of the world. It then lists four ethical principles, conceived at the global level, needed to achieve sustainable land use (SLU). Finally, it develops guidelines which can be used to facilitate a more effective implementation and realization of SLU. In the year of the UN Conference on Environment and Development (UNCED), such recommendations are important for improving the competence of political and economic decision-makers in taking action at national and international levels.

Dynamics of a Tularemia Outbreak in a Closely Monitored Free-Roaming Population of Wild House Mice.

Infectious disease outbreaks can be devastating because of their sudden occurrence, as well as the complexity of monitoring and controlling them. Outbreaks in wildlife are even more challenging to observe and describe, especially when small animals or secretive species are involved. Modeling such infectious disease events is relevant to investigating their dynamics and is critical for decision makers to accomplish outbreak management. Tularemia, caused by the bacterium Francisella tularensis, is a potentially lethal zoonosis. Of the few animal outbreaks that have been reported in the literature, only those affecting zoo animals have been closely monitored. Here, we report the first estimation of the basic reproduction number R0 of an outbreak in wildlife caused by F. tularensis using quantitative modeling based on a susceptible-infected-recovered framework. We applied that model to data collected during an extensive investigation of an outbreak of tularemia caused by F. tularensis subsp. holarctica (also designated as type B) in a closely monitored, free-roaming house mouse (Mus musculus domesticus) population in Switzerland. Based on our model and assumptions, the best estimated basic reproduction number R0 of the current outbreak is 1.33. Our results suggest that tularemia can cause severe outbreaks in small rodents. We also concluded that the outbreak self-exhausted in approximately three months without administrating antibiotics.

Evidence for Emergency Vaccination Having Played a Crucial Role to Control the 1965/66 Foot-and-Mouth Disease Outbreak in Switzerland.

Foot-and-mouth disease (FMD) is a highly contagious disease that caused several large outbreaks in Europe in the last century. The last important outbreak in Switzerland took place in 1965/66 and affected more than 900 premises and more than 50,000 animals were slaughtered. Large-scale emergency vaccination of the cattle and pig population has been applied to control the epidemic. In recent years, many studies have used infectious disease models to assess the impact of different disease control measures, including models developed for diseases exotic for the specific region of interest. Often, the absence of real outbreak data makes a validation of such models impossible. This study aimed to evaluate whether a spatial, stochastic simulation model (the Davis Animal Disease Simulation model) can predict the course of a Swiss FMD epidemic based on the available historic input data on population structure, contact rates, epidemiology of the virus, and quality of the vaccine. In addition, the potential outcome of the 1965/66 FMD epidemic without application of vaccination was investigated. Comparing the model outcomes to reality, only the largest 10% of the simulated outbreaks approximated the number of animals being culled. However, the simulation model highly overestimated the number of culled premises. While the outbreak duration could not be well reproduced by the model compared to the 1965/66 epidemic, it was able to accurately estimate the size of the area infected. Without application of vaccination, the model predicted a much higher mean number of culled animals than with vaccination, demonstrating that vaccination was likely crucial in disease control for the Swiss FMD outbreak in 1965/66. The study demonstrated the feasibility to analyze historical outbreak data with modern analytical tools. However, it also confirmed that predicted epidemics from a most carefully parameterized model cannot integrate all eventualities of a real epidemic. Therefore, decision makers need to be aware that infectious disease models are useful tools to support the decision-making process but their results are not equal valuable as real observations and should always be interpreted with caution.

Timely Reporting and Interactive Visualization of Animal Health and Slaughterhouse Surveillance Data in Switzerland

The reporting of outputs from health surveillance systems should be done in a near real-time and interactive manner in order to provide decision makers with powerful means to identify, assess, and manage health hazards as early and efficiently as possible. While this is currently rarely the case in veterinary public health surveillance, reporting tools do exist for the visual exploration and interactive interrogation of health data. In this work, we used tools freely available from the Google Maps and Charts library to develop a web application reporting health-related data derived from slaughterhouse surveillance and from a newly established web-based equine surveillance system in Switzerland. Both sets of tools allowed entry-level usage without or with minimal programing skills while being flexible enough to cater for more complex scenarios for users with greater programing skills. In particular, interfaces linking statistical softwares and Google tools provide additional analytical functionality (such as algorithms for the detection of unusually high case occurrences) for inclusion in the reporting process. We show that such powerful approaches could improve timely dissemination and communication of technical information to decision makers and other stakeholders and could foster the early-warning capacity of animal health surveillance systems.

From Theory to Practice: Improving the Impact of Health Services Research.

BACKGROUND: While significant strides have been made in health research, the incorporation of research evidence into healthcare decision-making has been marginal. The purpose of this paper is to provide an overview of how the utility of health services research can be improved through the use of theory. Integrating theory into health services research can improve research methodology and encourage stronger collaboration with decision-makers. DISCUSSION: Recognizing the importance of theory calls for new expectations in the practice of health services research. These include: the formation of interdisciplinary research teams; broadening the training for those who will practice health services research; and supportive organizational conditions that promote collaboration between researchers and decision makers. Further, funding bodies can provide a significant role in guiding and supporting the use of theory in the practice of health services research. SUMMARY: Institutions and researchers should incorporate the use of theory if health services research is to fulfill its potential for improving the delivery of health care.

How health care delay and avoidance decisions are affected by finances and health insurance

Objective. To identify how an individual's finances and health insurance coverage affects their decision whether to avoid or delay medical care. Methods. Secondary data analysis of The Effects of Financial and Insurance Considerations on Health Care Utilization 2007 telephone survey data. Study inclusion criteria. 18 years old, Harris County resident, and had a need for medical care within the past year. Post weighing was done to correct for non-response bias. Results. Survey decision makers were predominately minorities (60%), Female (70%), and insured (71%). Ninety-two percent of participants sought care when needed, however, of this population 39% delayed medical care. Fifty-six percent of participants who delayed medical care sought care in the Doctor's office. For those who replied "Yes" to considering health insurance and finances in deciding to avoid medical care, 61% stated that they were confused about their insurance coverage as the explanation why. Fifty-five percent of Respondents indicated that delaying medical care was due to not knowing whether medical care was necessary. Conclusion. Additional research needs to be conducted to examine the relationship between onset of medical symptoms and final medical diagnosis to identify whether survey participants who delayed or avoided medical care actions were appropriate responses to their initial medical symptoms and final diagnosis. ^

The feasibility of self-report advance directives among elderly patients with cognitive impairment

The central objective of this dissertation was to determine the feasibility of self-completed advance directives (AD) in older persons suffering from mild and moderate stages of dementia. This was accomplished by identifying differences in ability to complete AD among elderly subjects with increasing degrees of dementia and cognitive incompetence. Secondary objectives were to describe and compare advance directives completed by elders and identified proxy decision makers. Secondary objectives were accomplished by measuring the agreement between advance directives completed by proxy and elder, and comparing that agreement across groups defined by the elder's cognitive status. This cross-sectional study employed a structured interview to elicit AD, followed by a similar interview with a proxy decision maker identified by the elder. A stratified sampling scheme recruited elders with normal cognition, mild, and moderate forms of dementia using the Mini Mental-State Exam (MMSE). The Hopkins Competency Assessment Test (HCAT) was used for evaluation of competency to make medical decisions. Analysis was conducted on "between group" (non-demented $\leftrightarrow$ mild dementia $\leftrightarrow$ moderate dementia, and competent $\leftrightarrow$ incompetent) and "within group" (elder $\leftrightarrow$ family member) variation.^ The 118 elderly subjects interviewed were generally male, Caucasian, and of low socioeconomic status. Mean age was 77. Overall, elders preferred a "trial of therapy" regarding AD rather than to "always receive the therapy". No intervention was refused outright more often than it was accepted. A test-retest of elders' AD revealed stable responses. Eleven logic checks measured appropriateness of AD responses independent of preference. No difference was found in logic error rates between elders grouped by MMSE or HCAT. Agreement between proxy and elder responses showed significant dissimilarity, indicating that proxies were not making the same medical decisions as the elders.^ Conclusions based on these data are: (1) Self reporting AD is feasible among elders showing signs of cognitive impairment and they should be given all opportunities to complete advance directives, (2) variation in preferences for advance directives in cognitively impaired elders should not be assumed to be the effects of their impairment alone, (3) proxies do not appear to forego life-prolonging interventions in the face of increasing impairment in their ward, however, their advance directives choices are frequently not those of the elder they represent. ^

HOUSE-TO-HOUSE SURVEY OF ACCESS TO AND USE OF PUBLIC HEALTH FACILITIES IN METROPOLITAN LAGOS, NIGERIA

One of the broad objectives of the Nigerian health service, vigorously being pursued at all levels of government, is to make comprehensive health care available and accessible to the population at the lowest possible cost, within available resources. Some state governments in the federation have already introduced free medical service as a practical way to remove financial barriers to access and in turn to encourage greater utilization of publicly funded care facilities.^ To aid health planners and decision makers in identifying a shorter corridor through which urban dwellers can gain access to comprehensive health care, a health interview survey of the metropolitan Lagos was undertaken. The primary purpose was to ascertain the magnitude of access problems which urban households face in seeking care from existing public facilities at the time of need. Six categories of illness chosen from the 1975 edition of the International Classification of Disease were used as indicators of health need.^ Choice of treatment facilities in response to illness episode was examined in relation to distance, travel time, time of use and transportation experiences. These were graphically described. The overall picture indicated that distance and travel time coexist with transportation problems in preventing a significant segment of those in need of health care from benefitting in the free medical service offered in public health facilities. Within this milieu, traditional medicine and its practitioners became the most preferred alternative. Recommendations were offered for action with regard to decentralization of general practitioner (GP) consultations in general hospitals and integration of traditional medicine and its practitioners into public health service. ^

The cost effective management of Central Line-Associated Bloodstream Infections (CLABSIs) comparing the central line bundle to antimicrobialcoated central venous catheters: A systematic review

Central Line-Associated Bloodstream Infections (CLABSIs) are one of the most costly and preventable cases of morbidity and mortality among intensive care units (ICUs) in health care today. In 2008, the Centers for Medicare and Medicaid Services Medicare Program, under the Deficit Reduction Act, announced it will no longer reimburse hospitals for such adverse events among those related to CLABSIs. This reveals the financial burden shift onto the hospital rather than the health care payer who can now withhold reimbursements. With this weighing more heavily on hospital management, decision makers will need to find a way to completely prevent cases of CLABSI or simply pay for the financial consequences. ^ To reduce the risk of CLABSIs, several clinical, preventive interventions have been studied and even instituted including the Central Line (CL) Bundle and Antimicrobial Coated Central Venous Catheters (AM-CVCs). I carried out a formal systematic review on the topic to compare the cost-effectiveness of the Central Line (CL) Bundle to the commercially available antimicrobial coated central venous catheters (AM-CVCs) in preventing CLABSIs among critically and chronically ill patients in the U.S. Evidence was assessed for inclusion against predefined criteria. I, myself, conducted the data extraction. Ten studies were included in the review. Efficacy in reducing the mean incidence rate of CLABSI by the CL Bundle and AM-CVC interventions were compared with one another including costs. ^ The AM-CVC impregnated with antibiotics, rifampin-minocycline (AI-RM) is more clinically effective than the CL Bundle in reducing the mean rate of CLABSI per 1,000 catheter days. The lowest mean incidence rate of CLABSI per 1,000 catheter days among the AM-CVC studies was as low as zero in favor of the AI-RM. Moreover, the review revealed that the AI-RM appears to be more cost-effective than the CL Bundle. Results showed the adjusted incremental cost of the CL Bundle per ICU patient requiring a CVC to be approximately $196 while the AI-RM at only an additional cost of $48 per ICU patient requiring a CVC. ^ Limited data regarding the cost of the CL Bundle made it difficult to make a true comparison to the direct cost of the AM-CVCs. However, using the result I did have from this review, I concluded that the AM-CVCs do appear to be more cost-effective in decreasing the mean rate of CLABSI while also minimizing incremental costs per CVC than the CL Bundle. This review calls for further research addressing the cost of the CL Bundle and compliance and more effective study designs such as randomized control trials comparing the efficacy and cost of the CL Bundle to the AM-CVCs. Barriers that may face health care managers when implementing the CL Bundle or AM-CVCs include additional costs associated with the intervention, educational training and ongoing reinforcement as well as creating a new culture of understanding.^

Cost-effectiveness of intensified interventions to control healthcare-associated MRSA infections -- A systematic literature review

Methicillin Resistant Staphylococcus aureus healthcare-associated infections (MRSA HAIs) are a major cause of morbidity in hospitalized patients. They pose great economic burden to hospitals caring for these patients. Intensified Interventions aim to control MRSA HAIs. Cost-effectiveness of Intensified Interventions is largely unclear. We performed a review of cost-effectiveness literature on Intensified Interventions , and provide a summary of study findings, the status of economic research in the area, and information that will help decision-makers at regional level and guide future research.^ We conducted literature search using electronic database PubMed, EBSCO, and The Cochrane Library. We limited our search to English articles published after 1999. We reviewed a total of 1,356 titles, and after applying our inclusion and exclusion criteria selected seven articles for our final review. We modified the Economic Evaluation Abstraction Form provided by CDC, and used this form to abstract data from studies.^ Of the seven selected articles two were cohort studies and the remaining five were modeling studies. They were done in various countries, in different study settings, and with different variations of the Intensified Intervention . Overall, six of the seven studies reported that Intensified Interventions were dominant or at least cost-effective in their study setting. This effect persisted on sensitivity testing.^ We identified many gaps in research in this field. The cost-effectiveness research in the field is mostly composed of modeling studies. The studies do not always clearly describe the intervention. The intervention and infection costs and the sources for these costs are not always explicit or are missing. In modeling studies, there is uncertainty associated with some key model inputs, but these inputs are not always identified. The models utilized in the modeling studies are not always tested for internal consistency or validity. Studies usually test the short term cost-effectiveness of Intensified Interventions but not the long results.^ Our study limitation was the inability to adjust for differences in study settings, intervention costs, disease costs, or effectiveness measures. Our study strength is the presentation of a focused literature review of Intensified Interventions in hospital settings. Through this study we provide information that will help decision makers at regional level, help guide future research, and might change clinical care and policies. ^

Territory and Infrastructure : Strategic Identification and Project Pondering

El Territorio hoy es visto como una totalidad organizada que no puede ser pensada separando cada uno de los elementos que la componen; cada uno de ellos es definido por su relación con los otros elementos. Así, un pensamiento que integra diferentes disciplinas y saberes comienza a manejar una realidad que lejos está de definir certezas inamovibles, y comienza a vislumbrar horizontes estratégicos. La adaptación a la no linealidad de las relaciones que se dan sobre el territorio, y la diferencia de velocidades en las que actúan los distintos actores, nos exige hacer de la flexibilidad una característica esencial de la metodología de planificación estratégica. La multi-causalidad de los fenómenos que estructuran el territorio nos obliga a construir criterios cualitativos, entendiendo que nos es imposible la medición de estas cadenas causales y su reconstrucción completa en el tiempo; sin dejar por ello de edificar un marco profundo de acción y transformación que responda a una realidad cierta y veraz. Los fenómenos producidos sobre el territorio nunca actúan de manera aislada, lo que implica una responsabilidad a la hora de comprender las sinergias y la restricción que afectan los resultados de los procesos desatados. La presente ponencia corresponde a la Segunda Fase del proceso de identificación estratégica de los proyectos Plan Estratégico Territorial (PET) que se inició en el año 2005; dicho Plan es llevada a cabo por la Subsecretaría de Planificación Territorial del Ministerio de Planificación Federal y fue abordado sobre la base de tres pretensiones: institucionalizar el ejercicio del pensamiento estratégico, fortalecer la metodología de trabajo transdisciplinaria y multisectorial, y diseñar un sistema de ponderación de proyectos estratégicos de infraestructura, tanto a nivel provincial como nacional, con una fuerte base cualitativa. Este proceso dio como resultado una cartera ponderada de proyectos de infraestructura conjuntamente con una metodología que permitió consolidar los equipos provinciales de planificación, tanto en su relación con los decisores políticos como con los actores de los múltiples sectores del gobierno, y en estos resultados consolidar y reforzar una cultura del pensamiento estratégico sobre el territorio

Tendinitis rotuliana y pliometría en juniors de alto rendimiento

Habitualmente los trabajos y estudios publicados sobre el entrenamiento de la potencia pliométrica de miembros inferiores orientados hacia el alto rendimiento deportivo en baloncesto, son realizados sobre atletas de elite, pero no así sobre jugadores que están en la etapa del traspaso de las categorías Junior a las Elites, pero que, en muchos casos, entrenan juntos, sin que se respete su individualidad biológica, llevando en muchos casos a lesiones tendinosas por un inadecuado trabajo metodológico en estas etapas (15 a 17 años). Por otra parte se ha buscado desarrollar una serie de indicaciones metodológicos para favorecer la prevención de lesiones osteo-articulares en esta etapa de camino hacia el Alto Rendimiento. La rodilla de saltador, también conocida como tendinitis rotuliana o tendinopatía rotuliana, es una inflamación o lesión del tendón rotuliano, un tejido similar a una cuerda que une la rótula a la tibia (hueso de la espinilla). La rodilla de saltador es una lesión por sobrecarga (movimientos repetidos que causan irritación o daño en los tejidos en determinada zona del cuerpo). Saltar, caer y cambiar de dirección de manera constante pueden provocar torceduras, desgarros y daño en el tendón rotuliano. Por lo tanto, los jóvenes que regularmente practican deportes que implican saltar mucho todo el tiempo, como el baloncesto, pueden ejercer mucha presión en las rodillas. La rodilla de saltador puede parecer una lesión menor que no es realmente grave. Por este motivo, muchos jugadores siguen entrenando y compitiendo, y suelen ignorar la lesión o intentan tratarla por su cuenta