Proficiency testing (external quality assessment) of drug detection in oral fluid

Eighteen external quality assessment (proficiency testing) samples were prepared from client specimens collected with the Intercept^® oral fluid collection device and by spiking drug-free oral fluid. Samples were circulated in pairs at quarterly intervals to 13 UK and USA based laboratories for analysis by a panel of OraSure micro-plate Intercept^® enzyme immunoassay kits and hyphenated mass spectrophotometric techniques. During the survey, there was a single case of non-specificity in a false report for methadone. The major errors were of lack of sensitivity relative to the concentration thresholds specified for the immunoassays. The sensitivity for overall ‘present’/‘not found’ reports calculated as true positives/(true positives + false negatives) were for the amfetamine specific assay 50%, methyl-amfetamines 93%, barbiturates 64%, cannabinoids 73%, cocaine and metabolites 100%, benzodiazepines 69%, methadone 95%, opiates 79% (opiates excluding oxycodone 93%), phencyclidine 93% and human gamma-globulin 97%. A small number of the sensitivity errors were attributable to errors in chromatographic confirmation techniques.     

Regime transformation from below: Decentralization,local governance,and democratic reform in Nigeria

How realistic are democratic-governance strategies that emphasize local governance as a key component? Using Nigeria’s experience in local government and primary health care in the 1980s and 1990s as a case example, the article finds there were substantial shortfalls in local participation and program performance. These were caused by problems in the local political environment and local institutional design, in the national policy environment (particularly in the funding system), and by the stresses of structural adjustment, resource shortfalls, the natural physical environment, and weak leadership. These combined to create poor and inappropriate reward structures and lack of accountability. However, even though the Nigerian case was not successful, most of the specific problems that hurt it are remediable through policy changes at the national level. Several of these were under consideration at the time of the coups of 1992 and 1993.     

Do Śrāvakas understand emptiness?

Conclusions The present study has attempted to artriculate a central issue of Mahäyäna soteriology through an examination of the writings of two Mädhyamika masters, Bhävaviveka and Candrakïrti. The purpose here has been to demonstrate a further criterion for the retrospective designation of their respective philosophies with the terms Svtantrika and Prasangika an exhaustive study of the nature of the Hinayäna wisdom according to the Mädhyamika school would entail an analysis of the writings of many other masters, especially those who produced what has been called the Yogäcära-Mädhyamika synthesis. To attempt to determine the position of Maitreyanätha, for example, on this issue would entail an analysis of the famous Five Treatises (the Dharmadharmatävibhaa, the Madhyäntavibhaga, the Mahayanasutrlamkara, the Uttratantra, and the Abhisamayälamkära) as well as the myriad commentaries on these works. It is possible to speculate briefly here on what the position of Nägärjuna may have been on this issue and then go on to discuss the implications and possible motivations of the views of Bhävaviveka and Candrakïrti.     

PPS waivers: implications for Medicare, Medicaid, and commercial insurers

This paper compares the Medicare prospective payment system (PPS) to four all-payer rate-setting systems that operated under HCFA waiver authority. The study examines the experience of Medicare, Medicaid, and commercial insurers under the two approaches. Data from several American Hospital Association surveys and from Medicaid 2082 report forms are analyzed. The paper concludes that the all-payer waiver programs have been as successful as PPS in controlling the rate of growth in Medicare costs. In addition, Medicaid programs are more successful in controlling their outlays in all-payer rate-setting environments than when they "go alone." Finally, there is no evidence to suggest that hospitals can increase charges in response to greater financial need under either PPS or the state waivers. Nevertheless, it appears that commercial insurers are better able to compete with Blue Cross plans in all-payer rate-setting states than elsewhere.     

Assessment of competency for execution? A guide for mental health professionals

Assessment of competency for execution presents two compelling ethical questions for mental health professionals: whether clinicians can ethically provide such assessment, and if so, how it should be done in order to maximize quality and minimize ethical conflict. In this article we address the issue of whether to participate and, if so, how. The question of whether to participate is discussed by summarizing the arguments for and against participation and offering guidelines for making a decision. The question of how to proceed is discussed in two contexts: preadjudication (before a formal decision about competency) and postadjudication (following a determination of "incompetent" and transfer of the offender to another facility for treatment and further assessment). Finally, recommendations are made regarding research that would improve the quality of execution competency assessments.     

Garcia and the Political Safeguards of Federalism: Is There a Better Solution to the Conundrum of the Tenth Amendment?

In Garcia v. San Antonio Metropolitan Transit Authority (1985),Justice Harry Blackmun held that the Tenth Amendment does notprevent the Congress from subjecting state and local governmentsto the provisions of the Fair Labor Standards Act, concludingthat the "political safeguards offederalism" are generally adequateto protect state interests on the national scene. This articleexamines the intellectual foundations of the "political safeguardsof federalism" and finds them inadequate. It then surveys thepost-Garcia scholarship to ascertain whether an alternativetheory of the Tenth Amendment has emerged. Concluding that ithas not, the author suggests the need for afresh approach inview of the hints contained in Justice Sandra Day O'Connor'sopinion in Gregory v. Ashcroft (1991) that five justices maybe ready to reexamine the central thesis of Garcia.     

Medicaid in the 1990s: Trends, Innovations, and the Future of the "PAC-Man" of State Budgets

Rapidly escalating health-care inflation and congressionallymandated expansions have led to large increases in spendingfor Medicaid, the federal-state program of health care for thepoor. These increases came at a time when state budgets werealready under recession-induced stresses. In addition, 1991brought new pressures for Medicaid spending from the courtsand closer federal scrutiny and control over revenues used forthe program's state "match." Yet the Medicaid picture is farfrom bleak. Diversity, innovation, and an emerging stale policyrole also characterize the program in ways that epitomize thestrengths and weaknesses of the American intergovernmental system.