Cost-Effectiveness of Serum Cryptococcal Antigen Screening to Prevent Deaths among HIV-Infected Persons with a CD4+ Cell Count ≤100 Cells/μL Who Start HIV Therapy in Resource-Limited Settings

Background. Cryptococcal meningitis (CM) remains a common AIDS-defining illness in Africa and Asia. Subclinical cryptococcal antigenemia is frequently unmasked with antiretroviral therapy (ART). We sought to define the cost-effectiveness of serum cryptococcal antigen (CRAG) screening to identify per...

Full description

Saved in:
Bibliographic Details
Published in:Clinical infectious diseases 2010-08, Vol.51 (4), p.448-455
Main Authors: Meya, David B., Manabe, Yukari C., Castelnuovo, Barbara, Cook, Bethany A., Elbireer, Ali M., Kambugu, Andrew, Kamya, Moses R., Bohjanen, Paul R., Boulware, David R.
Format: Article
Language:English
Subjects:
AIDS
Antigens
Antiretrovirals
Biological and medical sciences
Cost control
Cost estimates
Cryptococcal meningitis
Fixed costs
HIV
HIV/AIDS
Human mycoses
Human viral diseases
Immunodeficiencies
Immunodeficiencies. Immunoglobulinopathies
Immunopathology
Infectious diseases
Medical sciences
Miscellaneous mycoses
Mortality
Mycoses
Viral diseases
Viral diseases of the lymphoid tissue and the blood. Aids
Citations: Items that cite this one
Online Access:Get full text
Tags: Add Tag
No Tags, Be the first to tag this record!
cited_by cdi_FETCH-LOGICAL-c2863-bdc025f477826f1b2ccf2f0f6883e2f4692e1ed8f3de0e1416bcfdec393e64a83
cites
container_end_page 455
container_issue 4
container_start_page 448
container_title Clinical infectious diseases
container_volume 51
creator Meya, David B.
Manabe, Yukari C.
Castelnuovo, Barbara
Cook, Bethany A.
Elbireer, Ali M.
Kambugu, Andrew
Kamya, Moses R.
Bohjanen, Paul R.
Boulware, David R.
description Background. Cryptococcal meningitis (CM) remains a common AIDS-defining illness in Africa and Asia. Subclinical cryptococcal antigenemia is frequently unmasked with antiretroviral therapy (ART). We sought to define the cost-effectiveness of serum cryptococcal antigen (CRAG) screening to identify persons with subclinical cryptococcosis and the efficacy of preemptive fluconazole therapy. Methods. There were 609 ART-naive adults with AIDS who started ART in Kampala, Uganda, and who had a serum CRAG prospectively measured during 2004–2006. The number needed to test and treat with a positive CRAG was assessed for ≥30-month outcomes. Results. In the overall cohort, 50 persons (8.2%) were serum CRAG positive when starting ART. Of 295 people with a CD4+ cell count ≤100 cells/μL and without prior CM, 26 (8.8%; 95% confidence interval [CI], 5.8%–12.6%) were CRAG positive, of whom 21 were promptly treated with fluconazole (200–400 mg) for 2–4 weeks. Clinical CM developed in 3 fluconazole-treated persons, and 30-month survival was 71% (95% CI, 48%–89%). In the 5 CRAG-positive persons with a CD4+ cell count ≤100 cells/μL treated with ART but not fluconazole, all died within 2 months of ART initiation. The number needed to test and treat with CRAG screening and fluconazole to prevent 1 CM case is 11.3 (95% CI, 7.9–17.1) at costs of $190 (95% CI, $132–$287). The number needed to test and treat to save 1 life is 15.9 (95% CI, 11.1–24.0) at costs of $266 (95% CI, $185–$402). The cost per disability-adjusted life year saved is $21 (95% CI, $15–$32). Conclusions. Integrating CRAG screening into HIV care, specifically targeting people with severe immunosuppression (CD4+ cell count ≤100 cells/μL) should be implemented in treatment programs in resource-limited settings. ART alone is insufficient treatment for CRAG-positive persons.
doi_str_mv 10.1086/655143
format article
fullrecord <record><control><sourceid>jstor_cross</sourceid><recordid>TN_cdi_crossref_primary_10_1086_655143</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><jstor_id>20750788</jstor_id><oup_id>10.1086/655143</oup_id><sourcerecordid>20750788</sourcerecordid><originalsourceid>FETCH-LOGICAL-c2863-bdc025f477826f1b2ccf2f0f6883e2f4692e1ed8f3de0e1416bcfdec393e64a83</originalsourceid><addsrcrecordid>eNp1kMFu1DAQhiMEEqXAGyANB7igUDuOHedYpYVdKUBFCkW9RF5n3HXZjSPbC-wj8B48BicegIfgSUgIKidOM5r55tPoT5KHlDynRIojwTnN2a3kgHJWpIKX9PbYEy7TXDJ5N7kXwjUhlErCD5IflQsxPTUGdbSfsMcQwBlo0O-2UPn9EJ12WqsNHPfRXmEPjfaIve2vIDo48zgeRThBFdcB1NaN88XyfbrsJyN2cIY-uD7AZxvXoKA6yZ9BhZsNVG43Hv76-o0S8mcSjn5-r-Fi7aCJysdJA-dr9GrYg-3hLQa38xrT2m7tZG4wxvGNcD-5Y9Qm4IO_9TB59-L0vFqk9ZuXy-q4TnUmBUtXnSYZN3lRyEwYusq0NpkhRkjJMDO5KDOk2EnDOiRIcypW2nSoWclQ5Eqyw-Tp7NXeheDRtIO3W-X3LSXtlHw7Jz-CT2ZwUGFMznjVaxtu6IyRspS8GLnHM-d2w_9dj2bmOkTn_zlIwUkhp6fSeW9DxC83e-U_tqJgBW8XHy7by8XrUl68qtuG_QZqLqit</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype></control><display><type>article</type><title>Cost-Effectiveness of Serum Cryptococcal Antigen Screening to Prevent Deaths among HIV-Infected Persons with a CD4+ Cell Count ≤100 Cells/μL Who Start HIV Therapy in Resource-Limited Settings</title><source>JSTOR Archival Journals and Primary Sources Collection【Remote access available】</source><source>Oxford Journals Online</source><creator>Meya, David B. ; Manabe, Yukari C. ; Castelnuovo, Barbara ; Cook, Bethany A. ; Elbireer, Ali M. ; Kambugu, Andrew ; Kamya, Moses R. ; Bohjanen, Paul R. ; Boulware, David R.</creator><creatorcontrib>Meya, David B. ; Manabe, Yukari C. ; Castelnuovo, Barbara ; Cook, Bethany A. ; Elbireer, Ali M. ; Kambugu, Andrew ; Kamya, Moses R. ; Bohjanen, Paul R. ; Boulware, David R.</creatorcontrib><description>Background. Cryptococcal meningitis (CM) remains a common AIDS-defining illness in Africa and Asia. Subclinical cryptococcal antigenemia is frequently unmasked with antiretroviral therapy (ART). We sought to define the cost-effectiveness of serum cryptococcal antigen (CRAG) screening to identify persons with subclinical cryptococcosis and the efficacy of preemptive fluconazole therapy. Methods. There were 609 ART-naive adults with AIDS who started ART in Kampala, Uganda, and who had a serum CRAG prospectively measured during 2004–2006. The number needed to test and treat with a positive CRAG was assessed for ≥30-month outcomes. Results. In the overall cohort, 50 persons (8.2%) were serum CRAG positive when starting ART. Of 295 people with a CD4+ cell count ≤100 cells/μL and without prior CM, 26 (8.8%; 95% confidence interval [CI], 5.8%–12.6%) were CRAG positive, of whom 21 were promptly treated with fluconazole (200–400 mg) for 2–4 weeks. Clinical CM developed in 3 fluconazole-treated persons, and 30-month survival was 71% (95% CI, 48%–89%). In the 5 CRAG-positive persons with a CD4+ cell count ≤100 cells/μL treated with ART but not fluconazole, all died within 2 months of ART initiation. The number needed to test and treat with CRAG screening and fluconazole to prevent 1 CM case is 11.3 (95% CI, 7.9–17.1) at costs of $190 (95% CI, $132–$287). The number needed to test and treat to save 1 life is 15.9 (95% CI, 11.1–24.0) at costs of $266 (95% CI, $185–$402). The cost per disability-adjusted life year saved is $21 (95% CI, $15–$32). Conclusions. Integrating CRAG screening into HIV care, specifically targeting people with severe immunosuppression (CD4+ cell count ≤100 cells/μL) should be implemented in treatment programs in resource-limited settings. ART alone is insufficient treatment for CRAG-positive persons.</description><identifier>ISSN: 1058-4838</identifier><identifier>EISSN: 1537-6591</identifier><identifier>DOI: 10.1086/655143</identifier><identifier>CODEN: CIDIEL</identifier><language>eng</language><publisher>Oxford: The University of Chicago Press</publisher><subject>AIDS ; Antigens ; Antiretrovirals ; Biological and medical sciences ; Cost control ; Cost estimates ; Cryptococcal meningitis ; Fixed costs ; HIV ; HIV/AIDS ; Human mycoses ; Human viral diseases ; Immunodeficiencies ; Immunodeficiencies. Immunoglobulinopathies ; Immunopathology ; Infectious diseases ; Medical sciences ; Miscellaneous mycoses ; Mortality ; Mycoses ; Viral diseases ; Viral diseases of the lymphoid tissue and the blood. Aids</subject><ispartof>Clinical infectious diseases, 2010-08, Vol.51 (4), p.448-455</ispartof><rights>2010 Infectious Diseases Society of America</rights><rights>2010 by the Infectious Diseases Society of America 2010</rights><rights>2015 INIST-CNRS</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c2863-bdc025f477826f1b2ccf2f0f6883e2f4692e1ed8f3de0e1416bcfdec393e64a83</citedby></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.jstor.org/stable/pdf/20750788$$EPDF$$P50$$Gjstor$$H</linktopdf><linktohtml>$$Uhttps://www.jstor.org/stable/20750788$$EHTML$$P50$$Gjstor$$H</linktohtml><link.rule.ids>315,786,790,27957,27958,58593,58826</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&amp;idt=23099857$$DView record in Pascal Francis$$Hfree_for_read</backlink></links><search><creatorcontrib>Meya, David B.</creatorcontrib><creatorcontrib>Manabe, Yukari C.</creatorcontrib><creatorcontrib>Castelnuovo, Barbara</creatorcontrib><creatorcontrib>Cook, Bethany A.</creatorcontrib><creatorcontrib>Elbireer, Ali M.</creatorcontrib><creatorcontrib>Kambugu, Andrew</creatorcontrib><creatorcontrib>Kamya, Moses R.</creatorcontrib><creatorcontrib>Bohjanen, Paul R.</creatorcontrib><creatorcontrib>Boulware, David R.</creatorcontrib><title>Cost-Effectiveness of Serum Cryptococcal Antigen Screening to Prevent Deaths among HIV-Infected Persons with a CD4+ Cell Count ≤100 Cells/μL Who Start HIV Therapy in Resource-Limited Settings</title><title>Clinical infectious diseases</title><addtitle>Clinical Infectious Diseases</addtitle><addtitle>Clinical Infectious Diseases</addtitle><description>Background. Cryptococcal meningitis (CM) remains a common AIDS-defining illness in Africa and Asia. Subclinical cryptococcal antigenemia is frequently unmasked with antiretroviral therapy (ART). We sought to define the cost-effectiveness of serum cryptococcal antigen (CRAG) screening to identify persons with subclinical cryptococcosis and the efficacy of preemptive fluconazole therapy. Methods. There were 609 ART-naive adults with AIDS who started ART in Kampala, Uganda, and who had a serum CRAG prospectively measured during 2004–2006. The number needed to test and treat with a positive CRAG was assessed for ≥30-month outcomes. Results. In the overall cohort, 50 persons (8.2%) were serum CRAG positive when starting ART. Of 295 people with a CD4+ cell count ≤100 cells/μL and without prior CM, 26 (8.8%; 95% confidence interval [CI], 5.8%–12.6%) were CRAG positive, of whom 21 were promptly treated with fluconazole (200–400 mg) for 2–4 weeks. Clinical CM developed in 3 fluconazole-treated persons, and 30-month survival was 71% (95% CI, 48%–89%). In the 5 CRAG-positive persons with a CD4+ cell count ≤100 cells/μL treated with ART but not fluconazole, all died within 2 months of ART initiation. The number needed to test and treat with CRAG screening and fluconazole to prevent 1 CM case is 11.3 (95% CI, 7.9–17.1) at costs of $190 (95% CI, $132–$287). The number needed to test and treat to save 1 life is 15.9 (95% CI, 11.1–24.0) at costs of $266 (95% CI, $185–$402). The cost per disability-adjusted life year saved is $21 (95% CI, $15–$32). Conclusions. Integrating CRAG screening into HIV care, specifically targeting people with severe immunosuppression (CD4+ cell count ≤100 cells/μL) should be implemented in treatment programs in resource-limited settings. ART alone is insufficient treatment for CRAG-positive persons.</description><subject>AIDS</subject><subject>Antigens</subject><subject>Antiretrovirals</subject><subject>Biological and medical sciences</subject><subject>Cost control</subject><subject>Cost estimates</subject><subject>Cryptococcal meningitis</subject><subject>Fixed costs</subject><subject>HIV</subject><subject>HIV/AIDS</subject><subject>Human mycoses</subject><subject>Human viral diseases</subject><subject>Immunodeficiencies</subject><subject>Immunodeficiencies. Immunoglobulinopathies</subject><subject>Immunopathology</subject><subject>Infectious diseases</subject><subject>Medical sciences</subject><subject>Miscellaneous mycoses</subject><subject>Mortality</subject><subject>Mycoses</subject><subject>Viral diseases</subject><subject>Viral diseases of the lymphoid tissue and the blood. Aids</subject><issn>1058-4838</issn><issn>1537-6591</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2010</creationdate><recordtype>article</recordtype><recordid>eNp1kMFu1DAQhiMEEqXAGyANB7igUDuOHedYpYVdKUBFCkW9RF5n3HXZjSPbC-wj8B48BicegIfgSUgIKidOM5r55tPoT5KHlDynRIojwTnN2a3kgHJWpIKX9PbYEy7TXDJ5N7kXwjUhlErCD5IflQsxPTUGdbSfsMcQwBlo0O-2UPn9EJ12WqsNHPfRXmEPjfaIve2vIDo48zgeRThBFdcB1NaN88XyfbrsJyN2cIY-uD7AZxvXoKA6yZ9BhZsNVG43Hv76-o0S8mcSjn5-r-Fi7aCJysdJA-dr9GrYg-3hLQa38xrT2m7tZG4wxvGNcD-5Y9Qm4IO_9TB59-L0vFqk9ZuXy-q4TnUmBUtXnSYZN3lRyEwYusq0NpkhRkjJMDO5KDOk2EnDOiRIcypW2nSoWclQ5Eqyw-Tp7NXeheDRtIO3W-X3LSXtlHw7Jz-CT2ZwUGFMznjVaxtu6IyRspS8GLnHM-d2w_9dj2bmOkTn_zlIwUkhp6fSeW9DxC83e-U_tqJgBW8XHy7by8XrUl68qtuG_QZqLqit</recordid><startdate>20100815</startdate><enddate>20100815</enddate><creator>Meya, David B.</creator><creator>Manabe, Yukari C.</creator><creator>Castelnuovo, Barbara</creator><creator>Cook, Bethany A.</creator><creator>Elbireer, Ali M.</creator><creator>Kambugu, Andrew</creator><creator>Kamya, Moses R.</creator><creator>Bohjanen, Paul R.</creator><creator>Boulware, David R.</creator><general>The University of Chicago Press</general><general>University of Chicago Press</general><general>Oxford University Press</general><scope>BSCLL</scope><scope>IQODW</scope><scope>AAYXX</scope><scope>CITATION</scope></search><sort><creationdate>20100815</creationdate><title>Cost-Effectiveness of Serum Cryptococcal Antigen Screening to Prevent Deaths among HIV-Infected Persons with a CD4+ Cell Count ≤100 Cells/μL Who Start HIV Therapy in Resource-Limited Settings</title><author>Meya, David B. ; Manabe, Yukari C. ; Castelnuovo, Barbara ; Cook, Bethany A. ; Elbireer, Ali M. ; Kambugu, Andrew ; Kamya, Moses R. ; Bohjanen, Paul R. ; Boulware, David R.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c2863-bdc025f477826f1b2ccf2f0f6883e2f4692e1ed8f3de0e1416bcfdec393e64a83</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2010</creationdate><topic>AIDS</topic><topic>Antigens</topic><topic>Antiretrovirals</topic><topic>Biological and medical sciences</topic><topic>Cost control</topic><topic>Cost estimates</topic><topic>Cryptococcal meningitis</topic><topic>Fixed costs</topic><topic>HIV</topic><topic>HIV/AIDS</topic><topic>Human mycoses</topic><topic>Human viral diseases</topic><topic>Immunodeficiencies</topic><topic>Immunodeficiencies. Immunoglobulinopathies</topic><topic>Immunopathology</topic><topic>Infectious diseases</topic><topic>Medical sciences</topic><topic>Miscellaneous mycoses</topic><topic>Mortality</topic><topic>Mycoses</topic><topic>Viral diseases</topic><topic>Viral diseases of the lymphoid tissue and the blood. Aids</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Meya, David B.</creatorcontrib><creatorcontrib>Manabe, Yukari C.</creatorcontrib><creatorcontrib>Castelnuovo, Barbara</creatorcontrib><creatorcontrib>Cook, Bethany A.</creatorcontrib><creatorcontrib>Elbireer, Ali M.</creatorcontrib><creatorcontrib>Kambugu, Andrew</creatorcontrib><creatorcontrib>Kamya, Moses R.</creatorcontrib><creatorcontrib>Bohjanen, Paul R.</creatorcontrib><creatorcontrib>Boulware, David R.</creatorcontrib><collection>Istex</collection><collection>Pascal-Francis</collection><collection>CrossRef</collection><jtitle>Clinical infectious diseases</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Meya, David B.</au><au>Manabe, Yukari C.</au><au>Castelnuovo, Barbara</au><au>Cook, Bethany A.</au><au>Elbireer, Ali M.</au><au>Kambugu, Andrew</au><au>Kamya, Moses R.</au><au>Bohjanen, Paul R.</au><au>Boulware, David R.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Cost-Effectiveness of Serum Cryptococcal Antigen Screening to Prevent Deaths among HIV-Infected Persons with a CD4+ Cell Count ≤100 Cells/μL Who Start HIV Therapy in Resource-Limited Settings</atitle><jtitle>Clinical infectious diseases</jtitle><stitle>Clinical Infectious Diseases</stitle><addtitle>Clinical Infectious Diseases</addtitle><date>2010-08-15</date><risdate>2010</risdate><volume>51</volume><issue>4</issue><spage>448</spage><epage>455</epage><pages>448-455</pages><issn>1058-4838</issn><eissn>1537-6591</eissn><coden>CIDIEL</coden><notes>istex:8FC3B44C924F247B960E6DD97B05A2D43AA80786</notes><notes>ark:/67375/HXZ-ZHN98WML-S</notes><abstract>Background. Cryptococcal meningitis (CM) remains a common AIDS-defining illness in Africa and Asia. Subclinical cryptococcal antigenemia is frequently unmasked with antiretroviral therapy (ART). We sought to define the cost-effectiveness of serum cryptococcal antigen (CRAG) screening to identify persons with subclinical cryptococcosis and the efficacy of preemptive fluconazole therapy. Methods. There were 609 ART-naive adults with AIDS who started ART in Kampala, Uganda, and who had a serum CRAG prospectively measured during 2004–2006. The number needed to test and treat with a positive CRAG was assessed for ≥30-month outcomes. Results. In the overall cohort, 50 persons (8.2%) were serum CRAG positive when starting ART. Of 295 people with a CD4+ cell count ≤100 cells/μL and without prior CM, 26 (8.8%; 95% confidence interval [CI], 5.8%–12.6%) were CRAG positive, of whom 21 were promptly treated with fluconazole (200–400 mg) for 2–4 weeks. Clinical CM developed in 3 fluconazole-treated persons, and 30-month survival was 71% (95% CI, 48%–89%). In the 5 CRAG-positive persons with a CD4+ cell count ≤100 cells/μL treated with ART but not fluconazole, all died within 2 months of ART initiation. The number needed to test and treat with CRAG screening and fluconazole to prevent 1 CM case is 11.3 (95% CI, 7.9–17.1) at costs of $190 (95% CI, $132–$287). The number needed to test and treat to save 1 life is 15.9 (95% CI, 11.1–24.0) at costs of $266 (95% CI, $185–$402). The cost per disability-adjusted life year saved is $21 (95% CI, $15–$32). Conclusions. Integrating CRAG screening into HIV care, specifically targeting people with severe immunosuppression (CD4+ cell count ≤100 cells/μL) should be implemented in treatment programs in resource-limited settings. ART alone is insufficient treatment for CRAG-positive persons.</abstract><cop>Oxford</cop><pub>The University of Chicago Press</pub><doi>10.1086/655143</doi><tpages>8</tpages><oa>free_for_read</oa></addata></record>
fulltext fulltext
identifier ISSN: 1058-4838
ispartof Clinical infectious diseases, 2010-08, Vol.51 (4), p.448-455
issn 1058-4838
1537-6591
language eng
recordid cdi_crossref_primary_10_1086_655143
source JSTOR Archival Journals and Primary Sources Collection【Remote access available】; Oxford Journals Online
subjects AIDS
Antigens
Antiretrovirals
Biological and medical sciences
Cost control
Cost estimates
Cryptococcal meningitis
Fixed costs
HIV
HIV/AIDS
Human mycoses
Human viral diseases
Immunodeficiencies
Immunodeficiencies. Immunoglobulinopathies
Immunopathology
Infectious diseases
Medical sciences
Miscellaneous mycoses
Mortality
Mycoses
Viral diseases
Viral diseases of the lymphoid tissue and the blood. Aids
title Cost-Effectiveness of Serum Cryptococcal Antigen Screening to Prevent Deaths among HIV-Infected Persons with a CD4+ Cell Count ≤100 Cells/μL Who Start HIV Therapy in Resource-Limited Settings
url http://sfxeu10.hosted.exlibrisgroup.com/loughborough?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2024-09-22T03%3A21%3A59IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-jstor_cross&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Cost-Effectiveness%20of%20Serum%20Cryptococcal%20Antigen%20Screening%20to%20Prevent%20Deaths%20among%20HIV-Infected%20Persons%20with%20a%20CD4+%20Cell%20Count%20%E2%89%A4100%20Cells/%CE%BCL%20Who%20Start%20HIV%20Therapy%20in%20Resource-Limited%20Settings&rft.jtitle=Clinical%20infectious%20diseases&rft.au=Meya,%20David%20B.&rft.date=2010-08-15&rft.volume=51&rft.issue=4&rft.spage=448&rft.epage=455&rft.pages=448-455&rft.issn=1058-4838&rft.eissn=1537-6591&rft.coden=CIDIEL&rft_id=info:doi/10.1086/655143&rft_dat=%3Cjstor_cross%3E20750788%3C/jstor_cross%3E%3Cgrp_id%3Ecdi_FETCH-LOGICAL-c2863-bdc025f477826f1b2ccf2f0f6883e2f4692e1ed8f3de0e1416bcfdec393e64a83%3C/grp_id%3E%3Coa%3E%3C/oa%3E%3Curl%3E%3C/url%3E&rft_id=info:oai/&rft_id=info:pmid/&rft_jstor_id=20750788&rft_oup_id=10.1086/655143&rfr_iscdi=true