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PubMedDate not supplied

Controlling costs and improving diabetes care.

A simplification of the threat that diabetes poses to industrialized society is that the costs of inadequate treatment in terms of dollars, suffering, and functional impairment, despite increasing knowledge, are ever increasing. This increased threat is a result of the combined effects of the rising incidence of diabetes, the increasing costs of adequate care, and the perverse effects of a medical care system that fails to encourage lifelong patient commitment and behavior change.

Case Management↗
PubMed2003

Combinatorial auction design.

Combinatorial auctions allow for more expressive bidding in which participants can submit package bids with logical constraints that limit allowable outcomes. This type of auction can be useful when participants' values are complementary or when participants have production and financial constraints. However, combinatorial auctions are currently rare in practice. The main problems confronted in implementing these auctions are that they have computational uncertainty (i.e., there is no guarantee that the winning bids for such an auction can be found in a "reasonable" amount of time when the number of bidders and items becomes larger) and that the auction is cognitively complex and can lead participants to pursue perverse bidding strategies. This article describes a type of combinatorial auction that, during laboratory testing, eliminated these problems and produced extremely efficient outcomes.

Journal Article↗
PubMed1989

Delusions and hallucinations as a reflection of the subcultural milieu among psychotic patients of the 1930s and 1980s.

Delusions and hallucinations reported in the social histories of 150 patients admitted to an East Texas state hospital during the 1930s and of 150 patients admitted during the 1980s were examined for content that would characterize and contrast the patient subcultural milieu of the two time periods. Patients admitted during the 1930s tended to reflect the material deprivation and personal powerlessness of the great depression in delusions of great wealth and positive "special powers." The hallucinatory visions and voices of the 1980s patients reflected a more threatening and negative subcultural milieu, with more visions of blood, snakes, and dead people or animals. Command hallucinations to hurt, to kill, or to do "perverse things" would also suggest that the subculture milieu of the 1980s had become more dangerous.

Adolescent↗
PubMed2003

History, causality, and sexology.

In 1896, Krafft-Ebing published Psychopathia Sexualis. Popularly defined as hereditary weakness or taintedness in the family pedigree, degeneracy was called upon as a causal explanation for perversions of the sexual instinct. Although Krafft-Ebing accepted Karl Ulrichs proposal that homosexuality could be innate and probably located in the brain, he paid little attention to neuropathological sexology. Alfred Binet challenged Krafft-Ebing's orthodoxy by explaining fetishism in terms of associative learning, to which Krafft-Ebing's response was that only those with a hereditary taint would be vulnerable. Thus did the venerable nature-nurture antithesis maintain its rhetoric, even to the present day. Krafft-Ebing died too soon to meet the Freudian challenge of endopsychic determinism, and too soon also to encounter the idea of a developmental multivariate outcome of what I have termed the lovemap. Like other brain maps, for example the languagemap, the lovemap requires an intact human brain in which to develop. The personalized content of the lovemap has access to the brain by way of the special senses.

Austria↗
PubMed1994

Socio-demographic trends in Northern Ireland, 1971 to 1991.

"Northern Ireland has demographic and socio-economic structures which set it apart from the rest of the United Kingdom and religion impacts on this social demography more than in any other 'developed' society. Peripherality also serves to underpin some of the distinctiveness of the Province. Socio-economic and demographic data from Population Censuses and demographic data from Annual Reports of the Registrar General are analysed. The socio-demographic trends between 1971, 1981 and 1991 are traced and the spatial patterns are described. Many of the spatial patterns have been remarkably persistent over time and the problems that arise from this are unlikely to be addressed fully given the Province's perverse polity."

Demography↗
PubMed1979

Psychotherapy of an aging transvestite.

Proper categorization of individuals with gender dysphoria allows rational psychotherapy. The treatment of an aging transvestite who requested sexual reassignment is presented to demonstrate the clinical features of the disorder and the course of the illness. The initial task was to place the patient into the proper clinical category of individuals with gender dysphorias. The clinical details of this disorder include an episoidic course with individuals who have previously had clear masculine identities. In the past they have been labeled secondary or marginal transsexuals as well as fetishtic cross-dressers. The patient, who had a long-standing history of cross-dressing, reacted to specific life stresses by the symptomatic wish for sexual reassignment. The individual psychotherapy consisted of phases of symptomatic expression, emerging depression, interpersonal awareness, symptom resolution and disavowel of the wish for sexual reassignment. The genesis of this perversion appears to be identification with a phallic maternal figure. Discussion of the descriptive and dynamic literature is reported in relation to the reported case. Identification of important losses in this patient's recent life allowed proper diagnosis and appropriate ongoing therapy to prevent the patient from irreversible surgery for a condition that was a symptom not an ingrained belief of gender dysphoria.

Adult↗
PubMed1985

Coping with a transvestitic mate: clinical implications.

The transvestite's mate often seeks psychiatric consultation following discovery of her partner's cross-dressing. The clinical management of such situations is complex and mandates investigation of how such women have coped with the knowledge that their partner wears women's clothes for sexual arousal. This report reviews the coping styles of 20 women married or living with transvestitic men. Depression, hostility, sadism and alcohol abuse were methods utilized to cope with their perverse mate. Therapeutic strategies are discussed to help such women during the initial stages of a consultation so that they may develop sufficient insight and information to intelligently manage the dilemma in which they find themselves.

Adult↗
PubMed1987

Treatment guidelines: antiandrogen and counseling of paraphilic sex offenders.

Paraphilic syndromes, of which there are at least 40, are known legally as perversions and on the street as kinky and bizarre sex. Paraphilia accounts for a very high proportion of sex-offending that is prosecuted as criminal. A new treatment which combines a hormonal antiandrogen with sexological counseling therapy is becoming widely adopted in America and Europe. The treatment is available also to noncriminal paraphiliacs whose syndrome is a source of interpersonal suffering and crisis.

Arousal↗
PubMed2000

Safety of the new fluoroquinolones compared with ciprofloxacin.

Significant safety issues that have arisen with fluoroquinolones include phototoxicity, cardiotoxicity, tendinitis, CNS effects and drug interactions. Ciprofloxacin is well tolerated; the incidence of adverse events is low and serious adverse events are rare. Levofloxacin has a reduced CNS adverse event rate compared with ofloxacin. Sparfloxacin has significant phototoxicity and potential cardiac toxicity. Grepafloxacin has significantly increased adverse event rates, particularly gastrointestinal intolerance. Taste perversion and nausea are common. Trovafloxacin has an increased potential for CNS adverse reactions, notably dizziness. Post-marketing surveillance data indicate the possibility of serious hepatic reactions and pancreatitis. Interactions between fluoroquinolones and drugs metabolised by the hepatic cytochrome P450 system affect the clearance of theophylline and caffeine. Quinolone absorption is significantly reduced by co-administration of antacids. Hospitalised patients are likely to be receiving multiple-drug therapy, but drug interactions are avoidable. The interactions of specific fluoroquinolones should be checked prior to prescription.

Anti-Infective Agents↗
PubMed2005

Binarisms, regressive outcomes and biases in the drug policy interventions: a theoretical approach.

The golden age of drug policy was characterized by the informal regulation of drug use. Formalization of the control over regulation and its increasingly strict, aggressive character led to the emergence of a binary attitude. The main binarisms: pharmaceutical or drug; ban or tolerance; punishment or treatment; psychopathological or pathopsychological approach; subjective or objective knowledge; traditional or alternative. On the basis of Kuhn's paradigm theory, these binarisms can be integrated. Drug policy interventions based on the binary attitude have had regressive effects. Using the work of Sam Sieber, the author distinguishes nine regressive influences: functional imbalance, perverse diagnosis, ricochet, overload, goal displacement, exploitation, provocation, classification, and placation. The regressive influences have caused the escalation of "the drug problem," which in turn has led to further regressive interventions. This vicious circle could be broken by eliminating the four biases--the paternalistic, elitist, rationalist, and activist biases--underlying the regressive interventions.

Austria↗
PubMed1981

The development of sexuality and eroticism in humankind.

Sexuality includes eroticism. Though its determinants are multivariate and developmentally sequential, most current biological theories arbitrarily exclude social determinants, and vice versa. Developmentally, masculinization is not necessarily synonymous with defeminization, nor feminization with demasculinization. In the development of brain and behavior, behavior that appears to be either male or female may actually be sex-shared but sex-different in the threshold for its expression. Parent-child bonding is a precursor of subsequent erotosexual pair-bonding. Suppression of erotosexual rehearsal play in childhood is a precursor of postpubertal and adult erotosexual pathology. The criterion defining the heterosexual, bisexual, and homosexual conditions is the sex of the partner with whom a limerent (falling-in-love) pairbond is possible; and there is no evidence that pubertal sex steroids, per se, are responsible for which of the three it will be. The phases of an erotosexual encounter are proception, acception, and conception. The disorders of proception, manifested in both imagery and practice, are the paraphilic syndromes (formerly known as perversions). The disorders of acception may be either hypophilic deficiencies, or hyperphilic increases. The disorders of conception are those of infertility. There is a nonsystematic relationship of erotosexualism to the hormonal cycle of the menses and to gerontological hormonal changes.

Animals↗
PubMed1999

Fluoroquinolone toxicity profiles: a review focusing on newer agents.

For 2 decades fluoroquinolones have been found to be generally well-tolerated and safe. Adverse events may be inherent to the class or influenced by structural modifications. The commonest adverse events are gastrointestinal tract (GI) and central nervous system (CNS) reactions; nephrotoxicity and tendinitis are infrequent, but agents differ greatly in phototoxic potential. Fluoroquinolones are safe in elderly, human immunodeficiency virus-infected, and neutropenic patients, but because of possible effects on articular cartilage, they are not currently recommended for children or pregnant women. Four new agents have recently been licensed. Levofloxacin causes few GI or CNS adverse events and is minimally phototoxic. Sparfloxacin infrequently causes GI or CNS effects but is associated with relatively high rates of phototoxicity and prolongation of the electrocardiographic QTc interval (Q-T interval, corrected for heart rate). Grepafloxacin causes relatively high rates of GI effects, taste perversion, and QTc interval prolongation, but it is minimally phototoxic. Trovafloxacin is associated with a moderate rate of GI effects and a relatively high incidence of dizziness but has low phototoxic potential.

Anti-Infective Agents↗
PubMed1987

Studies on the aetiology and pathogenesis of motor neuron diseases. 1. Lathyrism: clinical findings in established cases.

Lathyrism is a toxic disease of the motor system constantly associated with primary consumption of the seed of Lathyrus sativus (chickling or grass pea). Neurological examination was performed on 38 affected subjects drawn from four regions of the Indian subcontinent endemic for lathyrism. All showed a consistent and largely symmetric pattern of neurological deficit similar to that displayed by 5 Europeans with longstanding lathyrism now living in Israel. Hallmarks of lathyrism include a pyramidal pattern of motor weakness combined with greatly increased tone in the thigh extensors and adductors and in the gastrocnemius muscles so that the more severely affected walk on the balls of their feet with a lurching scissoring gait. Extensor plantar responses are uniformly present in such cases, and the knee and ankle tendon reflexes are exaggerated and often clonic. Hoffmann signs and exaggerated biceps and/or triceps tendon jerks are also found in the most severely affected. Sensory signs are absent, although perverse sensations in the legs are frequently reported at the onset. Walking difficulties commonly begin suddenly but may also appear subacutely or insidiously. Some individuals experience partly reversible symptoms suggestive of a diffuse CNS excitation of somatic, motor and autonomic function.

Adult↗
PubMed2004

Inequalities in accessing hip joint replacement for people in need.

OBJECTIVES: To quantify the effects of rurality and socio-economic disadvantage on prior evidence of need for total hip joint replacement and use of health services after adjusting for age and gender. DESIGN: Self-completion validated questionnaire mailed directly to subjects. SETTINGS: Geographical areas covered by Wiltshire and Sheffield Health Authorities in England. PARTICIPANTS: Random stratified sample of 15,000 aged 65 years and over taken from the central age-sex registers. MAIN OUTCOME MEASURE: Prior need for hip joint replacement surgery and whether general practice and hospital services were being used as assessed by the questionnaire. RESULTS: The response rate was 78% after three mailings. Prevalence of need for total hip replacement in the over 64s was 3.4% (95% confidence interval is 3.0% to 3.8%) and in those without co-morbidity 5.4% (95% confidence interval is 4.8% to 6.0%). There were inequalities demonstrated due to age, geography, and deprivation, but not rurality in accessing general practice and hospital services. People who were poor had more need. Older people in need were less likely to be accessing health services. CONCLUSIONS: There is an important unmet need for hip joint replacement in older people with marked inequalities in levels of need and use of services. The use of numbers of people waiting as a performance indicator is perverse for this procedure. We have urgently to expand orthopaedic services and the training of orthopaedic surgeons in England.

Aged↗
PubMed1997

Effect of the introduction of a financial incentive for fee-paying A&E attenders to consult their general practitioner before attending the A&E department.

BACKGROUND: The Health (Out-Patient Charges) Regulations 1994 were designed to encourage those Irish patients liable for their own health care costs to attend their GP before their local Accident and Emergency (A&E) department. Such patients are referred to as General Medical Services (GMS)-ineligible. Prior to the introduction of the regulations in March 1994, there was a perverse financial incentive for these patients to attend directly A&E departments instead of their GP. OBJECTIVE: The aim was to compare the number of GMS-ineligible patients referred by a GP during the year before and the year after the implementation of the Regulations. METHOD: This study involved the audit of all new attendances to a large A&E department, for 1 year before and after the introduction of the new regulations. The main outcome measures were the number of new attenders in the subsequent year, the proportion of GMS-ineligible attenders, the proportion of GMS-ineligible attenders referred by a GP and the proportion of GMS-ineligible attenders referred by a GP and categorized as having neither critical nor urgent complaints. RESULTS: The total number of new attenders in the year subsequent to the introduction of the regulations was 45,302, an increase of 4.9% on the previous year's total. The proportion of GMS-ineligible attenders decreased from 45.3 to 44% (-1.3%; 95% confidence interval (CI) -0.6 to -1.9). The proportion of GMS-ineligible attenders who were referred by a GP increased by 2.4% (95%; CI 1.7-3.1). The proportion of GMS-ineligible attenders, referred by a GP with complaints categorized as neither critical nor urgent, increased by 2.5% (95%; CI 1.8-3.2). CONCLUSIONS: The introduction of the regulations was associated with a small, but statistically significant, reduction in the number of GMS-ineligible patients who attended with non-emergency conditions. The proportion of GMS-ineligible attenders who were referred by a GP increased by 2.4% (95%; CI 1.7-3.1). The overall workload of the A&E department was, however, unaffected. Further evaluation of the effects of this reduction on the health status of patients is required.

Adult↗
PubMed1993

Medical technology and inequity in health care: the case of Korea.

There has been a rapid influx of high cost medical technologies into the Korean hospital market. This has raised concerns about the changes it will bring for the Korean health care sector. Some have questioned whether this diffusion will necessarily have positive effects on the health of the overall population. Some perverse effects of uncontrolled diffusion of technologies have been hinted in recent literature. For example, there is a problem of increasing inequity with the adoption of expensive technologies. Utilization of most of the expensive high technology services is not covered by national health insurance schemes; examples of such technologies are Ultra Sonic, CT Scanner, MRI, Radiotherapy, EKG, and Lithotripter. As a result, the rich can afford expensive high technology services while the poor cannot. This produces a gradual evolution of classes in health service utilization. This study examines how health service utilization among different income groups is affected by the import of high technologies. It discusses changes made within the health care system, and explains the circumstances under which the rapid and excessive diffusion of medical technologies occurred in the hospital sector.

Cost-Benefit Analysis↗
PubMed2003

Paying for pharmaceutical registration in developing countries.

Fees charged by drug regulatory authorities (DRAs) may be used as a policy instrument to speed up regulatory approval, to encourage retention of quality staff and to stimulate introduction of generics versus new chemical entities. Often, the cost recovery function of these registration fees is not related to the true cost of the pharmaceutical regulatory process. In this paper, we scaled new drug registration fees of various DRAs to indices of economic development - the GNP per capita and the total government health expenditure per capita. Based on our analyses of 34 countries, most DRA registration fees for new drug applications for developing/non-OECD countries are less than the current GNP/capita of that country or are about US dollars 5000 for each US dollars 1000 spent per capita on healthcare. At present, each US dollars 1000 new drug registration fee for the developing/non-OECD countries analyzed corresponds to a total pharmaceutical market share of about US dollars 85 million. Our analyses further suggest little relationship between DRA registration fees and drug approval times in developing countries. The situation is complex, however, as policy tradeoffs are important to consider. Differential registration fees, presumably designed to encourage locally produced versus imported products, may violate international trade regulations. Moreover, certain DRA registration fees may provide perverse incentives for the pharmaceutical industry. Developing countries should require that DRA registration fees be based on accurate accounting of the cost of services provided. At present levels, these fees could be increased without disincentive to the pharmaceutical industry. For new drug registration fees, our analyses suggest that developing countries could charge between 1-5 times their GNP per capita or between US dollars 17000 and US dollars 80000 for each US dollars 1000 spent per capita on healthcare.

Developing Countries↗
PubMed1990

People are not passive acceptors of threats to health: endogeneity and its consequences.

The effect of behaviour on health is a major area of contemporary epidemiological enquiry. Most epidemiological studies of the effect of behaviour on health assume that the levels of the behaviour-related variables are determined by factors other than those under study. However, in many instances, obvious examples are breastfeeding and smoking, not only do behaviours affect health but, conversely, individuals take into account their (observable and non-observable) health conditions when making behavioural decisions. In models which allow for the joint determination of health and behaviour, both health and behavioural variables are 'endogenous', that is, determined by forces acting within the model. Through some simple didactic examples it is shown that estimates of the effect of behaviour on health are biased if endogeneity is ignored. Review of the small empirical literature on this subject shows perverse results, such as a negative relationship between the use of prenatal care and infant mortality, when endogeneity is ignored. Standard procedures for taking account of the effects of endogeneity are described briefly.

Behavior↗