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PubMed2004

Inequalities in access to knee joint replacements for people in need.

OBJECTIVES: To quantify the effects of socioeconomic deprivation and rurality on evidence of need for total knee joint replacement and the use of health services, after adjusting for age and sex. METHODS: A random stratified sample of 15 000 people aged > or =65 years taken from central age/sex registers for the geographical areas covered by the previous Sheffield and Wiltshire Health Authorities. A self completion validated questionnaire was then mailed directly to subjects to assess need for knee joint replacement surgery and whether general practice and hospital services were being used. Subjects were followed up for 18 months to evaluate access to surgery. RESULTS: The response rate was 78% after three mailings. In those aged 65 years and over (with and without comorbidity), the proportion with no comorbid factors and in need of knee replacement was 5.1%; the rate of need among subjects without comorbidity was 7.9%. There were inequalities in health and access to health related to age, sex, geography, and deprivation but not rurality. People who were more deprived had greater need. Older and deprived people were less likely to access health services. Only 6.4% of eligible people received knee replacement surgery after 18 months of follow up. CONCLUSIONS: There is an important unmet need in older people, with significant age, sex, geographical, and deprivation inequalities in levels of need and access to services. The use of waiting list numbers as a performance indicator is perverse for this procedure. There is urgent need to expand orthopaedic services and training.

Age Factors↗
PubMed1991

Designing a deprivation payment for general practitioners: the UPA(8) wonderland.

OBJECTIVE: To analyse critically the deprived area payment introduced in the new general practitioner contract. The payment formula is based on the Jarman underprivileged area index (UPA(8)) and aims at compensating general practitioners for increases in workload. DESIGN: Evaluation of the deprived area payment against the stated policy objective with a set of criteria for developing resource allocation formulas. MAIN OUTCOME MEASURES: The degree to which the components of the Jarman index predict the workload of general practitioners; whether construction of the index is sensible and comprehensible; and how the formula incorporates the index and is likely to work in practice. RESULTS: The fact that the index relies on census data and the way the weighting was derived means that the formula will not accurately reflect the workload. The use of statistical transformations obscures the original policy intent. There has been no validation to support the application of the index as part of a national policy. The payments are not linked to the quality of service provided and may have the perverse effect of increasing list size. CONCLUSION: The formula used as the basis of the deprived area payments is poorly suited to the policy objective of compensating general practitioners for increases in workload. More research is urgently needed to enable the effect of the payment to be monitored and a more empirically sound set of incentives to be developed.

Family Practice↗
PubMed1995

Effect of recent health and social service policy reforms on Britain's mental health system.

The introduction of new policies in health and social services in Britain has changed the way community care is provided to seriously mentally ill people. Britain is creating the same problems that have existed in the United States, whereby clinicians struggle to provide services in an environment with multiple payers and perverse incentives. A simple system in Britain has been replaced with complicated organisational and financial structures that require almost impossible feats by local health and social service staff to coordinate care for patients for whom continuity of care is critical for their survival in the community and their wellbeing. Seriously mentally ill people are in the middle of these complicated problems. The creation of a local mental health authority that could be held responsible for community care, as exists in some American states, may be one solution.

Community Mental Health Services↗
PubMed2003

Social care's impact on emergency medicine: a model to test.

Mainly in response to the policy drive to avoid unnecessary acute hospital admissions and delayed discharge on social grounds, there has been a gradual development of social work services attached to emergency departments (EDs) in the UK. In the absence of a clearly articulated evidence base or debate about the roles of ED attached social workers, a model of ED based social work practice and indicative supporting evidence is presented. It is argued that social workers may be able to contribute to the efficiency and effectiveness of hospital services while providing a key point of access to social care services. A number of obstacles remain to the implementation of this model of service, including the narrow focus of current social care practice, the hours that a social work service is normally provided, chronic under-funding, and continuing perverse incentives in the health and social care system. More systematic evidence in the UK context is needed to support the case for change.

Emergency Service, Hospital↗
PubMed2007

Framing, truth telling and the problem with non-directive counselling.

In this paper several reasons as to why framing issues should be of greater interest to both medical ethicists and healthcare professionals are suggested: firstly, framing can help in explaining health behaviours that can, from the medical perspective, appear perverse; secondly, framing provides a way of describing the internal structure of ethical arguments; and thirdly, an understanding of framing issues can help in identifying clinical practices, such as non-directive counselling, which may, inadvertently, be failing to meet their own stated ethical aims. The effect of framing on how individuals interpret information and how healthcare choices are influenced by framing are described. Next, the role of framing in ethical discourse is discussed with specific reference to Judith Jarvis Thomson's philosophical mind experiment about abortion and the violinist. Finally, the implications of this analysis are examined for the practice of non-directive counselling, which aims at communicating information in a neutral, value-free way and thereby protecting patient autonomy.

Communication↗
PubMed2006

Wickedness or folly? The ethics of NICE's decisions.

A rebuttal is provided to each of the arguments adduced by John Harris, an Editor-in-Chief of the Journal of Medical Ethics, in two editorials in the journal in support of the view that National Institute for Health and Clinical Excellence's procedures and methods for making recommendations about healthcare procedures for use in the National Health Service in England and Wales are the product of "wickedness or folly or more likely both", "ethically illiterate as well as socially divisive", responsible for the "perversion of science as well as of morality" and are "contrary to basic morality and contrary to human rights".

Academies and Institutes↗
PubMed2001

Cascade effects of medical technology.

Cascade effect refers to a process that proceeds in stepwise fashion from an initiating event to a seemingly inevitable conclusion. With regard to medical technology, the term refers to a chain of events initiated by an unnecessary test, an unexpected result, or patient or physician anxiety, which results in ill-advised tests or treatments that may cause avoidable adverse effects and/or morbidity. Examples include discovery of endocrine incidentalomas on head and body scans; irrelevant abnormalities on spinal imaging; tampering with random fluctuations in clinical measures; and unwanted aggressive care at the end of life. Common triggers include failing to understand the likelihood of false-positive results; errors in data interpretation; overestimating benefits or underestimating risks; and low tolerance of ambiguity. Excess capacity and perverse financial incentives may contribute to cascade effects as well. Preventing cascade effects may require better education of physicians and patients; research on the natural history of mild diagnostic abnormalities; achieving optimal capacity in health care systems; and awareness that more is not the same as better.

Biomedical Technology↗
PubMedDate not supplied

Azelastine tablets in the treatment of chronic idiopathic urticaria. Phase iii, randomised, double-blind, placebo and active controlled multicentric clinical trial.

This trial was designed to study the efficacy and tolerability of azelastine in controlling symptoms of chronic idiopathic urticaria, using ebastine as validation group. Fifty-two adult patients were randomised to receive azelastine (4 mg), ebastine (10 mg) or 18 placebo for 21 days. Patients were required to visit the investigating physicians on three different occasions (days 0, 7 and 21). On each of these three study days, investigators assessed itching, wheals and erythema, based on a 4-point scale, and quality of life using a visual-analogue scale and subscale 9 of the Short Form 36 (SF-36) Health Survey. Patients entered daily assessments of itching on diary cards also using a 4-point scale. Furthermore, investigators assessed global efficacy and tolerability of the study medication on day 21 or upon premature discontinuation of the trial. Side effects and compliance were evaluated on each visit. A statistically significant reduction in itching was found for both active treatments compared with placebo. These improvements, which were statistically significant already after 1 day of treatment, continued over the course of 3 weeks. Additionally, both azelastine and ebastine were effective in improving symptoms such as wheals and erythema when compared to placebo. The quality-of-life parameters were unaffected by either treatment. Taste perversion (2 cases) and somnolence (1 case) were the only adverse drug reactions of azelastine. Ebastine, however, seemed to cause more often and more severe symptoms such as fatigue, sleepiness and asthenia. Global assessments of efficacy and tolerability performed by the investigators, also favoured azelastine. In conclusion, both azelastine and ebastine are effective and safe drugs, able to control symptoms of chronic idiopathic urticaria since the first day of treatment, and along a period of 3 weeks.

Adolescent↗
PubMed2001

Latest industry information on the safety profile of levofloxacin in the US.

This paper reviews the safety data for levofloxacin utilizing reports from clinical and post-marketing surveillance trials. The side effect incidence rates are 1.3% for nausea, 0.1% for anxiety, 0.3% for insomnia, and 0.1% for headache. No levofloxacin-related adverse events were reported at a rate higher than 1.3%, and most were lower. Four clinical trials were reported. Levofloxacin achieved superior clinical and microbiological results compared to ceftriaxone/macrolide combination, and was better tolerated. Results comparing IV azithromycin plus ceftriaxone versus 500 mg levofloxacin in hospitalised CAP demonstrated that levofloxacin performed better, with more adverse events associated with the comparators (levofloxacin 5.3%, comparators 9.3%). High-dose levofloxacin (750 mg) was also evaluated and found to be well tolerated. Surveillance data reported low ADR rates for levofloxacin: nausea 0.8%, rash 0.5%, abdominal pain 0.4%, and diarrhoea, dizziness, and vomiting 0.3%. Worldwide and US surveillance data confirmed that tendon rupture occurred in less than 4 per million prescriptions, taste perversion in less than 3 per million, convulsions in 2 per million, and photosensitivity, hepatitis, hepatic failure, QT prolongation, torsade de pointes or empyema all in less than 1 per million.

Adverse Drug Reaction Reporting Systems↗
PubMed2006

Female child sexual abuse within the family in a Hungarian County.

BACKGROUND: The aim of the study was to analyze the characteristics of intrafamiliar female child sexual abuse and to explore common features that may be utilized as targets for possible methods of prevention. We also described the medical and legal approaches to handling child neglect. METHODS: This was a descriptive, cross-sectional study on 52 sexually abused girls under the age of 18 at the Department of Obstetrics and Gynecology, Medical and Health Science Center of Debrecen. We prospectively recorded the data of all cases. Intrafamiliar events were defined if the victim and perpetrator belonged to the same family. Legal outcomes were also recorded. RESULTS: During the 16-year period, 209 cases of sexual abuse were seen in our clinic, 52 of them had been involved in child sexual abuse within the family. This accounts for 25% of adolescent cases. Eighty-six percent of the victims were pupils, 50% of them were between 11 and 14 years of age. The perpetrator was the victim's father in 44%, and the stepfather in 40%. There was a slight difference between the type of abuse among the pre- and postpubertal group of victims, but statistically it was not significant. The abuse occurred on multiple occasions in 52%. The occurrence rate of assault was the highest in the summer season (58%), mostly in the afternoon (42%) and it took place almost exclusively at home (98%). The mother accompanied the victim in 38% of the cases and the police in 40%. Vaginal penetration was the type of abuse in 75%, and sexual perversion in 25%. Six victims were physically injured, the presence of sperm could be confirmed on vulvovaginal smears in 2 cases. One pregnancy conceived. Nine cases were reported to the police and as a result of legal proceedings, 5 perpetrators have been sentenced. CONCLUSION: The majority of crimes take place within the family and are disclosed after multiple episodes. The small proportion of reported sexual assaults is the consequence of the lack of harmony between the Hungarian conditions of emergency care and the criminal law. Prevention calls for attention at all levels of child education, observation at off-school times, early involvement of health professionals, applying standardized medical guidelines and the modification of jurisdiction.

Adolescent↗
PubMed1996

Maternal obsessions of child sexual abuse.

Very few cases exist in the literature of maternal obsessional thoughts of child sexual abuse. Two such cases are described of mothers who experienced obsessional thoughts in the puerperium which concerned sexually abusing their own children. Obsessional thoughts of a sexual nature have been shown to occur commonly--in over 25% of those diagnosed with obsessive-compulsive neuroses. These obsessional thoughts concern actions which are usually identified as going against the sufferer's own value systems or involving sexual perversions. Obsessional thoughts of sexually abusing family members are rarely documented; there are no reports of obsessional thoughts experienced by a mother in the puerperium concerning sexual abuse of her own children. We report two cases of mothers suffering from obsessions of this nature at The Mother and Baby Unit (MBU), Queen Elizabeth Psychiatric Hospital, Birmingham.

Adult↗
PubMed1980

Sexual effects of antidepressents and psychomotor stimulant drugs.

Sexual dysfunction is common in depressive illness, most often occuring as loss of sexual interest, impotence, and a decline in the frequency of intercourse. Antidepressant drugs have been documented to improve sexual function in depression; however, adverse effects of sexual function also occur as a result of the drugs' interference with peripheral cholinergic and adrenergic function. MAO inhibitors may also ameliorate depression-related sexual dysfunction. These drugs also improve sperm count and sperm motility and may have a clinical use in moderate oligospermia. Stimulant drugs have been linked to a wide variety of sexual effects. Most dramatic is the increase in sexual arousal reported by many stimulant users. Increases in sexual activity and sexual perversion have both been related to stimulant use. Due to the high rate of pre-drug sexual aberration and the non-specific nature of stimulant arousal, caution should be exercised in postulating a direct effect on sexuality by stimulant drugs.

Animals↗
PubMed1996

The characterological basis of multiple personality.

This review has focused on the characterological features of dissociative identity disorder (DID), extending the "state versus trait" debate to the realm of the dissociative disorders. A number of different theories are presented describing DID as a variant of, on a continuum with, or being comorbid with the narcissistic and the borderline personality disorders. It is then hypothesized that DID is best considered a distinct characterological entity. Two theories are put forth, which describe a personality disorder whose predominant defense is dissociation. The more developed model which possibly has more explanatory value is the "dissociative character." In this schema, DID would be considered a lower-level dissociative character, utilizing primitive forms of dissociation in which splitting is enhanced by an autohypnotic defensive altered state of consciousness. These altered states originate in response to the overstimulation of external trauma, but get reactivated in the service of here-and-now intrapsychic conflicts. Recognition of this dual quality of dissociation seems helpful in psychodynamic treatment, which allows for analysis of the defense and analysis of the content of these states. The nature of the content of what is "in dissociation" appears to have a dreamlike quality to it that may correspond to previous trauma but also be subject to some secondary revision. There is clinical evidence to suggest that "dream work" of the ego is operative in both the representation of a separate self in dreams and in alter personalities. Another organizing influence which contributes to seemingly separate identities is that of perverse sexuality. It appears that a number of dissociated sexual pathways may be followed in the same individual, which encapsulate aggression, childhood trauma, anxiety, and a sense of self. When this exceedingly complex psychic structure is successful, it may then free up some ego to proceed with aspects of healthy development.

Borderline Personality Disorder↗
PubMed2001

The disregarded analyst and the transgressive process: discontinuity, countertransference, and the framing of the negative.

This paper describes the difficulty of working with patients who have adopted conflict solutions common to perversion. These analysands' rapid shifts from one discontinuous mental state to another draw the analyst into a regressive transference/countertransference engagement characterized by alternations of actualized self and object representations. The analyst's disengagement from this regressive interaction is crucial, but difficult. A detailed clinical example illustrates the process of disengagement as well as the transformation of this transference into a more traditionally consolidated one. A technical approach is suggested and questions of representation and symbolization are explored.

Affect↗
PubMed2002

Sexuality and textuality.

Post-Freudian theories have been criticized for abandoning what is basic to psychoanalysis: the biological body and sexuality as the source of intrapsychic motivation. Arguably, however, they are more present than ever before-for example, in explanations by theorists who propose therapeutic actions beyond interpretation, presymbolic enactments of procedural memories, or disclosures of the analyst's bodily states as an aspect of intersubjectivity. By contrast, the Freudian body was always a text whose mediated meanings require interpretation, for which Freud provided eloquent guides. It is this textuality, and not sexuality, that distinguishes a psychoanalytic approach: a psycho-logic constructed according to a grammar of desire that mediates experience and creates interpretable behavior, both in action and in speech. Theoretical changes in psychoanalysis are traced historically along the dimension of textuality, the example of perversion is invoked, and the conclusion drawn that any theoretical approach, traditional or post-Freudian, that expands an understanding of textuality contributes to the science of psychoanalysis.

Freudian Theory↗
PubMed2003

The place of annihilation anxieties in psychoanalytic theory.

Survival-related clinical reports are abundantly found in the works of classical, object-relational, and self psychological writers, but are underrepresented in major theoretical formulations on anxiety. Fears of being overwhelmed, merged, penetrated, fragmented, and destroyed, as contents of unconscious and conscious fantasies, are regularly interrelated with the typical dangers. Fifteen preliminary propositions invite closer study of such apprehensions and provide definitional components. Annihilation anxieties are triggered by survival threat; are found early but can be engendered throughout the life cycle; constitute a basic danger; are residuals of psychic trauma; have specifiable subdimensions; may occur in presymbolic form or be associated with fantasies in conflict/compromise formation; may arise with or without anticipation; may be accompanied by controlled or uncontrolled anxiety; are motives for defense; and may be associated with particularly recalcitrant resistances. The study of annihilation anxieties in relation to the basic danger series has both theoretical and clinical advantages, especially for understanding traumatic, anxiety, phobic, psychosomatic, addictive, narcissistic, borderline, and psychotic manifestations, as well as sexual problems (including perversions), nightmares, dissociative and panic states, and especially difficult resistances.

Adaptation, Psychological↗
PubMed2005

As the wheel turns: a centennial reflection on Freud's Three Essays on the Theory of Sexuality.

Freud's theories of psychosexual development, while highly original, were anchored in the explosion of scientific studies of sex in the nineteenth century. Most of these studies were based on masturbation, homosexuality, and deviance, with little attention given to normal sexuality. Around the turn of the century, the narrow interest in pathological sexuality and sexual physiology gradually gave way to a broader interest in normal sexuality. It was in the context of these expanding studies of sexuality that Freud proposed the first psychological view of sexuality, a theory that defined sex as being at the interface between soma and psyche. Libido theory, which Freud developed, is a theory of drives and conflicts. For Freud, libido was the major force in personality development, and he posited sexual conflicts as the heart of neuroses, sexual fixations as the essence of perversions. This article traces the way Freud's libido theory has served as one of the mainsprings in the development of psychoanalytic theory. It also addresses the major revisions that have taken place in libido theory, with a focus primarily on object relations theory, and the impact of culture on the way sex and sexual mores are parsed.

Freudian Theory↗
PubMed2006

Analyzing disavowed action: the fundamental resistance of analysis.

Several detailed analytic hours illustrate how, with the analyst's full participation, patients use the words, setting, and activity of analysis to gratify the very wishes they are analyzing, and so disavow the work of analysis. These gratifications, which are hidden in plain sight, are themselves disavowed in the apparent pursuit of analytic understanding. In this way the patient's and the analyst's use of the analytic situation becomes the fundamental resistance to the work itself. This process shares features in common with perversion. The painful but necessary task for both analyst and patient is to analyze this process as it is occurring, moment by moment, in the real time of the hour.

Humans↗