Contract Budgeting

Contract budgeting attempts to reconfigure public budgeting as a system of purchase contracts between provider agencies and central government. It draws its inspiration from a simple model of contract in which the purchaser buys clearly specified outputs from a provider at a preagreed price. Contract budgeting thus represents a fusion of output-based budgeting schemas with the newer enthusiasm for placing the public sector on a 'market' footing. This paper reviews the problems which confront any form of output based budgeting, and then analyses the specific issues of contractualization. It concludes that contract budgeting does not well fit the realities of budgeting in a complex public sector.     

High urine ethanol and negative blood and vitreous ethanol in a diabetic woman: a case report, retrospective case survey, and review of the literature

Several studies have shown that ethanol can be produced in urine infected with yeast or bacteria in vitro. We present the unusual case of a diabetic woman in whom ethanol was produced in her urine in vivo. The decedent was a 19-year-old woman who was noncompliant with her diabetes treatment. She presented to a local hospital in severe diabetic ketoacidosis and died shortly thereafter. Upon arrival at the hospital, a blood glucose of 553 mg/dL was detected. A urinalysis was positive for ketones (> 80 mg/dL), glucose (> 1000 mg/dL), and large budding yeast forms. A drug screen performed on the urine was positive for ethanol. At the coroner/medical examiner office, an autopsy was negative for significant anatomic findings. Toxicology analysis revealed a urine ethanol level 0.32 g/dL, although no ethanol was detected in blood or vitreous samples. A urine gram stain and culture identified Candida glabrata. A retrospective case review of all deaths related to diabetes examined at the coroner/medical examiner office from 1986 to 2003 did not reveal other cases with similar findings. This case of a noncompliant, juvenile-diabetic woman illustrates a rare finding of apparent in vivo glucose fermentation by C. glabrata to form ethanol in the urine. This case also highlights a potential difficulty in toxicologic analysis and interpretation using urine only.     

A comparison of the male customers of female street prostitutes with national samples of men

Previous research on customers of prostitutes has relied on small samples and qualitative interviews. Conceptions of customers have tended toward either the "every man" perspective, which implies customers are no different than other men, or the "peculiar man" perspective, which implies customers are characterized by stark differences or psychological inadequacies. This study compares a large sample of men (N = 1672) arrested for trying to hire street prostitutes with nationally representative samples of men. Customers were less likely to be married, less likely to be happily married if married, and more likely to report being unhappy in general than men in the national samples. Customers also expressed greater sexual liberalism and reported thinking about sex, masturbating, and participating in other aspects of the sex industry more frequently than men in general. Most differences were small, indicating customers as a category differ from other men in degree rather than quality.     

Accidental insulin overdose

Exogenous insulin has been used for many years to treat diabetes mellitus. Due to the complex nature of insulin therapy, there have been numerous accidental overdoses by these patients. Unfortunately, in other instances, insulin has been used as an agent for suicide and homicide in diabetics as well as nondiabetics. Presented here is a fatal case of accidental insulin overdose in a nondiabetic. Following the case presentation, we review insulin pharmacology and the methods of diagnosing insulin overdose postmortem. In any case of insulin overdose, a comprehensive scene investigation to document the amount and type of insulin used, along with information revealing the source of the insulin is critical. In addition, a complete autopsy, including appropriate laboratory studies, is needed to make a diagnosis in these cases. Proper attention should be given to collection and storage of blood samples, as these specimens often yield the strongest evidence of insulin overdose.     

Dr. Jekyll's waiver of Mr. Hyde's right to refuse medical treatment: Washington's new law authorizing mental health care advance directives needs additional protection

Mental health care advance directives are gaining popularity nationwide. Following a growing trend, the Washington State Legislature has recently passed a law allowing patients to draft mental health care advance directives that could be irrevocable. Patients who sign an irrevocable directive essentially waive their fundamental right to refuse treatment in the future. The United States Supreme Court has held that waivers of fundamental rights must be made knowingly, voluntarily, and intelligently. However, as passed, Washington's new law contains insufficient safeguards to guarantee such a waiver. This Comment proposes that the Washington State Legislature amend this law the require two additional protections: a "rights advocate" to explain the potential waiver of rights, and a written warning in the advance directive form. These safeguards will help ensure that patients make knowing and intelligent waivers of their fundamental right to refuse treatment.     

Landmark among decision-making and policy analyses and template for integrating alternative frames of reference: Glenn D. Paige,The Korean Decision

That policies and decisions provide distinctive foci for the application of scholarly attention is a hallmark of the last half of the 20th century. Among landmark invocations of such attention was and is Glenn D. Paige's The Korean Decision. Landmarks represent creative achievements that lay down original formulations or findings or point the ways to original findings, and they do so with high quality of method and exposition. The Korean Decision exhibited the first and fullest use of Richard C. Snyder's decision-making approach in the study of public order decisions and it did so in ways that opened new lines of inquiry. It also rendered evident equivalencies with the decision-centered conception of the policy sciences as formulated by Harold D. Lasswell and Myres S. McDougal. This reappraisal of Paige's classic work stresses explicit and implicit complementarities between one decision-making approach and the policy sciences. Several equivalencies illustrate points at which the addition or the overlap of one scheme to and with another may enrich alternative approaches to common phenomena, including observational standpoint, conceptions of the decision process, definition of decisional situations, crisis as a special occasion for decision, linkages among variables, and appraisal as a particular decision process function.     

Postmortem diagnosis of unsuspected diabetes mellitus established by determination of decedent's hemoglobin A1c level.

Although approximately 15.7 million Americans have diabetes mellitus, with the vast majority having type 2 diabetes, it is estimated that as many as 5.4 million are undiagnosed. The present case illustrates that undiagnosed diabetes can be a factor in otherwise unexplained deaths. A 39-year-old white male with no significant past medical history other than alcohol abuse was found deceased at his residence. The manner of death appeared to be natural, but no anatomic cause was found. Toxicological analysis revealed a blood ethanol level of 0.02 g/dL and was negative for drugs of abuse. Analysis of the vitreous fluid revealed a glucose level of 502 mg/dL. The blood glucose level was 499 mg/dL, and the hemoglobin A1c (HbA1c) level was 10.6%. Only trace urine ketones were detected, suggesting that the death was the result of hyperglycemic hyperosmolar non-ketosis (HHNK) from unsuspected diabetes. The postmortem HbA1c value serves as a definitive indicator of prolonged hyperglycemia. In order to aid the interpretation of the clinical data, this case is discussed in conjunction with a similar case of a known diabetic patient.     

Do Ministers Do What They Say? Ministerial Unreliability, Collegial and Hierarchical Governments

This paper is concerned with the extent to which individual members of governments reliably implement the decisions of the governments to which they belong, a matter which is rarely discussed, if ever, and yet can be critical for the operation of national executives. After a general presentation of the problem, the paper examines the reasons why members of collegial governments are more likely to be reliable than members of hierarchical governments. As 'cabinet' governments tend to be more collegial while 'presidential' governments tend to be more hierarchical, unreliability seems also more likely to take place in presidential governments, to the extent that these are indeed hierarchical. Progress in this area has been hampered so far by the absence of a tight operational definition of collegial and hierarchical governments: such a definition is presented here, opening the way for the empirical testing of the impact which the distinction may have on the reliability of members of governments.