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By K. Khabir. Golden State Baptist College.

SUMMARY AND CONCLUSIONS The crisis in medical malpractice insurance has arisen in a context of a dramatic increase in the overall scope and cost of litigation in the United States discount biaxin 250mg overnight delivery. However 500mg biaxin fast delivery, there are a number of factors specific to medi- cine that have accelerated this event discount biaxin 250mg mastercard. They have in common an under- mining of the doctor–patient relationship and include dissatisfaction with managed care order biaxin 500 mg without prescription, the increased use of technology in medicine, weak- ening the personal bonds between physician and patient, and rising expectations for medical interventions. Increasing severity has led to an unprecedented increase in the cost of malpractice claims, now surpassing $20 billion per year and still rising rapidly. A high percentage of America’s physicians are currently in litigation and 600 new claims are opened daily. In the highest risk specialties, 33 to 50% of all practitioners report a claim every year. Even worse, there is no evidence that malpractice suits reliably identify “bad” Chapter 15 / The Case for Legal Reform 223 doctors. Litigation outcomes are correlated with patient injury rather than medical negli- gence, and even paid claims are only weakly predictive of future litiga- tion problems for individual physicians. Certain specialties have become repetitive targets for malpractice suits because of the serious nature of the clinical problems rather than the quality of the medicine being prac- ticed. Although several factors have contributed to the increased cost of malpractice insurance, the rising cost of claims is by far the most impor- tant. Falling interest rates, higher costs for reinsurance, shrinking capac- ity, and judicial nullification of existing legal reforms are also issues. Since 1975, we have had direct experience with various legal reforms and clear knowledge of which of these are effective and which are not. It is best to effectuate legal reform as part of a comprehensive package based on California’s MICRA experience. A $250,000 cap on noneco- nomic damages is most important, but collateral source reform, a peri- odic payments rule, and control of attorney contingency fees are also important. Other reforms may be appropriate and useful, but a quarter century of experience indicates they will have much less impact than the MICRA statutes. In the absence of these reforms, it is predictable that the cost of malpractice insurance will continue to rise, as will the cost of medical care in general, defensive medicine will increase, and access to funda- mental health care will be increasingly imperiled. Confronting the New Health Care Crisis: Improving Health Care Quality and Lowering Costs by Fixing Our Medical Liability System. Medical Malpractice: Implications of Rising Premiums on Access to Health Care. Subcom- mittee on Health, Committee on Energy and Commerce, US House of Represen- tatives. Straight Talk on Medical Malpractice: American Trial Law- yers Association, 1994:20. Governor’s Select Task Force on Healthcare Professional Liability Insurance. Medical Malpractice Insurance: Mul- tiple Factors Have Contributed to Increased Premium Rates. Relation between negligent adverse events in the outcomes of medical malpractice litigation. Medical Malpractice Insur- ance: A Study of Market Conditions, 2003, pp. National Association of Insurance Commissioners 1999 Profitability Study, 1999. An Analysis of Harvey Rosenfield’s Report: “California’s MICRA”: LECG, 1997, p. Medical Liability Mutual Insurance Company Projected Effect on New York Professional Liability Costs of Capping Noneconomic Dam- ages: Milliman & Robertson, 1995. California’s medical malpractice crisis: Health Care Liability Alliance, 2003, pp.

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The trapezius mus- trapezius muscle posteriorly; the clavicle forms its base inferiorly order biaxin 500mg with mastercard. An inflamma- Three structures traversing the neck are extremely important tion of the trapezius causes a “stiff neck discount 250 mg biaxin free shipping. These structures are the common if a shirt collar is too tight buy biaxin 500 mg amex, the external jugular vein can be carotid artery biaxin 250mg overnight delivery, which carries blood to the head; the internal jugular seen as it courses obliquely across the sternocleidomastoid vein, which drains blood from the head; and the vagus nerve, which conducts nerve impulses to visceral organs. Cervical lymph nodes of the lateral neck region may protected in the neck by their deep position behind the sternocleido- become swollen and painful from infectious diseases of the oral mastoid muscle and by their enclosure in a tough connective tissue or pharyngeal regions. Most of the structures of the nucha are too deep to be of importance in surface anatomy. The spines of the lower cervical Internal Anatomy vertebrae (especially C7), however, can be observed and pal- pated when the neck is flexed. The organs of the neck are ridge that extends superiorly from vertebra C7 to the external highly integrated and packed into a relatively small area. Clinically, the ligamentum has to support the head,at the same time permitting flexibility. Surface and Regional © The McGraw−Hill Anatomy, Sixth Edition Anatomy Companies, 2001 308 Unit 4 Support and Movement Submandibular triangle Submental triangle Anterior cervical triangle Supraclavicular Carotid triangle triangle Posterior cervical Omotracheal triangle triangle Omoclavicular (a) (b) triangle Stylohyoid m. Surface and Regional © The McGraw−Hill Anatomy, Sixth Edition Anatomy Companies, 2001 Chapter 10 Surface and Regional Anatomy 309 1 8 2 3 7 4 8 5 9 6 9 10 1 11 2 12 3 13 4 14 15 7 5 16 6 1 Accessory n. Surface Anatomy Knowledge Check The trunk, or torso, is divided into the back, thorax (chest), ab- 9. Identify the pelvis and perineum are discussed in the following section. With reference to the triangles of the neck, where would in determining the location and condition of the visceral organs. Back TRUNK No matter how obese a person may be, a median furrow can be seen on the back, along with some of the spinous process of the The locations of vital visceral organs in the cavities of the trunk vertebrae (fig. The entire series of vertebral spines can be make the surface anatomy of this body region especially important. This position is important in determining defects of the vertebral column (see Objective 10 Identify various surface features of the trunk Clinical Considerations in chapters 8 and 11). The base of Objective 11 List the auscultation sites of the thorax the spine of the scapula is level with the third thoracic vertebra, and abdomen. Surface and Regional © The McGraw−Hill Anatomy, Sixth Edition Anatomy Companies, 2001 310 Unit 4 Support and Movement Spinous process of seventh cervical vertebra Deltoid m. Triangle of auscultation Inferior angle of scapula Median furrow over spinous processes of vertebrae Latissimus dorsi m. Several muscles of the scapula can be observed angle is felt as an elevation between the manubrium and body of on a lean, muscular person and are identified in figure 10. The sternal angle is important because it is located Many of the ribs and muscles that attach to the ribs can be seen at the level of the second rib. Because there is a space be- lower oblique boundary and can be easily identified when a per- tween the superficial back muscles in this area, heart and son inhales and holds his or her breath (see fig. The respiratory sounds are not muffled by the muscles when a stetho- costal angle (costal arch) is where the costal margins come to- scope is placed here. With the ex- women, their position varies according to age and the size and ception of the breasts and surrounding lymph nodes, the organs pendulousness of the breasts (fig. The paired clavi- left nipple in males is an important landmark for knowing cles and the jugular notch have already been identified as impor- where to listen to various heart sounds and for determining tant surface features of the neck, with regard to the thoracic whether the heart is enlarged. Several su- All but the first, and at times the twelfth, can be palpated. The perficial chest muscles can be observed or palpated and are sternum is composed of three separate bones (manubrium, body, therefore important surface features. These muscles are de- and xiphoid process), each of which can be palpated. Surface and Regional © The McGraw−Hill Anatomy, Sixth Edition Anatomy Companies, 2001 Chapter 10 Surface and Regional Anatomy 311 Deltoid m. Body of sternum Axilla Nipple Xiphoid process Groove over Rib linea alba FIGURE 10.

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D4 occupancy was thus inferred rather than established by a specific D4 antagonist 500 mg biaxin otc. When such a selective D4 antagonist order 250 mg biaxin otc, L-745 purchase biaxin 500 mg otc,870 trusted 250 mg biaxin, became available and was tested in 38 schizophrenics it proved ineffective at what were considered to be doses sufficient to occupy 50% of the D4 receptors (Bristow et al. It has not been used apparently to assess D4 receptor number in schizophrenic brain. There are few specific drugs for D3 receptors but D3 knock-out mice show no behavioural defects. Thus the significance of any DA receptor other than the D2 still remains to be established (see Seeman and Van Tol 1994; Sokoloff and Schwartz 1995; Strange 1994). Involvement of other NTs Acetylcholine Neuroleptic-induced Parkinsonism (but not tardive dyskinesias) can be reduced by antimuscarinic drugs. It is generally assumed that neuroleptic antagonism of DA- mediated inhibition in the striatum leaves the excitatory muscarinic action of ACh unchecked (Fig. The atypical neuro- leptics thioridizine and clozapine both have potent inherent antimuscarinic activity with PA2 values (7±8) similar to that for atropine and more than a hundredfold that of a typical neuroleptic-like haloperidol. Thus each compound has the ability to nullify its own antidopamine effect in the striatum and stop Parkinsonian symptoms developing (Fig. There is no evidence that antimuscarinic activity has any effect on schizo- phrenia and thioridizine has no more effect on negative symptoms than typical neuroleptics. Of course, since clozapine is also a weaker D2 antagonist than thioridizine this automatically reduces its ability to produce EPSs anyway. This has centred primarily on 5-HT2A receptors found in the limbic cortex, which are linked to neuronal excitation and believed to mediate the hallucinogenic effects of drugs such as lysergic acid diethylamide (LSD). Generally most atypical neuroleptics have higher affinity for 5-HT2 than D2 receptors while typical ones retain a preference for the D2 receptor. There is, however, no infallible separation since chlorpromazine (typical neuroleptic) is more active at 5-HT2A 366 NEUROTRANSMITTERS, DRUGS AND BRAIN FUNCTION Figure 17. Normally the inhibitory effects of DA released from nigrostriatal afferents on to striatal neuron D2 receptors is believed to balance the excitatory effect of ACh from intrinsic neurons acting on muscarinic (M2) receptors (a). Typical neuroleptics block the inhibitory effect of DA which leaves unopposed the excitatory effect of ACh (b) leading to the augmented activity of the striatal neurons and EPSs (see Fig. An atypical neuroleptic with intrinsic antimuscarinic activity reduces this possibility by counteracting the excitatory effects of released ACh as well as the inhibitory effects of DA (c). Thus the control of striatal neurons remains balanced than D2 receptors and remoxidpride (atypical) more active at D2 than 5-HT2A. Also differences in the values for the dissociation constants between experimental studies (see later) make comparisons between D2 and 5-HT2A potency somewhat difficult. No neuroleptic has purely 5-HT2A antagonist activity and a pure 5-HT2A antagonist drug may not have neuroleptic activity. Risperidone, an atypical neuroleptic with some benefit against negative symptoms, is the most potent of all neuroleptics at 5-HT2A receptors (K1: 0. Some in vitro measurements show it to have up to 25 times more affinity for 5-HT2A than D2receptors and PET studies indicate that at therapeutic doses it displaces a 5-HT2 ligand in preference to a D2 one. Clozapine is also claimed to occupy over 80% of 5-HT2 and less than half this number of D2 receptors at clinical doses. Neuroleptics with 5-HT2 antagonist activity not only produce fewer EPSs but 5-HT2 antagonists reduce neuroleptic-induced EPSs. Fibres from 5-HT neurons in the raphe nucleus innervate and yet, despite the observed 5-HT2A receptor link with neuronal excitation, appear to inhibit DA neurons in the SN (A9). Thus antagonism of 5-HT released onto them would increase their firing and so reduce the likelihood of EPSs, although how 5-HT2A antagonists can SCHIZOPHRENIA 367 overcome the established motor side-effects of another neuroleptic is less clear if that compound has already caused a depolarising block of the neurons. The mechanism by which 5-HT2 antagonism could ameliorate schizophrenic symptoms and what effect 5-HT has on mesolimbic and mesocortical pathways through A10 neurons is even less certain. The probability that neuroleptics benefit from a particular balance of DA and 5-HT2A antagonism is developed later.

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