By H. Anog. Mount Mercy College.

Medical Context It is not difficult to identify numerous factors affecting contempo- rary medical practice that have exacerbated medical malpractice liability within this broader cultural context clindamycin 150 mg online antibiotic resistance transfer. Although ideally it offered the potential of cost sav- ings buy clindamycin 150mg with mastercard antibiotic resistance nz, efficient medical practice patterns, and enhanced quality assess- ment and assurance, we have arrived at a place where virtually no major constituency is satisfied. Physicians and health care institutions are frustrated by reimbursement limitations, increased paperwork, and interruption of the traditional doctor–patient relationship. Patients decry access restrictions, reduced insurance coverage, and the need for frequent provider changes. Payors are unhappy with the resump- tion of significant increases in costs. Congress, seeing general dissat- isfaction with the system, has attempted to pass legislation (i. With virtually everyone disgruntled with significant aspects of their health care experience, the likelihood of malpractice suits increases. Because patient litigation against managed care organizations directly is limited by federal law (Employee Retirement Income Security Act [ERISA]), physicians often find they are targeted in litigation that might otherwise have been focused elsewhere. Suits alleging delayed diagnosis and failure to refer to appropriate specialists are especially potentiated because the real and imagined impediments of managed care in these areas resonate with juries. Contemporary medical advances, especially in the realm of “medi- cal miracles,” are almost all technologically based. High-tech care is often low touch, and the skills needed to operate in this complex medical environment are not necessarily those that facilitate good bedside manner. Moreover, as the boundaries of possible medical intervention expand, expectations also rise. This produces potential litigation over adverse outcomes even in the most medically desperate circumstances. Chapter 15 / The Case for Legal Reform 205 Severity Severity is an insurance term of art that refers to the cost of the average claim. By extension, it also connotes the range of potential adverse outcomes or the downside risk of taking a case to court. Since 1997, the increase in severity of medical malpractice litigation has been striking. The median malpractice verdict doubled from approx $500,000 to $1 million between 1997 and 2000 (11), and the mean verdict increased from $1. The likelihood of a plaintiff’s verdict exceeding $1 mil- lion increased from 34% in the period from 1994 to 1996 to 52% between 1999 and 2000 (12). Therefore, it is not surprising that the total medical malpractice tort cost rose from $8. The amplification in the cost of the outlier verdict has been even greater. Several states have seen malpractice awards in excess of $100 million (2). Until 2000, malpractice judgments were rarely, if ever, among the 10 largest in the United States in any given year. Moreover, this list included a $312 million award against a nursing home for the care of a single patient, and a California jury returned a $3 billion verdict against the tobacco companies for the lung cancer death of a single smoker. Thus, 4 of the 10 largest judgments in the United States involved adverse health care outcomes for single indi- viduals (14). By 2002, fully half of the 10 largest awards in the United States involved health care outcomes of single individuals (15). Frequency Frequency is another defined insurance term referring to the likeli- hood of a claim in a defined population of policyholders. Frequency is very high among all physicians and averaged 15 to 16% in recent years, although the differences among specialties are significant (see Fig. Approximately 55% of neurosur- geons report a claim (defined as a demand for payment) every year (16). This means the average neurosurgeon would face a new claim every other year.

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As a result discount clindamycin 150mg overnight delivery antimicrobial compounds, they adapt the environment to promote safe- may be reluctant to participate in activi- ty and maximum independence generic 150 mg clindamycin with visa antimicrobial qualities. Occupa- ties designed to maintain or improve their tional therapists may help individuals current level of function. Speech therapists ed to behavioral changes may result in may help individuals maximize their unsafe situations for the individual. Those speech capability as well as their ability to who are in denial about their condition swallow. In some instances cognitive and their limitations may also be exposed retraining and memory training may be to situations that could result in unsafe useful. Individuals are usually affected in cult, social interactions also become more middle or later life, with males affected difficult, resulting in increasing social iso- more frequently than women. Personality changes that may pro- duce violent or hostile behaviors further Manifestations of ALS stress support systems. Because Huntington’s disease has a Symptoms of ALS depend on the area of genetic component, family members may the nervous system affected; both upper be under the additional stress of knowing and lower extremities are affected. There that they may themselves be at risk for are two primary forms of ALS: developing Huntington’s disease. Coun- • Spinal form seling, education, and support can help to • Bulbar form reduce the stress that family members may be experiencing. The spinal form of ALS is characterized by muscular weakness, muscle atrophy Vocational Issues in Huntington’s Disease (decrease in size), spasticity, and hyperac- tive reflexes. Individuals may first com- Huntington’s disease is a progressive, plain of tripping, stumbling, or awk- degenerative disease; however, in the ear- wardness when walking or running. In the bulbar condition progresses and individuals have form individuals may first notice difficul- increasing difficulty with memory, com- ty in breathing, slurring of speech or low- munication skills, and physical ability, ered volume when speaking, or difficulty sheltered employment may be the most with swallowing. As the condition progresses, symptoms become worse, spreading to other parts of Amyotrophic Lateral Sclerosis the body so that eventually, whether the (ALS; Lou Gehrig’s Disease) individual first experienced the bulbar or spinal form of ALS, he or she eventually Amyotrophic lateral sclerosis (ALS), also experiences all the symptoms. Individuals sometimes referred to as Lou Gehrig’s dis- become increasingly weak and immobile. They may experience respiratory mus- current medical theory suggests a multi- cle weakness leading to breathing factorial etiology that may include genet- problems, and in later stages of the con- ic, viral, autoimmune, and neurotoxic fac- dition they may require ventilatory assis- Neuromuscular Conditions 101 tance in order to breathe. Cognitive func- Psychosocial Issues in ALS tion, sensation, vision, hearing, and bow- el and bladder function are usually not The social, economic, and psychologi- affected. It is common for individuals with ALS to Diagnosis of ALS experience fear, anxiety, and depression, especially as the condition progresses There is no reliable laboratory test to and the individual recognizes rapid pro- detect the presence of ALS. Diagnosis is gressive deterioration of physical func- usually based on the symptoms the indi- tion. Because of loss of mobility and in- vidual exhibits and their progression and creased dependency, feelings of helpless- the individual’s medical history, and by ness and powerlessness are also common. Some individuals may experience discour- agement and become angry as their phys- Treatment and Management of ALS ical limitations increase. They may ex- perience grief with each subsequent loss of There is no cure for ALS, and no effec- function. There may be loss in social rela- tive treatment is currently available. They may feel vidual with ALS to remain independent as guilty because of their increased depend- long as possible, be comfortable, and ence on others and may express concern avoid complications. Treatment of symp- and frustration over the burden they feel toms is used to maintain muscle function, is being placed on family members. Medications to reduce Since individuals with ALS need sub- spasticity may be used; however, these stantial help with most activities of daily can also increase muscle weakness and living, family members most often find cause sedation. Physical therapy may be themselves in a caregiving role even in helpful to maintain function and to the early stages of the individual’s condi- reduce the painful symptoms brought on tion. If the individ- Occupational therapists can provide sup- ual with ALS is also the major breadwin- port and help individuals to adapt their ner, financial issues may become a major environment in order to maximize func- concern. Individuals with speech difficul- to assume the caregiving role, which fur- ties may utilize speech therapists to help ther contributes to financial distress. Family members may also have feelings of Speech pathologists may be utilized to help powerlessness, anger, or anxiety about the individuals who have difficulty with swal- future. Using special techniques and equipment that enhance Guillain-Barré syndrome is an inflam- their functional capacity and independ- matory condition of the peripheral nerves ence in self-care can help them exert per- (nerves lying outside the central nervous sonal control over their life and thus system).

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Radiology 229:710-717 Daldrup HE generic clindamycin 150 mg on-line antimicrobial ointments, Link TM buy clindamycin 150mg with mastercard virus apparel, Blasius S et al (1999) Monitoring radiation- Ryan SP, Weinberger E, White KS et al (1995) MR imaging of induced changes in bone marrow histopathology with ultra- bone marrow in children with osteosarcoma: effect of granu- small superparamagnetic iron oxide (USPIO)-enhanced MRI. AJR Am J Roentgenol J Magn Reson Imaging 9:643-652 165:915-920 Daldrup-Link HE, Rummeny EJ, Ihssen B, Kienast J, Link TM Schmidt GP, Baur-Melnyk A, Tiling R, Hahn K, Reiser MF, (2002) Iron-oxide-enhanced MR imaging of bone marrow in Schoenberg SO (2004) Hochauflösendes Ganzkörpertumors- patients with non-Hodgkin’s lymphoma: differentiation be- taging unter Verwendung paralleler Bildgebung im Vergleich tween tumor infiltration and hypercellular bone marrow. Radiologe 44:889-898 Deely DM, Schweitzer ME (1997) MR imaging of bone marrow Seiderer M, Stäbler A, Wagner H (1999) MRI of bone marrow: op- disorders. Radiol Clin North Am 35:193-212 posed-phase gradient-echo sequences with long repetition Dunnill MS, Anderson JA, Whitehead R (1967) Quantitative his- time. J Path Bact Seneterre E, Weissleder R, Jaramillo D et al (1991) Bone marrow: 94:275-291 ultrasmall superparamagnetic iron oxide for MR imaging. Durie BGM, Salmon SE (1975) A clinical staging system for mul- Radiology 179:529-533 tiple myeloma. Correlation of measured myeloma cell mass Stäbler A, Baur A, Bartl R, Munker R, Lamerz R, Reiser MF with presenting clinical features, response to treatment, and (1996) Contrast enhancement and quantitative signal analysis survival. Cancer 36:842-854 in MR imaging of multiple myeloma: assessment of focal and Engelhard K, Hollenbach HP, Wohlfart K, von Imhoff E, Fellner diffuse growth patterns in marrow correlated with biopsies and FA (2004) Comparison of whole-body MRI with automatic survival rates. AJR Am J Roentgenol 167:1029-1036 moving table technique and bone scintigraphy for screening Stäbler A, Doma AB, Baur A, Krüger A, Reiser MF (2000) for bone metastases in patients with breast cancer. Eur Radiol Quantitative Assessment of Reactive Bone Marrow Changes in 14:99-105 Infectious Spondylitis. Radiology, Radiology 217:863-868 Frager D, Elkin C, Swerdlow M, Bloch S (1988) Subacute osteo- Stäbler A, Krimmel K, Seiderer M, Gartner C, Fritsch S, Raum W. Skeletal Radiol 17:123-126 W (1992) Kernspintomographische Differenzierung osteo- 82 A. Stäbler porotisch und tumorbedingter Wirbelkörperfrakturen: head: predictive value of MR imaging findings. Radiology Wertigkeit von subtraktiven Gradientenechosequenzen mit 212:527-535 verlängerter Repetitionszeit, STIR Sequenzen und Gd-DTPA. Vande Berg BC, Michaux L, Scheiff JM et al (1996) Sequential Fortschr Röntgenstr 157:215-221 quantitative MR analysis of bone marrow: differences during Stäbler A, Schneider P, Link TM, Schöps P, Springer OS, Dürr HR, treatment of lymphoid versus myeloid leukemia. Radiology Reiser M (1999) Intravertebral vacuum phenomenon following 201:519-523 fractures: CT study on frequency and etiology. J Comput Vanel D, Missenard G, Le Cesne A, Guinebretiere JM (1997) Red Assist Tomogr 23:976-980 marrow recolonization induced by growth factors mimicking Steinborn MM, Heuck AF, Tiling R, Bruegel M, Gauger L, Reiser an increase in tumor volume during preoperative chemothera- MF (1999) Whole-body bone marrow MRI in patients with py: MR study. J Comput Assist Tomogr 21:529-531 metastatic disease to the skeletal system. Radiology Tomogr 23:123-129 168:679-693 Steiner RM, Mitchell DG, Rao VM, Schweitzer ME (1993) Wilson AJ, Murphy WA, Hardy DC, Totty WG (1988) Transient os- Magnetic resonance imaging of diffuse bone marrow disease. Radiol Clin North Am 31:383-409 167(3):757-60 Tunaci M, Tunaci A, Engin G et al (1999) Imaging features of tha- Wismer GL, Rosen BR, Buxton R, Stark DD, Brady TJ (1985) lassemia. Eur Radiol 9:1804-1809 Chemical shift imaging of bone marrow: preliminary experi- Vande Berg BE, Malghem JJ, Labaisse MA, Noel HM, Maldague ence. AJR Am J Roentgenol 145:1031-1037 BE (1993) MR imaging of avascular necrosis and transient Yuh WTC, Zachar CK, Barloon TJ, Sato Y, Sickels WJ, Hawes DR marrow edema of the femoral head. Radiographics 13:501-520 (1989) Vertebral compression fractures: Distinction between Vande Berg BC, Malghem JJ, Lecouvet FE, Jamart J, Maldague BE benign and malignant causes with MR imaging. Radiology (1999) Idiopathic bone marrow edema lesions of the femoral 172:215-218 IDKD 2005 Metabolic and Systemic Bone Diseases* J. Freyschmidt Department of Radiology, Central Hospital, Bremen, Germany Introduction Radiology of hyperparathyroidism Metabolic bone diseases represent a fascinating nosolog- To understand the radiology of HPT, it is important to ic group, caused by inborn as well as acquired distur- know that only osteoblasts have classic receptors for bances of bone metabolism. In contrast, osteoclasts are stimulated by bone metabolism may be involved, resulting in various intercellular messengers (e. Only in later stages of the disease when Hyperparathyroidism the parathormone level has been increased over a longer period trabecular bone resorption may occur. Because Hyperparathyroidism (HPT) is defined as an increased HPT today is usually detected early through increased lev- level of parathormone and parathormone peptides in the els of serum calcium, we observe more patients with more serum. It can be devided into three types: bone and fewer patients with less bone, as in former times.

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These connections become visible channels or canaliculi Complete demineralization of bone leaves a flexible collagen that provide direct contact for osteocytes deep in bone framework discount clindamycin 150mg line antibiotics for uti new zealand, and the complete removal of organic matrix with other osteocytes and with the bone surface order clindamycin 150mg otc antibiotics for acne tetralysal. It is gen- leaves a bone with its original shape, but extremely brittle. The three principal cell types involved in bone Osteoclasts are cells responsible for bone resorption. Osteoclasts promote bone resorption by secreting Osteoblasts are located on the bone surface and are re- acid and proteolytic enzymes into the space adjacent to sponsible for osteoid synthesis. Surfaces of osteoclasts facing bone are tively synthesize proteins for export, osteoblasts have an ruffled to increase their surface area and promote bone abundant rough ER and Golgi apparatus. First, gaged in osteoid synthesis are cuboidal, while those less ac- osteoclasts create a local acidic environment that in- tive are more flattened. Numerous cytoplasmic processes creases the solubility of surface bone mineral. Second, connect adjacent osteoblasts on the bone surface and con- proteolytic enzymes secreted by osteoclasts degrade the nect osteoblasts with osteocytes deeper in the bone. Early in fetal mineralized, and in the process, osteoblasts become sur- development, the skeleton consists of little more than a car- rounded by mineralized bone. The process of replacing this cartilaginous model with ma- ture, mineralized bone begins in the center of the cartilage and progresses toward the two ends of what will later form the bone. As mineralization progresses, the bone increases in thickness and in length. The epiphyseal plate is a region of growing bone of par- ticular interest because it is here that the elongation and growth of bones occurs after birth. Histologically, the epi- physeal plate shows considerable differences between its leading and trailing edges. The leading edge consists pri- marily of chondrocytes, which are actively engaged in the synthesis of cartilage of the epiphyseal plate. These cells gradually become engulfed in their own cartilage and are replaced by new cells on the cartilage surface, allowing the process to continue. The cartilage gradually becomes calci- fied, and the embedded chondrocytes die. The calcified cartilage begins to erode, and osteoblasts migrate into the area. Osteoblasts secrete osteoid, which eventually be- comes mineralized, and new mature bone is formed. In the epiphyseal plate, therefore, the continuing processes of cartilage synthesis, calcification, erosion, and osteoblast in- vasion result in a zone of active bone formation that moves away from the middle or center of the bone toward its end. Insulin-like growth factor I (IGF-I), primarily produced by the liver in response to growth hormone, serves as a primary stimulator of chondrocyte activity and, ultimately, of bone growth. Insulin and thyroid hormones provide an additional stimulus for chondrocyte activity. Beginning a few years after puberty, the epiphyseal plates in long bones (as in the legs and arms) gradually become less responsive to hormonal stimuli and, eventu- The location and relationship of the three ally, are totally unresponsive. For exam- Long-Term Regulation of Plasma Calcium and ple, those in the fingers, feet, skull, and jaw remain re- Phosphate Concentrations sponsive, which accounts for the skeletal changes seen in acromegaly, the condition of growth hormone overpro- The hormonal mechanisms described here have a large ca- duction (see Chapter 32). It may take several minutes or hours for the bone structure generally referred to as remodeling. However, modeling occurs along most of the outer surface of the bone, these are the principal mechanisms that regulate plasma making it either thinner or thicker, as required. Remodeling is an The Chemistry of Parathyroid Hormone, Calcitonin, and adaptive process that allows bone to be reshaped to meet 1,25-Dihydroxycholecalciferol and the Regulation of changing mechanical demands placed on the skeleton. One of the primary regulators of allows the body to store or mobilize calcium rapidly. Synthetic peptides containing the first 34 amino terminal residues appear to be as active as the REGULATION OF PLASMA CALCIUM native hormone. AND PHOSPHATE CONCENTRATIONS There are two pairs of parathyroid glands, located on Regulatory mechanisms for calcium include rapid nonhor- the dorsal surface of the left and right lobes of the thyroid monal mechanisms with limited capacity and somewhat gland. Because of this close proximity, damage to the slower hormonally regulated mechanisms with much parathyroid glands or to their blood supply may occur dur- greater capacity. There are also similar mechanisms in- ing surgical removal of the thyroid gland. The primary physiological stimulus for PTH secretion is a decrease in plasma calcium.

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