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Institutional malpractice liability has potential advantages over individual liability in terms of patient welfare discount super avana 160 mg online erectile dysfunction medication nz, loss-spreading generic 160mg super avana fast delivery treatment of erectile dysfunction in unani medicine, and administrative efficiency. One goal is to get all major health carecon- tributors on the same page regarding safety. Under current law, (spe- cifically, the Employee Retirement Income Security Act), ERISA shield selectively shelters managed care organizations from liability for personal injury, although courts have evolved serviceable, if not entirely logical, distinctions between benefits determinations and clinical decisions that have resulted in de facto health plan liability in many cases (54). Aligning incentives was the premise behind the Clinton Administration’s controversial proposal to focus liability on health plans in connection with national health reform (55). The sub- sequent move away from tightly managed care made the case for ex- clusive health plan liability less compelling (56). This led to renewed Chapter 17 / New Directions in Liability Reform 269 interest in hospital-based enterprise liability (57), particularly as evi- dence accumulated that most medical errors need to be addressed at the organizational level (15). However, scholars continue to argue that managed care organizations are well-positioned to monitor physician practice (58) and promote long-term investment in safety (59). Ide- ally, health systems would not only integrate their patient safety and risk management efforts but would link these clinical activities to health insurance benefit design and provider payment practices (60,61). Institutional liability might improve patient compensation by linking the malpractice system to regulatory oversight that promotes early iden- tification of avoidable injury and prompt resolution of potential claims. Because malpractice suits involving severe harm are typically associ- ated with inpatient care and name multiple defendants, consolidated liability can substantially reduce delay and administrative cost when claims arise, particularly if the responsible institution has established a mediation or arbitration system to handle disputes. Large medical insti- tutions may also be better risk-bearers than individually insured physi- cians because they can diversify legal exposure over the full spectrum of clinical services and have access to a wider array of commercial coverage options and self-insurance vehicles. However, the greater vulnerability of corporate defendants to jury assessments of punitive damages might undercut some of these advantages (62). The principal barriers to adopting institutional liability are political. The American health care system is still fragmented; therefore, grassroots reforms that benefit large numbers of solo practitioners and small medical groups are most attractive to lawmakers. Further, the lobbying momentum for general business tort reform that typically builds during malpractice insurance crises makes it difficult to incor- porate provisions that would expand corporate liability in politically viable legislation. As was clear from the reaction to the Clinton pro- posal, physicians also worry that institutional liability will further shift clinical authority as well as legal and financial responsibility to corpo- rate organizations. On the other hand, the severity of the current mal- practice crisis, coupled with physicians’ sense that their autonomy has already been severely compromised, may eventually make the medical profession more supportive of comprehensive institutional liability. Information and Choice Information about medical errors and provider responsibility com- prises a fourth important category of cutting-edge malpractice reforms. If patients had perfect information, they would only choose competent physicians with whom they could agree in advance on acceptable criteria for care and for payment. However, in economist Patricia Danzon’s words: “Just as imperfect information undermines the efficient functioning of the mar- ket, imperfect information undermines the efficient functioning of the liability system... Therefore, an alternative is to focus reform on improving information for both providers and patients and on leveling the playing field between them. Informational measures take two common forms: error disclosure requirements involving spe- cific patients, and publicly available information about malpractice judgments and settlements. As the Danzon quote suggests, greater transparency regarding medi- cal errors might eventually open private contractual alternatives to tort liability. The primary objection to private contracting has been that patients are poorly informed and are not in a position to weigh the risks when they are in need of medical care. Private contracting would allow parties to contract out of judicially mandated tort rules and might specify the circumstances for liability, the basis for damages, and the rules and forum for dispute resolution (63). Institutional liability can also be structured around private contracts (64), with managed care plans and patients sharing the savings from cost-reducing contractual change through lower premiums for health insurance. By the end of 2003, eight states had made information about indi- vidual physicians’ malpractice histories publicly available on the Internet. States vary as to whether they disclose claims, settlements, or judgments and as to whether liability insurers or physicians are prima- rily responsible for reporting this information to the government.

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Am ever there is evidence for distraction injury involving the J Roentgoenol 176:373-380 10 buy generic super avana 160mg on line non prescription erectile dysfunction drugs. Wicky S buy super avana 160 mg otc relative impotence judiciary, Blaser PF, Blanc CH et al (2000) Comparison be- lateral compartment of the knee, or impaction injury in- tween standard radiography and spiral CT with 3D recon- volving the medial compartment. Evidence of later- struction in the evaluation, classification and management of al distraction injury includes sprain of the fibular collat- tibial plateau fractures. Eur Radiol 10:1227-1232 eral ligament and strain of the iliotibial band or popliteus 11. Anteromedial kissing contusions are closely as- tector CT in skeletal trauma. Semin Musculoskelet Radiol 8:147-156 sociated with posterolateral avulsion injury. Mutschler C, Vande Berg BC, Lecouvet FE et al (2003) traction fracture is suspected based on MRI findings, it is Postoperative meniscus: assessment at dual-detector row spiral reasonable to recommend plain radiography to exclude CT arthrography of the knee. Vande Berg BC, Lecouvet FE, Poilvache P et al (2002) Assessment of knee cartilage in cadavers with dual-detector spiral CT arthrography and MR imaging. Brossmann J, Preidler KW, Daenen B et al (1996) Imaging of osseous and cartilaginous intraarticular bodies in the knee: Multiple traumatic, degenerative, inflammatory, infec- comparison of MR imaging and MR arthrography with CT and CT arthrography in cadavers. Radiology 200:509-517 tious, and neoplastic conditions occur in and around the 15. Radiographs, ultrasound, CT, MR, and the postoperative meniscus of the knee: a study comparing arthrography each play a role in the imaging evaluation conventional arthrography, conventional MR imaging, MR of these conditions. Imaging is important not only to de- arthrography with iodinated contrast material, and MR tect or exclude disease, but also to stage, guide therapy, arthrography with gadolinium-based contrast material. Magee T, Shapiro M, Rodriguez J, Williams D (2003) MR Knee injury is the most frequent cause of sports-relat- arthrography of postoperative knee: for which patients is it ed disability. Huang GS, Yu JS, Munshi M et al (2003) Avulsion fracture of the knee: effect of field strength on efficacy. Am J the head of the fibula (the “arcuate” sign) : MR imaging find- Roentgoenol 161:115-118 ings predictive of injuries to the posterolateral ligaments and 18. Franklin PD, Lemon RA, Barden HS (1997) Accuracy of imag- posterior cruciate ligament. Am J Roentgoenol 180:381-387 ing the menisci on an in-office, dedicated, magnetic resonance 38. De Smet AA, Ilahi OA, Graf BK (1996) Reassessment of the imaging extremity system. Am J Sports Med 25:382-388 MR criteria for stability of osteochondritis dissecans in the 19. Skeletal Radiol 25:159-163 loskeletal system: technical considerations for enhancing im- 39. Kramer J, Stiglbauer R, Engel A et al (1992) MR contrast age quality and diagnostic yield. Speer KP, Spritzer CE, Goldner JL et al (1991) Magnetic res- oblique sagittal MR imaging. Radiology 175:276-277 onance imaging of traumatic knee articular cartilage injuries. Yu JS, Salonen DC, Hodler J et al (1996) Posterolateral aspect Am J Sports Med 19:396-402 of the knee: improved MR imaging with a coronal oblique 41. Radiology 198:199-204 injuries in the knee: frequency of associated focal subchondral 22. Am J Roentgoenol 174:1099-1106 Classification and detection of bone marrow lesions with mag- 42. Spitz DJ, Newberg AH (2002) Imaging of stress fractures in netic resonance imaging. Kapelov SR, Teresi LM, Bradley WG et al (1993) Bone con- loskeletal hemorrhage.

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Probably over 5 million people have used it at least once and many people are regular users order super avana 160mg with mastercard age related erectile dysfunction treatment. It is not surprising that cannabis is the most-seized drug and that the large majority of court cases involve this drug buy cheap super avana 160 mg line erectile dysfunction drug samples. Others are very much against the idea on both health and moral grounds but the former view has been taken by many police forces who now no longer prosecute those found with small amounts of the drug. There are many issues to debate, few of which have been discussed in detail in the UK. Currently, there is discussion of the medical aspects of the pharmacology of cannabis. There are suggestions, based on anecdotes, animal studies or pressure group opinions, that the drug can be useful to treat glaucoma, in the control of the muscle spasms that are one of the symptoms of multiple sclerosis and for appetite stimulation in cases of chemo- and radiotherapy. The status of cannabis is such that doctors cannot prescribe smokable cannabis to their patients, although synthetic THC preparations (nabilone) are available for nausea. There is growing pressure on the British government to change the law so that the required controlled clinical studies on the potential effects of cannabis can be carried out. A particular restriction on cannabis (and opium) is the offence of allowing your house (or any other premises you have responsibility for) to be used for growing cannabis or smoking it. These maximum penalties are only rarely imposed except where there is very large-scale supplying or trafficking. Most prison sentences for cannabis possession and small-scale supply are less than one year. Effects/risks Smoking cannabis causes a number of physical effects including increased heart rate, decreased blood pressure, bloodshot eyes, increased appetite and mild dizziness. The effects are rapid in onset and start within a few minutes and may last several hours depending on how much is taken. When eaten the effects are slower in onset but then DRUG DEPENDENCE AND ABUSE 509 longer in duration. Eating cannabis may mean a large dose is taken at once, making it difficult to avoid any unpleasant reactions. Cannabis has a mild sedative effect, not unexpected with the receptors for this drug being inhibitory. Many people find that when they first use cannabis nothing much happens. Generally cannabis makes people relax and they may become giggly and very talkative or alternatively quieter and subdued. The former effects may be due to disinhibitory actions of the cannabinoids. Users often report that they become more aware of music and colours and that time seems to stand still. While under the influence of cannabis, short-term memory may be impaired but this goes as the effects of the drug wear off. Accidents are more likely especially if people drive or operate machinery while on the drug since judgement and motor coordination are reduced and a mild ataxia ensues. Some people find that cannabis makes them anxious and paranoid, both inexperienced users or people who are anxious or those who consume strong varieties or high doses of cannabis. Very heavy use by people who already have a predisposition to mental health problems may lead to very distressing experiences. There is no conclusive evidence that moderate, long-term use of cannabis causes lasting damage to physical or mental health. However, it is probable that frequent inhalation of cannabis smoke over a period of years will contribute towards bronchitis and other respiratory disorders and possible cancers of the lung and parts of the digestive system. Regular users who stop smoking do not suffer withdrawal symptoms in the same way as with drugs like alcohol or the opioids. Even so, regular users can become psychologically dependent and come to rely on using cannabis, either as an aid to relaxation or as a social prop.

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