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If the contingency fee expected in the event of a win order viagra professional 100 mg otc xeloda impotence, discounted by the probability of losing purchase viagra professional 100 mg without prescription erectile dysfunction doctors in san fernando valley, exceeds the expected litigation costs, then the attorney will take the case. In summary, the functioning of the malpractice system is efficient in theory: the courts step in to compensate and deter where self-regulation has failed to prevent a breach of accepted standards of care; plaintiffs’ attorneys serve as gatekeepers, separating meritorious from unpromis- ing claims; and liability insurance ensures that providers are not bank- 230 Studdert, Mello, and Brennan rupted by a single large payout and resources are available to compen- sate patients. However, the actual operation of the system, as shown through its history and by empirical studies of litigation, presents a much more complicated story. EVOLUTION OF MALPRACTICE LITIGATION Despite several bursts of malpractice litigation in the 1800s (16,17), suing physicians was an arduous undertaking until the latter half of the 20th century (18,19). At that time, the judiciary began dismantling barriers that plaintiffs faced in bringing tort litigation (20). This shift occurred in many areas of accident law, but it was particularly promi- nent in medical malpractice in the 1960s and early 1970s (21,22). Judges discarded rules that had traditionally posed obstacles to litiga- tion. For example, most jurisdictions rolled back charitable immunity for hospitals. Courts also moved toward national standards of care and abandoned strict interpretations of the locality rule, which had required plaintiffs to find expert witnesses within the defendant’s immediate practice community (18). At the same time, expansion of doctrines such as informed consent and res ipsa loquitur (the rule that events, like retained instruments after surgery, carry an inference of negligence) paved new pathways to the courtroom (22). The more plaintiff-friendly environment fostered by these changes altered plaintiff attorneys’ cost– benefit calculus, leading to steady growth in litigation. The synergistic impact of changes in legal doctrine, advances in medical science, and the development of more coherent and visible standards of care eventually began to show in surges of litigation and plaintiff victories. By the mid-1970s, many states were facing a mal- practice crisis, although the situation varied considerably from state to state (23). Using data from the height of the crisis, Danzon identified a near 20-fold difference in claims rates and average payouts between low-activity states like Maine and a high-activity states like California and Nebraska (24). As claims and insurance premiums soared, major insurers exited the medical malpractice market, leaving many physicians without cover- age. Health care institutions and insurers clamored for policy changes to degrease the wheels of litigation. The exodus of insurers also forced several states to undertake insurance reform (25): legislatures established quasi- public bodies called “joint underwriting associations” to serve as insur- ers of last resort (18); special state patient compensation funds were introduced to absolve commercial insurers of responsibility for speci- Chapter 16 / Health Policy Review 231 fied dollar portions of malpractice payments; and public reinsurance mechanisms were established to fill gaps in the underwriting market. However, within several years, malpractice claims rates were climb- ing again, along with other types of personal injury litigation. The pre- mium spikes of the mid-1980s touched virtually every state, prompting an even more comprehensive round of tort reform (25,26). Legislators were drawn especially to caps on noneconomic and punitive damages. The diffuse nature of this crisis meant that many of the reforms affecting malpractice cut widely across tort litigation (26). Calm returned by the end of the 1980s, but these successive crises wrought significant changes in the professional liability insurance industry. The historical market dominance of large property and casualty insurers was supplanted by the growth of institutional self-insurance arrangements and “bedpan mutuals,” which are physician-owned and -managed insurance compa- nies with medical malpractice as their sole line of business. The 1990s saw little growth in claims rates and steady but generally manageable increases in average settlement amounts (28). Approxi- mately 70% of claims closed with no payment, and defendants won the majority of cases that went to trial (29). Many insurers experienced favorable “loss ratios,” the ratio of payments and administrative costs to premiums collected.

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Question about other symptoms (pain purchase 50mg viagra professional mastercard erectile dysfunction treatment san francisco, spasticity generic 100mg viagra professional with visa impotence ring, bowel or bladder dysfunction) 7. Encourage the use of appropriate use of assistive devices (scooters, walkers, wheelchairs, transfer equipment) 3. Encourage the initiation of symptom management—pain, spasticity, bowel, bladder dysfunction 6. Medications used to manage MS-related fatigue: CNS stimulants (methylphenidate) aminopyridines (currently being studied in research) amantidine (SE: headache, dizziness, rash) modafinil (SE: headache, tachycardia, palpitations, con- traindicated in LMVP) pemoline (liver cautions) SSRI antidepressants unique antidepressants—buprioprion (Wellbutrin®) (SE: seizure risk) 9. Pain inadequately defined, identified, or measured by an observer CHAPTER 11: THE SYMPTOM CHAIN IN MULTIPLE SCLEROSIS 55 C. Acute pain trigeminal neuralgia tonic spasms lightning-like extremity pain painful Lhermitte’s sign optic neuritis and retrobulbar pain 2. Chronic pain with insidious onset dysesthetic extremity pain bandlike pain in torso or extremities back pain with radicolopathy headache F. Trigeminal neuralgia probably arises from transmission of nerve impulses in areas of demyelination. In the chronic phase, anticonvulsants such as carbamaze- pine and gabapentin are used. Less common is the painful tetanic posturing of an arm or leg, usually on one side of the body. Treatment consists of carbamazepine, clonazepam, tizanidine, and baclofen. Lightning-like extremity pain can be treated with carbamazepine, gabapentin, and phenytoin. Lhermitte’s sign responds to the above medications and also to tricyclic antidepressant medications. Headache has been reported to be causally related to demye- linating lesions. When associated with a relapse, treatment with steroids may cause resolution of headache. Optic neuritis is due to inflammation and demyelination occurring in and around pain-sensitive meninges surrounding the optic nerve. Gabapentin—useful in dysesthetic and paroxysmal pain; better SE profile than phenytoin 3. Accentuation of DTR and clonus occurs, with exaggeration of flexor reflexes C. Spasms and stiffness are common in the quadriceps, hamstrings, and gastrocnemious muscles D. May be heightened during an exacerbation, with underlying infection, and with noxious stimuli E. Reduce muscle hypertonia by stretching spastic muscles and by application of warm or cold packs 4. Develop and improve useful automatic movements and thus promote maximal function 6. Supply supportive aids such as walkers, wheelchairs, crutches, orthoses, and special shoes F.

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The integrity of the greater trochanteric structures is therefore important for normal gait cheap 100 mg viagra professional visa impotence while trying to conceive. Abductor Tendons After Total Hip Arthroplasty The attachments of the abductor tendons about the greater trochanter of the hip can be divided into three Primary total hip arthroplasty (THA) is the second groups buy cheap viagra professional 100 mg online impotence forums. The main tendon of the gluteus medius muscle most common joint-replacement performed in the has a strong insertion covering the posterosuperior as- United States after primary total knee replacement, pect of the greater trochanter. It runs from posterior to anterior and inserts at the include hardware failure, such as mal-alignment or lateral aspect of the greater trochanter. Parts of the glu- loosening of the prosthesis, and soft-tissue abnormali- teus medius run anteriorly and cover the insertion of ties, including infection, joint instability, trochanteric the gluteus minimus tendon. The imaging gluteus medius tendon is usually thin and may be al- workup usually focuses on evaluating hardware fail- most purely muscular. The main tendon of the gluteus ure; however, especially if a transgluteal approach has minimus attaches to the anterior part of the trochanter. Coronal T1- weighterd spin-echo im- age (left image) and T2- weighted fat saturated (right image) demon- strating a complete tear (curved arrow) of the gluteus medius tendon (arrowheads) 24 C. Traditionally, MR imaging (MRI) has played a very The acetabular labrum is a fibrocartilaginous structure limited role in the evaluation of patients after THA, pri- that is firmly attached to the acetabular rim. At the an- marily because of susceptibility artifacts related to the teroinferior and posteroinferior margins of the joint, the metallic implants. Modifications of traditional MR se- labrum joins with the transverse ligament, which spans quences can be used to such artifacts. The labrum is normally of triangu- quality can be achieved in spin echo imaging by using a lar morphology and typically has low signal intensity on high bandwidth (at least 130 Hz/pixel), a high-resolution all imaging sequences. However, variations in signal matrix (512×512), sequences with multiple refocusing intensity and morphology do occur, including rounded pulses, and a frequency-encoding axis parallel to the long and flattened labra as well as absent labra [9-11]. Variations in signal intensity are most common in the su- It is important to recognize that, although more fre- perior labrum and may be seen on any imaging sequence quent in symptomatic patients, many MR findings, such [9, 10, 12]. Labral pathology is also commonly 6) and fatty atrophy of the gluteus medius and the poste- seen in patients with developmental dysplasia and those rior part of the gluteus minimus muscle are uncommon in with femoroacetabular impingement. The use of MR asymptomatic patients after THA and are therefore clini- arthrography and joint distention significantly increases cally relevant. Tears are recognized by the intrasubstance trochanteric pain or weakness after THA. These abnormalities are most common- ly located at the anterosuperior margin of the joint. Pitfalls in interpretation include the sulcus at the junc- tion of the labrum and the transverse ligament at the an- teroinferior and posteroinferior portions of the joint as well as the presence of a cleft or groove between the ar- ticular cartilage and the labrum. Stress and Insufficiency Fractures Stress and insufficiency fractures commonly involve the pelvis. Stress fractures are commonly identified in the proximal femur and typically occur along the medial as- pect of the femoral neck. Pubic rami stress fractures are one cause of groin pain, and imaging will help to differ- entiate these injuries from injuries to the anterior abdom- inal wall musculature and the adductor muscle origins [17, 18]. Common sites include the sacrum, pubic rami, and the ileum, including the supra-acetabular ileum. Insufficiency fractures of the subchondral portion of the femoral head have recently been recognized [19-21]. Previously, these lesions were often diagnosed as tran- sient osteoporosis of the hip. On MRI, an ill-defined low- signal-intensity line is visible on T1-weighted images, Fig.

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