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Starting with “S” for soft tissues will keep one from for- “D” refers to the distribution of abnormalities purchase kamagra effervescent 100mg otc. Recognizing soft-tissue most vividly exemplified by the distribution of erosions cheap 100 mg kamagra effervescent overnight delivery, (“S”) abnormalities will point to an area of major abnor- as may be seen distally in psoriasis and more proximally mality and should trigger a second or third look at the in rheumatoid arthritis buy discount kamagra effervescent 100 mg. The soft tissues dor- lelism discount kamagra effervescent 100mg amex, (2) overlapping articular surfaces kamagra effervescent 100mg for sale, and (3) three sally over the carpal bones are normally concave. All three can be especially applied to the the soft tissues over the dorsum of the wrist are straight carpal bones. Parallelism refers to the fact that any anatomic line volar to the distal radius suggests deep swelling when structure that normally articulates with an adjacent anatom- it is convex outward, as normally it should be straight or ic structure should show parallelism between the articular concave. Soft-tissue swelling along the radial and ul- cortices of those adjacent bones. This is exactly how jigsaw nar styloids may be seen in synovitis or trauma. If there is a piece of a jigsaw puzzle out of along the radial or ulnar side of a finger joint can indi- place, then that piece loses its parallelism to adjacent cate collateral ligament injury. Anatomically, this would cause overlapping articu- ment exist along the radial side of the index finger and lar surfaces. Therefore, the concepts of parallelism and the ulnar side of the small finger. If there is overlap ferentially around one interphalangeal or metacarpopha- of normally articulating surfaces, there should be disloca- langeal joint is highly suggestive of capsular or joint tion or subluxation at the site of those overlapping surfaces. Gilula This does not apply if one bone is foreshortened or bent, as Trauma with overlapping phalanges on a PA view of a flexed fin- ger. In that situation, one phalanx would overlap the adja- Traumatic conditions of the wrist basically can be classi- cent phalanx, but in the flexed PA position one would not fied as fractures, fracture-dislocations, and soft-tissue ab- normally see parallel articular surfaces at that joint. The third alignment concept refers to the fact that three Analysis of the carpal arcs, overlapping articular sur- carpal arcs can be drawn in any normal wrist when the wrist faces, and parallelism will help determine what exact and hand are in a neutral position, i. Arc I is a smooth curve along the bones normally parallel each other also identifies which proximal convex surfaces of the scaphoid, lunate and tri- bones have moved together as a unit away from a bone quetrum. Arc II is a smooth arc drawn along the distal con- that has overlapping adjacent surfaces. Arc III is a fractures and dislocations about the wrist are of the per- smooth arc that is drawn along the proximal convex sur- ilunate type, in which there is a dislocation with or with- faces of the capitate and hamate [3, 6]. When one of these out adjacent fractures taking place around the lunate. The arcs is broken at a joint, then something is probably wrong additional bones that may be fractured are named first with that joint, as ligament disruption; or when broken at a with the type of dislocation mentioned last. Two normal exceptions to the de- ilunate type of dislocations, whatever bone centers over scriptions of these arcs exist. In arc I, the proximal distal di- the radius (the capitate or lunate) is considered to be “in mension of the triquetrum may be shorter than the appos- place”. Therefore, if the lunate is centered over the radius, ing portion of the lunate. A broken arc I at the lunotrique- this would be a perilunate type of dislocation. If the cap- tral joint is a congenital variation when this situation arises. Therefore, if there were nent articular surface of the lunate that articulates with the fractures of the scaphoid and capitate, dorsal displace- hamate, a type II lunate. Another group of fracture-disloca- nate, which articulates with the proximal pole of the ha- tions that occur in the wrist are the axial fracture-dislo- mate). In a type II lunate, arc II may be broken at the distal cations, in which a severe crush injury may split the wrist surface of the lunate, where there is a normal concavity at along an axis around a carpal bone other than the lunate, the lunate hamate joint. Similarly, there can be a slight jog such as perihamate or peritrapezial axial dislocation, usu- of arc III at the joint between the capitate and hamate in this ally with fractures. At the proximal mar- gins of the scapholunate and lunotriquetral joints, these Ligamentous Instability joints may be wider due to curvature of these bones. Observe the outer curvature of these bones when analyzing There are many types of ligament instabilities, including the carpal arcs. Also, to analyze the scapholunate joint very subtle types; however, there are five major types of space width, look at the middle of the joint between paral- ligament instabilities that can be recognized readily based lel surfaces of the scaphoid and lunate to see whether there on plain radiographs.

In the glomerulus kamagra effervescent 100mg line, the driving force for fluid filtration men discount kamagra effervescent 100 mg, the lamina fenestra and the innermost part of the is the glomerular capillary hydrostatic pressure (PGC) 100mg kamagra effervescent overnight delivery. This pressure ultimately depends on the pumping of blood by the heart discount kamagra effervescent 100 mg without a prescription, an action that raises the blood pres- sure on the arterial side of the circulation buy kamagra effervescent 100mg cheap. Filtration is op- GFR Is Determined by Starling Forces posed by the hydrostatic pressure in the space of Bow- Glomerular filtration rate depends on the balance of hy- man’s capsule (PBS) and by the colloid osmotic pressure drostatic and colloid osmotic pressures acting across the (COP) exerted by plasma proteins in glomerular capillary glomerular filtration barrier, the Starling forces (see blood. Because the glomerular filtrate is virtually protein- Chapter 16); therefore, it is determined by the same fac- free, we neglect the colloid osmotic pressure of fluid in tors that affect fluid movement across capillaries in gen- Bowman’s capsule. The net ultrafiltration pressure gradi- CHAPTER 23 Kidney Function 389 ent (UP) is equal to the difference between the pressures to blood flow, resulting in an appreciable fall in capillary favoring and opposing filtration: hydrostatic pressure with distance. Finally, note that in the glomerulus, the colloid osmotic pressure increases substan- GFR Kf UP Kf (PGC PBS COP) (10) tially along the length of the capillary because a large vol- where Kf is the glomerular ultrafiltration coefficient. Esti- ume of filtrate (about 20% of the entering plasma flow) is mates of average, normal values for pressures in the human pushed out of the capillary and the proteins remain in the kidney are: PGC, 55 mm Hg; PBS, 15 mm Hg; and COP, 30 circulation. From these values, we calculate a net ultrafiltration poses the outward movement of fluid. In the skeletal muscle capillary, the colloid osmotic pres- sure hardly changes with distance, since little fluid moves across the capillary wall. In the “average” skeletal muscle The Pressure Profile Along a Glomerular capillary, outward filtration occurs at the arterial end and Capillary Is Unusual absorption occurs at the venous end. At some point along the skeletal muscle capillary, there is no net fluid move- Figure 23. Filtration pressure equilibrium probably is not at- illary in other vascular beds (in this case, skeletal muscle). Also, capillary hydrostatic pres- sure declines little (perhaps 1 to 2 mm Hg) along the length Several Factors Can Affect GFR of the glomerular capillary because the glomerulus contains many (30 to 50) capillary loops in parallel, making the re- The GFR depends on the magnitudes of the different terms sistance to blood flow in the glomerulus very low. Therefore, GFR varies with changes in K ,f skeletal muscle capillary, there is a much higher resistance hydrostatic pressures in the glomerular capillaries and Bow- A. The middle line is the sum of PBS and the capillary and a glomerular capillary. The differ- the typical skeletal muscle capillary, filtration occurs at the arte- ence between PGC and PBS COP is equal to the net ultrafiltra- rial end and absorption at the venous end of the capillary. In the normal human glomerulus, fil- stitial fluid hydrostatic and colloid osmotic pressures are neg- tration probably occurs along the entire capillary. Assuming that lected here because they are about equal and counterbalance each Kf is uniform along the length of the capillary, filtration rate other. B, In the glomerular capillary, glomerular hydrostatic pres- would be highest at the afferent arteriolar end and lowest at the sure (PGC) (top line) is high and declines only slightly with dis- efferent arteriolar end of the glomerulus. The bottom line represents the hydrostatic pressure in 390 PART VI RENAL PHYSIOLOGY AND BODY FLUIDS man’s capsule, and the glomerular capillary colloid osmotic plasma proteins (e. The glomeru- lar blood flow has important effects on GFR is that the lar ultrafiltration coefficient (Kf) is the glomerular equiva- COP profile is changed along the length of a glomerular lent of the capillary filtration coefficient encountered in capillary. It depends on both the hydraulic conductivity glomerular blood flow were low. Filtering a small volume (fluid permeability) and surface area of the glomerular filtra- out of the glomerular capillary would lead to a sharp rise tion barrier. In chronic renal disease, functioning glomeruli in COP early along the length of the glomerulus. As a are lost, leading to a reduction in surface area available for fil- consequence, filtration would soon cease and GFR would tration and a fall in GFR. On the other hand, a high blood flow would al- mones appear to change glomerular Kf and, thus, alter GFR, low a high rate of filtrate formation with a minimal rise in but the mechanisms are not completely understood. In general, renal blood flow and GFR change hand in hand, but the exact relation between GFR and renal Glomerular Capillary Hydrostatic Pressure. Glomerular blood flow depends on the magnitude of the other fac- capillary hydrostatic pressure (PGC) is the driving force for tors that affect GFR. Be- cause of autoregulation, P and GFR are maintained at rel- Several Factors Contribute to the High GFR GC atively constant values when arterial blood pressure is var- in the Human Kidney ied from 80 to 180 mm Hg. Below a pressure of 80 mm Hg, The rate of plasma ultrafiltration in the kidney glomeruli however, PGCand GFR decrease, and GFR ceases at a blood (180 L/day) far exceeds that in all other capillary beds, for pressure of about 40 to 50 mm Hg. One of the classic signs several reasons: of hemorrhagic or cardiogenic shock is an absence of urine 1) The filtration coefficient is unusually high in the output, which is due to an inadequate PGC and GFR.

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Therefore buy generic kamagra effervescent 100 mg line, anesthesiologists are advised to seek prompt neurological consultation for patients with persistent neurological complaints after regional blocks cheap kamagra effervescent 100 mg without prescription. Anesthesiologists should always be cognizant of the risk of epidu- ral hematoma formation after epidural blocks kamagra effervescent 100mg without a prescription. Because the window for regaining function after cord compression from an epidural hematoma may be as small as 6–8 hours cheap kamagra effervescent 100 mg without a prescription, often at issue in these claims is how promptly the hematoma was suspected and diagnosed purchase kamagra effervescent 100mg without a prescription, usually through magnetic resonance imaging scanning. Although plaintiffs often must concede that epidural hematomas are within the risks of the procedure, 130 Lofsky a failure to diagnose them in a reasonable time frame might not be. Because the risks of hematoma formation are higher when epidural catheters are used in combination with anticoagulants like heparin, warfarin, and enoxaparin (Lovenox®), anesthesiologists should communicate with surgeons and primary care physicians who could be writing anticoagulation orders for these drugs on their patients. The issue of whether regional blocks should be placed in patients who are already under general anesthesia remains controversial. A number of claims have occurred related to placement of interscalene and supraclavicular brachial plexus blocks for postoperative pain relief in shoulder surgeries performed under general anesthesia. Injuries have included total arm paralysis and direct trauma to the spinal cord. The allegation is always that if the patient had been awake when the block was performed, pain and paresthesias would have alerted the anesthe- siologist to improper needle placement and avoided the severe neuro- logical injury. Anesthesiologists should also carefully weigh the risks of performing thoracic and cervical epidural blocks on patients under general anesthesia or heavy sedation. These patients might not be com- pletely cooperative or able to communicate uncomfortable sensations to their physicians. Epidural and spinal blocks performed for surgical anesthesia often result in relative hypovolemia because of vasodilatation. Some anesthe- sia claims allege inappropriate use of these blocks in severely hypov- olemic patients or inadequate replacement of the resulting intraoperative fluid shifts. Line placement may become an issue, because central venous catheters or Swan-Ganz catheter lines can help clarify patients’ volume status if it is uncertain, although other factors such as blood pressure, heart rate, and urine output are also useful guides (4). Informed consent can become an issue in claims involving regional blocks simply because the alternative of general anesthesia usually exists. An anesthesiologist should provide some documentation that the more common risks of regional blockade were discussed with the patient and, ideally, that the alternatives to a block were also pre- sented. If there are particular reasons why an anesthesiologist prefers a regional block, such as poor patient respiratory status or anticipated airway difficulties, then it is also helpful if this is recorded. Blocks performed solely for postoperative pain relief should be explained as such, and the alternatives should be presented to the patient. Although considered well within the risks of epidural and spinal anesthetics, postsubdural puncture headaches remain a common cause Chapter 10 / Anesthesiology 131 of malpractice claims. As this is one of the more common complica- tions, it should likely be mentioned in the informed consent for all planned epidurals and spinals. Should an accidental dural puncture occur in a planned epidural anesthetic or should a patient complain of a classic positional headache afterward, the anesthesiologist should evaluate the patient and explain alternatives to treatment, such as pain medication and blood patching. Many of these claims seem to arise when the patient has felt ignored or has had to endure a time-consum- ing and expensive process to be evaluated and treated by a physician for a headache complaint. OPERATING ROOM FIRES Historically, operating room fires were associated with flammable anesthetics and static electricity. Although flammable agents have largely disappeared from modern operating rooms, fires and the mal- practice cases that can result from them unfortunately still remain. Modern developments such as electrical cautery, lasers, and paper and plastic disposables have enhanced the surgical environment while add- ing new risks of fire. Three conditions must be present for a fire to occur in the operating room. These include drapes, dressings, gauze, surgical gowns, syringes, hair, gastrointestinal gases, petroleum-based ointments, and most plastics. Any concentration of oxy- gen in excess of 21% should be considered enriched. These gases can accumulate around the operative site as well as under drapes and in body cavities, such as the oropharynx.

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Dalinka is helpful in evaluating the glenoid process of the scapu- seen on CT examinations discount kamagra effervescent 100 mg with mastercard. Sternoclavicular dislocations la as well as the precise location of the humeral head with may be anterior or posterior; of these purchase 100mg kamagra effervescent with amex, posterior disloca- respect to the glenoid cheap kamagra effervescent 100 mg otc. CT allows evalu- ulation is fracture of the surgical neck of the humerus buy 100mg kamagra effervescent. It is important to mention displacement of fragments buy kamagra effervescent 100mg without prescription, as this affects management. Fractures of the scapula, which Elbow may extend to the glenoid process and become intra-ar- ticular, are commonly seen in younger patients who have Conventional radiographic imaging of the elbow should sustained severe trauma. Displacement and elevation of these fat pads is a reliable Dislocations occurring commonly at the shoulder in- sign of intra-articular fluid. In the setting of trauma, the clude acromioclavicular joint separations; these may re- presence of displaced anterior and posterior fat pads at quire stress radiographs when initial images show no sep- the elbow should be considered presumptive evidence of aration at the acromioclavicular joint. The cortical sur- these structures may sometimes lead to surgical therapy. Comminuted fractures of the radial neck may be determine the appropriate alignment. The coracoclavicu- associated with radial shortening and malalignment at the lar distance may be assessed by comparison to the oppo- distal radial ulnar joint. This combination is referred to as site side with both sides included on a crosswise AP im- the Essex-Lopresti fracture. These may be associated with fractures of the Fractures of the coronoid process of the ulna are an- greater tuberosity or with compression fractures of the other common fracture at the elbow. These are almost al- posterolateral aspect of the humeral head (Hill-Sachs de- ways seen in association with or following posterior dis- formity). Fractures of the olecranon are of- (bony Bankart deformity) may also be identified; these ten displaced and readily identified, but some olecranon are best seen on axillary views of the shoulder. Knowledge of the normal rela- ly missed; it is estimated that nearly half are missed on tionship of the anterior cortex of the humerus to the the initial evaluation. A line drawn along the ante- illary view, or scapular-Y view facilitates diagnosis. On the in- sects the anterior third of the condyle, there may be a pos- ternal and external views, a clue may arise from the fact teriorly displaced supracondylar fracture. Fractures of the that the technologist is unable to obtain images in exter- lateral condyle and medial epicondyle are also common. Compression fractures of the anteromedial The most common dislocation of the adult elbow is the aspect of the humeral head are found in association with posterior dislocation. These are usually quite obvious and posterior dislocations, analogous to the Hill-Sachs defect not difficult to diagnose. These compression de- the Monteggia fracture-dislocation, in which an angulat- formities of the anteromedial aspect of the humeral head ed or displaced fracture of the proximal ulna is associat- present as a trough in the humeral head and are often best ed with a radial head dislocation. When doubt exists concerning overlap of the radial head on the capitellum on the AP im- the presence of a posterior dislocation, CT may be ex- age should indicate the presence of a dislocation. A line tremely valuable to determine that a dislocation is present drawn along the long axis of the radial neck should in- and to assess fracture of the humeral head. The history tersect the capitellum in every projection (radio-capitel- may be helpful in patients with posterior dislocations, lar line). Dislocations at the wrist include perilunate and lu- Radiographic examination of the wrist usually consists of nate dislocations. Perilunate dislocations are frequently three views: PA, lateral, and pronation-oblique projec- associated with fractures through the scaphoid waist (a tions. Additional views, including angle views of the trans-scaphoid perilunate dislocation). Virtually all per- scaphoid (with ulnar deviation), a “clenched fist” view, ilunate dislocations are dorsal. Lunate dislocations, in and carpal tunnel views, may be helpful in specific situ- contrast, are virtually all volar in direction and are rarely ations. Recently, a semisupinated oblique view was rec- seen in association with other fractures at the wrist. Scapho-lunate dissociation (rotary subluxation of the The most common fracture at the wrist in the adult scaphoid) results in abnormal rotation of the scaphoid population is the Colles fracture, which is much more fre- and is due to a disruption in the scapho-lunate and volar quent in elderly women than in men. This may occur alone or be part of oth- is a resultant dorsal tilt to the distal radial articular sur- er more complex injuries about the lunate axis. Subtle injuries may be difficult to detect when dis- The Galeazzi fracture is a fracture is of the distal radi- placement is minimal; these may be recognized only by al shaft associated with a dislocation at the distal radial the loss of the normal volar tilt to the distal radial artic- ulnar joint (i.

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However order 100 mg kamagra effervescent with amex, its forays into medical malpractice reform have essentially been limited to supporting the Bush Administration’s overall prefer- ences for restrictions on general tort litigation (44) order kamagra effervescent 100 mg with mastercard. Instead purchase kamagra effervescent 100 mg with visa, CMS should propose a system of error identification generic kamagra effervescent 100 mg without prescription, fair compensation discount 100mg kamagra effervescent with amex, and dispute resolution that would apply specifically to Medicare and Medicaid patients. The framework of such a system could be adopted by administrative rulemaking, although making it fully operational would likely require congressional action. Because of the voting power of the elderly, converting malpractice liability into a Medicare issue is politically perilous. Since its enactment, Medicare has been largely responsible for funding medical progress, promoting industrialization, and (more recently) imposing cost constraints—the forces described earlier as being prima- rily responsible for the current malpractice crisis: Medicaid has become the largest government health program, and pays for roughly half of 274 Sage U. Therefore, Medicare and Medicaid offer the most visible forum for debating the relationship between what America invests in health care and what it expects to receive when health care goes awry. Moreover, a system that provided immediate information and prompt compensation would have substantial advantages over conventional litigation for elderly claimants. EMPLOYER-SPONSORED HEALTH CARE AND THE WORKERS COMPENSATION ANALOGY Employer-sponsored private health insurance covers most Ameri- cans. Therefore, the current malpractice crisis affects the ability of businesses to attract and retain workers. Active involvement in health care purchasing also has made business better attuned to employees’ experiences as users of medical services. Moreover, industry’s contin- ued tolerance of avoidable physical harm in the health care system, especially when it is traceable to faulty systems design, contrasts sharply with general regulatory and self-regulatory changes since the 1960s, which have created a corporate culture exquisitely sensitive to health and safety issues and their relationship to productivity. Finally, health care is an economic engine throughout the country; liability crises reduce present-day prosperity and jeopardize future prospects. To address these issues, the business community could broker a com- promise approach to malpractice mirroring workers’ compensation, that limits liability but retains incentives for safety and assures prompt, reasonable payment in the event of injury. To accomplish this, employ- ers would need to set aside their parochial interests in using the mal- practice crisis as a poster child for general business tort reform to further their workers’ interests in safe, reliable health care. CONCLUSION This chapter analyzes the first medical malpractice insurance crisis of the 21st century in light of significant changes that have occurred in the health care system since previous crises. It concludes that the established debate over traditional tort reform incompletely defines current problems and leads to ineffective solutions. The chapter began by analogizing the malpractice crisis to the legend of Rip van Winkle and concludes with a different literary parallel. In the 1993 movie Groundhog Day, a retelling of Charles Dickens’ Christmas classic using a different holiday, actor Bill Murray plays a local weatherman assigned to cover the early February festivities in Punxatawny, Penn- sylvania. To his astonishment, he awakens each morning and finds Chapter 17 / New Directions in Liability Reform 275 himself reliving the day before, but he is the only person aware that the day’s events have already happened many times. Health care provid- ers, payers, and policymakers are experiencing a similar phenomenon in the current reiteration of the medical malpractice crisis and can profit from following the progression of Murray’s cinematic charac- ter. The first step is to gain insight into the consequences of one’s actions and inactions. The second step is to learn that better things happen when one uses those insights to help others rather than to help oneself. Only then does everyday life begin again, and only then does the future look brighter than the past. ACKNOWLEDGMENTS The author thanks Columbia law student Daniel Solitro for research assistance and The Pew Charitable Trusts’ Project on Medical Liability in Pennsylvania for financial support. Medical malpractice in twentieth century United States: The interac- tion of technology, law and culture, Internat J Technol Assessment in Health Care 1998;14(2):197–211. Charges for Obstetric Liability Insur- ance and Discontinuation of Obstetric Practice in New York. Medical Malpractice: Problems & Reforms—A Policy-Maker’s Guide to Issues and Information. Patients, Doctors, and Lawyers: Medical Injury, Malpractice Litigation, and Patient Compensation in New York. Relation between negligent adverse events and the outcomes of medical malpractice litigation.

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