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Patients with a neurological deficit are best studied with MRI purchase 160mg super avana amex, which is capable of demonstrating cord in- juries (Fig super avana 160mg. Bony abnormalities and facet joint dislocations are best seen with plain radiographs supple- mented with MDCT buy discount super avana 160 mg online. The standard axial CT views help in visualizing the spinal canal discount 160 mg super avana amex, facet joints, and spinous Fig. Bony fragments within the spinal canal can al- Traumas of the Axial Skeleton 113 Table 1. Systematic inspection of the images in cervical spine trauma Alignment Subluxation/ Radiographs MRI dislocation and CT Spinal cord Edema + Swelling + Hemorrhage + + Compression + Dissection + Epidural space Disk herniation + + Bone fragment + Hematoma + + Spinal column Vertebral body fracture + Posterior element fracture + Dislocation + Bony edema + Spondylosis + Ligaments Anterior longitudinal + ligament-rupture Posterior longitudinal + ligament-rupture Interlaminar ligament + (flava)-rupture Supra- or interspinous + ligament-rupture Fig. Parallel lines are drawn occlusion/dissection along the anterior vertebral Fig. Drawing of the AP cer- bodies, posterior vertebral bod- vical spine: a line through the ies, and connecting the spino- spinous processes should be laminar lines fairly straight Table 2. Imaging protocol Question Image procedure ♦ Trauma with spinal involvement? Dynamic views (flexion and exten- spine (sagittal, T2-weighted): anterior subluxation of C on sion) are contraindicated in the acutely traumatized spine. MRI of cervical spine C3 with disc herniation and In the unconscious patient, all three imaging modalities, (sagittal, T2-weighted): hyper- cord compression. In addition, 2D sagittal and coronal reformations are an essential part of the CT Cervical Spine Instability examination. When CT and MRI are available, we do not recom- The statement made by Denis more than 20 years ago, mend open-mouth views or oblique views of the spine. El-Khoury abnormalities, or both, is considered stable, is still valid Table 6. After the initial emergency treatment, the long- dislocations term survival and quality of life of the patient depend on Mechansim Type Stable Unstable the stability of the injury. Signs of instability on plain ra- of injury diographs are presented in Table 3. The three-column concept was originally intended for Hyperflexion Anterior subluxation (sprain) + the thoraco-lumbar spine, but it can be used, with some Bilateral interfacetal dislocation + Simple wedge fracture + modifications, in the lower cervical spine (Table 4). Clay-shoveler’s fracture + According to this concept, fractures affecting both the ante- Tear-drop fracture + rior and middle columns or all three columns are considered Odontoid fracture + + unstable. Magerl’s classification is based on biomechanics Hyperextension Dislocation (sprain or strain) + and is divided into three grades of severity (Table 5). Taking Avulsion fracture of the + posterior arch of C1 Fracture of the posterior arch of C1 + Table 3. Radiographic findings of cervical spine instability Tear- drop fracture of C2 + Laminar fracture + ♦ Widened interspinous space or facet joints Hangman’s fracture + ♦ Anterior listhesis greater than 3. Components of the three columns of the cervical spine (after Denis) into account the mechanism of injury, cervical spine frac- Column Components tures and fracture dislocations can be divided into three ma- jor groups (Table 6). Anterior Anterior longitudinal ligament Anterior annulus fibrosus Hyperflexion injuries Anterior vertebral body Middle Posterior vertebral body Flexion injury of the cervical spine results in anterior an- Posterior annulus fibrosus Posterior longitudinal ligament gulation or translation of a vertebral segement in the sagittal plane. This injury is caused by direct trauma to Posterior Posterior elements the head and neck while the cervical spine is in a flexed Facet capsules Interlaminar ligaments (flava) position or by other forces that cause hyperflexion of the Supra- or interspinous ligaments cervical spine. Prominent features of flexion injuries are disruption of the posterior ligamentous complex including the in- Table 5. Components Radiological signs of Typ-A-/B-/C-injuries terlaminar ligaments, the facet joint capsules, and the of the thoraco-lumbar spine according to Magerl posterior part of the annulus fibrosus. In the acute phase, the injury can appear stable although the inci- Typ A injury Reduction of vertebral body height Compression fracture Body splitting dence of delayed instability is high, ranging from 20% A1 Impaction fracture Enlarge interpedicle distance to 50%. Hyperflexion injuries are commonly associated A2 Splitting fracture Intraspinal fragments with acute disc herniation.

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External shocks to global reinsurance markets cheap super avana 160mg amex, includ- ing but not limited to the terrorist attacks of 2001 purchase super avana 160 mg amex, have significantly reduced available capacity cheap 160mg super avana free shipping. In this environment super avana 160 mg on-line, reinsurers are reluc- tant to devote scarce capital to areas, such as medical malpractice, that are characterized by infrequent but high-dollar losses. This reluctance derives, at least in part, from the publicity that attends occasional jury verdicts against hospitals or HMOs for amounts exceeding $50 mil- lion, even if the highest awards are often reduced or the cases are settled for lesser amounts. Recent legislation in New York to repeal periodic payment requirements that were generating extremely high nominal damages and to return to lump-sum awards can be seen as an attempt by hospitals to moderate the tendency of insurance actuaries in a tight market to make worst-case projections. Chapter 17 / New Directions in Liability Reform 263 APPROACHES TO COMPREHENSIVE LIABILITY REFORM Watching the legislative fight over malpractice reform as portrayed in partisan advertising and the press, one would think that the universe of expert opinion divided cleanly between those who favor $250,000 caps on noneconomic damages and those who oppose them. In fact, the sharpest division is between the stakeholders on one side (both physi- cians and plaintiff attorneys), who cast the debate in terms of noneco- nomic damage caps, and the academic community on the other, for whom a damage cap is at best a partial solution to only a subset of critical problems affecting the malpractice system. When the first damage caps were enacted in the 1970s and 1980s, the apparent cause of the malprac- tice crisis was an epidemic of frivolous claims and excessive jury awards that led commercial liability insurers to withdraw from the market. Research commissioned during that time, including the HMPS, demon- strated a wider range of shortcomings. Considered in light of this improved understanding, caps have the potential to moderate the cost and volatility of liability coverage but may worsen equally troubling aspects of the malpractice system, such as high rates of medical error and inadequate compensation for avoidable injury. Moreover, in today’s health care system, caps standing alone may be a less effective long-term response to volatile malpractice coverage than restructuring liability insurance markets (and health insurance markets) to better meet current demands on them. Therefore, most academics believe that some limits on damages are necessary, but only as part of a larger reform effort. Although many legislative initiatives continue to focus on “first-genera- tion” tort reforms such as damage caps and limits on attorneys’ contingent fees, proposals from the academic and policy communities have now entered their third or fourth generation (32,33). One can discern four general approaches around which academic thinking has coalesced. One approach focuses on returning control over malpractice litigation, and ultimately quality assurance, to persons with true medical expertise. The second approach seeks to replace the current fault-based tort system with mechanisms that would simplify the determination of substandard care and causation of injury and facilitate the payment of compensation. The third approach redirects liability risk from individual health professionals to medical institutions, such as hospitals and HMOs, that can bear it more efficiently and effectively. The fourth approach looks to informed con- sumers to enter into voluntary contractual arrangements with health care providers that modify various aspects of the tort system. However, the assumptions that underlie each vary, as do their objectives. Some aspects of each remain unresolved, which means that specific proposals that fall within the same approach may be in tension with one another. Finally, some approaches may be based on unstated rationales or have unanticipated consequences. Expert Resolution Reforms designed to confer expertise on the malpractice dispute reso- lution system continue to attract substantial support from physicians, who blame the problems with malpractice litigation on unscrupulous lawyers, naive and impressionable juries, unfocused judges, and decep- tive expert witnesses. Proposals to enhance clinical authority in litiga- tion dovetail with theories of patient safety based on voluntary, confidential reporting of medical errors in a “safe,” professional envi- ronment walled off from the medical malpractice system. Holding experts accountable to nonexperts is a longstanding prob- lem in society (34), and it is only natural for professionals to resist external review when the public expects it. No form of public account- ability is perfect: the legislative process is democratic but erratic; regulatory agencies are expert but bureaucratic, budget-obsessed, and prone to capture; and the civil justice system suffers from a range of familiar infirmities. Market accountability through incentive-based payment systems has greater potential than has generally been appre- ciated but is incapable of governing all of medicine (35). As a result, modern medicine still enjoys substantial self-regulatory privileges, including aspects of malpractice liability such as a standard of care determined by customary practice. Physicians nonetheless feel that the malpractice system is beyond their control, which compounds the uncertainties they experience from managed care, fraud and abuse oversight, demanding patients, and changing technology. Two expertise-related reforms that have been widely enacted are certificates of merit and medical screening panels (36). Certificates of merit exist in about one-third of states and require plaintiff attorneys to obtain expert assessments that claims are warranted before filing them. These provisions may be effective in reducing claims filed by inexperienced lawyers, who are less likely than malpractice special- ists to weed out meritless cases despite the financial incentive to do so created by contingent fee payment.

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The blastocyst enters the uterus buy discount super avana 160 mg line, leaves the surrounding uterine cervix so that the fetus may exit buy cheap super avana 160mg online. Human chorionic gonadotropin (hCG) generic 160mg super avana free shipping, produced by tro- maintenance of an established lactation and requires PRL phoblast cells of the developing embryo super avana 160 mg without a prescription, activates the cor- and numerous other hormones. Milk ejection is the pus luteum to continue producing progesterone and estra- process by which stored milk is released; “milk letdown” is diol beyond its normal life span to maintain pregnancy. Shortly after the embryo implants into the uterine wall, a pla- cells surrounding the alveoli and ejects milk into the ducts. Lactation is associated with the suppression of menstrual comes the major steroid-secreting organ during pregnancy. Major hormones produced by the fetoplacental unit are PRL on GnRH release and the hypothalamic-pituitary- progesterone, estradiol, estriol, hCG, and human placental ovarian axis. The hypothalamic-pituitary axis becomes activated during whereas low levels might indicate fetal stress. Human pla- the late prepubertal period, resulting in increased fre- cental lactogen has a role in preparing the breasts for milk quency and amplitude of GnRH pulses, increased LH and production. Most disorders of sexual development are caused by chro- latter half of pregnancy in order to conserve maternal glu- mosomal or hormonal alterations, which may result in in- cose consumption and make glucose available for the de- fertility, sexual dysfunction, or various degrees of intersex- veloping fetus. At the time of implantation, the trophoblast The life span of the sperm and an ovum is less than 2 days, cells of the early embryonic placenta begin to produce a so their rapid transport to the oviduct is required for fertil- hormone, human chorionic gonadotropin (hCG), which ization to occur. Immediately after fertilization, the zygote signals the ovary to continue to produce progesterone, the or fertilized egg begins to divide and a new life begins. Because the early embryo contains of the corpus luteum (and progesterone production), hCG a limited energy supply, the embryo enters the uterus prevents the onset of the next menstruation and ovulatory within a short time and attaches to the uterine en- cycle. The placenta, an organ produced by the mother and dometrium, a process that initiates the implantation phase. It also produces protein and favorable environment, enabling sperm survival for sev- steroid hormones, which duplicate, in part, the functions of eral hours. Under estrogen dominance, mucin molecules the pituitary gland and gonads. Some of the fetal endocrine in the cervical mucus become oriented in parallel and fa- glands have important functions before birth, including cilitate sperm migration. Parturition, the expulsion of the fully formed fetus from Sperm survival in the uterine lumen is short because of the uterus, is the final stage of gestation. The uterotubal junction also turition is triggered by signals from both the fetus and the presents an anatomic barrier that limits the passage of mother and involves biochemical and mechanical changes sperm into the oviducts. Of the mil- mother’s mammary glands must be fully developed and se- lions of sperm deposited in the vagina, only 50 to 100, usu- crete milk in order to provide nutrition to the newborn ally spaced in time, will reach the oviduct. Milk is produced and secreted in response to suck- sperm occur in the vagina, uterus, and at the uterotubal ling. Spermatozoa that survive can reach the ampulla prevents new ovulatory cycles. However, transport is mother regains metabolic balance, which has been reduced assisted by muscular contractions of the vagina, cervix, and by the nutritional demands of pregnancy and lactation, and uterus; ciliary movement; peristaltic activity; and fluid flow ovulatory cycles return. Semen samples with low sperm motility can attained during puberty, at approximately 12 years of age. The onset of puberty requires changes in the sensitivity, ac- There is no evidence for chemotactic interactions be- tivity, and function of several endocrine organs, including tween the egg and sperm, although evidence exists for spe- those of the hypothalamic-pituitary-gonadal axis. Sperm arrive in the vicinity of the egg at random, and some exit into the abdominal cavity. Although sperm remain OVUM AND SPERM TRANSPORT, motile for up to 4 days, their fertilizing capacity is limited FERTILIZATION, AND IMPLANTATION to 1 to 2 days in the female reproductive tract. Sperm can be cryopreserved for years, if agents such as glycerol are Sperm deposited in the female reproductive tract swim up used to prevent ice crystal formation during freezing.

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The branches to the hand extensor muscles generic 160mg super avana with visa, nerve crosses the elbow joint on the flexor namely cheap 160 mg super avana mastercard, to the common extensor muscle of side and divides at the level of the head of the fingers (A15) purchase 160mg super avana free shipping, the extensor muscle of the radius into two terminal branches order 160 mg super avana with amex, the su- little finger (A16), the ulnar extensor muscle perficial branch and the deep branch. The su- of the wrist (A17), the long abductor muscle perficial branch continues in the forearm on of the thumb (A18), and the short extensor the medial surface of the brachioradial muscle of the thumb (A19). Finally, the ter- muscle and then runs in the lower third be- minal branch of the deep branch, the poste- tween brachioradial muscle and radius to rior interosseous nerve, gives off branches to the extensor side in order to reach the back the long extensor muscle of the thumb of the hand. The deep branch obliquely (A20) and to the extensor muscle of the penetrates the supinator muscle, gives off index finger (A21). For the upper arm, the radial nerve gives off Clinical Note: Injury to the main nerve trunk the posterior cutaneous nerve of the arm in the area of the upper arm results in paralysis of (A–C1), which supplies a skin area on the the extensor muscles. This mainly affects the extensor side of the upper arm with sensory hand, leading to the so-called wristdrop (D) fibers, and the inferior lateral cutaneous nerve characteristic for radial paralysis: extension is of the arm (A–C2). In the middle third of the possible neither in the wrist nor in the fingers, upper arm, it gives off muscular branches thus making the hand drop down limply. Autonomic Thebranchforthemedialheadgivesoffalso zone (dark blue) and maximum zone (light the branch for the anconeus muscle (A5). The posterior cutaneous nerve of the forearm (A–C6) branches off in the region of the upper arm; it supplies a strip of skin on the radial extensor side of the forearm. At the level of the lateral epicondyle, muscular branches (C7) extend to the brachioradial muscle (A8) and to the long radial extensor muscle of the wrist (A9). Brachial Plexus 83 A Muscles supplied by the radial nerve (according to Lanz-Wachsmuth) 1 2 1 6 2 2 4 C 5 3 6 C 8 T 1 8 10 1 5 9 2 3 11 13 7 17 15 14 6 20 18 B Skin supplied by the radial nerve 21 10 13 (according to Lanz-Wachsmuth) 16 19 10 12 11 11 C Sequence of branches D Paralysis of the radial nerve (according to Lanz-Wachsmuth) Kahle, Color Atlas of Human Anatomy, Vol. The thoracic The nerves of the lower group (T7–T12), nerves, too, fit in well with this segmental the intercostal segments of which no longer organization. They take an Each of the twelve thoracic spinal nerves increasingly oblique downward path and divides into a posterior branch (A1) and an supply the muscles of the abdominal wall anterior branch (A2). Intercostalnerve1partici- fibers to the deep autochthonous back pates in forming the brachial plexus and muscles. Sensory innervation of the back sends only a thin branch to the intercostal comes mainly from the lateral branches of space. The area sup- well) gives off its lateral cutaneous branch to plied by the posterior branches of cervical the upper arm (intercostobrachial nerve) spinal nerves expands widely and includes (B14), where it connects with the medial cu- the occiput (greater occipital nerve) (D4). The last intercostal the lumbar region, sensory innervation of nerve running beneath the twelfth rib is re- the back comes from the posterior branches ferred to as the subcostal nerve; it runs ob- of the lumbar spinal nerves L1–L3 and the liquely downward across the iliac crest. We distinguish between an upper group and a lower group of inter- costal nerves. Thenervesoftheuppergroup(T1–T6)run uptothesternumandsupplytheintercostal muscles (C7), the superior and inferior pos- terior serrate muscles, and the transverse thoracic muscle. They give off sensory branches to the skin of the thorax, namely, the lateral cutaneous branches (AD8) at the anterior margin of the anterior serrate muscle, which further divide into anterior and posterior branches, and the anterior cu- taneous branches (AD9) close to the sternum, which also divide into anterior and poste- rior branches. Nerves of the Trunk 85 3 1 2 2 14 8 9 B Intercostobrachial nerve A Course of a thoracic nerve 4 3 9 7 8 8 13 12 11 10 15 6 5 15 16 18 17 C Muscles supplied by the intercostal nerves D Innervation of the skin of the trunk Kahle, Color Atlas of Human Anatomy, Vol. Its branches provide sensory Ilioinguinal Nerve (L1) and motor innervation to the lower limb. The branches of L1–L3 and part of L4 form Theilioinguinalnerve(A9)runsalongthein- the lumbar plexus, the roots of which lie guinal ligament and inguinal canal with the within the psoas muscle. The obturatornerve spermatic cord up to the scrotum, or with (A1) and the femoral nerve (A2) originate the round ligament of the uterus up to the from here, in addition to several short greater lips in the female, respectively. The remainder of the participates in the innervation of the broad fourth lumbar nerve and the L5 nerve join to abdominal muscles and supplies sensory form the lumbosacral trunk (A3), which then fibers to the skin of the mons pubis and the unites in the small pelvis with sacral upper part of the scrotum, or labia majora, branches 1 – 3 to form the sacral plexus. The sacral branches emerge from the ante- rior sacral foramina of the sacrum and form Genitofemoral Nerve (L1, L2) together with the lumbosacral trunk the The genitofemoral nerve (A10) divides al- sacral plexus; the main nerves originating ready in, or on, the psoas muscle into two from here are the sciatic nerve (A4) (common branches, the genital branch and the femoral peroneal nerve [A5] and tibial nerve [A6]). The genital branch runs in the abdominal wall along the inguinal ligament Lumbar Plexus through the inguinal canal and reaches the scrotum with the spermatic cord or, in the The lumbar plexus gives off direct short female, the labia majora with the round muscular branches to the hip muscles, ligament of the uterus.

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