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MICRA provides for a sliding scale: a plaintiff attorney keeps 40% of the first $50 cheap colospa 135mg free shipping spasms 1st trimester,000 of an award but “only” 21% (plus expenses) of a $1 million judgment cheap 135mg colospa fast delivery spasms near elbow. This rules protects patients, allowing more of an award to actually reach the injured patient. A patient with a $1 million award in a state with a contingency fee of 40% must give $400,000 (plus expenses) to his or her attorney as compared to $221,000 (plus expenses) under MICRA. These reforms have reduced California malpractice premiums by 40% in constant dollars since 1975, or less than 3% per year uncorrected for inflation (16). On average, California’s malpractice premiums have risen at a rate of only one-third the national average (Fig. There are considerable data that a $250,000 cap on noneconomic damages reduces malpractice premiums by 25 to 30% (2,28,36), and experience in California, Colorado, and other states is confirmatory. The mirror image of the positive effect of real reform can be seen in the experience of states that had caps on noneconomic damages that were invalidated by their state supreme courts. Ohio enacted MICRA- like reforms in 1975, but the Ohio Supreme Court nullified these in 1985. Malpractice insurance rates fell steadily until 1982, when the law was challenged in the courts. Since 1985, Ohio malpractice premiums have once again increased significantly and the state is dealing with a Chapter 15 / The Case for Legal Reform 215 Fig. In 2003, Ohio approved a new set of reforms in an effort to ameliorate the growing problem. By 2000, malpractice indem- nities in the state had increased 400% compared to 1998 (38). Alabama, Georgia, Illinois, Kansas, New Hampshire, North Dakota, and Washington have also had tort reforms nullified by their state supreme courts (4). Today, Georgia, Illinois, Oregon, and Washington are among the 19 states facing a professional liability crisis (4). New York did so in 1975, 1981, and 1986 with no observable improve- ment in the malpractice insurance situation (33). Florida and Texas have repeated similar experiences (24), and in 2003 both state legis- latures attempted to remedy the deteriorating medical-legal climate in their state with new reforms that do include caps on noneconomic damages. A work group of the American Academy of Actuaries concluded that to be effective, a package of medical malpractice reforms must include a $250,000 per injury limit on noneconomic damages and a collateral source offset (33). They found that reforms worked best when imple- mented together as a comprehensive program. Most significantly, they confirmed that porous caps with built-in exceptions or multipliers and peripheral reforms that do not include the fundamental elements of MICRA are predictably ineffective. States with $250,000 or $350,000 limits on noneconomic damages had average premium increases only one-third as large as those in states without caps between 2000 and 2001 (2,39). California’s experience over the preceding quarter century stands as firm testimony to these data. In 2002, the nonpartisan Congressional Budget Office estimated that the MICRA-based reforms contained in House Resolution 4600 (which failed to pass the Senate) would have lowered malpractice insurance premiums by 25 to 30% (40). Milliman USA analyzed medical malpractice claims in the 15 largest states from 1990 to 2001 and concluded that caps on noneconomic damages reduced medical malpractice loss costs for physicians (41). In this study, reform states like California and Colorado saw loss costs reduced 48 and 31%, respectively. In contrast, New York’s loss cost per physician stood at 300% compared to California, and Pennsylvania’s stood at 328%. In an earlier study, Milliman had estimated that a $250,000 cap on noneconomic damages in New York would reduce premium levels by 29% (32). Perhaps the most comprehensive study of this issue ever undertaken was that delivered by the Governor’s Select Task Force on Healthcare Professional Liability Insurance in Florida in 2002 (22). Testimony ran to 13 volumes and included physicians, lawyers, insurance industry representatives, regulators, legal scholars, professional organizations, and concerned citizens. The final report exceeds 300 pages and contains more than 1300 citations. The report takes note of Florida’s past history of unsuccessful reform and concludes that: “A cap on non-economic damages of $250,000 per incident limited only to healthcare professional liability cases is the only available remedy that can produce a necessary level of predictability... The authors noted that Florida’s unsuccessful previous attempts at reforms that did not include such a cap “are nothing more than a failed litany of alternatives” (22). Chapter 15 / The Case for Legal Reform 217 The National Association of Insurance Commissioners (NAIC) stud- ied the market for medical malpractice insurance to evaluate the current crisis in 2003 (28).

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On passing long flexor muscle of the thumb (A10) and the carpal tunnel generic colospa 135 mg without a prescription muscle relaxant antagonist, the nerve can be injured by pressure in older persons (carpal tunnel syn- to the radial part of the deep flexor muscle drome) order colospa 135mg amex muscle relaxant 114. Autonomic sensory palmar branch of the median nerve zone (dark blue) and maximum zone (light (A–C11) branches off to the skin of the ball blue). After passing through the carpal tunnel, the median nerve divides into three branches: the common palmar digital nerves I–III (A–C12), each of which bifurcates at the level of the metacarpophalangeal joints into two proper palmar digital nerves (A–C13). From the first common palmar digital nerve, a branch extends to the thenar eminence (short abductor muscle of thumb [A14], su- Kahle, Color Atlas of Human Anatomy, Vol. Brachial Plexus 77 A Muscles supplied by the median nerve (according to Lanz-Wachsmuth) 11 1 13 B Skin supplied by the median nerve C 6 C 7 1 C 8 3 T 1 4 5 8 6 7 10 2 9 8 11 16 14 15 12 17 11 D Paralysis of the median nerve 12 (according to Lanz-Wachsmuth) 13 13 C Sequence of branches Kahle, Color Atlas of Human Anatomy, Vol. Medial Fascicle (A–D) Thedeepbranch(AC9)sinksintothedepthof Ulnar nerve (C8–T1). Initially, the ulnar the palm and curves toward the thenar emi- nerve runs in the upper arm in the medial nence. Itgivesoffbranchesforallmusclesof bicipital sulcus without giving off any the hypothenar eminence (C10) (abductor branches. It crosses the lumbrical muscles III and IV (A15), and the elbow joint on the extensor side in a finally, at the thenar eminence, for the ab- bony groove, the sulcus for the ulnar nerve, ductor muscle of thumb (A16) and the deep at the medial epicondyle of the humerus. The Clinical Note: Injury to the ulnar nerve causes nervethenpassesbetweenthetwoheadsof the formation of a so-called clawhand (D), where the ulnar flexor muscle of the wrist to the the fingers are extended in the metacarpo- phalangeal joints but flexed in the proximal and flexor side of the forearm and runs beneath distal interphalangeal joints. It does not posture of the fingers is caused by paralysis of the pass through the carpal tunnel but extends interosseous muscles and lumbrical muscles, over the flexor retinaculum to the palm of which flex the phalanges in the metacarpo- the hand, where it divides into a superficial phalangeal joints but extend them in the proxi- branch and a deep branch. Failure of the flexor muscles causes the fingers to remain in In the forearm, the nerve gives off branches this posture due to the now predominant exten- (C1) to the ulnar flexor muscle of the wrist sor muscles. Since the little finger and the adduc- (A2) and to the ulnar half of the deep flexor tors of the thumb are paralyzed, thumb and little muscle of the fingers (A3). Autonomic arm and runs to the ulnar side of the back of zone (dark blue) and maximum zone (light the hand where it supplies the skin. Another sensory branch, the palmar branch of the ulnar nerve (BC5), branches off in the distal third of the forearm. It extends to the palm and supplies the skin of the hy- pothenar eminence. The superficial branch runs as common palmar digital nerve IV (BC6) toward the interdigital space between ring finger and little finger and divides into the proper palmar digital nerves (BC7), which supply sensory fibers to the volar aspects of the little finger and the ulnar side of the ring finger and reach to the distal phalanges on the extensor side of both fingers. There is a connection to a branch of the median nerve, called the com- Kahle, Color Atlas of Human Anatomy, Vol. Brachial Plexus 79 A Muscles supplied by the ulnar nerve (according to Lanz-Wachsmuth) 5 4 6 7 B Skin supplied by the ulnar nerve (according to Lanz-Wachsmuth) C 8 T 1 2 3 1 9 11 17 5 4 16 12 13 9 15 D Paralysis of the ulnar nerve 10 (according to Lanz-Wachsmuth) 14 14 6 8 7 C Sequence of branches Kahle, Color Atlas of Human Anatomy, Vol. From the nerve fascicle gives rise to the medial cutaneous trunk extending beneath the deltoid muscle nerve of the arm and the medial cutaneous to the front, numerous branches (D6) to the nerve of the forearm; both are exclusively deltoid muscle (D7) branch off and supply sensory nerves supplying the skin on the its various parts. Clinical Note: As a result of its location on the Medial cutaneous nerve of the arm (C8 – capsule of the shoulder joint, the nerve can be in- T1) (A, B). The nerve approaches the ante- jured by dislocation of the humerus or by rior surface of the upper arm below the axil- humeral neck fracture. Here it ramifies and supplies the the skin area over the deltoid muscle. Auto- its anterior branches and to the extensor nomic zone (dark blue) and maximum zone side of the upper arm with its posterior (light blue). The nerve runs below the fascia on the ulnar side of the forearm and passes in the lower third through the fascia with two branches, the anteriorbranch (AC1) and the ulnar branch (AC2). The anterior branch supplies the medial flexor side of the forearm almost up to the midline, and the ulnar branch supplies the upper region of the medial extensor side almost up to the midline. The area innervated by the medial cutaneous nerve of the forearm extends slightly to the upper arm and to the hand. Posterior Fascicle (D, F) The posterior fascicle gives rise to the axil- lary nerve and the radial nerve. This runs deep in- side the axilla and across the capsule of the shoulder joint around the surgical neck on the back of the humerus.

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The cell membrane discount colospa 135mg amex spasms catheter, composed of fluid loss exceeds fluid intake effective 135 mg colospa muscle relaxant end of life, may be a folded membranous extensions phospholipid and protein molecules, serious problem—especially in infants. Electrolytes are inorganic compounds that The mitochondria produce ATP regulates the passage of substances into form ions when dissolved in water. Mitochondria are lacking (a) The permeability of the cell membrane acids, bases, and salts. They are electrical currents, and in regulating abundant in the phagocytic white (b) Cell membranes may be specialized the activity of enzymes. Some of the between the cell membrane and the (a) Proteins are important structural enzymes in peroxisomes generate nucleus. Nucleoplasm is the material components of the body and are hydrogen peroxide, and one of them, within the nucleus. Protoplasm is a necessary for cellular growth, repair, catalase, breaks down excess hydrogen collective term for both the cytoplasm and division. Cytology © The McGraw−Hill Anatomy, Sixth Edition of the Body Companies, 2001 Chapter 3 Cytology 75 (g) The centrosome is the dense area of 6. The nucleotides in DNA consist of the sugar Synthesis is the production of DNA cytoplasm near the nucleus that deoxyribose, phosphate, and one of four and RNA to regulate cellular activity. The paired nitrogenous bases: adenine, guanine, Mitosis is the splitting of the cell’s centrioles play an important role in cytosine, or thymine. According to the law of nucleus and cytoplasm that results in cell division. RNA contains the sugar ribose (instead of and allows for the replacement support in the form of a cytoskeleton. A DNA molecule is in the shape of a the cell that have the same basic 8. The structural unit of the structure and that function in three bases called codons. Codons bond to molecule is a nucleotide, which consists producing movement. Cell division consists of a division of the substances between the nucleoplasm and brings to the growing polypeptide chain. Inorganic compounds that form ions chromosomes line up at the equator (d) hypertrophy. The phase of mitosis in which the (c) The bases adenine and thymine can 95% of the body are chromatids separate is called bond together. The enlarged skeletal muscle fibers that Essay Questions (d) the vacuole result from an increased work demand 1. Explain why a knowledge of cellular (e) the mitochondrion serve to illustrate anatomy is necessary for understanding 4. How is the study of cells important (b) the ductus (d) the uterine tubes. Cytology © The McGraw−Hill Anatomy, Sixth Edition of the Body Companies, 2001 76 Unit 3 Microscopic Structure of the Body 3. Distinguish between mitosis and the billions of dollars required to lipids similar? Describe the major events of complete the Human Genome Project What are enzymes and hormones? The brain is protected to some extent by various kinds of movement through the cell 14. Give examples of factors that contribute the blood-brain barrier—a membrane membrane and give an example of each. However, the (a) endoplasmic reticulum, (a) energy deficit, brain is still subject to trauma that can (b) ribosome, (b) hyperthermia, cause it to swell, much like an ankle (c) mitochondrion, (c) burns, swells with a sprain. Because the cranium (d) Golgi complex, (d) radiation, and is a cavity of fixed size, brain edema (e) centrioles, and (e) pathogens. Define inorganic compound and organic teratology, monosomy, trisomy, and movement of water across a membrane, compound and give examples of each.

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