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The sub- sequent move away from tightly managed care made the case for ex- clusive health plan liability less compelling (56) discount 20 mg celexa. This led to renewed Chapter 17 / New Directions in Liability Reform 269 interest in hospital-based enterprise liability (57) discount celexa 20 mg visa, 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...

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In patients with CT may not be able to detect other intra-articular abnor- conventional images indicating an avulsion of the greater malities generic celexa 20 mg visa. For this reason generic celexa 20 mg with visa, MRI may be even more useful trochanter, MRI should be preformed in order to evaluate as it can detect ligamentous injuries, meniscal tears and the intertrochanteric region for incomplete fracture. Osteochondral injuries of the femoral condyles displacement of the medial fragment. Avulsion fractures at process of the calcaneus occur and must be distinguished the insertion of the posterior cruciate ligament are often from normal variants in this location. Knowledge of the in- missed on conventional imaging and diagnosis often fol- sertion point of the posterior cruciate ligament in this lo- lows MRI performed for persistent ankle pain. This fracture, which can be usually readily demonstrable on tangential views of the demonstrated on conventional imaging, has an extremely calcaneus or on CT. When this fracture is identified, MRI will clearly the calcaneus and navicular. In adolescent athletes, epiphyseal separations are cult to see on conventional imaging and may require CT more common than ligamentous injuries. Asymmetry in the width of the growth plate or small fracture fragments on The Forefoot the metaphyseal side of the growth plate should be suffi- cient to establish the diagnosis in most cases. MR may be The Lisfranc fracture-dislocation of the tarso-metatarsal a valuable technique when the nature of the injury is in joints is a frequent injury. This injury is easily over- question and also allows evaluation of ligamentous struc- looked, and a careful examination of the relationships of tures about the knee. Ankle and Hindfoot In the forefoot, stress and other fractures of the metatarsals are not uncommon. Avulsions of the base of Conventional imaging of the ankle should include AP, in- the fifth metatarsal, at the point of insertion of the per- ternal oblique (“mortise”) and lateral images. Fractures oneus brevis muscle, should be distinguished from of the malleoli are common ,and careful examination for “dancer’s fracture” or Jones fracture.

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The cerebellum is divided into the medial best celexa 20 mg, deep- lying vermis of the cerebellum (A14) and the two cerebellar hemispheres (A15) order celexa 10 mg visa. White and Gray Matter (B) Upon dissecting the brain into slices, the white and gray matter, substantia alba et grisea, become visible on the cut surfaces. The gray matter represents a concentration of neurons and the white matter the fiber tracts, or neuronal processes, which appear light because of their white envelope, the myelin sheath. In the spinal cord (B16), the gray matter lies in the center and is en- closed by the bordering white matter (as- cending and descending fiber tracts). In the brain stem (B17) and diencephalon, the dis- tribution of gray and white matter varies. In the telen- cephalon (B18), the gray matter lies at the outer margin and forms the cortex, while the white matter lies inside. Thus, the dis- tribution here is the reverse of that in the spinal cord. The arrangement in the spinal cord repre- sents a primitive state; it still exists in fish and amphibians where the neurons are in a periventricular position even in the telen- cephalon. The cerebral cortex represents the highest level of organization, which is fully developed only in mammals. Base of the Brain, White and Gray Matter, Subdivision into Lateral Zones 13 3 4 1 5 9 6 8 7 10 11 2 12 13 15 A Basal view of the brain 14 16 17 18 B Distribution of white and gray matter 20 21 19 C Longitudinal zones of the CNS Kahle, Color Atlas of Human Anatomy, Vol. During their expansion, they push the brain developed into the organ of human in- early-developed brain parts into a deeper telligence. Since the ancestors are extinct, location and bulge outward (they become the developmental sequence can only be re- prominent).