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On T2-weighted or STIR MR images proven 300 mg avapro, contu- and the presence or absence of an associated meniscal sions appear as high-signal-intensity edema spreading cyst proven avapro 150mg. The radiologist should also note the presence of dis- out from the point of contact in the muscle belly buy cheap avapro 150mg on line. MRI, these appear as regions of edema centered at the A meniscal tear that heals spontaneously or following myotendonous junction, with partial or complete disrup- repair will often still contain intrameniscal signal on tion of the tendon from the muscle in more severe cases short-TE images that contacts the meniscal surface. Around the knee, muscle trauma affects the distal When the abnormality is also present on a T2-weighted hamstrings, distal quadriceps, proximal gastrocnemius, image, when there is a displaced fragment, or when a tear soleus, popliteus, and plantaris muscles. Tendonopathy can be painful or asymp- none of these features is present, MRI or CT examination tomatic; but most importantly, tendonopathy weakens after direct arthrography is useful. The patellar, examination, the presence of injected contrast within the quadriceps, and semimembranosus tendons are most fre- substance of a repaired meniscus is diagnostic of a quently involved around the knee. Sonographically, a degen- a partial meniscectomy; in these cases both the meniscal erated tendon appears enlarged, with loss of the normal shape and internal signal are unreliable signs of recurrent parallel fiber architecture, and often with focal hypoe- meniscal tear. A gap between the tendon noninvasive test for recurrent meniscal tears following fibers indicates that the process has progressed to partial partial meniscectomy. Similarly, on MR images, focal or dif- fuse enlargement of a tendon with loss of its sharp mar- Ligaments gins indicates tendonopathy. In those cases in which T2-weighted images show a focus of high signal intensi- T2-weighted images demonstrate ruptures of the cruciate, ty, surgical excision of the abnormal focus can hasten collateral, and patellar ligaments. Partial or complete dis- cross-sectional images are important to examine. The di- ruption of tendon fibers represents a tendon tear on MRI rect sign of a ligament tear is partial or complete disrup-. When macroscopic tearing is present, the radiolo- tion of the ligament fibers. While edema surround- gist should also examine the corresponding muscle belly ing a ligament is typically seen in acute tears, edema sur- for fatty atrophy (which indicates chronicity) or edema rounding an intact ligament is a nonspecific finding, (suggesting a more acute rupture). If the tear is complete, which can be seen in bursitis or other soft tissue injuries, the retracted stump should be located on the images as in addition to ligament tears. These last two tasks may require repositioning of have a more varied appearance. Synovium Secondary findings of ligament tears, such as bone con- tusions or subluxations, are useful when present, but do While radiographs can show medium and large knee ef- not supplant the primary findings, and do not reliably dis- fusions, other modalities better demonstrate specific syn- tinguish acute from chronic injuries, nor partial from ovial processes. In the knee, the anterior cruciate liga- hanced through-transmission on ultrasound images. A Imaging of the Knee 31 popliteal or Baker’s cyst represents distention of the pos- sections addresses the role of MRI following knee trau- teromedial semimembranosus-gastrocnemius recess of ma, focusing on the most common traumatic mechanisms the knee, and is easily seen with all cross-sectional and associated injuries to stabilizing structures. At least 11 other named bursae occur around will be placed on the detection of clinically suspected or the knee. The most commonly diseased ones are proba- occult soft-tissue and bone abnormalities that could be bly the prepatellar, superficial infrapatellar, medial col- exacerbated by repeat trauma or could lead to chronic in- lateral ligament, and semimembranosus-tibial collateral stability and joint degeneration unless treated. Synovitis due to infection, trauma, inflammatory arthritis, or crystal disease is readily identifiable in the Biomechanical Principles knee on both ultrasound and MR images. Power Doppler ultrasound or the use of ultrasound contrast agent may in- Kinematic laws dictate normal joint motion and the bio- crease sensitivity for active synovitis. Although the knee moves pri- amination, thickening of the usually imperceptibly thin marily as a hinge joint in the sagittal plane, it is also de- synovial membrane and enhancement of the synovium signed for internal-external rotation and abduction-ad- following intravenous contrast administration indicates duction. In Throughout the normal range of knee motion, the the knee, primary synovial osteochondromatosis appears menisci improve joint congruence and load distribution as multiple cartilaginous bodies within the joint on MR while the femorotibial contact points are shifting anterior- images, also visible on radiographs or CT if the bodies ly and posteriorly. The signal intensities of the bodies logical, but the menisci must shift with the contact points vary depending on their composition. Diffuse pigmented to avoid entrapment and crush injury by the femoral villonodular synovitis and focal nodular synovitis demon- condyles. Paired cruciate and collateral ligaments func- strate nodular, thickened synovium, which enhances fol- tion collectively with the menisci to maintain joint con- lowing contrast administration. The stress endured by each individual ligament in the synovium – which is very low in signal intensity depends on the position of the knee as well as the direc- on all MR pulse sequences, with blooming on gradient- tion and magnitude of mechanical load. In external rota- echo images – is an important, though inconstant, clue to tion, for example, the cruciate ligaments are lax whereas the diagnosis. Conversely, in internal rotation, the collateral lig- aments are lax whereas the cruciates become twisted Biomechanical Approach to Knee Trauma around each other, pulling the joint surfaces together and resisting varus or valgus rocking.

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Insurance companies writing at a combined ratio of 100% would then have profit equal to investment income avapro 300 mg discount. Since the start of the recent crises beginning in 2000 buy 300 mg avapro visa, the combined ratio of the average malpractice insurer has been between 130 and 140% generic avapro 150 mg fast delivery, meaning that for every pre- mium dollar collected, $1. Obviously, such numbers produce very large operating losses even when invest- ment income is included. SURPLUS An insurance company’s assets minus its liabilities equal its surplus. This represents the capital base of the company and, in a mutual or reciprocal insurance company, belongs to the policyholders. It is neces- sary to maintain significant surplus to support company operations and to maintain solvency during those years when unpredictably high losses are incurred. Insurance companies are regulated by State Departments of Insurance that require certain amounts of surplus to back each dollar of premium and reserves. The intent is to provide assurance to policy- 8 Gorney and Anderson holders that a company has sufficient assets to pay their claims, even if losses are greater than anticipated. Surplus is also needed to provide the capital backing necessary to accept new business. REINSURANCE Reinsurance is an agreement between insurance companies under which one company accepts all or part of the risk of the other. Most insurance companies insure only part of the risk assumed on any given policy. Smaller carriers may themselves cover the first $250,000 of loss, whereas larger companies may retain the first $1 million. The insurance company takes a portion of the premium collected from the policyholder and cedes it to the reinsurer to cover losses under clearly defined circumstances. This is the principle of spread of risk applied to insurance companies and is intended to mitigate the effect of very large losses on a single company. The less primary risk that the company retains, the more premium it has to pay to the reinsurer to cover the remaining policy limits. Thus, reinsurance is a necessary aspect of fi- nancial prudence for the vast majority of insurance companies; how- ever, it ultimately adds cost (the reinsurer’s profit or margin) in exchange for the protection it provides against unexpected or very large losses. Chapter 2 / Litigation 9 II LEGAL 10 Hiestand Chapter 2 / Litigation 11 2 What Every Doctor Should Know About Litigation A Primer on How to Win Medical Malpractice Lawsuits Fred J. Hiestand, JD SUMMARY This chapter explains what you should know to best look out for yourself and how you should go about doing so. Its premise is that just as patients should not leave decisions about the best course of medical treatment exclusively to medical profession- als, neither should you as a doctor or health care provider leave your fate as a defendant solely in the hands of your lawyer and insurer. No one representing you will be as affected as you are by the litigation in which you are a defendant; and, although your advocates are charged with looking after your best interests, your active and intelligent participation in how they do this is abso- lutely necessary if they are to be effective. Key Words: Defendant; storyteller; discovery; duty; causation; negligence; reform; MICRA. Understanding the essentials of litigation enables you to eliminate or at the very least minimize your liability and get on with your life. Not knowing this information leaves you with little or no control over your own destiny, a wisp to be buf- feted about by the devil’s breath of litigation. This chapter explains what you should know to best look out for yourself and how you should go about doing so. Its premise is that just as patients should not leave decisions about the best course of medical treatment exclusively to medical professionals, neither should you as a doctor or health care provider leave your fate as a defendant solely in the hands of your lawyer and insurer. No one representing you will be as affected as you are by the litigation in which you are a defendant; and, although your advocates are charged with looking after your best inter- ests, your active and intelligent participation in how they do this is absolutely necessary if they are to be effective. However, the information given here can—if properly digested—make your life safer and more secure from the slings and arrows of outrageous lawsuits.

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Electrical Slow-Wave Frequencies in the Stomach order avapro 150mg with visa, Small CONTROL OF DIGESTIVE FUNCTIONS Intestine order avapro 300 mg on-line, and Colon order 300mg avapro with visa. Electrical slow waves with essen- BY THE NERVOUS SYSTEM tially the same waveform occur at different frequencies in the gastric antrum and small and large intestinal circular The innervation of the digestive tract controls muscle con- muscle when recorded with intracellular electrodes (Fig. Slow waves occur at 3/min in the antrum, as high as ing and blood flow inside the walls of the esophagus, stom- 18/min in the duodenum, and 6 to 10/min in the colon. Depending on the kind of maximum contractile frequency of the muscle does not ex- neurotransmitter released, the neurons can activate or in- ceed the frequency of the slow waves, but it may occur at a hibit muscle contraction. The secretion of water, elec- lower frequency because all slow waves may not trigger trolytes, and mucus into the lumen and absorption from the contractions. The nervous system determines the nature of lumen are determined by the innervation. The amount of the contractile response during each slow wave in the inte- blood flow within the wall and the distribution of flow be- grated functional state of the whole organ. Sensory nerves transmit information on the state of the Electrical Slow Waves Without Action Potentials in the gut to the brain for processing. As a general rule, slow waves in the small central processing account for sensations that are localized intestinal circular muscle trigger action potentials and ac- to the digestive tract. These include sensations of discom- tion potentials trigger contractions. Slow waves are om- fort (such as upper abdominal fullness), abdominal pain, nipresent in virtually all mammalian species and may or and chest pain (heartburn). Neural interactions include the may not be accompanied by action potentials. Contrac- sensory inflow of information from the gut to the brain and tions do not occur in the absence of action potentials. This method records from many circular muscle state (psychogenic stress) to the gut. Shallow contractions appearing in the absence of ac- interaction underlies the symptoms of diarrhea and lower tion potentials on the slow waves reflect the responses of a abdominal discomfort often reported by students anticipat- few of the total population of muscle fibers under the elec- ing an examination. In this case, the action potential currents from the small number of fibers are too small to be detected by the surface electrode. With this method of recording, A Hierarchy of Neural Integrative Centers the size of an action potential appears larger when larger Determines the Moment-to-Moment Motor numbers of the total population of muscle fibers are depo- Behavior of the Digestive Tract larized to action potential threshold by each slow wave. The amplitude of phasic contractions associated with each The sympathetic, parasympathetic, and enteric nervous electrical slow wave increases in direct relation to the num- systems make up the divisions of the ANS that innervate ber of muscle fibers recruited to firing threshold by each the digestive tract. Level 1 is the ENS, which behaves Electrical Slow Waves and Interstitial Cells of Cajal. Level 2 consists of the preverte- stitial cells of Cajal (ICCs) are the generators of electrical bral ganglia of the sympathetic nervous system. Levels 3, 4, slow waves in the stomach and small and large intestine and 5 are within the CNS. Sympathetic and parasympa- CHAPTER 26 Neurogastroenterology and Gastrointestinal Motility 453 Small intestine Contraction 10 g 10 sec Slow waves 1. A, No action potentials appear at the crests of the slow waves, and Small the muscle contractions associ- intestine Contraction 10 g ated with each slow wave are small. B, Muscle action poten- tials appear as sharp upward- 10 sec downward deflections at the crests of the slow waves. Large- amplitude muscle contractions are associated with each slow Slow waves 1. Electrical slow waves trigger action potentials, and action potentials trigger con- tractions. Level 5 includes higher brain centers that provide in- Autonomic Parasympathetic Neurons Project to put for integrative functions at levels 3 and 4. Projections to the digestive tract from tramural control networks that make up the intrinsic these regions of the CNS are preganglionic efferents. The parasympa- thetic and sympathetic subdivisions are identified by the positions of the ganglia containing the cell bodies of the postganglionic neurons and by the point of outflow from 5 the CNS. Comprehensive autonomic innervation of the di- Higher brain centers 4 3 Central parasympathetic Central sympathetic centers centers ICC network 2 Prevertebral sympathetic ganglia 1 GI muscle Enteric nervous system FIGURE 26. Gastrointestinal, esophageal, and biliary tract Electrical slow waves originate in the networks of ICCs.

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