Medical malpractice in perspective. I--The American experience.

Concern over the possibility of an American style medical malpractice "crisis" in the United Kingdom has recently been voiced by members of both medical and legal professions. The validity of such fears is examined by reviewing the conditions that have given rise to the current American difficulties. It is argued that the rise in malpractice insurance premiums and associated restrictions in availability should be seen against the background of underwriting problems specific to medical liability in conjunction with a general decline in reinsurance cover. The evidence in relation to the clinical and resource implications of malpractice is analysed. In particular, arguments that increased litigation has influenced the practice of "defensive" medicine and the choice of specialty are critically examined. Medical malpractice claims and insurance are only part of a professional environment which is undergoing dramatic social and economic changes, many of which seem more plausible candidates to be treated as important influences on the nature and organisation of health care in the United States.     

The challenges of litigation in US courts and the actions tissue banks can take to meet those challenges

The growth of tissue banking from local non-profit organizations to national and multi-national corporations has increased the likelihood of litigation against tissue banks. The acquisition of tissue banks by corporate entities, many of whom are based in the US, means that tissue banks need to be prepared for the challenge of litigation in the US courts. The purpose of this paper is to help tissue banks meet those challenges by describing the nature of US litigation, the most common types of lawsuits against tissue banks and the steps that tissue banks can take to prepare for litigation in the US.     

Contingent Fees in Medical Malpractice Litigation—A Qualitative Assessment

The medical profession has experienced high liability insurance premiums accompanied by widespread use of contingent fees in medical malpractice litigation. It is worthwhile, therefore, to assess qualitatively the merits of contingent fees, the evidence suggesting that they are associated with unjustified litigation and their implications for the medical and legal professions.     

Work-based physiological assessment of physically-demanding trades: a methodological overview

Technological advances, modified work practices, altered employment strategies, work-related injuries, and the rise in work-related litigation and compensation claims necessitate ongoing trade analysis research. Such research enables the identification and development of gender- and age-neutral skills, physiological attributes and employment standards required to satisfactorily perform critical trade tasks. This paper overviews a methodological approach which may be adopted when seeking to establish trade-specific physiological competencies for physically-demanding trades (occupations). A general template is presented for conducting a trade analyses within physically-demanding trades, such as those encountered within military or emergency service occupations. Two streams of analysis are recommended: the trade analysis and the task analysis. The former involves a progressive dissection of activities and skills into a series of specific tasks (elements), and results in a broad approximation of the types of trade duties, and the links between trade tasks. The latter, will lead to the determination of how a task is performed within a trade, and the physiological attributes required to satisfactorily perform that task. The approach described within this paper is designed to provide research outcomes which have high content, criterion-related and construct validities.     

Teaching laparoscopic surgery: the need for guidelines.

There is a risk that minimally invasive surgery will fall into disrepute unless adequate steps are taken to reassure the public. Some form of accreditation after a recognised training scheme would go a long way towards allaying these fears. The cost of training surgeons must be addressed. Adequate training will probably pay dividends in reduced litigation. The royal colleges should be responsible for maintaining standards of teaching on recognised courses, setting criteria for accreditation, and supervising a national audit of all laparoscopic procedures.     

Toxicogenomics and toxic torts

One of the first practical applications of toxicogenomics will probably be in the context of toxic tort personal injury litigation. Gene expression changes that'fingerprint' exposure to particular classes of toxic substances can potentially be used to demonstrate exposure, prove causation and support novel damage claims in lawsuits brought by citizens injured by toxic exposures. Although the potential use of toxicogenomic data in toxic tort litigation is immense, there is a danger of premature use of such data before they have been adequately validated and characterized.     

CMPA not alone in pursuing huge reserves,CMAJ survey of US firms reveals.

Although Canada and the US are two separate worlds when medical malpractice is considered, actuaries across North America are looking into their crystal balls in an attempt to set reserves for uncertain future claims. Given the relatively low rate of litigation in Canada, some feel the Canadian Medical Protective Association is hoarding cash as it continues to raise premiums even though it has close to $1 billion in reserves. However, some experts suggest that this is just a prudent way to do business in an unpredictable environment. Milan Korcok looks at the situation facing physicians on both sides of the border.     

“禁止反悔”对药物专利申请文件的撰写和修改的影响

申请人在专利实质审查的过程中,缩小其保护范围使得专利获得了授权,但在主张侵权诉讼中因为禁止反悔原则,却不能将因对权利要求的修改而放弃的技术方案再纳入到专利权的保护范围中。因此,申请人应重视专利授权或者无效宣告程序中权利要求的修改,知晓未公开的针对审查意见通知书的答复也会成为日后侵权判定过程中的一个重要证据,在此,申请人应仔细思考、斟酌每一次权利要求的修改以及每一次审查意见的答复,不能为了在较短的时间内获得授权就同意审查员的观点放弃权利要求中的技术特征,必要时,可以对审查员的观点予以否定。讨论了禁止反悔对药物专利申请文件的撰写和修改的影响。     

The limits of post-national citizenship: European Muslims,human rights and the hijab

Innovative approaches to citizenship emerged in the 1990s. Post-national theory suggested that European minorities no longer needed national citizenship because supra-national political structures such as the European Court of Human Rights (ECtHR) offered them protections. Denationalized citizenship held that universal human rights were now available at the national level too as the Council of Europe's member countries had to incorporate human rights principles within their own jurisdictions. New forms of claims-making among European Muslims were cited as evidence of this trend as religious claims, especially relating to the hijab, began to be made through human rights litigation. This paper demonstrates the limits of post-nationalism through a discussion of the outcomes of such claims. While European Muslims are indeed mobilizing around human rights, there is no evidence – at the level of litigation – that this has helped them to win recognition of their religious or cultural rights. This paper explores the reasons for this.     

DNA-based patents: an empirical analysis

The perception of rising litigation rates is driving the push for patent reform.     

Vaccination-induced syphilis and the Hübner malpractice litigation

This article examines smallpox vaccination in the 19th century as background for a notorious medical malpractice case that occupied Bavarian courts from April 1853 until May 1854. Dr. Georg Hübner, the defendant, was accused of having initiated a small epidemic of syphilis by using the lymph of a syphilitic infant to vaccinate 13 infants. The litigation and its published contemporaneous discussion demonstrate conflicts in the understanding of syphilis, the hazards of having to make a purely clinical diagnosis, the effect of obsolete legal wording in medical litigation, and the attitude of leading physicians to a guilty colleague. This case ultimately led to efforts to make arm-to-arm smallpox vaccination safer, and by 1898 to abandon the technique in favor of bovine sources that were sterilized and stabilized by various methods.     

Can doctors place limits on their medical practices?

PHYSICIANS SHOULD EXERCISE GREAT CAUTION and probably seek legal counsel if they decide to place specific limits on the work they will do or patients they will see, lawyer Karen Capen warns. The BC Human Rights Council recently ruled that a physician had violated the province''s Human Rights Act when he declined to provide artificial insemination for a lesbian couple. The physician argued unsuccessfully that increased risks of litigation constituted a bona fide and reasonable justification for denying the service.     

Genes and patent policy: rethinking intellectual property rights

Concerns about human gene patents go beyond moral disquiet about creating a commodity from a part of the human body and also beyond legal questions about whether genes are unpatentable products of nature. New concerns are being raised about harm to public health and to research. In response to these concerns, various policy options, such as litigation, legislation, patent pools and compulsory licensing, are being explored to ensure that gene patents do not impede the practice of medicine and scientific progress.     

The Investigation of Obscure Deaths

Unexpected death from obscure causes places a responsibility on the coroner which is delegated to the police, the pathologist and the laboratory. Important insurance and civil litigation issues may be at stake and crime must not be overlooked. This article stresses the importance of (a) powers of observation, (b) awareness of possibilities, (c) a flexible mind and (d) competence in forensic pathology. Cases quoted and illustrated show mistakes which have caused error—and injustice.The importance of discussion with clinical colleagues is emphasized; painstaking autopsy and meticulous laboratory examinations are vital. Poisoning is particularly easily overlooked.     

海平面上升影响下广西钦州湾红树林脆弱性评价

全球气候变化所导致的海平面上升等现象对海岸带产生显著影响。红树林是生长在热带、亚热带沿海潮间带的生态系统,对海平面上升极为敏感。以广西钦州湾红树林生态系统为对象,采用SPRC(Source-Pathway-Receptor-Consequence)评估模式分析了气候变化所导致的海平面上升对红树林生态系统的主要影响。构建了以海平面上升速率、地面沉降/抬升速率、生境高程、日均淹水时间、潮滩坡度和沉积速率为指标的脆弱性评价体系。在GIS平台上量化各脆弱性指标,计算脆弱性指数并分级,建立了定量评价红树林生态系统脆弱性方法,实现了在不同海平面上升情景(近40年来广西海平面平均上升速率、IPCC预测的B1和A1FI情景)和时间尺度下(2030年、2050和2100年),广西钦州湾红树林生态系统脆弱性的定量空间评价。研究结果表明,在近40年广西海平面平均上升速率与B1情景下,钦州湾红树林在各评估时段表现为不脆弱。而在A1FI情景下,至2050年研究区域41.3%红树林为低脆弱,至2100年增加至69.8%。研究采用的SPRC评估模型、脆弱性评价指标体系和定量空间评估方法能够客观定量评价气候变化所导致的海平面上升影响下红树林生态系统脆弱性,可为制定切实可行的应对措施和保障海岸带生态系统安全提供科学依据。     

Effects of octopamine and forskolin on excitatory junction potentials of developing and adult moth muscle

Intracellular recordings were made from the dorsal longitudinal muscle of Manduca sexta to determine the effects of development and octopamine on the excitatory junction potential (EJP) produced in response to electrical stimulation of the motor nerve. Observations were made on pharate moths during the last 3 days before eclosion and on adults. In saline, the highest values for EJP amplitude and maximum rate of rise and for resting membrane potential are reached on the nineteenth day of the pupal period, the day the animal ecloses; adult values are slightly lower. In animals of all ages tested, DL-octopamine (5 X 10(-6) M) increases EJP amplitude and maximum rate of rise. Increases in amplitude are greater in animals at stage day 17 and 18 than in animals at stage day 19 and adult. Octopamine has no effect on EJP rise time (onset to peak) or recovery time (peak of EJP to 70% recovery). Octopamine causes a hyperpolarization of about 6 mV. The results show that developmental changes in synapse properties are paralleled only in part by changes induced by octopamine. Both development and octopamine increase EJP amplitude and maximum rate of rise, and neither alter rise time. EJP recovery time changes with development but not in response to octopamine. Forskolin (10(-4) M) mimics the effects of octopamine on day 17 animals. EJP amplitude and maximum rate of rise are increased by forskolin, and rise time and recovery time are unaffected. Forskolin, like octopamine, causes a 6 mV hyperpolarization of the muscle fiber. These results suggest that octopaminergic modulation at the Manduca sexta dorsal longitudinal neuromuscular junction may be mediated by changes in intracellular levels of cyclic AMP.     

The rise times of miniature endplate currents suggest that acetylcholine may be released over a period of time.

Models of miniature endplate currents predict 20-80% rise times of 100 microseconds or less. These predictions are substantially less than most of the rise times recorded in the literature. New measurements were made of rise times at the frog neuromuscular junction using extracellular recording. The mean 20-80% rise time was 250 microseconds. Rise times were variable; at 20 degrees C, 95% of them fell in a range from 140 to 460 microseconds. The most questionable assumption in the models is that the acetylcholine (ACh) is released instantaneously. Modifying the model, so that ACh diffuses from the vesicle through a pore, lengthens the rise time to observed levels. It has been proposed that ACh is released from the vesicle in exchange for Na+. However, the rise times of miniature endplate currents recorded in solutions in which the Na+ is replaced by sucrose are in the normal range. The Q10 for the rise of miniature endplate currents is approximately 2, which is consistent with the models and with temperature effects on pore formation in mast cells.     

Improved modelling of the impacts of sea level rise on coastal wetland plant communities

This study presents an enhanced methodology for modelling the impacts of sea level rise on coastal wetlands. The tool integrates dGPS-calibrated LiDAR data, isostatic uplift and sediment accretion rates to predict the location and extent of plant communities at three non-contiguous micro-topographical coastal wetlands in Estonia by 2100 in response to global sea level rise. Scenarios were run including sediment accretion, elevated sediment accretion and then discounting sediment accretion and dGPS calibration for comparison. Results showed an increase in surface elevation (related to sediment accretion and isostatic uplift) resulting in a decrease in local sea level in the majority of sites and scenarios in the north of the country, although a rise in local sea level is predicted in sites with limited allochthonous sediment supply, predominantly impacting higher elevation plant communities. Wetlands situated on the west coast are likely to maintain equilibrium with sea level as a result of lower sedimentation and isostatic uplift than more northerly sites. This study shows that dGPS-calibrated LiDAR data and sediment accretion are essential to maintain model validity in Baltic coastal wetlands due to their low relief and could considerably improve current sea level rise impact models for other regions.     

制度供给视角下的基本医疗体制改革之决策

基本医疗改革的财政投入模式应从单一关注医疗服务供给转向协同关注医疗服务产出，无过错医疗损害救济应纳入国家财政投入的预算体系。面对医疗损害的高发性，以救济为心的医疗侵权责任制度应向以预防中心的制度进行改革。医疗过失诉讼制度对医疗体系有着深刻的负面制约作用。基本医疗改革的决策应从更宏观的视角进行制度供给设计。