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The insur- ance markets should support the legal system by offering peace of mind to careful physicians and making compensation available to victims generic aspirin 100pills with mastercard. Insurers should dispose of meritless claims buy aspirin 100 pills otc, help providers improve their safety records, and weed out the worst offenders. Chapter 17 / New Directions in Liability Reform 255 Patient Care AVOIDABLE INJURIES The tort reform movement of the 1970s and 1980s was based on two related beliefs: (a) few incidents of actual negligence occur in health care, and (b) most litigation reflects social and financial influences apart from medical quality (10). Subsequent research, much of which is a direct outgrowth of public interest in malpractice reform, largely confirmed the second perception but refuted the first. The Harvard Medical Practice Study (HMPS) reviewed medical records from hos- pitalizations in New York State during 1984 and looked for associated liability claims; it concluded that roughly six unfounded claims were filed for every meritorious one (11). In a follow-up study, the severity of the plaintiff’s condition, not negligence or even medical causation, was the strongest predictor of payment through the legal system for cases evaluated by the HMPS (12). On the other hand, the HMPS reviewers found evidence of negligent injury in 1% of hospitaliza- tions; only one-eighth of these negligent injuries generated lawsuits, and only half of those claims were compensated through litigation. This mismatch between instances of actual negligence and legal pro- ceedings undercuts the deterrent effect of conventional malpractice liability on poor medical care (13). The HMPS helped alert an innovative group of physicians to serious safety problems in the health care system (14). By the late 1980s, qual- ity researchers had established that medical practice was far less coher- ent than it had previously appeared and that little data existed linking health care processes to successful outcomes. The patient safety move- ment grew up alongside these quality improvement efforts, with medi- cal errors demonstrating in salient fashion the need to replace traditional oversight of individual health professionals with a more systematic approach to process re-engineering that matched the growing sophis- tication of the health care industry. In 1999, the Institute of Medicine (IOM) published its landmark report, To Err is Human, and brought patient safety and its cousin, medical quality, onto the national political and policy agenda (15,16). The relationship between liability reform and the patient safety movement remains unsettled. On its face, To Err Is Human envisions a constructive role for institutional liability in promoting system-based safety and criticizes traditional malpractice law primarily for its focus on individual practitioners and, therefore, its chilling effect on efforts to gather and share information about error.

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A cascade of events occurs when the first protein recognizes preformed immune complexes aspirin 100 pills low cost, a large cross-linked mesh of antigen molecules bound to antibod- ies cheap aspirin 100 pills amex. In addition, complement can be activated when one of the proteins is exposed to the cell wall of certain bacteria. Initiation of this system results in edema, an influx of acti- vated phagocytic cells (chemotaxis), and local inflamma- tory changes. In contrast to the rapid onset of biological responses when antigen binds antibody, the consequences of T cell activation are not noticeable until 24 to 48 hours after antigen challenge. During this time, the T cells that initially recognize the anti- gen secrete factors that recruit and activate other cells (e. In this model, only the clone of lympho- cells possessing the antigen, or the surrounding tissue. A com- cytes that has the unique ability to recognize the antigen of inter- mon example is the delayed-type hypersensitivity reaction est proliferates, generating memory cells as well as effector cells specific to the inducing stimulus. This proliferation is initiated by to purified protein derivative (PPD), a response used to assess the interaction of a specific recognition lymphocyte (afferent prior exposure to the bacteria that cause tuberculosis. Cells then proliferate and differentiate into under the skin of sensitive individuals, PPD elicits the famil- either memory cells, which potentiate subsequent responses to iar inflammatory reaction characterized by local erythema the inciting antigen, or plasma cells, which secrete antibody. Cell-mediated immune responses, while slow to de- velop, are potent and versatile. These delayed responses provide for defense against many pathogens, including The Adaptive Immune Response Involves viruses, fungi, and bacteria. T cells are responsible for the Cellular and Humoral Components rejection of transplanted tissue grafts and containment of Depending on the nature of the stimulus, its mode of pres- the growth of neoplastic cells. A deficiency in T cell im- entation, and prior challenges to the immune system, an munity, such as that associated with AIDS, predisposes the antigen may elicit either a cellular or humoral immune re- affected patient to a wide array of serious, life-threatening sponse.

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Cells At a critical period in fetal development buy aspirin 100pills with mastercard, circulating in the arcuate nucleus of the hypothalamus appear to be the testosterone secreted by the testes of a male fetus changes sensors for leptin levels buy aspirin 100pills with amex. Physiological responses to low leptin the characteristics of cells in the preoptic area that are des- levels (starvation) are initiated by the hypothalamus to in- tined later in life to secrete GnRH. These cells, which crease food intake, decrease energy expenditure, decrease re- would secrete GnRH cyclically at puberty, had they not productive function, decrease body temperature, and increase been exposed to androgens prenatally, are transformed into parasympathetic activity. Physiological responses to high cells that secrete GnRH continually at a homeostatically reg- leptin levels (obesity) are initiated by the hypothalamus to ulated level. As a result, males exhibit a steady-state secre- decrease food intake, increase energy expenditure, and in- tion rate for gonadotropic hormones and, consequently, for crease sympathetic activity. This pattern is reinforced and synchronized Sleep Awake Sleep Awake Sleep throughout female reproductive life by the cyclic feedback of ovarian steroids, estradiol and progesterone, on secre- 80 tion of GnRH by the hypothalamus during the menstrual cycle (see Chapter 38). Steroid levels during prenatal and postnatal develop- 40 ment are known to mediate differentiation of sexually di- morphic regions of the brain of most vertebrate species. Others, such as the female men- strual cycle, repeat themselves approximately every 28 15 days. Still others, such as reproductive function in seasonal 10 breeders, repeat annually. The hypothalamus is thought to play a major role in regulating all of these biological 5 rhythms. Furthermore, these rhythms appear to be endoge- 0 nous (within the body) because they persist even in the ab- 6 12 18 24 6 12 18 24 sence of time cues, such as day/night cycles for light and Time of day (hours) dark periods, lunar cycles for monthly rhythms, or changes Circadian rhythms in some homeostatically FIGURE 7. Ac- regulated functions during two 24-hour pe- cordingly, most organisms, including humans, are said to riods. Alertness is measured on an arbitrary scale between sleep possess an endogenous timekeeper, a so-called biological and most alert. The circadian rhythms of the body are driven by the suprachi- asmatic nucleus (SCN), a center in the hypothalamus that mone increase greatly during sleep, in keeping with this serves as the brain’s biological clock.