Medical malpractice insurance. Part II. Some proposed solutions

Organized groups of physicians should be considered potential initiators of any concerted effort to solve the medical malpractice problem. This may occur by a number of means, among them (a) establishment of malpractice review panels, (b) a patient's compensation board, (c) no-fault malpractice insurance, (d) substitution of claims-made insurance policies for the present-occurrence system now in use, and (e) malpractice insurance funds supported by insurance premiums and administered by panels composed in part of insured physicians. Cooperation between the insurance industry and the legal and medical professions might make it unnecessary for external agencies to impose regulations and policies at some future date.

Medical malpractice insurance. Part I: A consideration of some of the factors

The "crisis" of medical malpractice insurance is a product of a number of factors, both social and economic. Physicians, patients, insurance companies, and lawyers have all made individual and collective contributions. Social forces, changing physicians' roles and reorientation of patient attitudes have made institution of litigation against doctors much more culturally acceptable. Contingency fees, the need for compensation, and aggressive legal attitudes have increased the number of lawsuits and the size of awards, inflation, recession, and other economic developments have caused the insurance industry to be concerned about their financial welfare. The responses of various groups to these factors are presented, and their effect upon the cost and availability of medical malpractice insurance are considered.

Physical characteristics of modern radiographic screen-film systems

The most important characteristics that determine the performance of a screen-film system are system sensitivity (speed), slope or the average gradient of the characteristic curve, latitude of the film, system resolution (MTF) and system noise. In addition to these, one has to consider secondary characteristics such as the base plus fog level, the base tint, safelight sensitivity, reciprocity law failure and film granularity while evaluating performance. A comprehensive study of many of these characteristics has been made for a number of film-screen systems on the market. The data has been tabulated in the form of what are called "characteristic tables of radiographic film-screen systems." In these tables, characteristics such as average gradient, base plus fog level, etc. which depend on film alone, appear along the horizontal axis and MTF values which essentially depend on screens only appear along the vertical axis. The body of the table contains the absolute speeds in units of mR-1 at 80 KVP (heavy filtration) and a quantum mottle index of the various film-screen combinations tested, since these depend both on the film as well as on the screens.

Differential diagnosis of pelvic masses by gray scale sonography

An approach to the sonographic differential diagnosis of pelvic masses based on their size, location, internal consistency, and definition of borders is presented. Diagnostic schemes were derived from correlating the sonographic features with histomorphology in 170 surgically proven pelvic masses. Besides separating pelvic masses into the conventional categories of cystic, complex, and solid, gray scale sonographic features of a pelvic mass can be used to subcategorize these masses into a more useful differential diagnoses. Although the features seen on a sonographic image were specific in only two types of pelvic masses (pattern specificity greater than 85%), the sonographic information can be effectively utilized for establishing differential diagnoses of pelvic masses. Among the various sonographic patterns observed, homogenously cystic adnexal masses were the least specific pattern, whereas a predominantly cystic, extrauterine mass with internal septation was highly specific for a pseudomucinous cystadenoma. Several pelvic masses such as dermoid cysts demonstrated more than one sonographic appearance and, therefore, had to be considered in more than one diagnostic category.

The law of agency as applied to radiology

Agency relationships are an intrinsic characteristic of the discipline of radiology. In the practice of the specialty, many individuals and groups act as agents for the radiologist. Understanding the basic elements of agency law is desirable for an appreciation of the liability incurred by the professional.

Evaluation of the central canal of the spinal cord in experimentally induced hydrocephalus

The central canal of the spinal cord has been proposed as a significant compensatory alternative pathway of cerebrospinal fluid (CSF) flow in hydrocephalus. Ten dogs were made hydrocephalic by a relatively atraumatic experimental model that simulates the human circumstance of chronic communicating hydrocephalus. The central canal was studied by histopathology and compared with 10 normal control dogs. In both groups the central canal of the spinal cord was normal in size, configuration, and histological appearance. In this experimental model dilatation of the canal and increased movement of CSF does not appear to be a compensatory alternative pathway.

Lower limb angiography in leprosy

Bilateral lower limb angiography was performed on 58 patients with leprosy and compared with bilateral lower limb angiography performed on 63 non-leprosy patients. The vessels in leprosy were narrow and constricted. Decreased blood flow through arteries in the distal third of the lower limb was present. Abnormal AV fistula formation in the thigh and calf muscles and in trophic ulcers of the feet was also seen. Deep inflammatory granulomatous reaction surrounding the arteries as a result of leprosy is a possible explanation for these angiographic findings and is felt to be related to trophic ulceration. These findings were specific for leprosy, precede clinical manifestations, and are helpful in management.

Tantalum tracheography in upper airway obstruction: 100 experiences in adults

A total of 100 tantalum cine laryngotracheograms were performed in adults with documented or suspected upper airway obstruction. With appropriate precautions, tantalum powder proved to be a safe material for delineating tracheal and laryngeal abnormalities. A cine recording to document tracheomalacia as well as a careful evaluation of the larynx are useful extensions of examination of patients with suspected upper airway obstruction. Tracheomalacia was found in 35% of our series; 29% showed laryngeal abnormalities. With modifications to correct for magnification, the tantalum tracheogram gives the surgeon the exact length of trachea to be resected. When tantalum becomes approved by the Food and Drug Administration, we expect that tantalum cine laryngotracheography will be the preferred means for study of upper airway obstruction.

Sonographic patterns in trophoblastic diseases

A range of sonographic patterns in patients with hydatidiform moles can be appreciated with gray scale ultrasonography, which more readily reveals areas of internal hemorrhagic degeneration and fetal growth within a molar mass. Sonography may be used to evaluate patients suspected of having recurrent or invasive trophoblastic disease; a focus of invasive trophoblastic tumor can be identified as a cluster of high-amplitude echoes within the myometrium, which is frequently associated with echo-free areas of hemorrhage. The enlargement or regression of theca lutein cysts associated with these disease processes can also be monitored.

Xeromammographic automatic exposure termination

A method of automatic exposure termination (AET) for xeromammography has been devised, significantly reducing the rate of repeat exposures due to poor choice of manual exposure factors. AET images are of good quality and are reliably produced. The concept of AET is based on the existence of an optimal transmitted exposure to the selenium plate, which is easily determined experimentally. In routine clinical xeromammography, a repeat rate of 20% was eliminated by the use of AET.

The central canal of the spinal cord in experimental hydrocephalus: preliminary results

The central canal of the spinal cord in certain animal species has been shown to be an alternative pathway of cerebrospinal fluid flow in experimentally induced hydrocephalus. Enlargement and increased movement of cerebrospinal fluid in the central canal has been proposed as a compensatory mechanism in hydrocephalus in humans. The central canal of the spinal cord was normal in 5 dogs and 2 primates made hydrocephalic by a relatively atraumatic experimental model which simulates the human disorder to chronic communicating hydrocephalus. Dilatation of the central canal is apparently not an important compensatory alternative pathway.

Negative-mode soft-tissue xeroradiography

Positive-mode xeroradiography is an excellent method of visualizing soft-tissue structures in mammography and other procedures; however, toner deletions over a large area may preclude adequate delineation of the soft tissues near high-density structures such as bone. Use of the negative mode in the development cycle provides excellent demonstration of the soft tissues without toner deletions and requires only about 70% of the exposure needed in the positive mode. Negative-mode images also exhibit greater changes in radiographic contrast than those observed with the positive mode. The extent of achilles tendon lacerations was shown particularly well by this technique.

Some applications of the law of evidence to the specialty of radiology

Certain rules or laws of evidence are particularly applicable to diagnostic images in whatever form they are used in court as evidence. The legal principles and precedents of this subject, including opinion evidence, hearsay evidence rule, best evidence rule, and the role of the radiologist as a medical expert witness, are discussed.

Application of the radiological sciences to advance clinical and fundamental knowledge of the animal kingdom. New Horizons for Radiologists Lecture

Many radiological techniques are useful in fundamental research. Selected clinical problems in animals as well as certain basic research projects are utilized to emphasize the potential of radiological imaging. The author describes the use of several radiological methods in studies of how birds breathe.

Informed consent: some newer aspects and their relation to the specialty of radiology

Several recent court decisions have focused the attention of radiologists upon the medicolegal subject of informed consent. Some of the legal principles and precedents of this subject are reviewed, and the impact and implications of recent legal decisions considered.

The production of cerebrospinal fluid in experimental communicating hydrocephalus

Utilizing an atraumatic model to produce chronic hydrocephalus, CSF production was measured during and after development of communicatin hydrocephalus. CSF volume production was significantly lower in animals with increased pressure. Animals with chronic hydrocephalus and normal pressures had abnormal CSF production. Diminished CSF production appears to offer a potential compensatory mechanism when CSF absorption is altered.

[Selected promising radiological imaging techniques (author's transl)]

This paper informes about physical basics of computerized axial tomography.

Evaluation of cerebrospinal fluid production in the development of communicating hydrocephalus

Diminished absorption of cerebrospinal fluid (CSF) is the most common cause of communicating hydrocephalus. Soon after the absorptive capacity is decreased, the CSF pressure increases, producing ventricular enlargement if the process is not halted. CSF production was measured by ventriculo-cisternal perfusion during and after the production of communicating hydrocephalus, using an atraumatic animal model. Animals with chronic hydrocephalus and normal pressure had normal CSF production. CSF production tended to be lower in animals with increased pressure. When CSF absorption is compromised, decreased CSF production does not appear to be a significant compensatory mechanism.

Rhinorrhea, ventricular radiopharmaceutical stasis and communicating hydrocephalus: evaluation by serial cisternography

Spontaneous cerebrospinal fluid rhinorrhea has been known to occur in association with hydrocephalus. The specific pathophysiology which results in a potential communication between the cerebrospinal fluid space (subarachnoid space) and the nasopharynx is unknown. The relationship of CSF movement and rhinorrhea was evaluated in ten random source mongrel dogs. These data suggest that spontaneous CSF rhinorrhea may occur during the early developmental phase of communicating hydrocephalus in dogs. At this time radiopharmaceutical movement showed ventricular entry and clearing. When the lateral ventricles enlarged, ventricular radiopharmaceutical stasis was seen and the rhinorrhea disappeared. This suggests that CSF rkinorrhea may act as a compensatory mechanism which partially protects the CSF compartment to withstand the extra CSF during the early development of communicating hydrocephalus.

Compartmental analysis of cerebrospinal fluid-blood albumin transfer: consideration of kinetics in normal animals and animals with chronic communicating hydrocephalus

Transfer of radioactively labelled albumin from the cerebrospinal fluid (CSF) to the blood was monitored in 15 dogs with normal cisternograms and in 8 dogs with induced communicating hydrocephalus. Blood concentration curves alone are of limited value and give less than satisfactory information about CSF distribution spaces and were corrected for albumin disappearance from the blood to other compartments. The transit time in animals with hydrocephalus was much greater than in normals and entry into the intravascular compartment was delayed. Mathematical analysis to the indicator movements appears to offer understanding about CSF compartments and transfer of molecules in different types of hydrocephalus.

Vaccine-induced canine distemper in a lesser panda

A fatal disease occurred in a lesser panda (Ailurus fulgens) 2 weeks after vaccination with modified live distemper vaccine. The disease clinically resembled canine distemper. Pathologically there was giant cell pneumonia, with canine distemper viral inclusion bodies in pulmonary and digestive tract epithelium. Viral isolates were indicative of an attenuated strain rather than virulent types.

Surgical repair of tusk injury (pulpectomy) in an adult, male forest elephant (Loxodonta cyclotis)

A 15-year-old male forest elephant housed in a zoo sustained a fracture of the right tusk that was 10 cm inside the cheek pouch, thus exposing the tusk canal. Treatment of the cavity by packing, topical application of antibiotics, and administration of various antiseptic preparations failed; however, the tusk grew. To treat the infected, growing tusks's root canal or pulp, surgery--comparable to a pulpectomy in man--was performed with successful results.