Legal liability and managed care.

In attempts to reduce the cost of mental health treatment, health insurers are turning to mechanisms for intensive oversight that fall under the rubric of managed care. These approaches have implications for the potential liability of clinicians and managed care entities. Clinicians may be confronted with legal duties to appeal adverse decisions, to disclose the impact of managed care on patients' treatment, and in some circumstances, to continue treatment after payment has been denied. Managed care entities are being held to duties to conduct review in a reasonable fashion, and may also have a duty to disclose the limitations managed care may place on patients' access to treatment, and to select appropriate providers of care. The law in this area is in an early stage of development and is likely to be refined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Judaism, genetic screening and genetic therapy

Genetic screening, gene therapy and other applications of genetic engineering are permissible in Judaism when used for the treatment, cure, or prevention of disease. Such genetic manipulation is not considered to be a violation of God's natural law, but a legitimate implementation of the biblical mandate to heal. If Tay-Sachs disease, diabetes, hemophilia, cystic fibrosis, Huntington's disease or other genetic diseases can be cured or prevented by "gene surgery," then it is certainly permitted in Jewish law. Genetic premarital screening is encouraged in Judaism for the purpose of discouraging at-risk marriages for a fatal illness such as Tay-Sachs disease. Neonatal screening for treatable conditions such as phenylketonuria is certainly desirable and perhaps required in Jewish law. Preimplantation screening and the implantation of only "healthy" zygotes into the mother's womb to prevent the birth of an affected child are probably sanctioned in Jewish law. Whether or not these assisted reproduction techniques may be used to choose the sex of one's offspring, to prevent the birth of a child with a sex-linked disease such as hemophilia, has not yet been ruled on by modern rabbinic decisions. Prenatal screening with the specific intent of aborting an affected fetus is not allowed according to most rabbinic authorities, although a minority view permits it "for great need." Not to have children if both parents are carriers of genetic diseases such as Tay-Sachs is not a Jewish option. Preimplantation screening is preferable. All screening test results must remain confidential. Judaism does not permit the alteration or manipulation of physical traits and characteristics such as height, eye and hair color, facial features and the like, when such change provides no useful benefit to mankind. On the other hand, it is permissible to clone organisms and microorganisms to facilitate the production of insulin, growth hormone, and other agents intended to benefit mankind and to cure and treat diseases.     

Legal liability of subordinate physicians, legal liability for management responsibility from the jurisprudence viewpoint

Within the bounds of the hospitalization contract and the department's work, the hospital management is liable for compensation for its own as well as its staff's culpable faults (liability of the accomplices) by contract and by offense. For the same damage, subordinate and senior physicians are liable by offense for malpractice and organization faults. To the outside, the hospital management and the medical staff are common debtors. To the inside, the hospital management bears the consequences by itself in case of a light negligence of a staff member, the damage is divided for medium negligence, and the staff member has to bear it alone after severe negligence. Beside the hospital, the physician with an authorization for billing is the contract partner of the patient with private treatment (physician side-contract). In a general practitioner hospital, the contract partner of the patient is only the general practitioner (divided hospitalization contract) and for work with outside-patients as a sideline the physician with an authorization for billing. Usually, the hospital management insures itself and all staff members for claims on compensation occurring during hospital tasks.     

Legal and ethical aspects of new reproductive technologies; the case of prenatal diagnosis

During metamorphosis of flatfish larvae, eye migration leads to a 90 degrees misalignment of the visual and vestibular frames of reference. In order to maintain vestibular eye stabilization, the vestibulo-ocular (V-O) pathways have to be radically reorganized. Here, we have examined the vestibular projections in turbot larvae and juveniles by means of conventional neurohistological techniques using horseradish peroxidase and fluorescent dextranamines as tracers. We have found that the vestibular projections to the rostral eye motor nuclei consist of five densely clustered groups of neurons projecting to the rostral eye motor nuclei, some through the ipsilateral, others through the contralateral medial longitudinal fascicle (MLF). In addition, there are three groups of vestibulo-spinal neurons. The most prominent of these gives rise to the ipsilateral vestibulo-spinal tract. The other two project contralaterally, one descending in the MLF, the other more laterally in the anterior funiculus of the spinal cord. These subnuclei of the vestibular complex are easily identifiable in larvae before metamorphosis, as well as in juvenile turbots. The number of projection neurons in each of the subnuclei is approximately doubled over the period of metamorphosis. Applying different tracers to rostrally and caudally projecting pathways, we found no double-labeled neurons, indicating that the V-O and vestibulo-spinal groups are distinct entities. However, by applying the two tracers ipsi- and contralaterally in the terminal fields in the rostral eye motor nuclei after metamorphosis, we found many double-labeled neurons in all the V-O subgroups. In contrast, we found only a small fraction of double-labeled vestibular neurons when the same strategy was applied to larval preparations. We conclude that 1) the basic organization of the vestibular nuclei of the turbot is similar to that of other teleosts, in larvae as well as juveniles; 2) there is a substantial increase in projection neurons over the period of metamorphosis in all the subgroups of the vestibular nuclear complex; and 3) many more of the V-O neurons project bilaterally to the rostral eye motor nuclei in juvenile than in larval turbots.     

Rapid trisomy diagnosis (21, 18, and 13) using fluorescent PCR and short tandem repeats: applications for prenatal diagnosis and preimplantation genetic diagnosis

PURPOSE AND METHODS: Prenatal diagnosis of fetal trisomies is usually performed by cytogenetic analysis from amniotic fluid. This requires lengthy laboratory procedures and high costs and is unsuitable for large-scale screening of pregnant women. An alternative method, which is rapid and inexpensive and may potentially be suitable for diagnosing trisomies even from single fetal cells, is the fluorescent polymerase chain reaction (F-PCR) using polymorphic small tandem repeats (STRs). RESULTS: In this paper we present data demonstrating that fluorescent PCR amplification of STRs can be used for rapid diagnosis of trisomy 21, trisomy 18, and trisomy 13 and can be successfully applied to both prenatal diagnosis and diagnosis of single cells. This study also reports significant numbers of prenatal diagnoses using quantitative fluorescent PCR. CONCLUSIONS: We believe that further studies of greater numbers of samples will determine the absolute reliability of this technique. These results also provide a model for trisomy diagnosis from single cells using multiple STR markers for either preimplantation genetic diagnosis or, potentially, diagnosis from fetal cells isolated from maternal blood.     

Cytogenetical problems in prenatal diagnosis

The effects of Microfibrillar Collagen Hemostat (MCH) and Gelfoam after surgical implantation into incision sites of the liver, kidney, and brain were studied in beagle dogs, rabbits, and beagle dogs, respectively. The results of these experimental animal studies suggest that MCH is comparable to Gelfoam with respect to biocompatibility, rate of bioassimilation, and a lack for adverse systemic effects. The brain, liver, and kidney tissues responded comparably to MCH and Gelfoam with a mild to moderate infiltration of macrophages and mononuclear cells. Most of the hemostatic compound had disappeared from the incision sites by Day 28 and completely disappeared by Day 84. The tissue degree response was interpreted as a factor in the process of bioassimilation of the two hemostatic materials. Both hemostatic compounds contributed to adhesion formation in the experimental models. The incidence of adhesions was somewhat lower for MCH than for Gelfoam, but both produced more adhesions than were found at the control sites. The adhesions were only to the adjacent structures and always localized to the surgical site. When MCH or Gelfoam is used under conditions similar to those in the present experimental study, where tissue approximation is impaired, and where growth of granulation tissue is stimulated by the physical presence of the hemostatic compound, there is the possibility for increased incidence of adhesion formation. However, when an intraperitoneal absorbable hemostatic compound is desired, the present studies in experimental animals suggest that MCH will be safe by exhibiting minimal tissue reaction.     

Neuropsychology, genetic liability, and psychotic symptoms in those at high risk of schizophrenia.

Neuropsychological assessments were compared among individuals at enhanced genetic risk of schizophrenia (n=157) and controls (n=34). The relationship between cognitive impairments and the presence of psychotic symptoms and measures of genetic risk was explored in the high-risk subjects. Neuropsychological differences were identified in many areas of function and were not accounted for by the presence of psychotic symptoms. Genetic liability was not associated with neuropsychological performance or with psychotic symptoms, but exploratory analysis showed some tests were associated with both liability measures. These results suggest that what is inherited is not the disorder itself but a state of vulnerability manifested by neuropsychological impairment, occurring in many more individuals than are predicted to develop the disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Coinheritance of alpha-thalassemia-1 and hemoglobin E/beta zero-thalassemia: practical implications for neonatal screening and genetic counseling

OBJECTIVES: To establish the urologic status of men with Behcet's syndrome, because studies assessing the urologic aspect of Beh?et's syndrome are rare. METHODS: During a 2.5-year period, we evaluated 104 male patients with Beh?et's syndrome, 16 to 50 years old (mean 31+/-7), using a urologic questionnaire and modified Boyarsky symptom score; 44 healthy men, 20 to 46 years old (mean 29+/-7), were used as control subjects. RESULTS: The frequency of epididymitis in patients with Beh?et's syndrome was 19.2% in this study. The mean irritative symptom score was 1.22+/-1.37 (significantly higher than the control group). The frequency of lower urinary tract symptoms (eg, dysuria, urgency, nocturia, terminal dribbling, and intermittency) was significantly higher in patients with Behcet's syndrome. CONCLUSIONS: In this study, the frequency of epididymitis in men with Behcet's syndrome was much higher than previously reported. Because some lower urinary tract symptoms were significantly more frequent in these patients, we conclude that screening of such patients with urologic questionnaire and symptom scoring is essential to identify those who need further urologic evaluation.