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The fiber plate of the basal plate lie ventrally: the nucleus of of the medial lemniscus (D26) (p generic zenegra 100 mg online. The fibers of the cerebral peduncle nucleus (eye muscles) zenegra 100mg overnight delivery, the red nucleus (C11) buy zenegra 100mg lowest price, (D27) are cut transversely and are inter- and the substantia nigra (C12) (consisting of spersed with a few pontine fibers running anouterreticularpartandaninnercompact across buy zenegra 100 mg. The sensory derivatives of the alar plate lie dorsally: the tectum of the mesen- D28Periaqueductal gray substance 100 mg zenegra for sale, central cephalon (quadrigeminal plate) (C13) (syn- gray. D Cross Section Through the Inferior Colliculi of the Midbrain (D) The inferior colliculus with its nucleus (nu- cleus of inferior colliculus) (D14) (synaptic relay station of the central auditory path- way) is seen dorsally. The transitional re- gion between pons and cerebral peduncles Plane of section and the most caudal cell groups of the sub- stantia nigra (D15) lie ventrally. The magno- cellular nucleus of the trochlear nerve (D16) Kahle, Color Atlas of Human Anatomy, Vol. Structure of the Midbrain, Inferior Colliculi 133 55 44 44 99 44 88 66 11 77 22 33 A Structure of medulla oblongata, pons, and midbrain 1313 99 1010 2929 99 1111 1212 1010 B Development of the midbrain C Organization of the midbrain into basal and alar plates 1414 2323 2828 1919 99 2222 1818 2020 2424 2525 1717 1616 2626 1515 1414 2727 1919 99 2222 1818 1717 1616 2424 2121 2020 2525 2626 2121 D Cross section through the midbrain at the level of the inferior colliculi, cellular staining (Nissl) and fiber staining (myelin) Kahle, Color Atlas of Human Anatomy, Vol. The ven- The two superior colliculi (A1) are seen dor- tral aspect on both sides is formed by the sally. In lower vertebrates, they represent corticofugal fiber masses of the cerebral the most important visual center and con- peduncles (AB19). In the superficial gray layer (A2) termi- Region of the Midbrain (B) nate the fibers from the occipital fields of The pretectal region (B21) situated orally to the cortex (corticotectal tract) (A3). The the superior colliculi represents the tran- optic layer (A4), which in lower vertebrates sition from the midbrain to the dien- consists of fibers of the optical tract, is cephalon. Hence, the cross section already formed in humans by fibers from the lateral contains structures of the diencephalon: genicular body. The deeper layers of cells dorsally on each side lies the pulvinar (B22), and fibers are collectively known as stratum in the middle the epithalamic commissure lemnisci (A5). Here terminate the spinotec- (B23), and ventrally the mamillary bodies tal tract (p. The pretectal region extends dor- lateral lemnisci, and fiber bundles of the in- solaterally with the principalpretectalnucleus ferior colliculi. The latter is an important relay sta- The aqueduct is surrounded by the peri- tion for the pupillary reflex (p. It fibers of the optical tract and the fibers of contains a large number of peptidergic neu- the occipital cortical fields terminate here. The mesencephalic nucleus of the across the epithalamic commissure to the trigeminal nerve (A7) lies laterally to it, and Edinger–Westphal nucleus (accessory ventrallytoitliethenucleusoftheoculomotor oculomotor nucleus). Ventral to the aque- nerve (A8) and the Edinger-Westphal nucleus duct are the Darkshevich’s nucleus (B26) and (accessory oculomotor nucleus) (A9) the interstitial nucleus (of Cajal) (B27), the (p. Dorsally to both nuclei runs relay stations in the system of the medial the posterior longitudinal fasciculus longitudinal fascicle (p. The main nucleus of the teg- nucleus situated further orally are impor- mentum is the red nucleus (AB11) (p. The essential synapses for (among others, the dentatorubral fasciculus) the rotation of the body around its longi- (A12). At its medial margin descend fiber tudinal axis lie in the interstitial nucleus, bundles of the oculomotor nerve (A13) in those for raising the head and upper body in ventral direction. Superior Colliculi, Pretectal Region 135 222 111 444 555 333 161616 777 888 666 999 101010 202020 111111 171717 181818 222 444 444 141414 555 333 151515 999 161616 131313 202020 777 888 121212 191919 111111 141414 151515 121212 171717 A Cross section through the mid- 181818 brain at the level of the superior 131313 colliculi 191919 222222 212121 161616 232323 252525 Planes of sections 666 262626 272727 111111 232323 252525 202020 262626 272727 161616 242424 191919 282828 B Cross section though the mid- brain at the level of the pretectal region Kahle, Color Atlas of Human Anatomy, Vol. The tracts of the substantia nigra form reaches from the oral part of the pons (A2) only loose pathways of fine fibers rather to the pallidum (AB3) in the diencephalon. Both nuclei are important relay stations of the extrapyramidal system (p. Afferent connections terminating in the anterior part Red Nucleus (A, B)! Fibers of the caudate nucleus, strionigral The nucleus (AB4) appears reddish in a fasciculus (B12) fresh brain section (high iron content,! It consists of the parvocellular corticonigral fibers (B13) neorubrum and the magnocellular paleoru- Afferent connections terminating in the brum situated ventrocaudally. Fibers of the precentral cortex (areas 4 dentate nucleus (B6) of the cerebellum and 6) (B15) runs in the superior cerebellar peduncle Efferent connections and terminates in the contralateral red nucleus.

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Another critical tradeoff is between administrability and accountability purchase 100 mg zenegra otc. For this reason 100 mg zenegra, the more promising proposals from a patient safety (deterrence) perspective (i order 100 mg zenegra with visa. For example quality zenegra 100 mg, plaintiffs may continue to take high-dollar cases to court while using an administrative system only for injuries not worth litigating proven 100mg zenegra. Institutional Liability As discussed earlier, the assignment of liability for personal injury to corporate entities (e. Proposals to systematize liabil- ity at higher levels of aggregation than individual health professionals (usually referred to as “enterprise liability” or “organizational liabil- ity”) have become a mainstay of academic thinking about malpractice reform, although they have attracted only occasional support from physicians (33). These range from modest measures encouraging voluntary efforts to coordinate liability among affiliated providers (such as a safe harbor from the federal anti-kickback statute allowing hospitals to provide malpractice insurance to physicians) to sweeping statutory mandates that confer exclusive liability on particular catego- ries of institutional providers. Institutional malpractice liability has potential advantages over individual liability in terms of patient welfare, loss-spreading, and administrative efficiency. One goal is to get all major health carecon- tributors on the same page regarding safety. Under current law, (spe- cifically, the Employee Retirement Income Security Act), ERISA shield selectively shelters managed care organizations from liability for personal injury, although courts have evolved serviceable, if not entirely logical, distinctions between benefits determinations and clinical decisions that have resulted in de facto health plan liability in many cases (54). Aligning incentives was the premise behind the Clinton Administration’s controversial proposal to focus liability on health plans in connection with national health reform (55). The sub- sequent move away from tightly managed care made the case for ex- clusive health plan liability less compelling (56). This led to renewed Chapter 17 / New Directions in Liability Reform 269 interest in hospital-based enterprise liability (57), particularly as evi- dence accumulated that most medical errors need to be addressed at the organizational level (15). However, scholars continue to argue that managed care organizations are well-positioned to monitor physician practice (58) and promote long-term investment in safety (59). Ide- ally, health systems would not only integrate their patient safety and risk management efforts but would link these clinical activities to health insurance benefit design and provider payment practices (60,61). Institutional liability might improve patient compensation by linking the malpractice system to regulatory oversight that promotes early iden- tification of avoidable injury and prompt resolution of potential claims. Because malpractice suits involving severe harm are typically associ- ated with inpatient care and name multiple defendants, consolidated liability can substantially reduce delay and administrative cost when claims arise, particularly if the responsible institution has established a mediation or arbitration system to handle disputes. Large medical insti- tutions may also be better risk-bearers than individually insured physi- cians because they can diversify legal exposure over the full spectrum of clinical services and have access to a wider array of commercial coverage options and self-insurance vehicles. However, the greater vulnerability of corporate defendants to jury assessments of punitive damages might undercut some of these advantages (62). The principal barriers to adopting institutional liability are political. The American health care system is still fragmented; therefore, grassroots reforms that benefit large numbers of solo practitioners and small medical groups are most attractive to lawmakers. Further, the lobbying momentum for general business tort reform that typically builds during malpractice insurance crises makes it difficult to incor- porate provisions that would expand corporate liability in politically viable legislation. As was clear from the reaction to the Clinton pro- posal, physicians also worry that institutional liability will further shift clinical authority as well as legal and financial responsibility to corpo- rate organizations. On the other hand, the severity of the current mal- practice crisis, coupled with physicians’ sense that their autonomy has already been severely compromised, may eventually make the medical profession more supportive of comprehensive institutional liability. Information and Choice Information about medical errors and provider responsibility com- prises a fourth important category of cutting-edge malpractice reforms. If patients had perfect information, they would only choose competent physicians with whom they could agree in advance on acceptable criteria for care and for payment. However, in economist Patricia Danzon’s words: “Just as imperfect information undermines the efficient functioning of the mar- ket, imperfect information undermines the efficient functioning of the liability system... Therefore, an alternative is to focus reform on improving information for both providers and patients and on leveling the playing field between them. Informational measures take two common forms: error disclosure requirements involving spe- cific patients, and publicly available information about malpractice judgments and settlements. As the Danzon quote suggests, greater transparency regarding medi- cal errors might eventually open private contractual alternatives to tort liability. The primary objection to private contracting has been that patients are poorly informed and are not in a position to weigh the risks when they are in need of medical care.

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Frequently the first symptom of visual loss generic zenegra 100mg on-line, but it does not stop the pro- retinitis pigmentosa is difficulty with gression of diabetic retinopathy discount zenegra 100mg on-line. Laser night vision (night blindness) 100mg zenegra, which usu- treatment is usually performed on an out- ally begins in late youth or early adult- patient basis buy zenegra 100mg amex. Total bilateral loss of vision can occur in later stages of the disease generic 100 mg zenegra with amex. There Retinal Detachment is no cure or treatment for the condition; however, a number of assistive devices With detached retina, the sensory lay- may be utilized to enhance function. De- tached retina may result from a sudden Macular Degeneration blow to the head, a tumor in the choroid layer, retinal degeneration caused from Degenerative changes in the macula, conditions such as arteriosclerosis, or the part of the eye needed for seeing fine hemorrhage with conditions such as dia- detail and central vision, results in a con- betic retinopathy. Symptoms may develop suddenly or Macular degeneration usually occurs slowly over time. Individuals may notice after the age of 50, from no apparent flashes of light or a loss of vision in dif- cause. Painless loss of central visual acu- ferent areas of the visual field, or they may ity is usually slow, with visual distortion experience a complete loss of vision in the or blurring of vision being the first symp- affected eye. Retinal detach- a blind spot in the center of their field of ment in one eye may indicate an in- vision that gradually increases in size as creased risk of detachment in the other the condition progresses. Prompt diagnosis and surgical treat- signs of macular degeneration are absent ment are essential to prevent permanent until central vision is affected, regular eye vision loss. A surgical procedure called examinations are important for early iden- Diagnostic Procedures for Conditions of the Eye 133 tification of the condition and so treat- cializes in evaluation and treatment of ment to its progress can be implemented. There are two types of macular pupils, as well as identifying any optic degeneration: dry form and wet form. Most cases of macular degeneration are dry Individuals may also be asked to view a form, in which there is atrophy (shrink- chart through an instrument called a re- age) and thinning of the macula, causing fractor. The type of through the refractor onto the retina to macular degeneration called wet form is estimate the eye’s ability to focus on dis- characterized by significant loss of vision tant objects. Also included in a compre- due to abnormal blood vessel formation hensive eye exam is a tonometry (described and hemorrhage. A retinal examination to check for retinal There is no treatment or cure for macular disease may also be included. This requires degeneration, but the use of assistive that the pupil of the eye be dilated. Activities such as reading may be- come difficult because of distortion of let- Tonometry is used to measure pressure in ters or parts of words or sentences in the the eye in order to detect glaucoma. An center of the reading material that appear instrument called a tonometer is placed to be missing. Large print with black type directly on the cornea after the cornea has and white background may make reading been anesthetized with drops of a local easier, as well as assistive devices such as anesthetic. DIAGNOSTIC PROCEDURES FOR CONDITIONS OF THE EYE Gonioscopy Comprehensive Eye Exam For gonioscopy, a special contact lens that contains a mirror is gently placed on Eye examinations usually include an the eye. The ophthalmologist uses the lens external eye exam that measures eye like the periscope of a submarine to exam- movements and the size of the pupils and ine structures inside the eye. Ophthalmoscopic Examination This part of the exam may be performed by an optometrist (nonphysician who A direct ophthalmoscopic examination is specializes in correcting refractive errors). It is performed with 134 CHAPTER 4 CONDITIONS OF THE EYE AND BLINDNESS an instrument called an ophthalmoscope measure refractive errors and perceptual that is placed close to the eye. The oph- dysfunctions of the eye, as well as to diag- thalmoscope contains a light that shines nose visual conditions and prescribe opti- into the eye and magnifies internal struc- cal corrections). Optometrists do not pre- tures so that the physician can note any scribe medications or perform surgery. Lenses for glasses are made by opticians, The internal structures of the eye may technicians who have been trained to fill also be observed with a slit lamp, a type optical prescriptions. They grind and con- of microscope that is placed in front of the struct the lens according to the prescribed eye. A tances must be corrected, bifocal or trifocal slit lamp is especially useful in identifying lenses may be prescribed.

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