Medical Malpractice in Public Healthcare Systems: An Empirical Investigation of Scheduled Damages

In the last decades, medical malpractice has been framed as one of the most critical issues for healthcare providers and health policy, holding a central role on both the policy agenda and public debate. The Law and Economics literature has devoted much attention to medical malpractice and to the investigation of the impact of malpractice reforms. Nonetheless, some reforms have been much less empirically studied as in the case of schedules, and their effects remain highly debated. The present work seeks to contribute to the study of medical malpractice and of schedules of noneconomic damages in a civil law country with a public national health system, using Italy as case study. Besides considering schedules and exploiting a quasi-experimental setting, the novelty of our contribution consists in the inclusion of the performance of the judiciary (measured as courts’ civil backlog) in the empirical analysis. The empirical analysis is twofold. First, it investigates how limiting compensations for pain and suffering through schedules impacts on the malpractice insurance market in terms of presence of private insurers and of premiums applied. Second, it examines whether, and to what extent, healthcare providers react to the implementation of this policy in terms of both levels and composition of the medical treatments offered. Our findings show that the introduction of schedules increases the presence of insurers only in inefficient courts, while it does not produce significant effects on paid premiums. Judicial inefficiency is attractive to insurers for average values of schedules penetration of the market, with an increasing positive impact of inefficiency as the territorial coverage of schedules increases. Moreover, the implementation of schedules tends to reduce the use of defensive practices on the part of clinicians, but the magnitude of this impact is ultimately determined by the actual degree of backlog of the court implementing schedules.

Factor analysis of responses to thermal, electrical, and mechanical painful stimuli supports the importance of multi-modal pain assessment

During the last decade, a multi-modal approach has been established in human experimental pain research for assessing pain thresholds and responses to various experimental pain modalities. Studies have concluded that differences in responses to pain stimuli are mainly related to variation between individuals rather than variation in response to different stimulus modalities. In a factor analysis of 272 consecutive volunteers (137 men and 135 women) who underwent tests with different experimental pain modalities, it was determined whether responses to different pain modalities represent distinct individual uncorrelated dimensions of pain perception. Volunteers underwent single painful electrical stimulation, repeated painful electrical stimulation (temporal summation), test for reflex receptive field, pressure pain stimulation, heat pain stimulation, cold pain stimulation, and a cold pressor test (ice water test). Five distinct factors were found representing responses to 5 distinct experimental pain modalities: pressure, heat, cold, electrical stimulation, and reflex-receptive fields. Each of the factors explained approximately 8% to 35% of the observed variance, and the 5 factors cumulatively explained 94% of the variance. The correlation between the 5 factors was near null (median ρ=0.00, range -0.03 to 0.05), with 95% confidence intervals for pairwise correlations between 2 factors excluding any relevant correlation. Results were almost similar for analyses stratified according to gender and age. Responses to different experimental pain modalities represent different specific dimensions and should be assessed in combination in future pharmacological and clinical studies to represent the complexity of nociception and pain experience.

Proteome analysis in cardiovascular pathophysiology using Dahl rat model

Dahl salt-sensitive (DS) and salt-resistant (DR) inbred rat strains represent a well established animal model for cardiovascular research. Upon prolonged administration of high-salt-containing diet, DS rats develop systemic hypertension, and as a consequence they develop left ventricular hypertrophy, followed by heart failure. The aim of this work was to explore whether this animal model is suitable to identify biomarkers that characterize defined stages of cardiac pathophysiological conditions. The work had to be performed in two stages: in the first part proteomic differences that are attributable to the two separate rat lines (DS and DR) had to be established, and in the second part the process of development of heart failure due to feeding the rats with high-salt-containing diet has to be monitored. This work describes the results of the first stage, with the outcome of protein expression profiles of left ventricular tissues of DS and DR rats kept under low salt diet. Substantial extent of quantitative and qualitative expression differences between both strains of Dahl rats in heart tissue was detected. Using Principal Component Analysis, Linear Discriminant Analysis and other statistical means we have established sets of differentially expressed proteins, candidates for further molecular analysis of the heart failure mechanisms.

A Metric to Evaluate and Synthesize Distributed Compliant Mechanisms

Compliant mechanisms with evenly distributed stresses have better load-bearing ability and larger range of motion than mechanisms with compliance and stresses lumped at flexural hinges. In this paper, we present a metric to quantify how uniformly the strain energy of deformation and thus the stresses are distributed throughout the mechanism topology. The resulting metric is used to optimize cross-sections of conceptual compliant topologies leading to designs with maximal stress distribution. This optimization framework is demonstrated for both single-port mechanisms and single-input single-output mechanisms. It is observed that the optimized designs have lower stresses than their nonoptimized counterparts, which implies an ability for single-port mechanisms to store larger strain energy, and single-input single-output mechanisms to perform larger output work before failure.

The Body of Margaret Atwood: Sex Work and Prostitution within Margaret Atwood's The Handmaid's Tale, Oryx and Crake, and The Year of the Flood

In this paper, I will argue that Canadian author Margaret Atwood uses fiscal and socially conservative dystopias to show how sex work and prostitution are choices that women would never have to make in a world with true gender equality. In these radically different worlds, women have no agency beyond their sexuality and no ability to express themselves as equals within either society. And while the structures of both societies, the society of The Handmaid’s Tale and that of both Oryx and Crake and The Year of the Flood, are inherently different, they both stem from modern conservative philosophies: for example, the country of Gilead in The Handmaid’s Tale holds Christian conservative beliefs on the role of religion in the state and the culturally designated roles of women. I define social conservatism as the idea that government organizations are used to pursue an agenda promoting traditional religious values such as “public morality” and opposing “immoralities” such as abortion, prostitution, and homosexuality. I define fiscal conservatism as an agenda promoting privatization of the market, deregulation and lower taxes. In this paper I argue that because these philosophies are incompatible with gender equality, they drive women to occupations such as sex work. Women find that they have no choices and sex work provides something to “trade.” For Offred, this “trading” is more limited, because she is a sex slave. For Oryx, this trading allows her to travel to the West, yet not before her childhood is marked by prostitution and pornography. Sex work allows for Ren to reclaim some agency over her life, yet she only chooses sex work because she is presented with few other options. All of these issues stem from the philosophies that define these dystopias.

Structural aspects of redox-mediated electron tunneling (Dedicated to the memory of professor Alexander M. Kuznetsov)

We investigated structural aspects of electron transfer (ET) in tunneling junctions (Au(1 1 1)vertical bar FcN vertical bar solution gap vertical bar Au STM tip) with four different redox-active N-thioalk(ano)ylferrocenes (FcN) embedded. The investigated molecules consist of a redox-active ferrocene (Fc) moiety connected via alkyl spacers with N = 4, 6, 8 and 11 carbon atoms to a thiol anchoring group. We found that for short FcNs (N = 4, 6,8) the redox-mediated ET response increases with the increase of the alkyl chain length, while no enhancement of the ET was observed for Fc1 1. The model of two-step ET with partial vibrational relaxation by Kuznetsov and Ulstrup was used to rationalize these results. The theoretical ET steps were assigned to two processes: (1) electron tunneling from the Fc group to the Au tip through the electrolyte layer and (2) electron transport from the Au(1 1 1) substrate to the Fc group through the organic adlayer. We argue that for the three short FcNs, the first process represents the rate-limiting step. The increase of the length of the alkyl chain leads to an approach of the Fc group to the STM tip, and consequently accelerates the first El' step. In case of the Fcl 1 junctions the rather high thickness of the organic layer leads to a decrease of the rate of the second ET step. In consequence, the contribution of the redox-mediated current enhancement to the total tunneling current appears to be insignificant. Our work demonstrates the importance of combined structural and transport approaches for the understanding of Er processes in electrochemical nanosystems. (C) 2010 Elsevier B.V. All rights reserved.

Heteroresistance to Fosfomycin Is Predominant in Streptococcus pneumoniae and Depends on the murA1 Gene

Fosfomycin targets the first step of peptidoglycan biosynthesis in Streptococcus pneumoniae catalyzed by UDP-N-acetylglucosamine enolpyruvyltransferase (MurA1). We investigated whether heteroresistance to fosfomycin occurs in S. pneumoniae. We found that of 11 strains tested, all but 1 (Hungary(19A)) displayed heteroresistance and that deletion of murA1 abolished heteroresistance. Hungary(19A) differs from the other strains by a single amino acid substitution in MurA1 (Ala364Thr). To test whether this substitution is responsible for the lack of heteroresistance, it was introduced into strain D39. The heteroresistance phenotype of strain D39 was not changed. Furthermore, no relevant structural differences between the MurA1 crystal structures of heteroresistant strain D39 and nonheteroresistant strain Hungary(19A) were found. Our results reveal that heteroresistance to fosfomycin is the predominant phenotype of S. pneumoniae and that MurA1 is required for heteroresistance to fosfomycin but is not the only factor involved. The findings provide a caveat for any future use of fosfomycin in the treatment of pneumococcal infections.

Reciprocal cooperation between unrelated rats depends on cost to donor and benefit to recipient

Background Although evolutionary models of cooperation build on the intuition that costs of the donor and benefits to the receiver are the most general fundamental parameters, it is largely unknown how they affect the decision of animals to cooperate with an unrelated social partner. Here we test experimentally whether costs to the donor and need of the receiver decide about the amount of help provided by unrelated rats in an iterated prisoner's dilemma game. Results Fourteen unrelated Norway rats were alternately presented to a cooperative or defective partner for whom they could provide food via a mechanical apparatus. Direct costs for this task and the need of the receiver were manipulated in two separate experiments. Rats provided more food to cooperative partners than to defectors (direct reciprocity). The propensity to discriminate between helpful and non-helpful social partners was contingent on costs: An experimentally increased resistance in one Newton steps to pull food for the social partner reduced the help provided to defectors more strongly than the help returned to cooperators. Furthermore, test rats provided more help to hungry receivers that were light or in poor condition, which might suggest empathy, whereas this relationship was inverse when experimental partners were satiated. Conclusions In a prisoner's dilemma situation rats seem to take effect of own costs and potential benefits to a receiver when deciding about helping a social partner, which confirms the predictions of reciprocal cooperation. Thus, factors that had been believed to be largely confined to human social behaviour apparently influence the behaviour of other social animals as well, despite widespread scepticism. Therefore our results shed new light on the biological basis of reciprocity.

Heteroresistance to penicillin in Streptococcus pneumoniae

Heteroresistance to beta-lactam antibiotics has been mainly described for staphylococci, for which it complicates diagnostic procedures and therapeutic success. This study investigated whether heteroresistance to penicillin exists in Streptococcus pneumoniae. Population analysis profile (PAP) showed the presence of subpopulations with higher penicillin resistance in four of nine clinical pneumococcal strains obtained from a local surveillance program (representing the multiresistant clones ST179, ST276, and ST344) and in seven of 16 reference strains (representing the international clones Spain(23F)-1, Spain(9V)-3, Spain(14)-5, Hungary(19A)-6, South Africa(19A)-13, Taiwan(23F)-15, and Finland(6B)-12). Heteroresistant strains had penicillin minimal inhibitory concentrations (MICs) (for the majority of cells) in the intermediate- to high-level range (0.19-2.0 mug/ml). PAP curves suggested the presence of subpopulations also for the highly penicillin-resistant strains Taiwan(19F)-14, Poland(23F)-16, CSR(19A)-11, and CSR(14)-10. PAP of bacterial subpopulations with higher penicillin resistance showed a shift toward higher penicillin-resistance levels, which reverted upon multiple passages on antibiotic-free media. Convergence to a homotypic resistance phenotype did not occur. Comparison of two strains of clone ST179 showed a correlation between the heteroresistant phenotype and a higher-penicillin MIC and a greater number of altered penicillin-binding proteins (PBP1a, -2b, and -2x), respectively. Therefore, heteroresistance to penicillin occurs in international multiresistant clones of S. pneumoniae. Pneumococci may use heteroresistance to penicillin as a tool during their evolution to high penicillin resistance, because it gives the bacteria an opportunity to explore growth in the presence of antibiotics before acquisition of resistance genes.

Cardiovascular regulation during administration of co-dergocrine to normal subjects

Whether and to what extent activation of peripheral presynaptic dopamine2-receptors may modulate the release of norepinephrine (NE) and so affect blood pressure (BP) in normal or hypertensive man is not clear. The hydrogenated ergotoxine derivative, co-dergocrine, given in effective antihypertensive rather than excessive experimental doses, has recently been shown to act predominantly as a peripheral dopamine2-receptor agonist in several species. Accordingly, BP regulation assessed has been in 8 normal men on placebo and after 3 weeks on codergocrine 4 mg/day. Co-dergocrine significantly reduced urinary NE excretion from 43 to 33 micrograms/24 h, supine and upright plasma NE 21 to 16 and 49 to 36 ng/dl, respectively, heart rate (-8 and -5%, respectively) and upright systolic BP, 115 to 102 mm Hg; upright diastolic BP also tended to be lower. A standard pressor dose of infused NE was lowered from 131 to 102 ng/kg/min, and the relationship between NE-induced changes in BP and concomitant NE infusion rate or plasma NE concentration was displaced to the left. Exchangeable sodium and plasma volume tended to be slightly decreased. Plasma and urinary electrolytes and epinephrine, plasma renin activity and aldosterone levels, pressor responsiveness to angiotensin II, the chronotropic responses to isoproterenol, and the NE-induced rise in BP, plasma clearance of NE, glomerular filtration rate and effective renal plasma flow were not consistently modified. The findings are consistent with effective peripheral dopamine2-receptor agonism by co-dergocrine in humans. Peripheral presynaptic dopaminergic activation may modulate sympathetic activity and BP in normal man.

Unions to Die For

The Copper County Strike of 1913 was heroic, tragic, and large in meaning, both for those who lived in it and for those haunted by it in the years that followed. Carl Ross was born in Hancock only hours before the strike erupted. His father was a printer for Työmies. I had the good fortune to meet Carl and work with him for some twenty years. Carl spoke often of the strike—of what it meant for him, his family, and the radical Finnish community in Superior, Wisconsin, where he grew up. I had never heard of the Copper Country strike before I met Carl, but what I heard about that strike resonated with some of my own experiences. I grew up in New Castle, Indiana, a town that left-wing journalist I.F. Stone called a “labor citadel” in the midst of hostile territory. I want to use these two recollections, Carl’s 1913 Strike reminiscences and my memories of New Castle, to talk about how some strikes carry a moral vision of enormous importance. The presentation will have three parts. In the first part I will relate a little of what Carl had to say about the Copper Country Strike. In the second part I will talk about strikes of my own experience. In the final part, I will talk about the differences in the structures of labor movements and the ethical implications of those differences.

Social Work Students’ Use of Knowledge in Direct Practice – Reasons, Strategies and Effects

This article describes a study of Swedish social work students’ use of knowledge during their field practice. Data was collected by using short written narratives, where the students reflect on situations from practice, situations they experienced as critical or problematic. The narratives were analysed with a method inspired by the interpretation theory of Paul Ricoeur. The article starts with a discussion adhering to the present trend of evidence-based social work practice. This is followed by a study of 144 narratives from social work students containing critical or problematic events. A quantitative description of the material as well as qualitative model of two type-strategies, that social work students use, is presented. The results show, among other things, that students use several forms of knowledge, where facts/evidence is one of several. The study also shows that there is a strong adaptation to varying critical situations. A conclusion is that it is difficult to a priori define the types and proportions of knowledge to use in social work practice.

Neighbourhoods Mobilise the Troops - Community Organising, Violence and Governmentality

The article reflects on the difficult relation between community work against domestic violence and local crime prevention under the conditions of the neoliberal state that cuts down on social benefits and promotes self-help, active citizenship and self-responsibility instead while at the same time restoring the punishing state with its strict regime of law-and-order. The author describes a project Tarantula - she started herself while being a social worker in Hamburg, Germany. Tarantula was aimed at strengthening social networks and the neighbours' willingness to get involved in favour of affected women. Although conceptualized as an emancipatory approach referring to community organizing in the tradition of social movements it is questionable whether and how this can really work in the current situation. At present, the field of crime control is being reconfigured as a result of political and administrative decisions, which, for their part, are based on a new structure of social relations and cultural attitudes. The demolition of the 'welfare state' means the re-coding of the security policy that facilitates the development of interventionist techniques that govern and control individuals through their own ability to act.

Different levels of policy change: A comparison between the public discussion on social security in Sweden and in Finland

The deep economic recession that hit Sweden and Finland at the beginning of the 90s, and the fall in public revenues and rapidly growing public debts that followed on it, triggered a development of cutbacks and restructuring measures which has resulted in a scientific debate over what this has meant for these countries’ systems of social policy, traditionally resting on the Nordic welfare state paradigm. In this connection, questions of to what extent changes made can be ascribed mainly to the economic constraints posed by the recession at all, or rather, to other more long-term societal trends or phenomena, including globalisation, European integration and/or ideational or ideological shifts among influential (elite) groups, have often been touched upon. Applying an ideas-centred approach, this paper attempts to contribute to the knowledge on the reasoning of influential elite societal groups in social policy issues before, during and after the 90’s recession, by empirically analysing their statements on social security made in the press. A distinction is made between three different levels of proposed policy changes, reaching from minor alterations of single programs to changes of the policy paradigm. Results show that the 1990s did not only mean the emergence of suggestions for minor cutbacks in and alterations of prevailing programmes. The share of suggestions implying de facto a (further) departure from the basic features of the social security system also showed that the model was under continuous pressure throughout the 90s. However, many of the changes suggested were not justified by any clear references to a policy paradigm in either country (or not justified at all). Instead, references to “purely” structural justifications did become more common over time. In this respect, as regards social security, our results cannot confirm the fairly popular notion among many researchers of a clearly ideological attack on the welfare state. However, it remains uncertain whether and to what extent the increased proportion of references to “structural realities” in the 90s should be interpreted as an indication of a change in the idea of what the welfare state is and what the goals behind it are. Results further show that the patterns of the discussion in the two countries studied bore a remarkable resemblance at a general level, whereas there are indications of differences in the driving forces behind suggestions for similar reforms in these two countries.

The Development of Social Work as a Speciality and the Profession in Estonia

For Estonia and its people social work is one of the vitally important fields that had to be built up from almost nothing since independence was regained in 1991. During Soviet times social work and social workers did not receive the necessary attention. Severe social problems were denied and kept hidden since according to official communist ideology, life in the Soviet Union was the best in the world and getting better all the time. Social workers did not receive specialised education and their functions were to be carried out by the workers of trade unions and the party, by teachers and by the workers of the personnel departments. In the 1990s big changes, having also an effect on social life, took place in the development of Estonian society. Concepts such as social work and social worker were rediscovered in Estonia. There are certain prerequisites for the success of any activity (including social work). One of the most important ones is being a professional, a worker with thorough preparation. Social work as an occupation requires specialised academic education, which is based on theoretical knowledge and practical skills that have been acquired through theoretical knowledge. Specialised knowledge is a foundation for attaining a specialised qualification. However, at the same time one has to keep in mind that social work as an occupation is constantly changing, there is no absolute knowledge - everything is relative, dynamic and changing (Tamm, 1998). The changing nature of the activity requires reflection by a social worker, who also has to be able to evaluate his/her work and its basis and learn from experiences. Academic specialised education implies also the development of a new professional identity and higher levels of competence. This underlines the necessity of specialised education.