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Complica- is also present in Bangladesh buy cheap kamagra soft 100 mg on-line cheap erectile dysfunction pills online uk, Greece purchase kamagra soft with mastercard impotence meaning, Cyprus, Iraq, Morocco, tions have not been noted but convalescence is occasionally Saudi Arabia, Somalia, Sudan, Tunisia, Turkey, the southern prolonged for weeks (Sabin, 1955; Bartelloni et al. Hannoun, per- Summer meningitis caused by Toscana virus sonal communication, 2005; Filipe, 1974; Thesh et al. Cases of sandfly fever begin to appear in and neurotropism of Toscana virus was reported more than April and gradually build to a peak in September. The viruses that cause sandfly fever (Naples and it was suggested that this phlebovirus might cast the vectors Sicilian viruses) have a wide geographical distribution, which themselves in the role of reservoirs because male sandflies were parallels that of P. In addition, venereal transmission eradicate malaria and dengue fever (Dunlap, 1981), as well as from infected P. Later reports of virus isolation and to generation in sandfly colonies suggested that this virus serologic studies indicate that phleboviruses are still present in could not be maintained indefinitely by vertical or venereal the Mediterranean coastal regions of Europe and North Africa, transmission. Consequently, the existence of a reservoir was © 2012 The Authors Medical and Veterinary Entomology © 2012 The Royal Entomological Society, Medical and Veterinary Entomology, doi: 10. Serological studies showed no evidence of viral leishmaniasis and phleboviral infections, which has been circulation among domestic or wild animals, although a assumed for a long time, was statistically established in south- Toscana virus strain was isolated from the brain of a bat, east France between L. The first large Italian study showed that Toscana virus was a Moreover, recent studies indicate that in relation to pre- prominent cause of summer meningitis in central Italy (Nico- viously accepted parameters: (a) the geographic distribution letti et al. Until recently, its known distribution was of sandfly-associated phleboviruses is much larger; (b) the limited to Italy and Portugal (Charrel et al. More number of phleboviruses infecting sandflies is higher; (c) the recently, as indicated by virus isolation or serological surveys, number of sandfly species involved in transmission may be the geographical distribution of the virus has been extended more important, and (d) the relationship between sandfly-borne to include France, Spain, Slovenia, Greece, Cyprus, Elba and phleboviruses and Leishmania parasites is tighter. Some studies have reported the presence of among sandfly-borne phleboviruses, Leishmania parasites and Toscana virus based on serological evidence using immunoflu- sandflies. This is particularly relevant because of the recent report of novel viruses that are closely related to but distinct from Toscana virus in Tunisia (Punique virus), France (Mas- Infections in humans. When symptomatic, the disease in humans is a severe, but uniformly non-fatal, influenza-like illness. In New phleboviruses patients with clinical manifestations, the initial symptom is high fever that is often biphasic. Subsequent symptoms are flu- Recently, virological and molecular evidence for the pres- like and include severe malaise, headaches, myalgia, arthralgia, ence of a phlebovirus closely related to but distinct from retrosternal pain, eye aches and nausea. Adria virus (a relative of Arbia residents do not have easy access to medical care and are virus) was detected, but not isolated, in phlebotomine sandflies unlikely to seek attention for such relatively minor complaints, collected in Albania and subsequently in a human case (Papa and thus their aetiology is never determined. Massilia virus was iso- true incidence of clinical illness caused by infection with these lated from P. Granada virus was isolated from sandflies (unidentified) than is indicated by the relatively few viral isolations obtained in Spain (Collao et al. Punique virus was isolated in from sick persons and from the limited serosurveys that have northern Tunisia from P. To date, there are no data mya1gia, headache and malaise of 3–5 days in duration to support the suggestion that they cause disease in humans. Vesicular stomatitis virus dis- sandfly-associated phleboviruses occur (Thesh et al. Clin- Very recently, the epidemiological link between human ical disease presents severe vesiculation and/or ulceration of © 2012 The Authors Medical and Veterinary Entomology © 2012 The Royal Entomological Society, Medical and Veterinary Entomology, doi: 10. Although Chandipura virus was later identified as the is clinically indistinguishable from foot-and-mouth disease. It cause of mild dengue-like symptoms in human patients, and occurs seasonally every year in the southeastern U. In 2004, a second outbreak with a fatality rate activity in the region has been focal and limited to isolated of >75% was reported in the eastern state of Gujarat (Chadha wildlife populations. Chandipura virus was reported to have been isolated from pools of wild-caught Phlebotomus spp. Strong evidence supports the role of bit- sandfly specimens belonging to the genus Sergentomyia ing arthropods as vectors of vesiculoviruses and indeed the (Geevarghese et al. Among arthropods, midges [Culicoides and domiciliary species prevalent in several parts of India. However, phlebotomine sandflies seem to from a hedgehog (Atelerix spiculus) in Nigeria, suggesting a be the only vectors to have been confirmed biologically. In humans, it causes a probable that phlebotomine sandflies are the only biological disease known as Carrion’s´ disease, which has two clinically vectors because they have been found infected in the absence distinct phases: an acute or haematic phase, known as ‘Oroya of clinical cases in humans or domestic animals. By contrast, blackflies, midges, That the two phases of this condition represented different mosquitoes and other non-haematophagous insects have only manifestations of the same disease was unknown until evidence been found to be infected during epidemics and probably serve provided in the late 1800s by Daniel Alcides Carrion,´ a as mechanical vectors (Letchworth et al. After 3 weeks, Carrion´ developed classic symptoms of the acute disease phase, thus establishing a common aetiology Chandipura virus encephalitis for these two syndromes. He died from bartonellosis on 5 October 1885 and was recognized as a martyr of Peruvian Another vesiculovirus, Chandipura virus, has recently medicine. It results in death in up to associated with less virulent bacterial strains, which are now 40% of untreated patients, but mortality can reach around 90% disseminating or re-emerging in previously disease-free areas when opportunistic infection with Salmonella spp. The burden of leishmaniases Carrion’s´ disease is restricted to central Peru, Ecuador and southwestern Colombia. In the past, most reported cases Among the phlebotomine sandfly-borne diseases, leishmani- occurred in regions of altitude ranging from 500 m to 3200 m ases are the most widespread. However, recent epidemics have been reported in previ- infectious diseases, such as Chagas’ disease and sleeping sick- ously non-endemic heights of the Amazon basin, which sug- ness, are generally regarded as neglected diseases because of gests that the endemic range of the disease is expanding. More- the lack of effective, affordable and easy-to-use drug treat- over, the El Nino-related˜ phenomenon of 1997–1998 resulted ments. As most affected patients live in developing countries, in an up to four-fold increase in B. Public human-biting phlebotomine species in the area, such as Lut- investment in treatment and control would decrease the dis- zomyia noguchii and Lu. The burden Lutzomyia verrucarum appears to be absent from Ecuador and of tegumentary forms of leishmaniasis is even higher in terms a competent vector is still to be identified (Alexander et al. The most likely vector in eases are epidemiologically unstable and result in unpredictable Colombia is Lutzomyia columbiana, which is closely related fluctuations in numbers of cases; hence, major epidemics are to Lu. Drug treatment is difficult and, although these dis- all areas of Colombia in which bartonellosis outbreaks have eases have severe social and psychological consequences, they occurred (Gamarra, 1964). Based on the data reported on Bartonella foci in Ecuador and Colombia, it appears that the epidemiology of bartonel- losis is far from being elucidated. Indeed, the disease is not Highlights and challenges in phlebotomine research restricted to elevations greater than 800 m, and also occurs in areas from which Lu. Outbreaks con- In April 2011 Professor Robert Killick-Kendrick gave a tinue to be recorded in areas in which B. Several issues concerning zomyia sandflies or even other arthropods may serve as vec- newly identified facets of Leishmania spp. In Ecuador, an increasing number of atypical cases with transmission by bite; observations on dispersal and flight speed, mono-phase verrucous cutaneous disease have been recorded in and the sources of sugars taken in nature and their possible recent times. American Journal of Tropical Medicine and Hygiene, World Health Organization (2010) Control of the leishmaniasis. Professional advice should be sought before taking, or refraining from taking, any action on the basis of the content of this publication. We cannot be held responsible for any errors or omissions therein, nor for the consequences of these or for any loss or damage suffered by readers or any third party informed of its contents.

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The change resulted in a decrease between November 2008 and March 2010 order kamagra soft mastercard erectile dysfunction caused by jelqing, examined the in the prevalence and frequency of injecting heroin order cheap kamagra soft online impotence xanax, as well impact that the changing market dynamics might have had as a decline in adverse health consequences related to 42 39 on drug use patterns. Also, a combination of heroin and 38 Horyniak and others, “How do drug market changes affect charac- methamphetamine was more commonly used by current teristics of injecting initiation and subsequent patterns of drug use? This practice has been reported particularly nature, as well as a latent indicator, of trends in drug use among marginalized migrant subpopulations of persons resulting in severe health consequences. In 2013, almost 71 per cent of clients in treat- Opioids stand out as a major drug of concern in North ment reported having used more than one substance, with America, Europe (particularly Eastern and South-Eastern polydrug use being more common among cocaine (80 per Europe) and Asia. Misuse of prescrip- nearly three out of every four people in treatment for drug tion drugs and use of cannabis and cocaine were most use disorders are treated for opioid use. The number of frequently reported among users of opioids, while primary people in treatment for cocaine use disorders remains quite cocaine users more frequently reported use of cannabis high in Latin America and the Caribbean, where nearly and opioids. Treatment related to cannabis use users in the Islamic Republic of Iran disorders is more prominent in Africa and Oceania than in other regions. This may be related to the limited treat- In the Islamic Republic of Iran, where opiates remain the ment options for users of other drugs in Africa, where main drug consumed by problem drug users, metham- nearly half of all admissions to treatment for drug use dis- phetamine use has emerged as another drug of concern in orders are for the use of non-specified substances, which recent years. Methamphetamine use has also been masks the true extent of the use of drugs of concern other described as a new form of polydrug use among opiate than cannabis. For example, a for disorders related to the use of amphetamines has been study at an opioid substitution treatment clinic in Zahedan increasing in Asia, half of the people in treatment for drug Province showed that methamphetamine use among use in the region are treated for opioid use disorders. At the global level, the proportion of 48 Zahra Alam-Mehrjerdi, Azarakhsh Mokri and Kate Dolan, “Methamphetamine use and treatment in Iran: a systematic review amphetamine-using cohort and correlates of methamphetamine from the most populated Persian Gulf country”, Asian Journal of dependence”, Journal of Substance Use, vol. Barr and Alireza Noroozi, “Meth- Iran”, International Journal of Drug Policy, vol. Mehrjerdi, “Crystal in Iran: methamphetamine or heroin Malaysia”, Journal of Food and Drug Analysis, vol. For each region, the number of people in100,000 4,000 treatment for the use of different drugs in the region is weighted by the total number of people treated in a country. Member States in Oceania (inFirst time in treatment particular, Australia and New Zealand) do not provide information on the proportion of people in treatment for the first time, and therefore informa-2,000 0 0 tion for Oceania is not reflected in the figures. Note: Data used for each point in time are based on reporting from countries in each region for the year cited or the latest year for which data are available. In Asia,CannabisCannabis OpioidsOpioids CocaineCocaine Amphetamine-type stimulantsAmphetamine-type stimulantsment for cannabis use disorders has increased in all regionsOther drugsOther drugs among those being treated for disorders related to the use since 2003, it has done so to a much greater extent in the of amphetamines, nearly 60 per cent are reported to be in Americas, Western and Central Europe and Oceania. At treatment for the first time; in Europe and Latin America, the same time, in the Americas, the proportion of people nearly 40 per cent of those being treated for cocaine use in treatment for cocaine use has decreased over the past disorders are reported to be in treatment for the first time. In Eastern and South-Eastern Europe, treat- treatment for disorders related to the use of other drugs, ment for opioid use disorders has been a matter of concern including those seeking such treatment for the first time. This reflects increasing trends in the use of cannabis and The increase in treatment demand related to cannabis use amphetamines and the resulting increase in people seeking in some regions warrants special attention. Treatment at or cocaine use disorders; however, they are typically in present consists of behavioural or psychosocial interven- their thirties and, in many subregions, reflect an ageing 52 tions that may vary from a one-time online contact, or a cohort of users in treatment and show an overall decrease brief intervention in an outpatient setting, to a more com- in the proportion of treatment demand. Budney and others, “Marijuana dependence and its treat- cohort”, Drug and Alcohol Dependence, vol. However, lower risk does not in awareness of potential problems associated with can- mean no risk: there are harmful health effects associated nabis use; and changes in the availability of treatment for with a higher frequency of cannabis use and initiation at cannabis. Unfortunately, detailed information on trends a very young age, especially among adolescents during the in the number of people in treatment and on potential time of their cognitive and emotional development. However, this increase in daily (or near-daily) cannabis use has not translated into an increased number of people 55 Nora D. Volkow and others, “Adverse health effects of marijuana seeking treatment, even when those in treatment referred use”, New England Journal of Medicine, vol. Lachenmeier and Jürgen Rehm, “Comparative risk assess- ment of alcohol, tobacco, cannabis and other illicit drugs using the although data on daily use are sparse, there is little evidence margin of exposure approach”, Scientific Reports, vol. Lopez-Quintero and others, “Probability and predictors of tran- they, and what are their implications for policy? Cheetham and Murat Yücel, “Cannabis and adolescent brain devel- opment”, Pharmacology and Therapeutics, vol. Anthony, “The epidemiology of cannabis dependence”, in Cannabis Dependence: Its Nature, Consequences and Treatment, Roger 59 Wayne Hall, “What has research over the past two decades revealed A. Kessler, “Com- ment refers to the situation where cannabis was the primary drug parative epidemiology of dependence on tobacco, alcohol, con- of concern. People in treatment when other drugs were the primary trolled substances, and inhalants: basic findings from the National drug of concern might be treated for their cannabis use at the same Comorbidity Survey”, Experimental and Clinical Psychopharmacol- time. Users may adjust (titrate) the amounts of cannabis they consume to achieve the desired psychoactive effect, although this has been shown to be more difficult for inexperienced users74 and users of Total number of people in treatment for whom cannabis was the primary drug of concern high-potency cannabis. Number who used cannabis on 20 or more days Several countries have adopted alternative measures to in the past month (millions) incarceration in minor cases involving possession of can- Number who used cannabis on 300 or more days nabis for personal consumption without aggravating cir- in the past year (millions) cumstances (for example, fines, warnings, probation, counselling or even exemption from punishment). In the United States, persons referred to treatment from Note: The data presented in the figure are for people aged 12 years and older; persons in treatment are those for whom cannabis was the the criminal justice system constitute a significant propor- primary drug of concern. Freeman and others, “Just say ‘know’: how do cannabi- effects of cannabis use could be decreasing age of initia- noid concentrations influence users’ estimates of cannabis potency tion, but there is little evidence that cannabis users are and the amount they roll in joints? All clients New clientsPrevalence of use among persons aged 16-59New clientsAll clientsPrevalence of use among persons agedPrevalence of use among persons aged 16-59 Prevalence of use among persons aged 16-5918-64 (Germany), 15-64 (Spain) andPrevalence of use among persons aged 16-24In Europe, referrals from the criminal justice system (from Prevalence of use among persons aged 16-59New clientsPrevalence of use among persons aged 16-24 Prevalence of use among persons aged 16-2416-59 (United Kingdom) the police, the courts and probation services) also make Prevalence of use among persons aged 16-24Prevalence of use among persons aged 16-59 Prevalence of use among persons aged an important contribution to the number of persons in Prevalence of use among persons aged 16-24 18-24 (Germany), 15-24 (Spain) and treatment as a result of their cannabis use. In many countries in Europe, important strides Given that persons who are dependent on cannabis are have been made in the provision of treatment with pro- often reluctant to seek treatment,79 an awareness and grammes that have been implemented, expanded or modi- understanding, particularly among youth, of the potential fied to address the needs of cannabis users, some having harm associated with cannabis use may encourage users adolescents and young adults as their target groups. In the United States there has been a con- tinuous decline in the perception among youth that can- Gender and drug use nabis use is harmful. The proportion of secondary school Men are considered to be three times more likely than students who see a “great risk” from regular cannabis use women to use cannabis, cocaine or amphetamines, whereas has declined since the early 1990s and there has been a women are more likely than men to engage in the non- particularly rapid decline since the mid-2000s. In Europe, to either gender being more or less susceptible or vulner- the perception of harm from cannabis use is higher among able to the use of drugs. According to European surveys conducted in genders are equally likely to use drugs once an opportunity 2003, 2007 and 2011, the percentage of students perceiv- to do so occurs. In most surveys, the prevalence of drug use is reportedly There could be considerable unmet demand for treatment higher among young people than among adults and the for cannabis use in Europe. It is estimated that there are gender divide in drug use is narrower among young people 3 million daily (or near-daily) cannabis users (persons who than among adults. Sznitman, “Cannabis treatment in Europe: a survey of which cannabis was either the primary or secondary reason services”, in A Cannabis Reader: Global Issues and Local Experiences 85 − Perspectives on Cannabis Controversies, Treatment and Regulation for entering treatment, suggesting that 10-30 per cent in Europe, vol. Cotto and others, “Gender effects on drug use, abuse, tion on Alcohol and Other Drugs, 2012, 2009 and 2004). The subregion Use and Health: Mental Health Detailed Tables (Rockville, Mary- accounts for almost one in four (24 per cent) of the total land, 2014). Although the preva- gender divide in drug use has also been changing in the lence of injecting drug use in East and South-East Asia is adult population, partly reflecting increasing opportuni- at a level below the global average, a large number of ties to use a particular substance.

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If a person is able to follow such a diet for 2 to 3 weeks buy line kamagra soft erectile dysfunction caused by vicodin, it forms one of the most useful tools we have in nutritional medicine buy kamagra soft 100mg overnight delivery erectile dysfunction fast treatment. This strongly reinforces their per- sistence with such a regimen and the rather tedious process of food challenge that follows. In the process of food challenge,12 it is usual to test one food per day, except in the case of grain and milk products, which may require a 2- to 3-day interval after challenge. Incriminated foods need not be eliminated for- ever, and individuals should always be encouraged to test small quantities of these foods later to see whether there is a lower threshold of consumption that their system can tolerate. If dietary liberalization is not emphasized, there is always a danger that sensitivity will begin to generalize and a per- son may become more restricted in lifestyle as he or she begins to react to more foods and environmental chemicals as a result of deteriorating adap- tive mechanisms. Serologic tests such as immunoglobulin G panels may be useful as a screen in circumstances in which elimination diets are difficult to implement (e. Specific immunoglobulin A tests such as antiendomysial antibodies may be relevant when specific conditions such as gluten intolerance are investigated, 148 Part One / Principles of Nutritional Medicine and antigliadin antibodies may be useful in monitoring dietary compliance in gluten-sensitive individuals. Little credence can be given to the wide- spread practice of food intolerance diagnosis through electrodermal methods. Assessment of Hormonal Function In our current state of knowledge, the assessment of endocrine parameters is one of the few ways in which we can obtain direct measures of control and regulatory functions. There is an intimate relationship between endocrine function and nutrition, with the thyroid, adrenal, and reproductive glands assuming special importance. Biochemical testing may be a poor guide to hormonal balance, and clinicians should acquaint themselves with both the subtle and gross manifestations of endocrine imbalances and the reciprocal relationships between nutritional status and glandular function. Good accounts of hypothyroidism,13 subclinical hypoadrenocortical- ism,14,15 and the relationships among some hormones, vitamins, and miner- als16 are available. The initial Chapter 6 / Assessment of Nutritional Status 149 history-taking may require up to 3 hours and is often still incomplete. However, after the first two or three sessions with a patient, we are in a posi- tion to develop a problem list, a probable diagnosis, and a provisional for- mulation. The problem list will remain the connecting link throughout the diagnos- tic and therapeutic processes. The problem-oriented method of record-keep- ing is a good way of tracking the vicissitudes of a patient’s medical progress. The provisional diagnosis, the conventional nosologic category, is an essential part of the formulation, even though it may be of limited explanatory value. The initial formulation is a working hypothesis that seeks to explain the patient’s situation in terms of organism-environment interactions. Its emphases will often reflect the particular interests and biases of the clinician concerned. Susanna is a 35-year-old teacher who had experienced moderately severe chronic fatigue in the months after a neck injury at work. Her neck pain had never completely resolved despite extensive treatments for the original injury whose exact nature was never fully established, except that there was no obvious bony or soft tissue disease. Before her injury, she described herself as “the life and soul of the party,” as well as a compulsive organizer and someone who “never stopped. She had been a vegetarian for several years and had chronic sleep difficul- ties which preceded her accident. Examination revealed a mesomorphic ectomorph with no obvious nutritional deficiency signs. Oversimplified though this formulation is, it provides clear avenues for investigation. While these avenues are being pursued, some inroads on the sleep problem could be made. Later on, it would be appropriate to look at lifestyle issues in terms of the person’s temperament and character traits. However, we could equally place disturbed nutrition at the center and explore some of the widespread ramifications of different nutritional deficiencies (see Figure 6-5). We also remember the teamwork concept and magne- sium’s important relationship with other vitamins and minerals (e. The principal summary involves tracking each problem and the accompanying investigations and interventions. This is especially useful in reminding one that interventions in one problem area will often have ram- ifications in another. Thus in the case of Susanna, one could lose sight of the low blood pressure and forget to regularly monitor it and thus miss the inter- ventions that might be having a positive effect on it. Laboratories will often provide summary data over time, but these data are seldom in the short-hand form that is useful for examining the big picture. It is useful to look at the detail of a test when it is done and then summarize for the purposes of later review. A mass of data that must be scrutinized in detail every time one looks over the testing history is not efficient and can lead to oversights. The patient and clinician should keep a copy of the testing process and its results for future reference; it is an essential baseline when the reintroduction of foods is considered or the emergence of inexplicable symptoms occurs. In recommending dietary changes or prescribing specific nutrients, it is important to keep things simple. It is only by doing one thing at a time that we can get any idea as to what is essentially therapeutic. Similarly, an individual who is a particular metabolic type may react favorably to some B vitamins but not to others (see the section on metabolic typing). Marked effects on brain func- tion or metabolism are not seen on a short-term basis with all nutrients, of course; but B vitamins, individual amino acids, essential fatty acids, calcium, and magnesium are examples of nutrients that can be tested individually as appropriate. Against this approach, we must weigh the injunction that nutrients work in teams and that it is overall dietary change that is crucial. Thesting teams of nutrients is fine as long as one clearly defines the testing boundaries (e. Applying too many therapeutic strategies at once may provide a good short-term effect, but when difficulties or relapses occur, one will have little idea about how to intervene with elegant minimalism. It is not uncommon to see patients who have been prescribed enzymes, acidifiers, probiotics, and a long list of adjuvant nutrients when only scant information from history or testing is available. It is possible to gradually wean an individual off one item at a time after a suitable therapeutic effect has been observed, but this is both clumsy and costly. The subject of nutrient interaction is complex and often paid insufficient attention by practitioners. Obvious interactions such as those between cal- cium and iron or zinc and copper are well known, but we should be aware that all supplements send a ripple of interaction through the system; and it is virtually impossible to imagine, let alone delineate, all the consequences. Watts and Rosenthal16 have attempted to expand our appreciation of this area; even cursory inspection of their interaction diagrams gives us greater respect for the far-reaching beneficial and harmful effects of providing large doses of supplemental nutrients.

They actions to date work hand-in-hand with the administration to help carry out the broad duties owed by the where the role of a hospital to patients discount kamagra soft line impotence by age. Those duties extend to the selection buy generic kamagra soft 100 mg on-line erectile dysfunction treatment home remedies, organization, and monitoring of physician as head both professional and non-professional staf, as well as the acquisition and maintenance of appropriate facilities and equipment to reasonably ensure that patients receive adequate and of a department or proper care. Generally, physicians in these positions are expected to: ▪ Exercise responsibility for the general clinical organization of the hospital. The Canadian Medical Protective Association 11 There is sometimes fear the head of a department or the chief of staf might be held responsible for any mishap caused by any other member of the medical staf or any other healthcare provider over whom it may be said they have administrative or supervisory responsibilities. It is always difcult to speculate about the extent to which legal liability might devolve in any hypothetical situation. Nevertheless, the head of a department or the chief of staf is not expected to be a guarantor of the work of other members of the medical staf or other healthcare providers. More specifcally, the liability of heads of departments or chiefs of staf does not extend to their being held liable simply for the negligence or civil responsibility of some other member of the medical staf or other healthcare providers, including medical students or residents. Liability is only engaged if they fail to act reasonably in carrying out the duties assigned to them by legislation and the by-laws of the hospital, or if they fail to intervene when they know, or ought to know, that a patient may come to harm without intervention. Damage awards The head of a Damages are awarded to a patient as a result of either a successful legal action against the department or defendant physician(s) or as a negotiated settlement of the claim. This is thought to be due in part to better medical care resulting in fewer patient safety incidents, increased awareness and understanding of patient safety members of the measures, and enhanced risk management procedures. It is useful, nevertheless, to review the medical staf or factors that contribute to the commencement of a legal action against a physician, as follows: other healthcare ▪ There has been a change in public attitude toward the fallibility of the physician. The perception has developed that, at least in some cases, the courts strain to fnd liability without apparent fault. Patients are most likely to sue when they feel they have not been kept informed about their progress or complications. Physicians are therefore encouraged to foster and maintain good communication with their patients. Certainly, the more complex medical and surgical treatment methods become, the greater the risk of more serious complications. Advances in medicine have resulted in the resuscitation and long-term survival of patients but with some of them, unfortunately, having severe and permanent disabilities. Items of damages for cost of future care and loss of income therefore loom large, and in the case of compromised babies, often amount to millions of dollars. One of the major factors giving impetus to the rise in the size of awards was the decision of the Supreme Court of Canada in 1978 that detailed the manner in which courts must proceed in assessing damages. The courts are now required to assess each item of damages separately, with the total often adding up to a substantial fgure. Individual amounts must now be calculated for each of the following items: The courts are now required to ▪ General or non-pecuniary damages assess each item of These are intended to compensate the injured party for pain and sufering, loss of damages separately, amenities, and loss of enjoyment of life. The proper approach to this item is functional, in with the total often the sense of providing injured persons with reasonable solace for their misfortune. This maximum award is to apply only in the most catastrophic of cases where the individual has sufered severe injuries, such as quadriplegia, and is fully aware of the extent of such injuries. This item also includes any subrogated claim the provincial or territorial healthcare agency may seek to advance for reimbursement of medical and hospital expenses incurred by the province or territory on behalf of the patient. The courts have demonstrated a propensity, based on the opinion of rehabilitation experts, to favour a home-care environment for the seriously disabled, including compromised babies. This often necessitates home modifcation or even acquisition of a new home and employment of specialized attendant care. The cost may well exceed $200,000 a year; with ever- increasing life expectancies for the disabled, this lump sum amount for future care often amounts to millions of dollars. The calculation of the cost of future care is done on a self-extinguishing basis, such that the entire amount of the capital sum set aside will be used up by the time the last payment for future care is made. While the fund for future care is discounted to current values to refect the anticipated investment income it will generate over the years, the reality is that some of this investment income will be lost through taxation. The Canadian Medical Protective Association 13 the fund will be exhausted too soon if the disabled patient is also required to use the money to pay the income tax on investment earnings generated by the fund. The courts have been persuaded that there must be a gross-up on the lump sum award to provide additional funds to pay income tax. The calculation of this gross-up has at times increased the lump sum award for future care by 50% or more. In some instances the patient may be too young to be working, or may be temporarily unemployed. In these cases, there is no established loss of income but rather a loss of earning capacity. In calculating loss of earning capacity the court will look to the patient’s level of education, and employment experience or expectations. For injured infants, the courts will look to other factors including the education and occupation of the parents and average wage statistics. The Supreme Court of Canada has repeatedly held that the loss of income is to be calculated using the gross amount of the patient’s income and not the net income the While the majority patient receives after paying income taxes, even though the patient is not required to pay of legal claims income tax on an award for loss of income. The Supreme Court of Canada has again held that no defended, it is deduction is to be made to account for such collateral source payments when calculating the patient’s loss of income. Bearing in mind that many legal actions take 5 years or more to proceed through the courts, this item can also serve to infate damage awards signifcantly. As well, family members are entitled to claim for loss of fnancial support where the patient has died as a result of the medical injury. These amounts are calculated on an apportionment of the net after-tax income of the deceased that the family member might have expected to receive. Such an award will only be made where the misconduct of the physician is so malicious, oppressive, and high-handed that exemplary or punitive damages are necessary to serve as a deterrent. In Québec, the unlawful and intentional infringement of rights protected under the Québec Charter can justify the award of punitive damages. The two aspects most responsible for this increase are the claims for loss of income and earning capacity, and the cost of future care. Structured settlements Substantial savings may be achieved in the cost of future care through greater use of structured settlements, whereby an annuity is purchased to provide a guaranteed tax-free stream of payments to ensure the injured patient receives the necessary future care and attention for life. The savings fow from favourable impaired life ratings often available for pricing annuities, as well as the avoidance of a tax gross-up calculation on the capital amount awarded or allocated for future care. There is the certainty and stability of payments into the future as the annuity is non-assignable. A capital amount or lump sum paid to the patient is vulnerable to poor decisions concerning investments or misuse of the money and so the capital may be dissipated well before the future monetary requirements to provide care to Physicians should the patient are exhausted. A structure may also ofer fexibility, with the annuity being tailored to not fall into the trap vary the stream of payments to take anticipated changes in economic conditions or the patient’s circumstances into account.