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However avana 100mg visa, there are a number of areas in which insurance differs from other businesses order 50mg avana with mastercard. The most important area is the need to collect an appropriate amount of premium today to cover the cost of losses and legal defense that may order 100 mg avana, and often do cheap 100 mg avana otc, occur 4 to 6 years in the future. By definition, actual future costs are unknown at the time the insurer must price and sell the policy. If insurers seriously underesti- mate future costs and fall into insolvency, the physician is left without the liability protection that he or she paid for, but the liability remains. Therefore, the choice of a malpractice insurance company is an impor- tant one for physicians. The true value of a policy (as opposed to its cost) may not be apparent until years after the purchase, when a claim must be defended and possibly paid. The following principles of insurance and definitions of key terms are intended to facilitate that choice. SPREAD OF RISK Physicians as a group, knowing some of them will be sued and will have to pay litigation costs and losses, pool resources to share the total burden of the group. In any given year, not every physician will be sued, Chapter 1 / Insuring the Practice of Medicine 5 but all will contribute to cover the costs of those who are. In return, the individual physician is protected in similar fashion when he or she is the target of litigation. By assembling a large enough group, the burden on any individual, even those faced with large claims, can be reduced. The law of large numbers puts prediction of outcomes on a more sound statistical footing. UNDERWRITING The insurance company reviews every physician applicant and divides the group into multiple subgroups that share similar risk pro- files. Some of the attributes that significantly affect risk include the level of education and training, specialty, the state and county where the practice is located, nature of practice, unusual practice profiles, clinical setting, and previous litigation history. This means, for example, that a neurosurgeon in Florida will be asked to pay a very different premium than a pediatrician in California. In theory, the costs of litigation, expense, and profit could simply be added up and divided equally among all policyholders. However, that would mean that physicians at lower risk for claims would be subsidizing those at higher risk. Periodically, a prudent insurance carrier reviews each policy- holder’s experience to determine whether the risk profile has changed. This involves a review of the litigation experience, the practice pro- file, and any changes in medical, legal, or professional status (e. The purpose of this exercise is to be sure the premium burden continues to be equitably apportioned among the pool. ACTUARIAL SCIENCE AND FINANCIAL MARKETS Actuaries use a variety of complex mathematical models to esti- mate future loss and legal defense costs based on past experience, estimates of future trends in claims severity and frequency, and the anticipated composition of the risk pool. These models must reflect the impact of past and prospective changes in the economic (e. Because there is a long time gap from the collection of premiums to the closing of the average claim file, these models must also reflect the value of invest- ment income. Part of the fiduciary responsibility of any insurance company is to responsibly invest premium until the money is needed 6 Gorney and Anderson to pay future losses and expenses. The investment income collected during that period can be used to subsidize the actual cost of premi- ums. For this reason, insurance rates are sensitive to the state of the investment markets, primarily interest rates. As interest rates rise or fall, the amount of money available to subsidize policyholder charges varies.

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Women with such an injury gen- significant impact on the individual’s gen- erally remain fertile and are capable of eral lifestyle avana 200mg. Social Issues Sexual intercourse may be more diffi- cult in conditions involving spasticity purchase avana 50 mg on line, Many factors associated with disorders such as cerebral palsy or multiple sclero- of the nervous system can affect social sis buy avana 200 mg with mastercard. A supportive environment cheap 200 mg avana otc, in- and arousal experienced as part of sexual cluding the family, plays an instrumental excitement may make the spasms worse. In other instances, special arrangements Misinterpretation or misperception of the for positioning or other technical assis- individuals’ disability and associated tance may be necessary for sexual inter- functional limitations, however, can act course to occur. Some form of sexual expression is possible Although some functional limitations for almost all individuals with a disabili- associated with neurological conditions ty. Individuals may need to learn new are visible, such as the mobility restric- forms of sexual expression to meet their tions indicated by use of a wheelchair, needs, or in other instances they may others are not so readily recognizable. Those who do not understand instead coddling the individual or hiding the consequences of multiple sclerosis their own displeasure over the individ- may interpret fatigue as laziness or at- ual’s actions. Visual and percep- Some of the symptoms or behaviors tual problems associated with brain injury manifested in the neurological condition may be interpreted as clumsiness. Indi- may be more troublesome to the individ- viduals with spina bifida who need ready ual exhibiting the symptom than to those access to a restroom may be viewed as around them. Individuals may fear be- having a neurotic preoccupation with the coming a burden on family members and location of restroom facilities. The conse- consequently withdraw from close per- quences of stroke, which may involve sonal interactions, while family members, emotional lability or memory, attention, willing and anxious to provide help and or judgment problems, may be perceived support, are hurt at what they view as the by others as rudeness, insensitivity, or irre- individual’s rejection of their attempts to sponsibility rather than manifestations of help. The gait disturbance assume that others would not want to or slurred speech associated with multiple interact with them because of their dis- sclerosis may be viewed by others as a sign ability, when actually they are greatly of intoxication. Because not all social events or Individuals with epilepsy, for example, situations are accessible to individuals may encounter social stigma because of using a wheelchair, they may either avoid outdated and erroneous beliefs about the an activity or make special arrangements cause or meaning of the seizures they ex- to attend it. Seizures can be frightening for have made provisions for accessibility, those who observe them. For standing may cause people to avoid social example, a multilevel historic site may contact with individuals with epilepsy so only be accessible to individuals in wheel- as to avoid the possibility of witnessing a chairs through a back entrance or freight seizure. In order to reach a stage for pres- people to avoid individuals with cerebral entation, individuals may need to be palsy with communication difficulties “pushed” up a ramp rather than negoti- because they want to avoid the discom- ate the ramp themselves. In addition, differ- fort of attempting to understand what the ent angles of eye contact can create multi- individual is saying. This can produce Family members may become overly pro- an impression of differing social stature, tective, shielding individuals from re- both in the individuals and in those with sponsibility. Social interaction difficulties associated In other instances family members may with neurological disorders may be man- find it difficult to express anger toward ifest in poor social performance, social their family member with a disability, anxiety, and low self-esteem. Individuals General Issues in Nervous System Conditions 117 with such a disorder may experience con- stress may precipitate symptoms, as it siderable frustration, as well as lowered self- does in epilepsy or multiple sclerosis. Some neu- ence poor motor speed or decreased pro- rological conditions result in impaired cessing ability as a result of disability are capacity for social perceptiveness, dis- rushed or feel stressed, the quality of their tractibility, an absence of social initiation, work may suffer. These symptoms can sig- ed by a neurological condition, alternate nificantly affect individuals’ ability to means of communicating in the work- interact effectively in social settings. In place or job modifications may be need- these instances, social skills training or ed. In many instances, even though continuing supervision or prompting in individuals’ communication may be dif- the social setting can help individuals to ficult to understand, patience and practice integrate more fully into social situations. Nervous System Some conditions have specific charac- teristics that must be considered in an The capabilities of individuals with assessment of the workplace. For example, nervous system conditions vary widely, for individuals with epilepsy it is impor- depending on the nature of the condi- tant to assess the degree to which seizures tion. For progressive conditions or condi- are controlled and to identify whether tions characterized by remissions and any stimuli in the work environment exacerbations, such as multiple sclerosis, could precipitate seizures. Hot, humid ongoing evaluation of limitations and environments should be avoided by indi- remaining function is necessary. Indi- er conditions, such as spinal cord injury viduals with high thoracic spinal cord or traumatic brain injury, in which the injuries or cervical injuries often experi- damage is permanent but not progressive, ence difficulty with heat regulation and initial evaluation of capabilities and consequently should avoid extremes of remaining function may suffice. In addition, because of the Brain damage affects a number of func- loss of sensation in the extremities, situ- tions, all of which should be assessed.

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Throughout adulthood buy discount avana 50mg line, androgens are responsible for maintaining the An androgen is a substance that stimulates the growth of structural and functional integrity of all reproductive tis- the male reproductive tract and the development of sec- sues discount avana 200 mg on-line. Castration of adult men results in regression of the re- ondary sex characteristics purchase avana 50 mg. Androgens have effects on al- productive tract and involution of the accessory glands cheap 200mg avana amex. Shortly after treat- gens for cellular proliferation; therefore, physicians at- ment, testicular concentrations of androgens decline be- tempt to totally ablate the secretion of androgens by the cause of the low levels of circulating LH and FSH. Generally, two options for those patients are surgi- expectation is that androgen-dependent cancer cells will cal castration and chemical castration. Lupron]) are usually used in combination with other drugs One option for chemical treatment of these patients is in order to block most effectively androgenic activity. For the use of analogs of GnRH, the hormone that regulates the example, one of the androgen-blocking drugs includes 5 - secretion of LH and FSH. Long-acting GnRH agonists or an- reductase inhibitors that prevent the conversion of testos- tagonists reduce LH and FSH secretion by different mecha- terone to the highly active androgen dihydrotestosterone nisms. In addition, desensitization of the pituitary gonadotrophs to GnRH, antiandrogens, such as flutamide, bind to the androgen leading to a reduction of LH and FSH secretion. GnRH antagonists the treatment requires nonhormonal therapies, including bind to GnRH receptors on the pituitary cells, prevent en- chemotherapy and radiation. Androgens Are Responsible for Secondary Sex drogens have multiple effects on skeletal and cardiac mus- Characteristics and the Masculine Phenotype cle. Because 5 -reductase activity in muscle cells is low, the androgenic action is due to testosterone. Testosterone Androgens effect changes in hair distribution, skin texture, stimulates muscle hypertrophy, increasing muscle mass; pitch of the voice, bone growth, and muscle development. Hair is classified by its sensitivity to androgens into non- Testosterone, in synergy with GH, causes a net increase in sexual (eyebrows and extremities); ambisexual (axilla), muscle protein. Hair follicles metabolize testos- kidneys, adipose tissue, and hematopoietic and immune terone to DHT or androstenedione. The kidneys are larger in males, and some renal the growth of facial, chest, and axillary hair; however, enzymes (e. Normal axillary and pubic hair growth triglyceride concentrations higher in men, compared to in women is also under androgenic control, whereas excess premenopausal women, a fact that may explain the higher androgen production in women causes the excessive prevalence of atherosclerosis in men. In- creased sensitivity of target cells to androgenic action, es- pecially during puberty, is the cause of acne vulgaris in The Brain Is a Target Site for Androgen Action both males and females. Most of those areas also contain ing of the vocal cords are also androgen-dependent. Eu- aromatase and many of the androgenic actions in the brain nuchs maintain the high-pitched voice typical of prepuber- result from the aromatization of androgens to estrogens. The pituitary also has abundant androgen receptors, but no The growth spurt of adolescent males is influenced by a aromatase. The enzyme 5 -reductase is widely distributed complex interplay between androgens, growth hormone in the brain, but its activity is generally higher during the (GH), nutrition, and genetic factors. Sexual dimorphism in the cludes growth of the vertebrae, long bones, and shoulders. Because of the latter, precocious puberty is as- spring, in humans, sexual activity and procreation are not sociated with a final short adult stature, whereas delayed tightly linked. Superimposed on the basic reproductive puberty or eunuchoidism usually results in tall stature. An- mechanisms dictated by hormones are numerous psycho- 664 PART X REPRODUCTIVE PHYSIOLOGY logical and societal factors. In normal men, no correlation is To establish the cause(s) of reproductive dysfunction, found between circulating testosterone levels and sexual physical examination and medical history, semen analysis, drive, frequency of intercourse, or sexual fantasies. Simi- hormone determinations, hormone stimulation tests, and larly, there is no correlation between testosterone levels and genetic analysis are performed.

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