论《消费者权益保护法》第49条对医疗纠纷的适用问题

医患关系是以生活消费为内容的消费关系 ,存在医患双方事实上的实力对比的悬殊 ,对医疗纠纷应当适用《消费者权益保护法》第 49条有关惩罚性赔偿的规定     

“多次违法行为”入罪之思考——以多次非法行医为视角

我国法律规定未取得医生执业资格的人非法行医,被卫生行政部门行政处罚两次以后,再次非法行医的,应当以非法行医罪追究其刑事责任。此种将多次行政处罚后再实施违法的行为纳入刑事犯罪构成要件或者说作为罪量要素的定罪模式是合理的,不违反禁止重复评价原则和刑法谦抑性原则。但为了防止刑事制裁范围的肆意扩大,应从违法主体、违法程序及违法次数上对"非法行医被二次行政处罚后再次非法行医"入罪进行一定的限制,以实现人权保障和惩罚犯罪的有机统一。     

刑事强制医疗客观要件的反思与重构

强制医疗的客观要件包括行为条件和侵害法益条件两方面。通过对司法实践的考察发现:强制医疗的客观要件不仅存在放任精神病人继续实施危害社会行为的风险,而且还存在不规范适用的情况。出现上述问题的根源在于强制医疗的客观要件自身具有不合理性,只有改革强制医疗的客观要件,才能够化解风险、规范司法适用。不限制危害行为和侵害法益是国外强制医疗客观要件的普遍模式。我国应当将"实施的行为的社会危害性已经达到犯罪程度"作为强制医疗的客观要件,同时有必要丰富强制医疗的执行方式,在住院治疗之外,增加门诊治疗。     

浅谈基层医疗机构职代会职权行使保障机制建设

在实践中,基层医疗机构职代会职权行使往往流于形式,职代会组织不能有效发挥其应有作用。分析原因,由于基层医疗机构具有明显区别于其他事业单位的行业特殊性,单位领导尤其是一把手对职代会作用的认识程度、重视程度、支持力度,对职代会职权行使产生重要影响,因而应建立包括学习培训制度、目标考核制度、督导调研制度、集体研究会议决定制度、权力监督约束制度在内的职代会职权行使保障机制,确保职代会作用的有效发挥。     

Significant Differences in PostMortem Heart Weight Before and After Dissection Using the Short-Axis Dissecting Method

Correctly assessing heart weight can be critical at postmortem examination. The current international guidelines advocate using the short-axis method in dissecting the heart and the heart weighed when the blood is emptied. However, it did not specify at what point the heart should be weighed or how the blood should be emptied. This study compared heart weights at three different time points during the heart examination (immediately after dissecting out of the pericardial sac with blood still in chambers, blood washed/removed from heart chambers without the heart opened, and the heart completely opened, blood emptied, and pad dried). This was to illustrate the variation in measurement and potential errors when the heart is weighed at different time of dissection. The results show that there were statistical and clinical significant differences between the heart weights at each weighing points. We recommend the heart to be completely dissected with any blood and residual washing/rinsing water emptied before being weighed. Although performed in this study, the effect of pad drying the heart on heart weight was not explored and was a limitation in this study.     

Postmortem Computed Tomography in Firearm Homicides: A Retrospective Case Series,

Postmortem computed tomography (PMCT) is integrated into the evaluation of decedents in several American medical examiner offices and medicolegal death investigative centers in many other countries. We retrospectively investigated the value of PMCT in a series of firearm homicide cases from a statewide centralized medical examiner’s office that occurred during 2016. Autopsies were performed or supervised by board-certified forensic pathologists who reviewed the PMCT scans prior to autopsy. PMCT scans were re-evaluated by a forensic radiologist blinded to the autopsy findings and scored by body region (head–neck, thoracoabdominal, and extremities). Injury discrepancies were scored using a modified Goldman classification and analyzed with McNemar’s test. We included 60 males and 20 females (median age 31 years, range 3–73). Based on PMCT, 56 (79.1%) cases had injuries relevant to the cause of death in a single body region (24 head–neck region, 32 thoracoabdominal region). Out of these 56 cases, 9 had a missed major diagnosis by PMCT outside that region, including 6 extremity injuries visible during standard external examination. Yet all had evident lethal firearm injury. We showed that PMCT identifies major firearm injuries in homicide victims and excludes injuries related to the cause of death in other regions when a single body region is injured. Although PMCT has a known limited sensitivity for soft tissue and vascular pathology, it can be combined with external examination to potentially reduce or focus dissections in some of these cases depending on the circumstances and medicolegal needs.     

Postmortem Changes of Female External Genitalia and Their Importance in Suspected Sexual Abuse

Examination of the female external genitalia to assess for sexual abuse is performed in living individuals, and the interpretation of the findings is based on evidence-based studies. However, in the deceased, no such studies are available, and postmortem changes could present as suspicious findings that can be mistaken for trauma. Patches of discoloration in the hymen were reported previously in one case as hypostasis (i.e., livor and lividity), and based on this finding, it was listed as a finding that is not associated with trauma. This was a retrospective study that was conducted in the Center of Forensic and Legal Medicine in Dammam, Saudi Arabia over a 4-year period. The study included 30 deceased women in whom photographic documentation of their external genitalia was assessed for postmortem changes. The postmortem interval ranged from less than 24 h to more than 100 days, and the ages of these deceased women were in the 20–40 year-old age group. In cases where the hymen, vagina, and/or fossa navicularis were clearly visible, none of these areas showed any hypostatic discoloration. A comparison between antemortem and postmortem appearance of the hymen in one case clearly showed the absence of hypostatic changes in the hymen. In conclusion, any discoloration of the external genitalia that is detected in a female decedent requires serious consideration.     

Postmortem Computed Tomography and Magnetic Resonance Imaging of Gunshot Wounds to the Neck

Postmortem magnetic resonance imaging (MRI) is rarely used for the radiologic assessment of gunshot injuries, although it has clear advantages over postmortem computed tomography (CT) with regard to the imaging of soft tissue injuries. Another benefit in using MRI is that lodged projectiles composed of nonferromagnetic material such as lead present only marginal metal artifacts compared with severe artifacts on CT. This case report presents CT and MRI findings in a case with two gunshot wounds to the neck: a perforating wound and a nonperforating wound with a lead bullet lodged in the cervical spine. The decedent underwent CT and MRI before the scheduled autopsy. A ring of radiopaque material under the dermis in the fatty tissue was identified at both entrance wounds on CT, which was indicative of contact shots. The perforating gunshot was clearly indicated on CT by bullet fragments along the wound channel through the perforated 6th cervical vertebra and the fractured cricoid cartilage at the exit wound. The second trajectory, however, was only assumed based on the presence of gunshot residues at the entrance wound and the position of the lodged bullet. The radiologic assessment was severely impeded by the metal artifacts on CT. Barely noticeable metal artifacts on MRI allowed for clear visualization of the soft tissue injuries and the ruptured medulla oblongata. Only MRI clarified the soft tissue injuries of the brainstem noninvasively, which could provide specific and graphic information on the rapidity of death and the incapacitation of the victim.     

Evaluating the Potential for Unintentional Occupational Exposure to Fentanyl and Fentanyl Analogues Among Medicolegal Death Investigators and Autopsy Technicians

Recent increases in deaths in the United States from synthetic opioids such as fentanyl and fentanyl analogues (fentanyls) have raised concerns about possible occupational exposures to these potent agents. Medicolegal death investigators and autopsy suite staff might perform job tasks involving exposure to fentanyls. The potential for exposure to fentanyls among medicolegal death investigators and autopsy technicians at a state medical examiner's office was evaluated through review of caseload characteristics, injury and illness logs, and procedures and policies and discussions with management and employee representatives. The evaluation showed that this medical examiner's office had low potential for work-related exposure to fentanyls; its standard operating procedures and personal protective equipment requirements should reduce the potential for occupational exposure. Medicolegal death investigation agencies can develop and implement guidance to control exposures and provide workforce education and training to reduce the potential for work-related exposure to fentanyls.     

医改的抉择:政府主导还是市场化——基于医疗卫生服务及其市场特殊性的分析

医疗卫生改革理应寻求解决民众的"看病难"、"看病贵"问题.医疗卫生服务及其市场是医改中所有问题的归结点.在对医疗卫生服务与其市场的特殊性进行分析中,表明医疗服务市场不同于一般的商品市场与服务市场,在政府与市场的分工上针对其特点进行合理界定,既否决单纯的市场主导,也否决一味的市场化,而是二者的理性结合.