论医疗侵权诉讼中的举证责任倒置规则

医患关系的紧张再次引起了人们对医疗侵权诉讼中举证责任倒置这一规则的关注。在对有关基本知识和人们争议焦点的分析之后,提出了应该在准确理解医疗侵权诉讼中举证责任倒置的适用条件和内容的基础上,结合这一规则设置的目的在当事人之间合理地进行举证责任的分配。     

关于医疗侵权诉讼中医方举证能力的初步探讨

1医疗侵权诉讼中的医方举证责任与证据 医疗侵权诉讼中的举证责任倒置实质是举证责任的一种重新分配,它对证据的提供提出了更高的要求.在医疗诉讼实践中如何正确理解举证责任,如何保全和提供证据,一直是医方和社会都十分关注的问题.     

关于医疗纠纷中"举证责任倒置"热点问题的探讨

最高人民法院于 2 0 0 2年 4月 1日起正式实施的《最高人民法院关于民事诉讼证据的若干规定》中第四条第八项明确规定 :“因医疗行为引起的侵权诉讼 ,由医疗机构就医疗行为与损害结果之间不存在因果关系及不存在医疗过错承担举证责任。”这与《民事诉讼法》中“谁主张谁举证”的方式正好相反 ,即一方当事人提出主张而由对方当事人承担举证责任 ,称为“举证责任倒置”。这就意味着在我国医疗侵权的诉讼中 ,如果医疗机构不能举证该医疗行为与损害结果之间不存在因果关系 ,法院将依法推定医疗行为有过错 ,或推定该医疗行为是造成损害结果的原因…     

药物不良反应侵权诉讼问题研究

药物不良反应侵权诉讼是一种特殊的民事侵权诉讼。药品的生产者、药品经营者以及医疗机构都可能成为诉讼中的被告。药物不良反应侵权诉讼中的许多案件事实实行举证倒置。主要举证倒置事实有:药品缺陷、因果关系、免责事由、医疗过错等。     

举证责任倒置对医疗纠纷诉讼的影响

举证责任倒置是一般举证责任原则的例外,在医疗纠纷诉讼中施行举证责任倒置的法理依据。主要是医患双方的诉讼地位不平等和医患双方的信息不对称,导致患方举证困难,实施新的举证规则后,必将会对医疗纠纷诉讼产生一系列的影响,医方对此要有深刻的认识并积极研究其对策。     

医疗侵权诉讼举证责任倒置若干问题评议

20 0 2年 4月 1日始 ,《最高人民法院关于民事诉讼证据的若干规定》(以下简称“若干规定”)正式生效 ,近来新闻热炒的焦点之一是所谓的“医疗侵权诉讼举证责任倒置”。具体内容见“若干规定”的第四条第八项 :“因医疗行为引起的侵权诉讼 ,由医疗机构就医疗行为与损害结果之间不存在因果关系及不存在医疗过错承担举证责任。”众多的专家解说此条时 ,总是极富鼓动性地告诉公众 :2 0 0 2年 4月 1日以后告医院 ,患方就很轻松了 ,只需证明自己有损害事实 ,并且曾在被告处就诊就无需再举证了。本文试就“医疗侵权诉讼中患方举证责任的负担”、“…     

医疗侵权中的因果关系

医疗侵权诉讼中的因果关系认定是个十分复杂的问题.本文首先阐明了法律上的因果关系概念,并介绍了大陆法系和英美法系对因果关系认定的不同理论,指出在医疗侵权诉讼中两大法系的做法值得我国借鉴.     

正确认识医疗诉讼的举证责任倒置、规范医务人员的医疗行为

针对就如何正确理解医疗诉讼举证责任倒置的规定,举证责任倒置给我国医疗卫生界带来挑战,以及如何适应举证责任倒置规定等问题进行了论述,提出了提高医务人员法律素质,依法行医,防范医疗纠纷的办法。     

举证责任倒置与临床实践中证据的思考

医疗纠纷的举证责任倒置对医疗患双方产生广泛而深远的影响,也使医学与法律产生了碰撞,这就要求医务工作者在临床实践中既要为患者服务又要做到每个临床决策都必须有章可循,有法可依,有据可查以维护自己的合法权益,正确认识举证责任倒置的要求和掌握在临床实践中遵循证据的方法以避免陷入越来越多的医疗纠纷。     

事实自证制度在医疗侵权案件中的运用

在处理医疗事故侵权损害赔偿案件中,归责原则和举证责任具有至关重要的地位。我国现行的医疗事故侵权损害赔偿的归责原则和举证责任存在着诸多不和谐之处。应该引进英美法中的事实自证的证明方式。事实自证的证明方式在处理医疗侵权损害赔偿案件中有其优势。     

The Impact of Face Skin Tone vs. Face Symmetry on Perceived Facial Attractiveness

The purpose of this study was to assess and compare the relative contribution of skin tone and symmetry on judgment of attractiveness regarding female faces. Two hundred and fifteen Mozambican adults were presented with a set of faces, and instructed to rate their degree of attractiveness along a continuous scale. Chi-square, factorial weight analyses and ANOVA were used to analyze the data. Face skin tone had a significant impact on the participants' attractiveness judgment of target faces. However, the target face skin tone contribution to the participants' attractiveness judgment (5% of the total variance) was much weaker than the contribution of the target face symmetry (85% of the total variance). These results imply that skin bleaching, common among Black people across sub-Saharan African countries, is not only dangerous to the health of those who practice it, but it is unlikely to make them appear much more attractive.     

一种全面的、细化的治疗皮肤病思路的探索

传统的疾病治疗思路或模式显得相对单一和笼统。全面的、细化的疾病治疗应包括病因治疗、病机治疗、症状治疗、体征治疗和指标治疗五个方面。以湿疹和寻常型银屑病的治疗为例介绍全面的、细化的治疗皮肤病思路,期望这一思路能得到他人的认可和推广。     

A Comparison of Three Methods of Teaching Skin Self-Examinations

Skin self-examinations are essential for the early identification and treatment of skin cancers. However, little is known about the most effective methods for teaching skin cancer detection and skin self-examination. This study compared three skin cancer education methods that are commonly used in the primary care setting: viewing a videotape, reading brochures, and one-on-one instruction from a nurse practitioner. One hundred forty-three young adults were randomly assigned to one of the four conditions (educational intervention or wait list) and completed measures of skin cancer knowledge, ability to visually discriminate cancerous versus noncancerous skin growths, and behavioral ability to perform a skin self-examination immediately (Time 1) and 3 weeks (Time 2) after the educational intervention. Results showed that participants across all educational interventions had significantly higher skin cancer knowledge compared to those in the wait-list control group, and these knowledge scores were maintained for 3 weeks. Participants in the brochure condition scored significantly higher than participants in all other conditions on an observational measure of skin self-examination. Demographic variables, such as gender and ethnicity, were not found to be related to performance on any of the dependent measures. These findings provide preliminary evidence that knowledge of skin cancer may be enhanced through a variety of educational techniques and that written materials (e.g., brochures) may represent the minimal intervention level necessary for teaching adults how to perform thorough skin self-examinations.     

鼻烟窝皮瓣修复拇指大面积皮肤缺损的临床应用

探讨鼻烟窝皮瓣在修复拇指大面积皮肤缺损中的方法和治疗效果。从2008年1月～2013年10月间应用桡动脉在解剖鼻烟窝穿支为血管蒂的鼻烟窝皮瓣,逆行修复拇指大面积皮肤缺损26例,年龄17岁～55岁。术后平均随访时间25个月,皮瓣全部成活。皮瓣色泽及质地与健侧拇指背侧皮肤相近,拇指活动度基本正常。因此,鼻烟窝皮瓣是一种简便经济、效果理想、患者易于接受的术式,适合应用于拇指大面积皮肤缺损的治疗。     

颈部横切口外翻式颈动脉内膜切除术治疗颈动脉狭窄

讨论采用颈部横切口,实施外翻式颈动脉内膜切除术在治疗颈动脉粥样硬化性狭窄性疾病中的疗效。总结2009年4月1日到2009年10月20日共10例患者临床资料,分析术前术后的影像学资料和临床症状的比较。手术均获成功,患者术后临床症状均改善,术后影像学资料显示狭窄部位均获得完全改善。术后3个月,切口处皮肤基本没有麻木感。外翻式颈动脉内膜切除术在治疗颈动脉狭窄中,具有手术时间短、术后再狭窄率低、增厚内膜及斑块剥离彻底等优点,应用改进的颈部横切口,切口沿皮肤自然皱纹,并采用皮内缝合方法,术后不用拆线,既达到美观效果,又可以明显缩短患者住院时间。     

Vaginoplasty in Male to Female Transsexuals Using Penile Skin and Urethral Flap

ABSTRACT.

Objectives: Vaginoplasty presents the main problem in male to female surgery. There are many operative techniques that can be used, but none is ideal. We present our one stage vaginoplasty in male to female sex reassignment surgery.

Patients and Methods: The principle of our technique is based on penile disassembly and usage of all penile entities for vaginoplasty except corpora cavernosa. We developed our disassembly technique on a very large number of severe hypospadias reconstruction and adrenogenital “conversions.” Penile skin flaps and urethral work are used in each of these. Our new vagina consists of two parts: a long vascularized urethral flap and a pedicled island tube skin flap created from the penile skin. The urethral flap is embedded into the skin tube. The tube, consisting of skin and urethral flap, is inverted, thus forming the new vagina. The new vagina is inserted into the previously prepared perineal cavity between the urethra, bladder, and rectum. The new vagina is fixed to the sacrospinous ligament. The labia minora and majora are formed from the remaining penile and scrotal skin.

Results: The follow-up ranged from 3 months to 6 years (mean 4.6 years). Good cosmetic and functional results were obtained in 77 out of 89 patients (87%).

Conclusions: The technique provides results that have the most normal anatomical and physiological characteristics, in comparison to other methods, since all penile entities are used (except corpora cavernosa) to form almost normal external female genitalia. Vaginoplasty using pedicled penile skin with a urethral flap could be a very good alternative to other methods of vaginoplasty.     

Continuous Access to Competing Stimulation as Intervention for Self-Injurious Skin Picking in a Child with Autism

Children with autism frequently display self-injurious behavior (SIB), but skin picking—a less severe topography of SIB—has not been the focus of much clinical research. The present study evaluated a home-based intervention that was implemented with a 9-year-old girl who had autism and picked her fingers with resulting tissue damage. The intervention allowed the girl to hold and manipulate preferred objects during play and leisure activities. Evaluated in an ABAB reversal design, intervention essentially eliminated skin picking. Clinical and research implications are discussed.     

Skin picking in patients with obesity: Associations with impulsiveness and self‐harm

Previous studies suggest elevated prevalence rates of skin picking and self‐harm in patients with obesity compared to individuals in the general population. Hence, further studies should investigate prevalence rates and correlates of skin picking in this population – especially its differentiation to self‐harm. Skin picking and obesity are both associated with specific facets of impulsiveness. This relation should be explored to shed light on potentially shared mechanisms in etiology. Therefore, the present study examined the occurrence of skin picking and its associations with impulsiveness and self‐harm in a sample of pre‐bariatric surgery patients with obesity class II/III. Within the routine preoperative psychiatric evaluation, a total of 139 bariatric surgery candidates (78% female, BMI range 35–69) completed a self‐report questionnaire assessing sociodemographic variables, anxiety, depression, self‐harm, impulsiveness, and skin picking severity (urges: frequency, intensity, controllability; behavior: frequency, intensity, controllability; resistance, emotional distress, impairment, and avoidance). Ten participants (7.2% of the sample) reported recurrent skin picking leading to skin damage, repeated attempts to decrease skin picking, and psychosocial impairment (emotional distress, impairment in functional areas, avoidance) due to skin picking. In line with previous findings, skin picking severity shows a medium correlation with attentional impulsiveness. The majority of self‐harm types were not associated with skin picking severity. The current study reveals a high occurrence of skin picking compared to the general population. The results indicate an association between skin picking severity and attentional impulsiveness. Further research is needed to investigate the differentiation of skin picking and self‐harm in more detail.     

指动脉背侧支皮瓣在手指末节皮肤缺损治疗中的临床应用

分析指背动脉背侧支与其血管网联合供血滋养皮瓣在指末端皮肤缺损的修复中的应用效果。取中节手指固有动脉的背侧支为蒂血管,逆行切取指背皮瓣31例共35指,移植修补位于远端指间关节或其远端的皮肤缺损。若同时伴有骨、关节、肌腱等的损伤,则予以同期修复。本研究中最大切取皮瓣1.5cm×3.5cm,平均随访6±0.5个月(3至9个月),皮瓣成活率100%,皮瓣两点辨别觉9±0.2mm,95%的患者具有良好的指间关节活动能力。因此,指动脉背侧支皮瓣手术操作简单,术后成功率高且患者恢复效果好。     

应用烧伤整形外科技术治疗大面积皮肤撕脱伤

探讨大面积皮肤撕脱伤的治疗方法。分析总结大面积皮肤撕脱伤及合并损伤17例,根据伤情综合应用清创撕脱皮肤缝合、带蒂真皮下血管网皮瓣回植、撕脱皮肤反取皮回植、组织瓣转移修复、游离皮片移植、头皮取皮术、异体／异种皮移植、创面持续负压吸引VSD等治疗方法,观察创面修复、肢体外观及功能恢复情况。结果17例患者经综合治疗后创面均愈合。功能部位均予全层皮片或皮瓣修复;19处创面有深部组织外露,予皮瓣或肌瓣修复;随访6个月～3年,所有肢体功能良好。根据皮肤软组织损伤情况而综合运用多种烧伤整形外科技术修复大面积撕脱伤可缩短疗程,并最大可能保留受伤区域的功能与外观,改善患者生活质量。