The fine line of defensive medicine.

Defensive medicine is a practice that has been utilized by clinicians in efforts of preventing patient dissatisfaction and malpractice claims and may be done through either omission or commission. As much as 57% of physicians have disclosed that they practice defensive medicine. However, this practice does not necessarily prevent malpractice claims and more importantly, neither does it equate to good medical practice, with some leading to poor outcomes. Unfortunately, there is a high percentage of malpractice claims lodged against clinicians in both primary care and hospital settings. Specialists such as surgeons, obstetricians, and gynecologists face the highest claims. In particular, during the SARS CoV-2 pandemic, with new challenges and limited treatment algorithms, there is an even greater concern for possible bourgeoning claims. Counteracting defensive medicine can be accomplished through decriminalizing malpractice claims, leaving physician oversight up to state medical boards and hospital claims management committees. Additional tort reform measures must also be taken such as caps on noneconomic damages to ensure emphasis on beneficence and nonmaleficence. Once these are in place, it may well serve to increase clinician-patient trust and improve patient independence in the shared decision-making process of their treatment, allowing clinicians to practice their full scope of practice without feeling wary of potential malpractice claims.

Copper-Zinc-Tin-Sulfide Thin Films via Annealing of Ultrasonic Spray Deposited Nanocrystal Coatings.

Thin polycrystalline films of the solar absorber copper-zinc-tin-sulfide (CZTS) were formed by annealing coatings deposited on molybdenum-coated soda lime glass via ultrasonic spraying of aerosol droplets from colloidal CZTS nanocrystal dispersions. Production of uniform continuous nanocrystal coatings with ultrasonic spraying requires that the evaporation time is longer than the aerosol flight time from the spray nozzle to the substrate such that the aerosol droplets still have low enough viscosity to smooth the impact craters that form on the coating surface. In this work, evaporation was slowed by adding a high boiling point cosolvent, cyclohexanone, to toluene as the dispersing liquid. We analyzed, quantitatively, the effects of the solvent composition on the aerosol and coating drying dynamics using an aerosol evaporation model. Annealing coatings in sulfur vapor converts them into polycrystalline films with micrometer size grains, but the grains form continuous films only when Na is present during annealing to enhance grain growth. Continuous films are easier to form when the average nanocrystal size is 15 nm: using larger nanocrystals (e.g., 20 nm) sacrifices film continuity.

Formation of Copper Zinc Tin Sulfide Thin Films from Colloidal Nanocrystal Dispersions via Aerosol-Jet Printing and Compaction.

A three-step method to create dense polycrystalline semiconductor thin films from nanocrystal liquid dispersions is described. First, suitable substrates are coated with nanocrystals using aerosol-jet printing. Second, the porous nanocrystal coatings are compacted using a weighted roller or a hydraulic press to increase the coating density. Finally, the resulting coating is annealed for grain growth. The approach is demonstrated for making polycrystalline films of copper zinc tin sulfide (CZTS), a new solar absorber composed of earth-abundant elements. The range of coating morphologies accessible through aerosol-jet printing is examined and their formation mechanisms are revealed. Crack-free albeit porous films are obtained if most of the solvent in the aerosolized dispersion droplets containing the nanocrystals evaporates before they impinge on the substrate. In this case, nanocrystals agglomerate in flight and arrive at the substrate as solid spherical agglomerates. These porous coatings are mechanically compacted, and the density of the coating increases with compaction pressure. Dense coatings annealed in sulfur produce large-grain (>1 µm) polycrystalline CZTS films with microstructure suitable for thin-film solar cells.

Facile fabrication of polyanhydride/anesthetic nanoparticles with tunable release kinetics.

This work illustrates a two-step strategy for the fabrication of polymer/drug nanoparticles. Utilizing solvent/non-solvent precipitation and gaseous basification, composite nanoparticles with 0-100% drug loadings are fabricated. Drug release kinetics are dictated by nanoparticle composition allowing future tuning for therapeutic applications.

Cu(2)ZnSnS(4) nanocrystal dispersions in polar liquids.

Cu(2)ZnSnS(4) (CZTS) nanocrystals sterically stabilized with oleic acid and oleylamine ligands and dispersed in nonpolar organic liquids have been extracted into, and electrostatically stabilized in, polar liquids by covering their surfaces with S(2-).

Nasal airway function after maxillary surgery: a prospective cohort study using the nasal obstruction symptom evaluation scale.

PURPOSE: To examine nasal airway function using a disease-specific quality-of-life survey instrument in subjects undergoing Le Fort I osteotomy without simultaneous rhinosurgical procedures. MATERIALS AND METHODS: We conducted a prospective cohort study of nasal airway function in consecutive Le Fort I osteotomy patients, who had not received simultaneous rhinosurgical procedures, between 2007 and 2008 at Kaiser Permanente Oakland Medical Center. We administered the Nasal Obstruction Symptom Evaluation (NOSE) survey before and 3 months after surgery. Clinical and radiographic examinations were performed, and the relevant medical and demographic factors were analyzed. RESULTS: The initial study sample comprised 55 patients, of whom 5 were excluded. Of the remaining 50 patients (median age 21 years, 60% women), the maxilla was advanced (median 4 mm, interquartile range 3 to 5) with minimal vertical change. During the follow-up period (median 5.5 months), significant improvement was seen in the NOSE scores for the cohort, with a median decrease of 10 units (P = .0005). Patients with moderate nasal obstruction (preoperative NOSE score >25) had the greatest improvement (P < .001). Those with severe nasal obstruction (preoperative NOSE score >50) improved, however, this did not reach statistical significance (P < .0625). The NOSE scores worsened in 10 patients; of these, 6 had minimal change. However, 4 had significant worsening, with 2 having symptomatic complaints. No predictor variables were identified in this small subgroup; however, individual case analyses revealed 1 subject with postoperative turbinate inflammation on the side of maxillary segmentalization and 1 had nasal septal buckling. CONCLUSIONS: Our overall findings have suggested that nasal airway function improved after maxillary advancement and that subjects with greater preoperative NOSE scores (>25) were more likely to experience relief of nasal obstructive symptoms.

Complications following surgically assisted rapid palatal expansion: a retrospective cohort study.

PURPOSE: To examine the prevalence of complications and characterize the associated clinical findings in patients undergoing surgically assisted rapid palatal expansion (SARPE). MATERIALS AND METHODS: A retrospective evaluation was conducted of all patients who underwent SARPE from January 2004 through December 2008 at Kaiser Permanente Oakland Medical Center. Medical records were abstracted, and demographic factors and relevant comorbidities were identified. Clinical features of patients with complications (surgical and/or dental) after SARPE were characterized. RESULTS: One hundred thirty-one patients comprised the study sample and 11 patients were excluded. Of the remaining 120 patients (median age, 29.5 yrs; interquartile range, 22.0 to 39.0 yrs), 51.7% were women, 41 developed at least 1 complication, 33 had surgical complications, 18 had dental and/or periodontal problems, and 10 developed both surgical and dental or periodontal problems. Asymmetric and/or inadequate expansion was the most frequent surgical complication, found in 13.3% of the study cohort, and gingival recession (8.3%) was the most common dental complication. Two patients developed catastrophic periodontal bone defects resulting in loss of the central incisors; these patients had eccentric interdental osteotomies that caused separation of the bone from the root surface of the central incisors followed by postoperative osteotomy site infections. CONCLUSIONS: Overall, the present findings suggest that, although major complications after SARPE were rare, asymmetric or inadequate expansion and dental and/or periodontal problems primarily involving the central incisors accounted for most complications. Future prospective and long-term follow-up studies are needed to identify individual risk factors that may predispose patients to adverse outcomes after SARPE.

Gender differences in the effects of streptozotocin-induced diabetes on parasympathetic vasodilatation in the rat submandibular gland.

OBJECTIVES: Submandibular vasodilatory responses are impaired in male streptozotocin-diabetic rats. However, the effects of diabetes on submandibular vascular reactivity in female rats have not been examined. The purpose of this study was to determine whether there are gender differences in the effects of diabetes on parasympathetic vasodilatation in the rat submandibular gland. METHODS: Diabetes was induced using streptozotocin, and vascular responses (calculated as the % increase in submandibular vascular conductance) to parasympathetic stimulation (1-10 Hz) were measured using laser-Doppler flowmetry. To estimate the relative contributions of nitric oxide (NO), prostacyclin (PGI2) and endothelium-derived hyperpolarizing factor (EDHF), vascular conductance was measured before and after inhibition of cyclooxygenase (COX) and NO synthase (NOS). RESULTS: Frequency-dependent increases in blood flow were observed in both male and female rats, but the contribution of EDHF was greater in females than in males. Further, PGI2 appeared to play a role only in males. Vasodilatory responses were diminished in all diabetic animals, and when compared with their respective controls the degree of impairment was similar in males and females. However, in diabetic males inhibition of COX and NOS had little or no effect, whereas inhibition of NO, but not COX, resulted in a further significant decrease in vascular responses in diabetic females. CONCLUSIONS: Parasympathetic vasodilatation in the rat submandibular gland is diminished equally in diabetic males and females. However, in males diabetes predominantly impairs PGI2- and NO-dependent vasodilatation, whereas in females the contribution of EDHF-mediated pathways are affected and NO-dependent vasodilatation is preferentially maintained.