Potential Effects of Dobbs v. Jackson Women's Health on Civil Commitment Law.

Since the publication of the U.S. Supreme Court's decision in Dobbs v Jackson Women's Health in June of 2022, much attention has been paid to the direct effects of that decision on reproductive health care for pregnant or potentially pregnant individuals; and to the potential effects of the Court's approach in Dobbs to other established precedent related to privacy and autonomy, such as rights to contraception and marriage equality. This Article will explore another potential negative consequence of Dobbs; its potential effect on the constitutional parameters of the law of civil commitment and involuntary medication of the mentally ill.The foundational Supreme Court case establishing the parameters of the State's right to involuntarily commit an individual to a mental institution was decided only two years after Roe v. Wade. In 1975, the Supreme Court in O'Connor v Donaldson held that an individual has a liberty interest in "prefer[ring] one's home to the comforts of an institution," and that a State could not, "without more," confine a non-dangerous individual. The two-prong test of requiring a showing of both mental illness and dangerousness to one's self or to others has remained the cornerstone of civil commitment law ever since.The language and analysis of O'Connor is similar to that of Roe, the abortion rights case overturned by Dobbs. In particular, the grounding of the right to avoid civil commitment in the individual liberty and privacy interests are common themes in the two cases. The current Court, in its decision in Dobbs, has cast substantial doubt on the continued vitality of that analysis; and one can easily imagine a reconceptualization of O'Connor along the lines of Dobbs that substantially alters the requirements for civil commitment. In particular, the reliance in Dobbs and other recent Supreme Court opinions on historical precedent as a linchpin of originalist analysis could lead the Court to search for justifications in colonial or 19th-century mental health practices, time periods which predate modern psychiatric science.This Article will explore the parallels in approach between Roe and O'Connor, and will suggest ways in which the post-Dobbs Supreme Court majority might disrupt the civil commitment status quo, including potential expansion of civil commitment or other detention of pregnant individuals for the protection of the fetus; and possible relaxation of the dangerousness requirement for civil commitment articulated in O'Connor.

Comparative results of trauma scoring systems in fatal outcomes.

BACKGROUND: Trauma scoring systems are vital tools in assessing patient injuries and determining risk of mortality. This study was designed to test which score--the Injury Severity Score (ISS), the Trauma and Injury Severity Score (TRISS), TRISS plus comorbidities (TRISSCOM) or the new International Classification of Disease (ICD-9)-Based Injury Severity Score (ICISS)--has the greatest predictive value at a Level 2 trauma center. METHODS: In this retrospective chart review, data for 39 trauma deaths over a 30-month period were collected from the Stamford Hospital Trauma Registry. RESULTS: Patients with ISS less than 15 who later died were significantly older than patients with ISS from 15 to 24 (P = 0.038) and ISS of 25 (P = 0.013). The TRISSCOM and a modification further stratifying age both produced significantly lower mean survival predictions when compared to other scores (P = 0-0.041). Only the modified TRISSCOM was highly predictive (score < 0.2) in the most severely injured patients (identified by ISS > 25). CONCLUSION: The TRISSCOM and its modification performed significantly better than the other scores assessed. Elderly patients may require special treatment when included in scoring system comparisons.

Substance abuse and diagnosis of cervical spine injuries: policy consideration.

BACKGROUND: Cervical spine injury occurs in 2% to 6% of patients with blunt injury. Standard cervical radiographs are widely accepted as a primary screen, but may miss injuries. Diagnoses are further confounded by patients' use of alcohol or drugs, which may delay diagnosis. OBJECTIVE: To compare the rate of incomplete cervical radiographs and to compare the sensitivity of cervical radiographs and neck computed tomography (CT) in patients with cervical spine injury, with and without substance abuse. DESIGN: A retrospective chart review. SETTING: A community teaching hospital. PATIENTS: Eighty-five high-severity trauma cases between 6/1/03 and 5/28/05. METHODS: Retrospective chart review of cervical spine imaging studies, alcohol levels, toxicology screens and clinical diagnosis. RESULTS: Cervical radiographs generated false negatives or incomplete studies in all injured patients with significant levels of alcohol (> or = 80 mg/ dL) or drugs detected on toxicology screens. Cervical CT produced no false negatives. CONCLUSIONS: Drug and alcohol screens are important adjunct studies to identify patients with substance abuse who are more prone to sustain cervical spine injury that is likely to be missed by plain cervical radiographs. Cervical CT maybe a better primary imaging study for detection of cervical spine injury in trauma patients with suspected substance abuse.

Changes in radiographic abnormalities in organ donors: associations with lung transplantation.

BACKGROUND: Only 20% of organ donors are considered suitable for lung transplantation. No extensive study exists that has evaluated changes in thoracic radiographic abnormalities in organ donors. The purpose of this study was to determine the impact of radiographic abnormalities on successful transplantation. METHODS: In a retrospective survey of 110 organ donors, chest radiographs (N = 417) taken during the initial 24 hours after admission and just before organ harvest were evaluated for 9 radiographic criteria, radiographic diagnoses and clinical characteristics and their association with lung transplantation. RESULTS: Initial lung densities were present in 37% of lungs; there were bilateral infiltrates in 25% of cases. During evaluation (69.7 +/- 60 hours), 38% of right lungs and 28% of left lungs improved radiographically. Up to 51% of lungs with initial infiltrates resolved completely. Worsening of lung infiltrates was more common in the non-transplant group (p = 0.02); however, improvement in densities was not associated with transplantation (p = 0.6). Multivariate analysis determined that moderate and severe lung densities (OR 7.68, p = 0.01; OR 10.8, p = 0.004) and bilateral infiltrates (OR 4.79, p = 0.02) were independent predictors of rejection for transplantation. With densities removed from the model, the number of abnormal diagnoses on the final films was an independent predictor of rejection for transplantation (OR 3.23, p = 0.003). CONCLUSIONS: More than 33% of proposed organ donors initially have lung infiltrates, with >33% showing improvement or resolution, but this improvement does not impact on procurement. Multiple abnormal radiographic diagnoses also contribute to transplant rejection.

A comparison of rat tracheal transplant models: implantation verses anastomotic techniques for the study of airway rejection.

BACKGROUND: In rodent models, investigators have transplanted donor tracheas into a recipient rat's abdomen or s.c. tissue to study airway rejection. We describe a modification of this model, which provides improved histology to study the airway injury related to obliterative bronchiolitis. METHODS: The standard technique of implanting the donor trachea was compared to a model in which a tracheal Y graft was created by anastomosis of the donor trachea to the recipient airway. Syngeneic and allogeneic tracheal grafts (Lewis and Brown Norway rats) were harvested at 2 and 4 weeks using each model (eight groups). RESULTS: Gross patency at the tracheal anastomosis grafts was 100%. All donor tracheas, which were implanted without an anastomosis, were occluded with mucus (syngeneic) or granulation tissue (allogeneic). Syngeneic implant grafts demonstrated significantly less lumenal granulation tissue 35.3%+/-32 than the allograft implant group (95.3%+/-9.2, P=0.0005 at 4 weeks). The anastomotic allograft group demonstrated significantly less lumenal granulation tissue 48.3%+/-23.7 when compared with the implanted allograft group (P=0.003). The implanted allograft demonstrated a severe loss of epithelial integrity by 2 weeks (16.7%+/-38), which progressed to complete loss by 4 weeks (P=0.0001 and P=0.0001 vs. native). This loss was significantly more than that of the anastomotic group at 2 weeks (89.5%+/-13, P=0.004) and 4 weeks (88.3+/-29, P=0.005). CONCLUSIONS: The rat tracheal allograft anastomosed to the recipient airway demonstrated less lumenal granulation tissue obstruction and better preservation of epithelial integrity than an implant allograft, suggesting that an open airway improves assessment of transplant-related changes associated with rejection.

Selected contribution: mechanisms that may stimulate the resolution of alveolar edema in the transplanted human lung.

Pulmonary edema is common in organ donors and lung transplant recipients. Therefore, we assessed the responsiveness of human donor lungs to pharmacological agents that stimulate clearance of alveolar edema. Organ donors whose lungs were rejected for transplantation were studied. After resection, transport (4 degrees C), and rewarming (37 degrees C) of lungs, alveolar fluid clearance was measured with (n = 8 donors) or without (n = 23 donors) beta-adrenergic stimulation. Terbutaline-stimulated clearance (10(-4) M) was higher than unstimulated clearance (7.1 +/- 1.3 vs. 4.8 +/- 2.4%/h, P < 0.01). Second, we determined whether medications given to the organ donor were associated with the extent of pulmonary edema or the rate of alveolar fluid clearance in the harvested lung. Preharvest administration of dopamine in low to moderate doses was associated with faster alveolar fluid clearance (r = 0.62, P < 0.01). Preharvest administration of diuretics was associated with lower extravascular lung water-to-dry weight ratios. This study provides the first evidence that a beta(2)-adrenergic agonist stimulates alveolar fluid clearance in the human donor lung. Aerosolized beta(2)-adrenergic agonists may have therapeutic value for hastening the resolution of alveolar edema during the management of donors before resection of lungs for transplantation or in the posttransplant setting.

Emergent surgery for massive pulmonary embolism on the basis of clinical diagnosis.

We treated a 52-year-old man for a large pleural effusion that had occurred after he fell from a ladder. Upon discharge from the hospital, the patient collapsed and was nonresponsive and hypotensive. We suspected the cause to be pulmonary embolism. When it became evident that this patient would die without emergent intervention, he was taken to surgery. A massive clot was removed from the left pulmonary artery, and multiple smaller clots were removed from both pulmonary arteries. The patient recovered and was discharged from the hospital on the 11th postoperative day. To our knowledge, this is the 1st report of pulmonary embolectomy being performed on the basis of clinical diagnosis alone.

Transfusion for coagulopathy after heart surgery: efficacy of laboratory studies.

Limited information exists regarding transfusions specifically for coagulopathy following cardiac surgery and the value of pre- and postoperative coagulation tests. Procedures (86% coronary bypass, 7.5% valve, and 6.5% combined valve and bypass) on 478 patients were reviewed; 101 patients (21%) were transfused for postoperative coagulopathy. Compared to those not transfused, patients with coagulopathy were significantly older and smaller, and they had more combined valve procedures, emergency operations, and preoperative heparin treatment as well as longer crossclamp and bypass times. Three preoperative tests showed significant differences in the coagulopathy group: activated clotting time, partial thromboplastin time, and antithrombin-III level. Four postoperative tests showed significant differences between the groups: prothrombin time, partial thromboplastin time, fibrinogen level, and fibrin split products at 10 dilutions. Patient characteristics and pre- and postoperative testing can identify patients at high risk of transfusion specifically related to coagulopathy.

Reimagining the learned intermediary rule for the new pharmaceutical marketplace.

For the past decade, the learned intermediary rule--the rule of tort law that provides that drug manufacturers may satisfy their duty to warn of a drug's dangers by warning the prescribing physician rather than the end user of the drug--has been the subject of vigorous academic debate. That debate has been largely moot, however, as the courts have proven reluctant to make significant inroads on the protection offered by the Rule to drug manufacturers. This Article proposes a new approach to the Rule. Part I discusses the history and overwhelming adoption of the Rule pursuant to the Restatement (Second) of Torts. Part II argues that changes in the health care delivery system have resulted in a legal system that introduces market distortions by effectively immunizing the pharmaceutical industry from the legal and social consequences of its own actions. Part III then sets forth a reconceptualization of the Rule, which preserves the Rule's benefits with respect to the drug industry, the health care system, and the goals of tort law, while also strengthening the protection the tort system offers to individuals injured by prescription drugs.

Bleichner's hernia - lumbar hernia.

BACKGROUND: We present a case of a lumbar hernia and a review of the literature of this rare hernia type. CASE REPORT: The case and the review will discuss the unusual presentations reported, common etiologies, the importance of early operative repair based on the high rate of incarceration and the recent recommendations regarding repair techniques. CONCLUSIONS: Lumbar hernias are rare cases, but should be pursued in diagnosis and treated aggressively because of the high rate of incarceration. Repair can be accomplished with a minimally invasive technique.

Hemorrhage related reexploration following open heart surgery: the impact of pre-operative and post-operative coagulation testing.

PURPOSE: Our objective was to determine the association of pre-operative and post-operative coagulation testing abnormalities with the cause of post-operative bleeding requiring re-exploration following cardiac surgery. METHODS: Retrospective chart review of post-operative bleeding and the incidence of re-exploration for hemorrhage in 2263 adult patients undergoing elective and emergency open heart surgery which included coronary artery bypass, valvular, and combined valve coronary procedures. RESULTS: Eighty-two patients (3.6%) required re-exploration. Sixty-six percent had surgical bleeding; the remaining 34% were coagulopathic (no surgical site found). The pre-operative PT and ACT were significantly elevated in coagulopathic patients (P<0.005). Post-operative ACT, PT, and APTT were increased and fibrinogen levels were decreased in coagulopathic patients (P<0.05). CONCLUSIONS: Pre-operative testing (ACT, PT) weakly correlated with post-operative coagulopathy. Post-operative coagulation abnormalities were identified with high risk ratios and good diagnostic accuracy when using testing cut-off values to assist in surgical decision making.

DNA sequence context and multiplex hybridization reactions: melting studies of heteromorphic duplex DNA complexes.

Heteromorphic hybrid duplex DNA complexes are duplex states, other than perfectly matched duplexes, that can form when single strands comprising several different perfectly matched duplexes are simultaneously present in solution. Such cross-hybridization "side reactions" are of particular nuisance in multiplex reaction schemes, where many strands are designed to hybridize in parallel fashion with only their corresponding perfect complement strand. Relative to the perfect match duplexes, the sequence dependent features of these heteromorphic duplex states and their thermodynamic stability are an important consideration for multiplex hybridization reaction design. We have measured absorbance versus temperature melting curves and performed differential scanning calorimetry measurements on various mixtures of eight different 24 base single strands. When perfect complementary pairs of strands are mixed in single reactions, four perfectly matched duplexes form. When mixtures of strands that are not perfectly matched are prepared and analyzed, melting transitions for cross-hybridization are observed along with significant hyperchromicity changes. This is indicative of a melting hybrid, heteromorphic duplex states formed from two nonperfectly matched strands. In addition, when both the perfectly matched and noncomplementary strands are mixed together (in multiplex hybridization reactions) at molar ratios of 1:1, 3:1, and 1:3, evidence of perfect duplex and heteromorphic duplex complexes is found in all cases. A new analytical tool for considering heterogeneous, duplex complexes in multiplex hybridization mixtures is presented and employed to interpret the acquired melting data.

Induction of mast cell activation and CC chemokine responses in remodeling tracheal allografts.

Activated mast cells release stored and newly synthesized mediators that influence the caliber and responsiveness of inflamed airways. In this work, we show that alloimmune-mediated mechanisms induce mast cell activation and expression of CC chemokines in remodeling rat tracheal allografts. Decreased expression of rat mast cell protease (RMCP) I and II, in concert with tryptase release in tracheal allografts, identified degranulation of stored serine proteases as an early mast cell response to allotransplantation. Transient upregulation of c-Kit expression occurred in a synchronous manner, suggesting that c-Kit receptor signaling controls mast cell responses. Increased expression of CC chemokine ligand (CCL) 2 and CCL3 by RMCP I-positive cells identified mast cells as epithelial and mesenchymal sources of chemoattractant chemokines in allograft airways. Cyclosporin A immunosuppression both attenuated and delayed these changes in mast cell phenotypes. Incubation of rat basophil leukemia 2H3 cells with CCL2 or CCL3 decreased surface c-Kit expression, an effect blocked by protease inhibitors. By controlling surface receptor availability, CC chemokines may regulate c-Kit signaling via a novel proteolytic mechanism. These data suggest that targeting alloimmune responses and restoring quiescence of mast cells may attenuate the development of fibroproliferative and obstructive distortions of bronchiolar architecture in lung allografts.

Assessment of lungs rejected for transplantation and implications for donor selection.

Present criteria for donor-lung selection exclude more than 85% of lungs. We aimed to establish if potentially suitable lungs are rejected for transplantation. We obtained 29 pairs of rejected lungs and assessed them by physiological, microbiological, and histological methods. Most donor lungs had no or mild pulmonary oedema (24/29 [83%]), intact alveolar fluid clearance (17/23 [74%]), and normal or mildly abnormal histological findings (18/29 [62%]). When all factors were considered, including microbiological and non-lung donor factors, 12 (41%) of 29 pairs of rejected lungs would have been potentially suitable for transplantation. Our findings emphasise the urgent need for prospective scientific assessment of selection of donors for lung transplantation.