Determining predictors of underlying etiology and clinical deterioration in patients with physiologic instability in the emergency department

Thesis (M.A.)--Boston UniversityShock is a critical state defined by inadequate oxygen delivery to tissues. It is well known in the critical care community that early diagnosis and treatment of shock are crucial to improving patient outcomes. However, in many cases, when a state of circulatory shock has been reached, irreversible damage already occurred. In the present study, we broadened our patient cohort from those with shock to those with physiologic instability with the intent of finding predictive factors that allow us to recognize when a patient is at risk for deterioration or when it is already occurring. These patients included patients with pre-shock, shock, and other forms of dysfunction. The purpose of this study was to determine the predictors of underlying etiology of physiologic instability as well as the likelihood of clinical deterioration in these various states, using elements from the physical exam, history, laboratory values, and vital sign measurements. This study was a prospective observational study of patients, from November 15, 2012 to March 1, 2013, found to have physiologic instability in the emergency department at an urban, academic tertiary-care hospital with 55,000 annual visits. Physiologic instability was defined as any one of the following abnormalities: heart rate (HR) > 130, respiratory rate (RR>24), shock index (SI) > 1, systolic blood pressure (SBP) 4.0 mmol/L, for a time period of more than five minutes. We identified 540 patients, 74.8% of which were included. Data describing epidemiology, and elements from the patient history and physical exam were abstracted from physician charts and the final etiology of physiologic instability, defined as septic, cardiogenic, hypovolemic, hemorrhagic, or other, was adjudicated by a physician. Blood samples from a subset of our patient group were collected from the hospital hematology laboratory and sent to the Wyss Institute to be analyzed using a novel bacterial detection assay. All of the covariates that data was collected for were analyzed to determine their diagnostic and prognostic value. [TRUNCATED

The Dobbs Effect: Abortion Rights in the Rear-View Mirror and the Civil Rights Crisis that Lies Ahead

On June 24, 2022, seven weeks after the first-ever leak of a draft opinion, the United States Supreme Court circulated its decision in Dobbs v. Jackson Women’s Health Organization, defying stare decisis, overruling fifty years of precedent, and shattering the hopes of millions of Americans, who wished the leaked opinion was a fiction that would never come to be. As the leaked draft forewarned, Roe v. Wadeis no longer the law of the land. No longer is a woman’s right to terminate a pregnancy—to exercise bodily autonomy and be free to control the trajectory of her life—protected as a fundamental right guaranteed by the Due Process Clause of the Fourteenth Amendment of the Federal Constitution. This sea change in the Court’s Fourteenth Amendment substantive due process jurisprudence raises serious questions about the viability of stare decisis and the future of those fundamental civil rights that are not explicitly named in the Constitution. With abortion rights now in the country’s rear-view mirror, this Essay examines the Court’s historic opinion, which calls into question the legitimacy of other substantive due process implied rights, and exposes the majority’s “history and tradition” justification for abolishing a constitutional right as mere pretext. It also offers insight into the legal, practical, and societal complications that lie ahead. Of course, no one has a crystal ball; however, as Justices Breyer, Sotomayor, and Kagan said in their dissent, “no one should be confident that this majority is done with its work.

The Case for LGBT Equality: Reviving the Political Process Doctrine and Repurposing the Dormant Commerce Clause

As a reaction to the Supreme Court’s historic marriage equality decision earlier this summer, many Southern state legislators opposing the trend toward LGBT-protective laws have proposed legislation that would essentially prohibit municipalities from carving out new antidiscrimination protections for the LGBT community. Conservative Senator Bart Hester spearheaded the passing of one of these “anti” antidiscrimination laws in Arkansas, and states like Texas, West Virginia, Michigan, and Oklahoma are not far behind. These “Hester-type laws” are strikingly similar to the Colorado amendment struck down by the Romer v. Evans Court 20 years ago. Both the Colorado amendment and the new wave of Hester-type laws implicate the precise concerns that the Court’s limited application of the political process doctrine was designed to protect. They restructure the political process in a way that obstructs the LGBT community—and only that community—from achieving beneficial legislation at a local level. Since equal access to the political process is a right guaranteed by the Constitution, this article first submits that Hester-type laws would not pass constitutional muster under the political process doctrine. Despite the perfect doctrinal fit, however, it is questionable whether the political process doctrine survives post–Schuette v. BAMN. Alternatively, this article suggests a novel and groundbreaking argument for invalidating Hester-type laws under the Court’s Dormant Commerce Clause jurisprudence. As recognized in Heart of Atlanta Motel v. U.S., private discrimination in public accommodations does affect interstate commerce. Assuming that LGBT-friendly businesses will flee states with Hester-type laws and migrate toward states with more robust protections for the LGBT community, this article submits that Hester-type laws create a problem of economic isolationism, which in the aggregate could negatively impact interstate commerce. It is not uncommon for a constitutional doctrine to undergo a metamorphosis. Just as the principles of due process transformed from economics to personal liberty to match the needs of the time, so too should the doctrine of the Dormant Commerce Clause evolve from protecting equality in interstate commerce to protecting equality in public accommodations for the LGBT community

Contemplating \u3cem\u3eMasterpiece Cakeshop\u3c/em\u3e

Next term, in Masterpiece Cakeshop v. Colorado Civil Rights Commission, the Supreme Court will consider whether a baker’s religious objection to same-sex marriage justifies his violation of Colorado’s public accommodation law in refusing to bake a cake for a same-sex wedding. At the centerpiece of Masterpiece Cakeshop is a clash between the First Amendment’s Free Exercise Clause and the Fourteenth Amendment’s Equal Protection Clause or, more precisely, the principles of equality in commercial life as grounded in Colorado’s public accommodation law. In exploring the purpose inherent in regulating private conduct through public accommodation laws, this Essay suggests that the reconciliation of these seemingly irreconcilable interests is rooted in their common intrinsic value: maintaining the social order. Ultimately, Masterpiece Cakeshop provides an opportunity for the Court to reclaim the grounding principles inherent in public accommodation laws that recognize the civic duty in “serving the public” and hold that free exercise must bow to equal protection when necessary to maintain the social order

Speech Narcissism

From its embryonic stage during the civil rights era to its modern-day presence on college campuses, the political correctness movement has undergone an extreme metamorphosis. In the university setting, it was originally intended to welcome diverse views by encouraging minority students to feel part of the learning environment and to contribute to the “marketplace of ideas.” Recently, however, as students more frequently demand trigger warnings and safe spaces in response to speech that they deem personally offensive, the use of political correctness measures on college campuses has had the unintended consequence of chilling speech. Contrary to longstanding First Amendment principles, college campuses are becoming environments in which the most vulnerable among the student population can exercise a “heckler’s veto,” silencing speech that is subjectively offensive to the most sensitive students. During the 2016 presidential election, Trump supporters praised his unfiltered campaign rhetoric and divisive Tweets while others condemned them, criticizing his unscripted approach as offensive in the name of political correctness. The contrast between Trump supporters’ chants of “lock her up” at rallies and college students’ demands for safe spaces and trigger warnings is noteworthy; these diverse groups fall at the opposite ends of a speech-tolerance spectrum. On the one end of the spectrum, political correctness is shunned; on the other end, it is demanded. In debunking the purported justifications for the use of extreme political correctness measures on college campuses, this Article adds to the ongoing discussion of the changing landscape of privately imposed speech rules for public discourse and posits that both ends of the speech tolerance spectrum reflect a form of speech narcissism. The new normal in speech rights has abandoned the central meaning of the First Amendment—the freedom to engage in “uninhibited, robust, and wide-open” debate on matters of public concern. The “my way or the highway” approach to public discourse is the antithesis of the free speech principles thought essential to secure liberty and democracy. In response to this trend, state legislatures are passing Freedom of Speech statutes that safeguard speech in the classroom and on the quad. While these laws are a positive step toward countering the negative effects of political correctness, this Article suggests that speech offensiveness is a matter of ethics and education that cannot be remedied solely by law. “True grit” and compassion training are necessary antidotes to the thin-skinned, speech-averse students who demonstrate zero tolerance for any expression that is personally offensive

Beyond the fiber: Novel spider silk coatings and adhesives

Natural spider silks have long been recognized for their combination of incredible strength and elasticity. Spider silk is more elastic than nylon, tougher than Kevlar, and stronger than steel by weight. Due to an inability to farm spiders, much work has been done to produce spider silks in transgenic hosts for large -scale production. Our work was done using recombinant spider silk proteins produced in transgenic goats and the bacteria E. coli. More recently spider silks have also been recognized for their biocompatibility and lack of immunogenicity. Spider silks\u27 incredible strength and ability to be implanted safely within the body makes them highly desirable for use in industry and the medical field. Recently our team has developed a novel procedure to solvate recombinant spider silks in pure water, allowing them to be used safely in a variety of in vivo applications. Uses for spider silk coatings and adhesives are very broad. The focus of the research described here is to coat medical implants and other medical materials. The application of a spider silk coating to materials such as heart stents, implants, and catheters will drastically increase their biocompatibility, decrease the chance of infection as well as recovery time due to decreased tissue growth in response to the foreign object. Coatings can also be functionalized to release antibiotics, antifungals, and other medications. These coatings have shown promise in adhering to silicone and increasing the hydrophilicity of the naturally hydrophobic silicone surface. As for adhesives they have applications varying from the medical field to the textile industry and their strength rivals that of conventional glues on the market. These adhesives can be applied to wood, plastics, stainless steel, silicone, and many other substrates