Service Delivery, Resource Allocation and Access to Justice: Greiner and Pattanayak and the Research Imperative

In this essay, we reflect on Jim Greiner and Cassandra Pattanayak’s provocative article reporting the results of a randomized controlled trial evaluating legal assistance to low-income clients at the Harvard Legal Aid Bureau. Studying the outcomes of appeals from initial denials of unemployment insurance benefit claims Greiner and Pattanayak asked, what difference does legal representation make? Their answer is that “an offer of HLAB representation had no statistically significant effect on the probability that a claimant would prevail, but that the offer did delay the adjudicatory process.” That is, not only was an offer of legal assistance immaterial to the case outcome, it may have harmed clients’ interests. The Greiner and Pattanayak findings challenge our intuition, experience and deeply-held professional belief that lawyer representation of indigent clients in civil matters is fundamental to the pursuit of justice. Our first reaction is that the study must have fatal conceptual or methodological flaws – the researchers studied the wrong thing in the wrong way. Even when we learn that the study is credible and well designed, we doubt that this kind of research is a worthwhile use of our time or money relative to serving needy clients. Finally, and perhaps most importantly, we worry that the published results will only serve as fodder for the decades-long political assault on legal services for the poor. If replicated across venues, however, studies like Greiner and Pattanayak’s can tell us a great deal about individual representation, program design and systemic access to justice questions. In fact, we cannot make genuine progress in any of these areas – much less marshal the case for more robust legal aid investments and the right to counsel in some civil cases – without better evidence of when, where and for whom representation makes a difference. Fortunately, developments in law schools, the professions and a growing demand for evidence-driven policymaking provide support, infrastructure and incentive for such research. For these reasons, we urge legal services lawyers and clinical law professors to collaborate in an expansive, empirical research agenda

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Case Report of Optic Disc Drusen with Simultaneous Peripapillary Subretinal Hemorrhage and Central Retinal Vein Occlusion

A 52-year-old Chinese gentleman presented with right eye floaters and photopsia over one week. His visual acuities were 20/20 bilaterally. Posterior segment examination showed a right eye swollen optic disc and central retinal vein occlusion (CRVO) associated with an area of subretinal hemorrhage adjacent to the optic disc. Fundus fluorescein (FA) and indocyanine green angiographies (ICGA) of the right eye did not demonstrate choroidal neovascularization (CNV), polypoidal choroidal vasculopathy (PCV), or retinal ischemia. Ultrasound B-scan revealed optic disc drusen (ODD). In view of good vision and absence of CNV, he was managed conservatively with spontaneous resolution after two months. Commonly, ODD may directly compress and mechanically rupture subretinal vessels at the optic disc, resulting in peripapillary subretinal hemorrhage, as was likely the case in our patient. Mechanical impairment of peripapillary circulation also results in retinal ischemia and may trigger the development of choroidal neovascularization (CNV) and/or polypoidal choroidal vasculopathy (PCV), leading to subretinal haemorrhage. Compromise in central venous outflow with increased retinal central venous pressure from the direct mechanical effects of enlarging ODD results in central retinal vein occlusion (CRVO). Patients with subretinal hemorrhage and CRVO from ODD should be monitored closely for the development of potentially sight-threatening complications

Prognostic Factors for Visual Outcome in Traumatic Cataract Patients

. Purpose. To investigate the prognostic factors for visual outcome in traumatic cataract patients. Methods. The demographic features of traumatic cataract patients in Central China were studied. The factors that might influence the visual outcome were analyzed. The sensitivity and specificity of OTS (ocular trauma score) in predicting VA were calculated. Results. The study enrolled 480 cases. 65.5% of patients achieved VA at >20/60. The factors associated with the final VA were initial VA, injury type, wound location, the way of cataract removal, and IOL implantation. The sensitivities of OTS in predicting the VA at NLP (nonlight perception), LP/HM (light perception/hand motion), and ≥20/40 were 100%. The specificity of OTS to predict the final VA at 1/200-19/200 and 20/200-20/50 was 100%. Conclusion. The prognostic factors were initial VA, injury type, wound location, cataract removal procedure, and the way of IOL implantation. The OTS has good sensitivity and specificity in predicting visual outcome in traumatic cataract patients in long follow-up

Retinal Vessel Diameters and Their Relationship with Cardiovascular Risk and All-Cause Mortality in the Inter99 Eye Study: A 15-Year Follow-Up

properly cited. Purpose. To describe associations between retinal vessel diameters and cardiovascular risk markers and mortality. Methods. The present study included 908 persons aged 30 to 60 years. Vessel diameters were expressed as central retinal venular equivalent (CRVE) and central retinal arteriolar equivalent (CRAE). Multiple linear regression analyses and Cox regression models were used. Results. Multiple linear regression analyses showed that narrower CRAE was associated with higher systolic blood pressure, age, and higher HDL cholesterol, whereas wider CRAE and CRVE were associated with smoking. Narrower CRVE was associated with higher HDL cholesterol. In an age-adjusted model, associations between wider CRVE and risk of ischemic heart disease were found ( < 0.001). Wider CRVE was associated with all-cause mortality (HR = 2.02, = 0.033) in a model adjusted for age, gender, and blood pressure. However, the association was not statistically significant after additional adjustment for smoking. Conclusions. The associations between retinal vessel diameters and known cardiovascular risk factors were confirmed. All-cause mortality was not associated with retinal vessel diameters when adjusting for relevant confounders

Research resource: interplay between the genomic and transcriptional networks of androgen receptor and estrogen receptor alpha in luminal breast cancer cells

The cellular response to circulating sex steroids is more than the sum of individual hormone actions, instead representing an interplay between activities of the evolutionarily related steroid hormone receptors. An example of this interaction is in breast cancer, where the risk of dying from estrogen receptor-_ (ER_)-positive disease decreases approximately 4-fold when androgen receptor (AR) expression is high. In this study, we used chromatin immunoprecipitation sequencing (ChIP-seq) and microarray expression profiling to investigate the genomic and transcriptional cross talk between AR and ER_ signaling in a luminal breast cancer cell line model, ZR-75–1. Expression profiling demonstrated reciprocal interference between 5_-dihydrotestosterone (DHT)- and 17_-estradiol (E2)-induced transcriptional programs. Specifically, regulation of 26% of E2 and 15% of DHT target genes was significantly affected by cotreatment with the other hormone, in the majority of cases (78–83%) antagonistically. Pathway analysis suggested that DHT cotreatment, for example, depleted E2-regulated pathways in cell survival and proliferation. ChIP-seq identified substantial overlap between the steroid receptor cistromes in ZR-75–1 cells, with 10–13% of AR- and ER_-binding sites located within 10 kb of the other receptor. Enrichment of androgen response elements in ER_-binding sites and vice versa was revealed by motif analysis, and AR-binding sites were enriched about E2-responsive genes affected by DHT cotreatment. Targeted ChIP and expression analysis revealed locus-specific outcomes when AR and ER_ bind to the same DNA region. This work provides the first cistrome data for two steroid receptors in the same cell, insight into the antagonistic interplay between estrogens and androgens in luminal breast cancer, and an important resource for future work aimed at evaluating interrelated steroid receptors in different cellular systems.Eleanor F. Need, Luke A. Selth, Tiffany J. Harris, Stephen N. Birrell, Wayne D. Tilley and Grant Buchana