Stepification

Multistep tests pervade the law to the point that they appear to be a fundamental feature of legal reasoning. Famous doctrines such as Chevron or qualified immunity take this form, as do more obscure doctrinal formulas. But surprisingly, these doctrinal formulations as a class are relatively new. The reality is that the intellectual moment that gave rise to Chevron was one in which multiple older doctrines that relied on multifactor balancing were replaced by new tests formulated as multistep inquiries in which each step was a discrete inquiry. This Article provides the first historical and normative account of this phenomenon—which I refer to as “stepification.” It charts both the rise of the new multistep tests as well as the intellectual climate that gave birth to these formulations, offering a theory of why courts chose to reorganize the law in this way at the time they did. Additionally, it argues that there are transsubstantive normative advantages and disadvantages to this mode of organizing doctrine, and it offers an accounting of the implications of historical stepification. In doing so, this Article aims to shed light on a historical phenomenon and on trends in modern legal disputes (such as recent cases over partisan gerrymandering and the future of Auer) that illustrate the work that stepification continues to do within our legal culture

Incidental Finding of Benign Multicystic Peritoneal Mesothelioma: A Case Report

Introduction: Benign multicystic peritoneal mesothelioma represents a rare benign variant of peritoneal mesothelioma, with fewer than 150 cases reported to date. Malignant transformation may occur. We present a patient with an incidental finding of an intra-abdominal mass consistent with benign multicystic peritoneal mesothelioma.Case presentation: A 51 year-old male presented to the ED with traumatic injuries. During workup, calcified cystic lesions in the pelvis were incidentally noted. Final pathology favored a diagnosis of benign multicystic mesothelioma of the peritoneum. Follow-up imaging obtained three months post-operatively revealed no evidence of recurrent or metastatic disease.Conclusion: Multicystic peritoneal mesothelioma has been identified as a distinct subtype of peritoneal mesothelioma, with long-term survival achievable through the use of cytoreductive surgery and HIPEC. Although prognosis is relatively favorable, recurrence rates are high, with low potential for malignant transformation. Post-operative surveillance with routine imaging is warranted

Racial disparities in presenting stage and surgical management among octogenarians with breast cancer: a national cancer database analysis.

BACKGROUND: As the US faces a diverse aging population, racial disparities in breast cancer outcomes among elderly patients remain poorly understood. We evaluate the association of race with presenting stage, treatment, and survival of invasive breast cancer among octogenarians. METHODS: Women (≥ 80 years) with invasive breast cancer were identified in 2004-2020 NCDB. To facilitate comparison, only non-Hispanic Black and non-Hispanic White patients were included; patients of Hispanic ethnicity were excluded. Demographics, tumor characteristics, and treatments were assessed by race. Overall survival was compared using the logrank test. Multivariable logistic and Cox proportional hazard regression models were developed to evaluate the independent association of race with outcomes of interest. RESULTS: Of 222,897 patients, 19,059 (8.6%) were Black. Most patients had stage I ER + HER2- invasive ductal carcinoma. Black patients more frequently had greater comorbidities, low income and education, and advanced stage (p < 0.001 each; ref: White). Following adjustment, Black women had increased likelihood of Stage III/IV over time, as well as increased odds of chemotherapy (AOR 1.22, 95% CI 1.15 - 1.29) and non-operative management (AOR 1.82, 95% CI 1.72 - 1.92; ref: White). Although Black patients had lower survival rates compared to White, race was not associated with 5-year mortality following adjustment for stage, receipt of surgery, and adjuvant treatments (p = 0.34). CONCLUSIONS: Inferior survival among elderly Black patients appears be driven by advanced stage at presentation. While such disparities are narrowing in the present era, future work must consider upstream interventions to ensure equitable outcomes for all races

Disparities in outcomes of colorectal cancer surgery among adults with intellectual and developmental disabilities.

BACKGROUND: Disparities in colorectal cancer screening have been documented among people with intellectual and developmental disabilities (IDD). However, surgical outcomes in this population have yet to be studied. The present work aimed to evaluate the association of IDD with outcomes following colorectal cancer resection. METHODS: All adults undergoing resection for colorectal cancer in the 2011-2020 National Inpatient Sample were identified. Multivariable linear and logistic regression models were developed to examine the association of IDD with risk factors as well as outcomes including mortality, complications, costs, length of stay (LOS), and non-home discharge. The study is limited by its retrospective nature and did not capture disease staging or time of diagnosis. RESULTS: Among 722,736 patients undergoing colorectal cancer resection, 2,846 (0.39%) had IDD. Compared to patients without IDD, IDD patients were younger and had a higher burden of comorbidities. IDD status was associated with increased odds of non-elective admission (AOR 1.40 [95% CI 1.14-1.73]) and decreased odds of treatment at high-volume centers (AOR 0.64 [95% CI 0.51-0.81]). Furthermore, IDD patients experienced significantly greater LOS (9 vs 6 days, p<0.001) and hospitalization costs ($23,500 vs$19,800, p<0.001) relative to neurotypical patients. Upon risk adjustment, IDD was significantly associated with 2-fold increased odds of mortality (AOR 2.34 [95% CI 1.48-3.71]), 1.4-fold increase in complications (AOR 1.41 [95% CI 1.15-1.74]), and 6.8-fold increase in non-home discharge (AOR 6.83 [95% CI 5.46-8.56]). CONCLUSIONS: IDD patients undergoing colorectal cancer resection experience increased likelihood of non-elective admission, adverse clinical outcomes, and resource use. Our findings highlight the need for more accessible screening and patient-centered interventions to improve quality of surgical care for this at-risk population

Examining safety of cardiac surgery in patients with preoperative cardiac arrest.

BACKGROUND: Although postoperative cardiac arrest is a well-studied complication of cardiac surgery, few guidelines exist regarding timing of surgery in preoperative cardiac arrest (pCA). We examined the association between delayed timing of operation and postoperative outcomes following cardiac surgery in a large cohort of pCA. METHODS: Adults with a diagnosis of pCA undergoing a cardiac operation were identified in the 2016-2020 National Inpatient Sample. Those requiring surgery within 24 hours fo cardiac arrest were excluded. Patients who underwent a cardiac procedure after 5 days of cardiopulmonary resuscitation were classified as Delayed (others: Early). Multivariable regression models were constructed to evaluate associations between delayed timing of surgery with in-hospital mortality, postoperative complications, hospitalization duration, and costs. RESULTS: Of an estimated 9,240 patients meeting study criteria, 4,860 (52.6%) received delayed cardiac surgery. Following entropy balancing, delayed surgery was significantly associated with decreased odds of in-hospital mortality (Adjusted Odds Ratio [AOR] 0.75, 95% Confidence Interval [CI] 0.58 - 0.97). However, delayed operation demonstrated greater odds of postoperative thromboembolic (AOR 1.44, 95% CI 1.02 - 2.04), and infectious (AOR 1.65, 95% CI 1.31 - 2.08) complications. Notably, delay did not alter odds of neurologic complication, and was linked to a decrement in per-day costs (β -$2,100, 95% CI -2,600 - -1,700). CONCLUSIONS: While preoperative cardiac arrest remains challenging, the present study demonstrates the safety profile of delaying cardiac operation among patients tolerating at least 24 hours of a delay to surgery. Future studies are needed to elucidate the factors associated with favorable outcomes in this population

Outcomes in REBOA by Sex: Results From the American Association of Surgery for Trauma (AAST) Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) Trial

Background: Female patients have smaller diameter femoral vessels than men and higher rates of procedural complications for elective vascular surgeries. We investigated sex differences in REBOA outcomes including vascular access complications. Methods: Retrospective data query from the AORTA database for 779 patients who underwent REBOA from 2013 to 2023. Demographics, physiology, and outcomes were examined. Univariable and multivariate analyses were performed. Results: Among 779 patients who received REBOA, 22.6% (n=176) were female, and the mean age was 43.0 (+/-18.0) years. The mean Injury Severity Score (ISS) was 34.0 (±15.0). The mean admission Glasgow Coma Scale (GCS) was 8.2 (±5.3) and systolic blood pressure (SBP) at the time of aortic occlusion (AO) was 66.0 (±33.7) mmHg. Female patients were more likely to sustain blunt trauma (91.1% vs. 74.9%; p<0.001) and had marginally higher ISS (36.5 [±15.7] vs. 33.3 [±14.7]; p=0.06). Female patients had lower GCS at admission (7.3 [±5.1] vs. 8.4 [±5.3]; p=0.019). There were no significant differences in vascular complications including pseudoaneurysm, hematoma, traumatic AV fistula, or distal embolism. Acute kidney injury was more common among males (29.4% vs. 13.6%; p<0.001). Hospital length of stay did not differ significantly (15.6 [±18.3] vs. 18.7 [±24.6] days; p=0.43). There was no difference in hospital mortality (52.3% vs. 47.1%) after accounting for clinical factors in the multivariable regression model (adjusted OR 1.07; 95% CI 0.66-1.73; p=0.78). Discussion: Patients who receive REBOA are critically ill. Female patients who receive REBOA do not have significantly more access-related complications than male patients

Characterization of 111In3+ complexes of DTPA amide derivatives: biodistribution and clearance studied by gamma imaging

A large series of structurally related diethylenetriaminepentaacetic acid amide derivatives with different structures and lipophilic properties were synthesized and radiolabeled with 111In3+. Two of the more hydrophobic compounds studied ([111In]L9 and [111In]L10) showed high affinity for human serum albumin (HSA). The biodistribution and clearance properties shown by all complexes upon injection in Wistar rats were followed by gamma imaging. The blood retention time of the chelates correlates better with their binding to HSA than with their hydrophilic/lipophilic ratio. Hydrophilic and negatively charged complexes undergo renal retention, while the majority of the lipophilic complexes are retained in the blood for a longer period of time and are cleared through the liver.http://www.sciencedirect.com/science/article/B6T9Y-43X3775-F/1/b025cc67d43a82f7dead68ec99e0f4b

Structural and in vivo studies of metal chelates of Ga(III) relevant to biomedical imaging

The solution chemistry and structure of the complex of the triazamacrocyclic ligand NOTP (1,4,7-triazacyclononane-1,4,7-tris(methylenephosphonate)) with Ga3+ in D2O have been investigated by 1H, 71Ga and 31P NMR spectroscopy. These NMR results show the presence of a 1:1 Ga(NOTP)3- complex, with a highly symmetrical, pseudo-octahedral geometry, possibly with a C3 axis. The 1H spectrum shows that the triazamacrocyclic chelate ring is very rigid, with all the ring protons non-equivalent. The complex is stable in aqueous solution in a wide pH range. Its high thermodynamic stability agrees well with previous results from biodistribution and [gamma] imaging studies in Wistar rats with 67Ga3+ chelates of triaza macrocyclic ligands, which showed that the neutral chelates 67Ga(NOTA) (where NOTA is 1,4,7-triazacyclononane-1,4,7-triacetate) and 67Ga(NOTPME) (where NOTPME is 1,4,7-triazacyclononane-1,4,7-tris(methylenephosphonate monoethylester)) have similar in vivo behaviour, with high stability and rapid renal excretion, but the high negatively charged 67Ga(NOTP)3- has a considerably slower kidney uptake and elimination.http://www.sciencedirect.com/science/article/B6TGG-40X8D8M-26/1/b0839261f5ddd424e05a2da9204295a