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Building on the field of critial race theory, which took a theoretical approach to questions of race and the law, this book offers a practical look at the way racial bias plays out at every level of the legal system, from witness identification and jury selection to prosecutorial behaviour and defence decisions.

Prior studies have used vital signs and laboratory measurements with conventional modeling techniques to predict acute kidney injury (AKI). The purpose of this study was to use the trend in vital signs and laboratory measurements with machine learning algorithms for predicting AKI in ICU patients. The eICU Collaborative Research Database was queried for five consecutive days of laboratory measurements per patient. Patients with AKI were identified and trends in vital signs and laboratory values were determined by calculating the slope of the least-squares-fit linear equation using three days for each value. Different machine learning classifiers (gradient boosted trees [GBT], logistic regression, and deep learning) were trained to predict AKI using the laboratory values, vital signs, and slopes. There were 151,098 ICU stays identified and the rate of AKI was 5.6 per cent. The best performing algorithm was GBT with an AUC of 0.834 ± 0.006 and an F-measure of 42.96 per cent ± 1.26 per cent. Logistic regression performed with an AUC of 0.827 ± 0.004 and an F-measure of 28.29 per cent ± 1.01 per cent. Deep learning performed with an AUC of 0.817 ± 0.005 and an F-measure of 42.89 per cent ± 0.91 per cent. The most important variable for GBT was the slope of the minimum creatinine (30.32%). This study identifies the best performing machine learning algorithms for predicting AKI using trends in laboratory values in ICU patients. Early identification of these patients using readily available data indicates that incorporating machine learning predictive models into electronic medical record systems is an inevitable requisite for improving patient outcomes.

Control over cell engraftment, survival, and function remains critical for heart repair. We have established a tissue engineering platform for the delivery of human mesenchymal progenitor cells (MPCs) by a fully biological composite scaffold. Specifically, we developed a method for complete decellularization of human myocardium that leaves intact most elements of the extracellular matrix, as well as the underlying mechanical properties. A cell-matrix composite was constructed by applying fibrin hydrogel with suspended cells onto decellularized sheets of human myocardium. We then implanted this composite onto the infarct bed in a nude rat model of cardiac infarction. We next characterized the myogenic and vasculogenic potential of immunoselected human MPCs and demonstrated that in vitro conditioning with a low concentration of TGF-β promoted an arteriogenic profile of gene expression. When implanted by composite scaffold, preconditioned MPCs greatly enhanced vascular network formation in the infarct bed by mechanisms involving the secretion of paracrine factors, such as SDF-1, and the migration of MPCs into ischemic myocardium, but not normal myocardium. Echocardiography demonstrated the recovery of baseline levels of left ventricular systolic dimensions and contractility when MPCs were delivered via composite scaffold. This adaptable platform could be readily extended to the delivery of other reparative cells of interest and used in quantitative studies of heart repair.

Emergent surgical conditions are common in geriatric patients, often necessitating major operative procedures on frail patients. Understanding risk profiles is crucial for decision-making and establishing goals of care. We queried NSQIP 2015–2019 for patients ≥65 years undergoing open abdominal surgery for emergency general surgery conditions. Logistic regression was used to identify 30-day mortality predictors. Of 41,029 patients, 5589 (13.6 ​%) died within 30 days of admission. The highest predictors of mortality were ASA status 5 (aOR 9.7, 95 ​% CI,3.5–26.8, p ​< ​0.001), septic shock (aOR 4.9, 95 ​% CI,4.5–5.4, p ​< ​0.001), and dialysis (aOR 2.1, 95 ​% CI,1.8–2.4, p ​< ​0.001). Without risk factors, mortality rates were 11.9 ​% after colectomy and 10.2 ​% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4 ​% and 100 ​% following colectomy and small bowel resection, respectively. In older adults undergoing emergent open abdominal surgery, septic shock, ASA status, and dialysis were strongly associated with futility of surgical intervention. These findings can inform goals of care and informed decision-making. •In older adults undergoing emergency general surgery, establishing goals of care remains a challenge.•Certain preoperative variables disproportionately impact mortality.•Septic shock, an ASA status of 5, and dialysis can raise mortality by up to 80 ​%.•Colectomy, small bowel resection, and peptic ulcer repair are strongly associated with the highest mortality.•These findings can help tailor the goals of care and decision-making.

Background The use of emergency tourniquets among military personnel has helped to dramatically reduce battlefield deaths and has recently gained popularity in the civilian sector. Yet, even well-trained individuals can find it difficult to assess proper tourniquet application. Emergency tourniquets are typically deemed sufficiently tightened through cursory visual confirmation or pulse assessment. These indicators are not always accurate and are difficult to assess during chaotic events where fast and effective tourniquet application by both trained and untrained personnel can contribute significantly to saving lives. Towards addressing these issues, we have developed the Tourniquet Integrated Monitor (TiMON) as an easy-to-use real-time pressure sensing device designed to seamlessly integrate with pre-existing emergency tourniquets. Here, we present the results of two studies in which the TiMON was tested among a group of soldiers participating in the Army Expeditionary Warrior Experiments (AEWE) as well as in a group of untrained civilians from Massachusetts General Hospital. Methods In the first study, 30 soldiers with prior tourniqueting experience were asked to apply a TiMON equipped CAT tourniquet onto a leg mannequin with (unblinded) and without (blinded) assistance from the TiMON’s output. In the second study, 30 lay volunteers from Massachusetts General Hospital with no prior tourniquet training were recruited and taught how to apply a tourniquet under normal conditions prior to being asked to perform the same exercises as the soldiers. In both studies, data collected for statistical analysis consisted of the real-time applied pressure along with the elapsed time for each subject to finish applying the emergency tourniquet. Results Subjects in both groups utilizing the TiMON had greater success in applying emergency tourniquets at the civilian clinically recommended occlusion range of 180 to 300 mmHg (soldiers: 86.67% assisted vs 33.33% unassisted; untrained volunteers: 93.33% assisted vs 40.00% unassisted). In terms of applied pressure, no significant mean differences were observed in either group (soldiers p -value = 0.13; untrained volunteers p -value = 0.26), however the unblinded subjects were found to exhibit significantly lower variances in applied pressure compared to those who were blinded (soldiers p -value < 0.0001; untrained volunteers p -value < 0.0001). In terms of application speeds, no significant differences in means and variances were observed in the soldiers ( p -values = 0.85 and 0.61, respectively), while mildly significant increases in application times were observed in the untrained volunteers ( p -value = 0.036). Conclusion Trained soldiers and lay volunteers using the TiMON were able to consistently apply tourniquets at clinically recommended occlusion pressures between 180 and 300 mmHg with significantly less under and over tightening while minimizing any negative effects to their application speeds. Despite it being their first time using the TiMON, both groups were able to quickly apply emergency tourniquets at significantly improved and consistent success rates regardless of prior training and experience.

Introduction: English proficiency and race are both independently known to affect surgical access and quality, but relatively little is known about the impact of race and limited English proficiency (LEP) on admission for emergency surgery from the emergency department (ED). Our objective was to examine the influence of race and English proficiency on admission for emergency surgery from the ED. Methods: We conducted a retrospective observational cohort study from January 1–December 31, 2019 at a large, quaternary-care urban, academic medical center with a 66-bed ED Level I trauma and burn center. We included ED patients of all self-reported races reporting a preferred language other than English and requiring an interpreter or declaring English as their preferred language (control group). A multivariable logistic regression was fit to assess the association of LEP status, race, age, gender, method of arrival to the ED, insurance status, and the interaction between LEP status and race with admission for surgery from the ED. Results: A total of 85,899 patients (48.1% female) were included in this analysis, of whom 3,179 (3.7%) were admitted for emergent surgery. Regardless of LEP status, patients identifying as Black (odds ratio [OR] 0.456, 95% CI 0.388-0.533; P<0.005), Asian [OR 0.759, 95% CI 0.612-0.929]; P=0.009), or female [OR 0.926, 95% CI 0.862-0.996]; P=0.04) had significantly lower odds for admission for surgery from the ED compared to White patients. Compared to individuals on Medicare, those with private insurance [OR 1.25, 95% CI 1.13-1.39; P <0.005) were significantly more likely to be admitted for emergent surgery, whereas those without insurance [OR 0.581, 95% CI 0.323-0.958; P=0.05) were significantly less likely to be admitted for emergent surgery. There was no significant difference in odds of admission for surgery between LEP vs non-LEP patients. Conclusion: Individuals without health insurance and those identifying as female, Black, or Asian had significantly lower odds of admission for surgery from the ED compared to those with health insurance, males, and those self-identifying as White, respectively. Future studies should assess the reasons underpinning this finding to elucidate impact on patient outcomes.

Background: Affiliations between community and academic hospitals are increasing. However, their impact on transfer practices remains under-characterized. Objectives: To understand the impacts of hospital affiliation on transfer practices and hospital resource utilization. Design: Retrospective cohort study. Methods: We included patients ⩾18 years who were transferred from a 178-bed community hospital to a tertiary academic hospital between January 2015 to December 2019. Interrupted time series analysis was used to evaluate changes in outcomes after the affiliation in January 2017. Our primary outcome was the change in quarterly rate of early discharge (discharge within 48 hours post-transfer). Secondary outcomes included change in quarterly proportions of low-income patients, patients residing at a far distance from the hospital, and ICU admissions. We performed a sub-analysis in patients transferred to a surgical specialty that evaluated the tri-annual rate of operative management (surgical or interventional radiology procedure performed <72 hours after admission). Results: Among 144 included patients, 93 (64.6%) were transferred post-affiliation and 63 (43.1%) were transferred to a surgical specialty. No significant trends were seen across outcomes in the pre-affiliation period. Relative to the former period, there was a quarterly decrease in early discharge rates (P = .027) and a quarterly increase in the percentage of patients residing at a long distance from the transferring hospital (P = .027) after affiliation. There was also a relative tri-annual decrease in the rate of operative management (P = .039). Conclusion: Post-affiliation, the volume of transfers and utilization of resources at the receiving hospital increased. The percentage of transfer patients residing farther from the transferring hospital also increased.

BackgroundThe education of civilians and first responders in prehospital tourniquet (PT) utilization has spread rapidly. We aimed to describe trends in emergency medical services (EMS) and non-EMS PT utilization, and their ability to identify proper clinical indications and to appropriately apply tourniquets in the field.MethodsA retrospective cohort study was conducted to evaluate all adult patients with PTs who presented at two Level I trauma centers between January 2015 and December 2019. Data were collected via an electronic patient query tool and cross-referenced with institutional Trauma Registries. Medically trained abstractors determined if PTs were clinically indicated (limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). PTs were further designated as appropriately or inappropriately applied (based on tourniquet location, venous tourniquet, greater than 2-h ischemic time). Descriptive statistics and univariate analyses were performed.Results146 patients met inclusion criteria. The incidence of yearly PT placements increased between 2015 and 2019, with an increase in placement by non-EMS personnel (police, firefighter, bystander, and patient). Improvised PTs were frequently utilized by bystanders and patients, whereas first responders had high rates of commercial tourniquet use. A high proportion of tourniquets were placed without indication (72/146, 49%); however, the proportion of PTs placed without a proper indication across applier groups was not statistically different (p = 0.99). Rates of inappropriately applied PTs ranged from 21 to 46% across all groups applying PTs.ConclusionsPT placement was increasingly performed by non-EMS personnel. Present data indicate that non-EMS persons applied PTs at a similar performance level of those applied by EMS.Study LevelLevel III

Purpose This study aims to identify predictors of discharge to post-acute care in geriatric emergency general surgery (EGS) patients. Methods This is a retrospective study of geriatric emergency general surgery (EGS) patients at a tertiary care facility between 2017 and 2018. Inclusion criteria were ≥ 65 years old and presented directly from home. Non-survivors or those admitted from a healthcare facility were excluded. The primary outcome was discharge to home versus post-acute care. Results Out of 577 patients, the median age was 74, and 36.9% were discharged to a post-acute care facility. Factors predicting discharge to post-acute care were: mobility aid use (1.92, [1.19–3.11], p = 0.008), cerebrovascular accident (4.67, [1.99–10.94], p < 0.001), delirium (11.06, [2.29–53.43], p = 0.003), pre-operative transfusion (2.39, [1.13–5.08], p = 0.023), fall history (3.74, [1.90–7.36], p < 0.001), AKI (5.42, [2.61–11.25], p < 0.001), and lack of capacity to consent (4.11, [2.10–8.02], p < 0.001). Non-operative management was protective against discharge to post-acute care (0.38, [0.24–0.60], p < 0.001). Conclusion Early recognition of the role of these factors in influencing discharge disposition may help with clinical decision-making and discharge planning.

The performance of the Emergency Surgery Score (ESS), a validated risk calculator, in the elderly emergency general surgery (EGS) patient remains unclear. We hypothesized that ESS accurately predicts outcomes in elderly EGS patients, including octogenarians and nonagenarians. Using the 2007–2017 National Surgical Quality Improvement Program (NSQIP) database, we included all EGS patients ≥65 years old. The correlation between ESS, mortality and morbidity was assessed in the 3 patient cohorts (>65, octogenarians and nonagenarians), using the area under the curve (AUC). A total of 124,335 patients were included, of which 34,215 (28%) were octogenarians and 7239 (6%) were nonagenarians. In patients ≥65 years, ESS accurately predicted mortality (AUC 0.81). For octogenarians and nonagenarians, ESS predicted mortality moderately well (AUC 0.77 and 0.69, respectively. ESS accurately predicts mortality and morbidity in the elderly EGS patient, but its accuracy in predicting morbidity decreases for nonagenarians. •The predictive ability of the Emergency Surgery Score (ESS) in the elderly population is unknown.•ESS accurately predicts mortality in EGS patients ≥65 years (AUC 0.81).•ESS predicted mortality moderately well in octogenarians (AUC 0.77) and nonagenarians (AUC 0.69). The Emergency Surgery Score is a well-established risk calculator for emergency general surgery (EGS) patients, but its predictive ability in the elderly population is unknown. ESS accurately predicting mortality in EGS patients ≥65 years (AUC 0.81) and moderately-well in octogenarians (AUC 0.77) and nonagenarians (AUC 0.69).