California v. Texas: Avoiding an Antidemocratic Outcome.

The Affordable Care Act ("ACA") contains a section titled "Requirement to Maintain Essential Minimum Coverage." Colloquially known as the Individual Mandate, this section of the Act initially established a monetary penalty for anyone who did not maintain health insurance in a given tax year. But with the passage of the Tax Cuts and Jobs Act, the monetary penalty was reset to zero, inducing opponents of the ACA to mount a legal challenge over the Individual Mandate's constitutionality. As the third major legal challenge to the ACA, California v. Texas saw the Supreme Court punt on the merits and instead decide the case on grounds of Article III standing. But how would the ACA have fared if the Court had in fact reached the merits? Did resetting the Individual Mandate penalty to zero uncloak the provision from the saving construction of Nat'l Fed'n of Indep. Bus. v. Sebelius? This Note posits that, had the Court reached the merits, it would have found the Individual Mandate no longer met the requirements for classification as a tax under the rule relied on in NFIB. Moreover, it argues that the Court would have found the unconstitutional provision to be inseverable from the ACA insofar as it was integral to funding both the novel structure of the reformed healthcare system and the prohibition against insurance carriers denying coverage due to a pre-existing condition. This examination ultimately reveals that an outright repeal of the ACA would have been antidemocratic in the face of current consensus opinion that favors the reform and highlights the impact its abrogation would have had.

Timing of surgical repair and resource utilisation in infants with complete atrioventricular septal defect.

INTRODUCTION: Variation exists in the timing of surgery for balanced complete atrioventricular septal defect repair. We sought to explore associations between timing of repair and resource utilisation and clinical outcomes in the first year of life. METHODS: In this retrospective single-centre cohort study, we included patients who underwent complete atrioventricular septal defect repair between 2005 and 2019. Patients with left or right ventricular outflow tract obstruction and major non-cardiac comorbidities (except trisomy 21) were excluded. The primary outcome was days alive and out of the hospital in the first year of life. RESULTS: Included were 79 infants, divided into tertiles based on age at surgery (1st = 46 to 137 days, 2nd = 140 - 176 days, 3rd = 178 - 316 days). There were no significant differences among age tertiles for days alive and out of the hospital in the first year of life by univariable analysis (tertile 1, median 351 days; tertile 2, 348 days; tertile 3, 354 days; p = 0.22). No patients died. Fewer post-operative ICU days were used in the oldest tertile relative to the youngest, but days of mechanical ventilation and hospitalisation were similar. Clinical outcomes after repair and resource utilisation in the first year of life were similar for unplanned cardiac reinterventions, outpatient cardiology clinic visits, and weight-for-age z-score at 1 year. CONCLUSIONS: Age at complete atrioventricular septal defect repair is not associated with important differences in clinical outcomes or resource utilisation in the first year of life.

Asphyxiation due to dry ice in a walk-in freezer.

BACKGROUND: Exposure to a high concentration of environmental carbon dioxide (CO2) can result in poisoning through direct toxicity and by displacing atmospheric oxygen (O2). Dry ice undergoes sublimation to a gaseous state at -78.5 degrees C (-109.3 degrees F), which is heavier than air and can accumulate in dependent areas. CASE REPORT: We report the case of a 59-year-old man found in cardiac arrest shortly after entering a recently repaired walk-in freezer that contained dry ice. First responders and bystanders did not recognize the proximate hazardous environment but were fortunately uninjured. A careful Emergency Department history coupled with rapid case investigation by the Medical Examiner's Office led to the determination of the cause of death and the elimination of the ongoing hazard. CONCLUSION: This case illustrates the lethal consequences of improper storage of dry ice and the need to consider toxic environmental exposure as a cause of sudden cardiac arrest.

Feasibility and utility of three-dimensional color flow echocardiography of the aortic arch: The "echocardiographic angiogram".

Two-dimensional transthoracic echocardiography (2DE) is the most commonly used diagnostic modality to evaluate congenital and acquired abnormalities of the aortic arch. However, 2DE is frequently limited in this ability due to the three-dimensional character of the arch and its interrelationships with other vascular structures. Recently, three-dimensional echocardiography (3DE) with 3D color flow Doppler became commercially available. We examined the feasibility and utility of 3DE with 3D color Doppler in the evaluation of patients with congenital (native and postoperative) abnormalities of the aortic arch. We found that 3DE color flow provides important diagnostic information in patients with aortic arch anomalies, in a manner that is quick and user-friendly. In addition, 17 of the 26 patients had their 3DE findings confirmed by additional modalities, providing reasonably significant validation for our findings with 3DE.

Right ventricular outflow tract stent as a bridge to surgery in a premature infant with tetralogy of Fallot.

Despite dramatic progress in neonatal cardiac surgery, prematurity and low birth weight remain risk factors for poor outcome. Attempts to delay intervention with supportive therapy have been shown to increase morbidity and mortality. We present a case of an 840 gram, 28-week gestation newborn with tetralogy of Fallot, in whom palliation was achieved with a right ventricular outflow tract stent. This management allowed subsequent successful complete repair.

Characteristics of the interatrial communication in patients undergoing transcatheter device closure of atrial septal defects for cryptogenic stroke.

BACKGROUND: Prior studies suggest that patent foramen ovale (PFO) diameter >4 mm is associated with a high probability of cryptogenic ischemic stroke (CIS). METHODS: We evaluated all patients diagnosed with CIS who underwent closure of intra-atrial communication (IAC) using the Amplatzer atrial septal defect (ASD) occluder in our institution between August 1997 and March 2004. For each IAC, echocardiographic diameters and balloon-stretched diameters were recorded. Stretchability index was calculated as the ratio of stretched diameter to unstretched diameter. RESULTS: Fifty-six patients met the inclusion criteria for this study. There was an inverse logarithmic relationship between unstretched IAC diameter and stretchability index. For the 28 smaller defects, the median IAC diameter was 2 mm, and median stretchability index was 5.58 (range 2.6-15). For the 28 larger defects, median diameter was 6 mm, and median stretchability index was 2.38 (range 1.05-5). The difference in stretchability index between the two groups was significant (P < 0.0001). CONCLUSION: Our data bring into question the concept that the diameter of the defect would singularly predict the probability of stroke.