Practice and Procedure under Amended Rule 11 of the Federal Rules of Civil Procedure

The purpose of this article is to explore the substantive provisions of amended Rule 11 and its historic antecedents, the procedure by which sanctions may be sought and/or imposed, the sanctions which the court may impose and the persons upon whom the sanctions can be imposed

Some Practical Implications of Civil RICO Cases

Enacted as Title IX of the Organized Crime Control Act of 1970, the Racketeer Influenced and Corrupt Organizations Act (commonly known by the appellation RICO or The RICO Act ) was the end product of a lengthy legislative effort to develop new legal remedies to deal with the problem of organized crime. In recent years, however, the statute has become the focus of controversy as plaintiffs, compelled by the possibility of winning treble damages and attorney\u27s fees, have sought to apply the civil remedies provision of the Act to all types of cases, including those involving what might be termed garden variety business fraud. The civil damages provision of the RICO Act has been the subject of much legal commentary. Unfortunately, previous articles have generally provided the practitioner with little guidance regarding some of the practical aspects of civil RICO litigation, i.e., how to determine when your client has a civil RICO claim, where and when to file the action and, most importantly, how (and hopefully how not) to try a civil RICO case. The purpose of this article is to set forth some approaches to these practical problems

Practice and Procedure under Amended Rule 11 of the Federal Rules of Civil Procedure

The purpose of this article is to explore the substantive provisions of amended Rule 11 and its historic antecedents, the procedure by which sanctions may be sought and/or imposed, the sanctions which the court may impose and the persons upon whom the sanctions can be imposed

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Some Practical Implications of Civil RICO Cases

Enacted as Title IX of the Organized Crime Control Act of 1970, the Racketeer Influenced and Corrupt Organizations Act (commonly known by the appellation RICO or The RICO Act ) was the end product of a lengthy legislative effort to develop new legal remedies to deal with the problem of organized crime. In recent years, however, the statute has become the focus of controversy as plaintiffs, compelled by the possibility of winning treble damages and attorney\u27s fees, have sought to apply the civil remedies provision of the Act to all types of cases, including those involving what might be termed garden variety business fraud. The civil damages provision of the RICO Act has been the subject of much legal commentary. Unfortunately, previous articles have generally provided the practitioner with little guidance regarding some of the practical aspects of civil RICO litigation, i.e., how to determine when your client has a civil RICO claim, where and when to file the action and, most importantly, how (and hopefully how not) to try a civil RICO case. The purpose of this article is to set forth some approaches to these practical problems

Arctic Permafrost Thawing Enhances Sulfide Oxidation

Permafrost degradation is altering biogeochemical processes throughout the Arctic. Thaw-induced changes in organic matter transformations and mineral weathering reactions are impacting fluxes of inorganic carbon (IC) and alkalinity (ALK) in Arctic rivers. However, the net impact of these changing fluxes on the concentration of carbon dioxide in the atmosphere (pCO2) is relatively unconstrained. Resolving this uncertainty is important as thaw-driven changes in the fluxes of IC and ALK could produce feedbacks in the global carbon cycle. Enhanced production of sulfuric acid through sulfide oxidation is particularly poorly quantified despite its potential to remove ALK from the ocean-atmosphere system and increase pCO2, producing a positive feedback leading to more warming and permafrost degradation. In this work, we quantified weathering in the Koyukuk River, a major tributary of the Yukon River draining discontinuous permafrost in central Alaska, based on water and sediment samples collected near the village of Huslia in summer 2018. Using measurements of major ion abundances and sulfate (SO42-) sulfur (34S/32S) and oxygen (18O/16O) isotope ratios, we employed the MEANDIR inversion model to quantify the relative importance of a suite of weathering processes and their net impact on pCO2. Calculations found that approximately 80% of SO42- in mainstem samples derived from sulfide oxidation with the remainder from evaporite dissolution. Moreover, 34S/32S ratios, 13C/12C ratios of dissolved IC, and sulfur X-ray absorption spectra of mainstem, secondary channel, and floodplain pore fluid and sediment samples revealed modest degrees of microbial sulfate reduction within the floodplain. Weathering fluxes of ALK and IC result in lower values of pCO2 over timescales shorter than carbonate compensation (∼104 yr) and, for mainstem samples, higher values of pCO2 over timescales longer than carbonate compensation but shorter than the residence time of marine SO42- (∼107 yr). Furthermore, the absolute concentrations of SO42- and Mg2+ in the Koyukuk River, as well as the ratios of SO42- and Mg2+ to other dissolved weathering products, have increased over the past 50 years. Through analogy to similar trends in the Yukon River, we interpret these changes as reflecting enhanced sulfide oxidation due to ongoing exposure of previously frozen sediment and changes in the contributions of shallow and deep flow paths to the active channel. Overall, these findings confirm that sulfide oxidation is a substantial outcome of permafrost degradation and that the sulfur cycle responds to permafrost thaw with a timescale-dependent feedback on warming