Are Rule 26(c) Protective Orders Viable Against Grand Juries? The Ninth Circuit Rejects Balancing Test in Favor of a per se Rule: United States v. Janet Greeson\u27s A Place for Us (in re Grand Jury Subpoena Served on Meserve)

This comment compares the Fourth, Eleventh, and Ninth Circuits\u27 per se rule with the Second Circuit\u27s balancing approach. It concludes that the courts adopting the per se rule made unwarranted findings by overstating the reach of protective orders by construing them as improper de facto grants of immunity. The courts also understated the retained power of a grand jury by declining to recognize that even when a protective order exists, a grand jury can still call witnesses, have a court compel testimony, or use leaked information for prosecution even though it is sealed.s Further, these courts could have applied a balancing approach without experiencing the problems they suggest such an approach creates

Are Rule 26(c) Protective Orders Viable Against Grand Juries? The Ninth Circuit Rejects Balancing Test in Favor of a per se Rule: United States v. Janet Greeson\u27s A Place for Us (in re Grand Jury Subpoena Served on Meserve)

This comment compares the Fourth, Eleventh, and Ninth Circuits\u27 per se rule with the Second Circuit\u27s balancing approach. It concludes that the courts adopting the per se rule made unwarranted findings by overstating the reach of protective orders by construing them as improper de facto grants of immunity. The courts also understated the retained power of a grand jury by declining to recognize that even when a protective order exists, a grand jury can still call witnesses, have a court compel testimony, or use leaked information for prosecution even though it is sealed.s Further, these courts could have applied a balancing approach without experiencing the problems they suggest such an approach creates

A Retrospective Comparison of Daptomycin Thrice-Weekly Versus Q48H Dosing in Hemodialysis Patients with Vancomycin-Resistant Enterococcus (VRE) or Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia

Background. Multi-drug resistant bacteria are a growing concern in healthcare. Daptomycin is being used with increasing frequency in the treatment of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) bacteremias in hemodialysis (HD) patients. Thrice-weekly dosing of daptomycin in this population would allow for coordination of dosing with common outpatient HD schedules. The aim of this study is to determine if thrice-weekly dosing of daptomycin is equivalent to dosing every 48 hours in patients receiving chronic intermittent hemodialysis. Equivalence will be assessed with regard to microbiological cure, clinical cure, hospital length of stay, and mortality. Methods. All patients with positive blood cultures who received at least one dose of daptomycin between January 1st 2009 and December 31st 2010 at Indiana University Health Methodist and University Hospitals were identified. Adult patients with end-stage renal disease on a stable thrice-weekly hemodialysis regimen, confirmed VRE or MRSA bacteremia, and at least three doses of inpatient daptomycin therapy were enrolled in the study. Results. Twelve patients met criteria for inclusion in this study. Nine received daptomycin every 48 hours for the treatment of bacteremia, and three received daptomycin thrice-weekly after dialysis. There was no difference in time to clearance of blood cultures between the Q48H and thrice-weekly groups (2.11±2.15 days vs. 4.33±4.16 days; p=0.241).Length of hospital stay was not statistically significantly different between the two groups (22.8 days vs. 14.9 days; p=0.065).Conclusions. Thrice-weekly dosing of daptomycin may be effective for the treatment of bacteremia in hemodialysis patients

Hemopericardium and Cardiac Tamponade Associated with Dabigatran Use

OBJECTIVE: To describe 2 cases of hemopericardium following treatment with dabigatran. CASE SUMMARIES: A 70-year-old male with a history of dabigatran use presented with cough, fatigue, and bloody stools. The patient had a large hyperdense pericardial effusion caused by accumulation of bloody fluid, leading to hypotension and shock. Approximately 1000 mL of hemorrhagic fluid was drained from the pericardial space. A 77-year-old female was admitted for treatment of pneumonia and atrial fibrillation. Dabigatran was initiated and, after 6 doses, the patient developed abdominal pain, respiratory distress, and shock. She was diagnosed with pericardial effusion leading to cardiac tamponade. Pericardiocentesis and thoracentesis procedures removed a cumulative total of 2000 mL of bloody fluid. DISCUSSION: Dabigatran is an oral direct thrombin inhibitor approved for the reduction of stroke and systemic embolism risk in patients with nonvalvular atrial fibrillation. In December 2011, the Food and Drug Administration released a statement describing serious bleeding events associated with dabigatran use. According to the Naranjo scale, the cases presented here had probable associations between hemopericardium and dabigatran. While there is no known literature supporting this relationship, there are documented cases of warfarin-induced hemopericardium. CONCLUSIONS: These case reports highlight the potential for dabigatran to cause hemopericardium and cardiac tamponade. Additional reports may better elucidate (or characterize) the risk of dabigatran-induced hemopericardium and cardiac tamponade

“Rebuilding our community”: Hearing silenced voices on Aboriginal youth suicide

This paper brings forth the voices of adult Aboriginal First Nations community members who gathered in focus groups to discuss the problem of youth suicide on their reserves. Our approach emphasizes multilevel (e.g., individual, family, and broader ecological systems) factors viewed by participants as relevant to youth suicide. Wheaton’s conceptualization of stressors (1994; 1999) and Evans-Campbell’s (2008) multilevel classification of the impacts of historical trauma are used as theoretical and analytic guides. Thematic analysis of qualitative data transcripts revealed a highly complex intersection of stressors, traumas, and social problems seen by community members as underlying mechanisms influencing heightened levels of Aboriginal youth suicidality. Our multilevel coding approach revealed that suicidal behaviors were described by community members largely as a problem with deep historical and contemporary structural roots as opposed to being viewed as individualized pathology

Use of Cilostazol for Secondary Stroke Prevention: An Old Dog with New Tricks?

OBJECTIVE: To evaluate the safety and efficacy of cilostazol for secondary prevention of non-cardioembolic ischemic stroke. DATA SOURCES: PubMed and MEDLINE searches were performed (January 1970-September 2011) using the key words cilostazol, antiplatelet, aspirin, acetylsalicylic acid, secondary stroke prevention, ischemic stroke, intracerebral hemorrhage, intracranial, cerebrovascular accident, and transient ischemic attack. Additionally, reference citations from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: Articles published in English and relevant primary literature evaluating the efficacy and safety of cilostazol in the secondary prevention of atherosclerotic ischemic stroke were included. DATA SYNTHESIS: Antiplatelet therapy plays a vital role in the multifaceted approach to secondary stroke prevention. Current American Heart Association/American Stroke Association clinical guidelines for secondary stroke prevention support the use of aspirin, clopidogrel, and combination aspirin/extended-release dipyridamole. The antiplatelet, antithrombotic, and vasodilatory effects of cilostazol make it a potential alternative agent for atherosclerotic stroke prevention. Recent literature has demonstrated superior efficacy of cilostazol 100 mg twice daily for secondary stroke prevention compared to placebo and aspirin. Three clinical trials were reviewed (1 placebo-controlled, 2 aspirin-controlled), all of which were conducted in Japan or China. Cilostazol reduced the primary outcome of recurrence of stroke, with significantly fewer major bleeding events when compared to aspirin. CONCLUSIONS: Available literature suggests that cilostazol may be safer and more effective than aspirin in the secondary prevention of stroke in Asian patients. Further large-scale studies in more heterogeneous study populations are warranted to determine whether cilostazol is a viable therapeutic option for patients with a history of non-cardioembolic ischemic stroke

Analysis of Anti-Xa Concentrations in Patients on Treatment Dose Enoxaparin: a Retrospective Chart Review

The purpose of this retrospective chart review was to determine the correlation between full weight-based enoxaparin use and the frequency of anti-Xa concentrations within the defined therapeutic range; to ascertain if anti-Xa monitoring is being appropriately ordered in relation to the timing of enoxaparin dose (after 3 consistent therapeutic doses and 3-5 hours post-dose); to establish if the evidence-based recommended dose adjustment protocol that was studied in the pediatric population was utilized; and if this yielded anti-Xa concentrations within the target range (0.6 – 1.1 IU/mL) for an adult population. The data may suggest a lack of correlation between BMI and whether or not the anti-Xa concentration is within the therapeutic range. Further prospective studies are needed to confirm this finding, and to determine the utility of the available dose adjustment nomogram

A Comparison of the Rough Sphere Rotational Diffusion Model with Experimental Results for Liquid Methyl Iodide

No abstract available