text:
The 1998 Report of the ABA Business Law Sections Committee on Business Ethics warns that "even when precautions are taken, lawyers still risk accusations of self-dealing. The lawyer who goes into business with a client faces a heavy burden of establishing both informed consent and transactional fairness.... ." 4 Legal malpractice expert Ronald Mallen put the point more bluntly: "You not only have the opportunity to become a multimillionaire, you have the opportunity to get sued." 5 It is important to note that a number of leading firms have refused to give in to the pressures (from clients as well as from partners) to invest in clients in view of these risks.
3. what firms can do to manage the risks inherent in these situations.
Investing in clients businesses falls into the class of conflicts defined by legal ethics codes as those involving personal, financial, or business interests of the lawyer that may conflict with those of the client. In order to demonstrate the central problem that these types of conflicts cause, we will examine a recent case that exemplifies all of the problems that can (or, some would argue, are likely to) arise when lawyers or their firms invest in their clients businesses. In Rhodes v. Buechel, 7 the investment took the form of a share in the business set up for the clients by the attorneys to manage and profit from the clients intellectual property in certain inventions. The conflicts of interest that arose from this circumstance were the focal points in the litigation. In considering this case, it is important to understand that it is an example in microcosm of the kinds of conflict of interest issues and problems that arise whenever a lawyer or a law firm tries to serve as both counsel to, and investor in, a clients business. Although the facts are somewhat complex, which is typical of such arrangements, it is important to summarize them in order to demonstrate the real implications of such relationships in general.
At the time of the decision, the plaintiff had been a patent lawyer in private practice in New Jersey for 34 years. Defendant Buechel was a professor of orthopedic surgery in New Jersey. There was also a second defendant, Pappas, a mechanical engineer. The two defendants met in 1974 and began a highly successful joint venture inventing and licensing the use of various prosthetic devices. Together they developed a large number of successful patents, and were widely recognized as leaders in their field. At the very beginning of their relationship they recognized the need for competent patent counsel. Accordingly, Pappas recommended to Buechel that they consult with Rhodes, with whom Pappas had previously worked.
From 1974 until 1981 Rhodes was in partnership with two other patent lawyers, Bain and Gilfillan. Following their initial meetings, the court found all parties agreed "that Rhodes, Bain and Gilfillan would receive a one-third interest in any inventions that Buechel and Pappas would bring them, in return for legal work to include drafting and prosecuting patent applications, both foreign and domestic, working on licenses for exploiting the inventions and providing other assistance and advice as necessary." When reduced to a written agreement, the fee and services elements of the agreement were memorialized as described, but the agreement was only expressed to apply to a single, specific invention.
An assignment was also prepared by these same lawyers, and executed by Buechel and Pappas, assigning a one-third interest in the same identified invention to the law firm. The court noted that the agreement was defective in a number of respects, including (1) the clients were not told that the fee arrangement was not customary; (2) in describing the services to be provided, the prosecution and defense of infringement and interference proceedings were omitted; and (3) the clients were not advised to obtain independent counsel with respect to the fee arrangement and the business arrangements with Rhodes. Rhodes then compounded these problems by creating a corporate entity  for "tax reasons," which later turned out to be incorrect and contrary to everyones interests  to which the patent on the first invention was assigned by all the parties.
In due course, stock was issued as follows: one-third each to Buechel and Pappas, and one-ninth each to the three lawyers. Again, the court found that there was no disclosure of the conflict or advice to Buechel and Pappas to consult independent counsel. The first patent was successful, and in succeeding years until 1983, although no further fee agreements were executed, 18 additional patents, for other inventions, were applied for and assigned to the same corporate entity. There is no doubt of the success of the venture, as it earned at least $50 million in royalties.
In the early 1980s, Rhodes withdrew from his partnership with Bain and Gilfillan, resulting in acrimonious correspondence among the lawyers as to the future financial arrangements between the parties. Various changes also occurred in the way in which the patent business was structured, and in the relationships between the clients and the lawyers. However, notwithstanding that there was no agreement with Bain and Gilfillan, now his former partners, Rhodes continued to work "diligently" on an additional 27 patent applications and various patent licensing agreements  without additional compensation. Buechel and Pappas also did considerable research and other work on the inventions.
3. basis for any fee award or forfeiture.
Ethical Obligations  The court found that Rhodes egregiously and continuously failed to meet his fundamental ethical obligations of disclosure and failed to obtain consent from Buechel and Pappas throughout their relationship. The provision of the New York Code considered by the court in Rhodes v. Buechel was DR5-104(A) (22 NYCRR 1200.23(a)), which states, in pertinent part, that "[a] lawyer shall not enter into a business transaction with a client if they have differing interests therein . . . unless the client has consented after full disclosure."
(3) the client consents in writing thereto."
Thus, the Model Rule provision is somewhat more strict than the New York Code provision, among other things requiring that both the transmittal of the disclosure and the consent be in writing, the transaction be "fair and reasonable," and the client be given the opportunity to consult independent counsel.
Section 207 of the Restatement (Third) of the Law Governing Lawyers (to be published shortly by the American Law Institute) essentially follows the Model Rule, with some minor linguistic changes (such as that writing is only mandated where required by law). Accordingly, it is unlikely that a court in any other jurisdiction looking at the facts of Rhodes v. Buechel would have reached a different conclusion based on an ethics code using the Model Rule, rather than the New York Code formulation.
 "Rhodes failed to inform his clients to seek independent counsel, perhaps because it was not in his best interest to do so. More specifically, it is likely that independent counsel would advise against a percentage ownership of the property, as opposed to payment of services rendered based on a quantum meruit basis. Such would alleviate the imbalance of equities found herein."
 "Rhodes failed to advise his clients of the great potential for a lawsuit in cases where the attorney is also a co-owner of a business entity."
 "Rhodes failed to disclose that as a result of wearing two hats he might be rendered objectively incapable of deciding what is in the clients best interests. For example, as the profit margin widens and the personal stakes become increased, Rhodess objectivity may become lessened."
 "Rhodes is desirous of a percentage of the property interest because of the unique entrepreneurial opportunity presented and its likelihood of great success. This he fails to disclose."
 "Rhodes failed to inform his clients that it might be in the clients bests interests to perform particular legal services, but not in his best interest, because such could substantially reduce profits and trigger hours of hard work."
 "Rhodes failed to inform his clients that he was an employee at will and as such could be terminated at any point in time, giving rise to the false perception that they had to be co-owners infinitely."
This list was not intended to be exhaustive of all conflicting interests contemplated, but clearly illustrates that each instance in which Rhodes failed to make full and complete disclosure to his clients constituted a separate violation of the ethics rules.
. Historically, courts have treated this area of law, attorney-client fee arrangements, with special concern, applying principles different from those set forth by commonplace commercial contracts so as to uphold the integrity of our legal and judicial systems. See, Matter of Schanzer, 7 A.D.2d 275 (1st Dept. 1959), affd. 8 N.Y.2d 972 (1960); Martin v. Camp, 219 N.Y. 170 (1916).
Rhodess fundamental conflict of interest with his clients, and his failure to honor his clients interests over his own, constituted a breach of his fiduciary obligations as an attorney.
In light of his unethical actions, Rhodess request for compensation for the life of the inventions was deemed to be a violation of his fiduciary obligations to his clients. The court also considered a total forfeiture of any fees prior to termination. However, "in the interest of fairness," the court did make a quantum meruit award (of $1.5 million) for Rhodess many years of work. The basis for this decision was, first, that he had worked diligently and achieved great success for his clients and, second, that to do otherwise would create an inequitable and unjust enrichment of Buechel and Pappas.
This case has profound and important lessons for all lawyers who contemplate engaging in relationships that involve conflicts of interest, both generally as well as of the particular kind considered here.
Only documentation evidencing full disclosure and, in many circumstances, the actual receipt by the client of independent legal advice that the arrangement is fair and reasonable, the disclosure is adequate, and the consent is appropriate, will offer any basis for avoiding problems flowing from the conflict.
Consent will not be inferred under any circumstances, and fresh, actual consent is required whenever fresh disclosure is required.
It is clear that the courts retain the absolute authority to supervise attorneys fees  including even fees where there was an express agreement. Rhodes v. Buechel simply reinforces the point that this power extends to undoing apparently binding writings of all kinds, even trusts and corporate agreements.
Some readers may be tempted to suggest that the facts in Rhodes v. Buechel are egregious, and that the case should not be used to preclude without exception prudent investment, including taking fees in the form of investment interests in clients. In the comment to Model Rule 1.8, there is a reference to business transactions with clients where "the lawyer has no advantage in dealing with the client." The examples given, however, do not relate to investment, but rather to purchasing "products or services that the client generally markets to others."
The question that will ultimately be presented to a jury in these situations is whether the lawyers investment stake was sufficient enough from the lawyers point of view, to impair his or her objectivity. After all, a lawyer representing General Motors is presumably entitled to invest in a mutual fund that, in turn, invests in General Motors. However, determining where the dividing line falls between this example and the situation in Rhodes v. Buechel is precisely why the ethical rules and legal principles discussed here exist. Certainly, the more material the investment in relation to the rest of the lawyers practice, the greater the risk of triggering these ethical and legal issues. It is important to note, however, that the size of the lawyers stake is not the sole determinant of its propriety. On the contrary, the fundamental issue is whether the stake is sufficient to impair, or to create the appearance that it may impair, the lawyers exercise of independent judgment on behalf of the client.
 If you fail to make adequate disclosure, you are bound to lose.
 If you make disclosure, it will have to be so extensive that it may put off any rational client.
 If you make full disclosure, and the client accepts it and gives consent, that consent is only adequate until any new disclosure obligation arises.
 If you get consent, that consent is limited to your right to continue to act as lawyer; it does not operate to reduce your obligation of fidelity to the client.
In sum, it is not extravagant to state the proposition that accepting engagements with unresolved conflicts of interest may be the equivalent of writing an unequivocal warranty of satisfaction to the client. At worst, the lawyer may be held liable for the clients economic loss. At a minimum, the lawyer jeopardizes his or her right or ability to collect some or all of his or her fees.
The only way for a law firm to ensure that it will never face allegations such as those made in Rhodes v. Buechel is to avoid investing in clients altogether, and to refuse to take stock in lieu of traditional legal fees. Courts presume that business transactions between attorneys and their clients are fraudulent, and the burden rests with the attorney to demonstrate otherwise. 25 Moreover, juries are notoriously unsympathetic to law firm defendants. Against this backdrop and after careful consideration of all the attendant risks, many firms have adopted policies prohibiting all types of client investments. Should a firm decide that this most conservative approach is impractical, however, the following risk management recommendations, taken together, should help to mitigate the risk of malpractice claims.
No individual partner should be able to bind a firm by accepting an engagement involving any conflict of interest, particularly one involving an investment in a client.
Since engagements involving investments in clients clearly constitute a risk to the law firm as a whole, it is common sense that the partner with an interest in the decision to take on the engagement also has a conflict vis-à-vis his or her partners. Thus, for the protection of everyone in the firm, the separate and distinct decisions as to (1) whether to take on the engagement at all, (2) whether the client disclosure made or proposed is adequate, and (3) what other protections are required, need to be made independently of the introducing partner, based on full knowledge of the facts. In addition, if an investment is to be permitted, the firm must, in advance, determine in what form, in what amount, through what investment vehicle, and subject to what controls the firms investment will be made.
Accordingly, it is essential that law firms establish a clear policy  with supporting forms, systems, and procedures  in connection with the oversight and management of new client intake generally, and investments in clients specifically. This policy should require that all relevant decisions be made before the engagement is commenced, and be made not by the introducing partner but by an independent partner or committee, following the delivery to that independent partner or committee of all information necessary for a reasoned judgment as to the risks and benefits to the firm from accepting or rejecting the engagement, or from agreeing to or rejecting an investment in the client. A clear and consistent review process and criteria will assist in defending against any later challenge of the investment.
2. Full disclosure of all conflicts and potential conflicts of interest must be made to the client in accordance with Model Rule 1.8(a).
(iv) the client consents to the transaction in writing.
Disclosure under Rule 1.8(a) should be detailed and comprehensive, and should include any and all potential conflicts the lawyer can foresee. 26 The consequences of potential conflicts should also be disclosed. For example, if it is possible that the law firm may have to withdraw from the representation if a potential conflict is actualized, that possibility must be fully and clearly explained. Firms should clearly avoid the use of "blanket" waivers whenever they invest in clients. Blanket waivers are usually short consent forms presented as a matter of routine and in standard "boilerplate" language to all new clients, wherein the client purports to consent to all, or to certain, specified classes of potential future conflicts of interest. Almost by definition, a blanket waiver is bound to fail the tests set out in Rhodes v. Buechel. Only after a thorough, clear, and detailed disclosure can a clients written consent provide any protection to the firm.
In addition, not only must the engagement letter include the advice that the client seek independent counsel to review the fee arrangement, but the client should actually do so; even sophisticated clients should be encouraged to consult with independent counsel. The Supreme Court of Minnesota recently found that a loan transaction between an attorney and client that was consummated in one day violated Rule 1.8(a), because it did not give the client the opportunity to consult with an independent lawyer. 27 The existence of such independent advice approving the proposed arrangement is the best protection the lawyer can have that it will actually be enforced. Any lawyer giving such independent advice must be mindful, not only of the extent of disclosure and the nature of the conflict, but also  as provided in most versions of the ethics codes  that the arrangement is fair and reasonable to the client.
3. Investments should be made on behalf of the law firm as a whole, not by individual attorneys.
Regardless of any individuals integrity and intentions, a lawyers objectivity and independence of judgment can be seriously impaired where that lawyer has a personal stake in the finances of a client. The larger the investment in proportion to the lawyers own net worth, the greater the danger that the lawyer will be improperly influenced. When an individual invests in a client, the risks are borne by the law firm as a whole, while the potential benefit will accrue only to the individual. It is therefore wise to prohibit investments by individual attorneys, and require that any investments or acceptance of stock be undertaken by the firm itself.
4. Investments should not be the exclusive form of payment of fees.
There are two risks associated with taking stock in lieu of fees. First is a conflict of interest claim brought by the client, an investor, or a regulatory body. Second is that the client may sue for return of fees under Model Rule 1.5, on the grounds that the fee was excessive. 28 A combination of traditional legal fees and stock will help to support a law firms argument that its actions were objective and its judgment independent, should it ever have to face a jury in a malpractice action. For the same reason, the amount of stock accepted by the firm should be relatively small in proportion to the total fee.
In addition, the retainer agreement with the client should clearly state that both parties consider the payment of cash and stock to be reasonable  regardless of the future value the stock may attain. In this scenario the law firm is clearly taking the risk that, if the stock loses all value, that portion of its fee will be zero. The firm should also not take the risk that, if the stock value increases dramatically, the client will sue for return of that stock on the grounds that the amount ultimately paid for legal services was excessive.
5. Investments should be made through a separate investment vehicle set up for that purpose, with some element of independent investment advice and management.
The creation of a separate investment trust does not eliminate conflicts of interest, nor will it prevent conflicts claims by clients or third parties. Indeed, some have argued that the creation of a separate investment vehicle is an elevation of form over substance. Nevertheless, such an arrangement coupled with independent management helps to reinforce the appearance of an arms-length transaction. It has the benefit of placing an additional step between the law firm and the client, which may help to mitigate damages in the unfortunate event that a conflict-based malpractice claim is argued to a jury.
6. Investments should be small enough to be non-material to the law firm or the client.
A law firm should never invest in a client to such an extent that the firm gains a controlling interest in the clients business, or even the appearance of a controlling interest. In addition, if the investment represents a significant portion of the firms total revenues, it will be that much harder to prove that the firms legal advice was objective, and not motivated by self-interest. There is no "bright line" at which a de minimis investment suddenly transforms into an interest that establishes a conflict of interest. The best that can be said is that the more material the investment in relation either to the rest of the lawyers practice or to the clients business, the greater the risk of triggering the ethical and legal issues discussed in this article. Even absent a controlling interest, the stake may be sufficiently great to trigger these problems; but if there is a controlling interest, then the problems are likely to be unavoidable.
Once a law firm has invested in a client, it is likely that the investment will last for as long as the attorney-client relationship. The difficulties associated with explaining to a client the firms decision to sell the clients stock before the representation is concluded are myriad, and could potentially damage the relationship with the client. The firm should, therefore, carefully scrutinize the client before undertaking any investment, and consider whether a "permanent" investment is in its best interests.
8. Schedule a regular review and, where necessary, revision of the clients written consent.
There are cases that reinforce the Rhodes v. Buechel requirement that, if and when conflicts actually arise, a fresh and full disclosure must be made, and a fresh and express waiver must be obtained  even where the original waiver was made by a sophisticated consumer of legal services. 29 For each client in which a law firm has an investment, a regular review of the clients written consent should be scheduled, in order to ensure compliance with the firms ongoing duty to disclose.
The ethics rules have created a trap for the profession by permitting lawyers to accept engagements where conflicts exist if they make "full disclosure" and obtain "consent." These rules ignore the fact of the lawyers underlying fiduciary obligation  that cannot be waived  to provide competent representation wherein absolute fidelity and priority to the clients interests are paramount at all times. This legal obligation as a fiduciary essentially transforms the lawyer who accepts engagements under terms involving an investment stake in the client into something close to a guarantor of a successful outcome. Once a client establishes a breach of that fiduciary duty, the damages assessed against the lawyer will likely be directly related to the size of the clients loss, however great. Analysis by a court or jury of a lawyers actions in these cases is always conducted in hindsight, and the strong presumption that business transactions between attorney and client are fraudulent creates a very difficult hurdle for the law firm defendant to overcome.
In order to protect themselves from unwitting liability that may be impossible to defend or controvert, law firms are therefore wise to institute policies and procedures designed to ensure independent oversight and control of all engagements that may involve these (and other) conflicts of interest. All possible steps should be taken to avoid even the appearance of undue influence over the client, or preferential treatment vis-à-vis other investors. No policies, procedures, or risk management techniques can eliminate the conflict of interest created when a law firm invests in one of its clients, but adherence to the techniques described here should help to mitigate the consequences of those conflicts.
Maharaj, THE CUTTING EDGE: FOCUS ON TECHNOLOGY More Firms Are Willing to Work for Stock Options, Equity: Professionals are accepting lower salaries  and stock  in hopes of cashing in on a booming market, Los Angeles Times, January 24, 2000.
Baker, Who Wants to Be a Millionaire?, ABA Journal, February 2000, at 36.
3 Smith, Venture Law Group Prospers By Focusing on Web Startups, Wall Street Journal, March 22, 2000.
6 Many of the lawyers professional liability claims seen at Chubb Executive Risk (reported by applicants and insureds) involve conflicts of interest, and many of those are the result of alleged self-dealing on the part of a law firm. Generally speaking, these claims contain allegations that the lawyers had a piece of the deal, and that this potential profit led them to elevate their own interests over those of the client. In several instances, the appearance of a conflict was created by a fee arrangement in which the firms compensation was contingent on the success of the clients business. The plaintiff in these claims may be the client, but may also be a third party allegedly injured by the collusion between the law firm and client.
7 Rhodes v. Buechel, N.Y.L.J., March 18, 1998, at 28 (N.Y. Sup. Ct. 1998), affd, 685 N.Y.S.2d 65 (A.D. 1 Dept. 1999).
10 Matter of Cooperman, 83 N.Y.2d 465, 472 (N.Y. 1994). See also Cummings v. Sea Lion Corporation, 924 P.2d 1011 (Alaska 1996)(attorney has fiduciary relationship to clients separate and apart from the ethics rules).
11 Rhodes v. Buechel, supra.
12 For an extended treatment of the entire subject of the law governing business transactions between lawyer and client, see Maltz, Lawyer-Client Business Transactions: Caveat Counsellor, 3 Geo. J. Legal Ethics 291 (1989). While this article pre-dates the current rash of investing in clients, it treats all of the issues which these transactions raise.
13 Rhodes v. Buechel, supra; see also Forrest Park Assocs. Ltd. Partnership v. Kraus, 175 A.D.2d 60 (1st Dept. 1991).
14 Committee on Professional Ethics and Conduct of the Iowa State Bar Association v. Mershon, 316 N.W.2d 895, 898 (Iowa 1982); In the Matter of George H. Miller, 568 S.W.2d 246, 251 (Mo. 1978).
16 Maltz, at 310, 311.
17 Rhodes v. Buechel, supra. See also Blecher & Collins, P.C. v. Northwest Airlines, Inc., 858 F.Supp. 1442 (C.D.Cal. 1994).
18 Mershon, 316 N.W.2d at 897, 898; In the Matter of George H. Miller, 568 S.W.2d at 251; Nesbit v. Lockman, 34 N.Y. 167 (N.Y. 1866).
19 Rhodes v. Buechel, supra.
20 Maltz, at 298, 299.
22 Rhodes v. Buechel, supra; see also Mershon, 316 N.W.2d 895.
23 Mershon, 316 N.W.2d at 899, citing Goldman v. Kane, supra.
25 In the Matter of the Disciplinary Proceeding against Dennis O. McMullen, An Attorney at Law, 127 Wash.2d 150, 896 P.2d 1281 (Wash. 1995). See also Mershon, 316 N.W.2d at 898. See also Maltz, at 314-316.
(2) the client consents after consultation...."
27 In re the Application for the Discipline of Jerrold M. Hartke, 529 N.W.2d 678 (Minn. 1995).
28 Model Rule 1.5 states that "[a] lawyers fee shall be reasonable."
See, e.g., Blecher & Collins, supra.
University Law Center in 1990.
Anthony E. Davis is a Partner at Moye, Giles, OKeefe, Vermeire & Gorrell, LLP (in New York and Colorado), advising lawyers and law firms on legal profession and legal ethics issues, and in the area of law firm risk management and loss control. He is an Adjunct Professor of Law, teaching "Legal Profession" at Brooklyn Law School. In addition to several books on law firm risk management, he has written and lectured widely on a variety of legal profession and ethics issues. He is a Director and Treasurer of the Association of Professional Responsibility Lawyers and Chair of the Professionalism, Ethics and Competency Committee of the Section of Law Practice Management of the American Bar Association. He received his law degree from Cambridge University, and an LL.M. from New York University School of Law. He is admitted in New York, Colorado, and as a solicitor in England.

matches: v. v. v. v. v. v. v. v. v. v. v. v. v. v. v. v. v. v. v. v. v. v.


RAYMOND ALFORD BRADFORD, Plaintiff-Appellant, v. M. BROOKS, Dietician; YU, Doctor; PEPPERCORN, Dr., Defendants-Appellees.
Before: THOMAS, Chief Judge, and HAWKINS, and McKEOWN, Circuit Judges.
The district court did not abuse its discretion by requiring Bradford to post a security after declaring him a vexatious litigant and finding that he did not have a reasonable probability of prevailing on the merits. Under Local Rule 151(b) of the Eastern District of California, the court may order a party to give security in accordance with the California Code of Civil Procedure's provisions relating to vexatious litigants. See Wolfe v. George, 486 F.3d 1120, 1125 (9th Cir. 2007) (upholding as constitutional California's prefiling requirements on vexatious appellate litigants)2 ; Hamilton v. Keystone Tankship Corp., 539 F.2d 684, 686 (9th Cir. 1976) (“Rule 83 of the Federal Rules of Civil Procedure allows the district court to formulate local rules to the extent they are not inconsistent with the federal rules.”).
The district court properly concluded that Bradford is a vexatious litigant. A litigant is vexatious where previously “declared to be a vexatious litigant by any state or federal court of record in any action or proceeding based upon the same or substantially similar facts, transaction, or occurrence.” Cal. Civ. Proc. Code § 391(b)(4). Bradford was declared a vexatious litigant in Bradford v. Klarich, Superior Court of California, County of Kings Case No. 05C0349, a case in which Bradford sued medical staff at CSP-Corcoran for “the same or substantially similar” allegations of deliberate indifference to his medical needs.
The district court also properly concluded that there is no reasonable probability that Bradford will prevail on his claims. To prevail in his medical indifference claims, Bradford “must show that the course of treatment the doctors chose was medically unacceptable under the circumstances and ․ show that they chose this course in conscious disregard of an excessive risk to [his] health.” Jackson v. McIntosh, 90 F.3d 330, 332 (9th Cir. 1996) (internal citations omitted). Bradford's claims amount to no more than mere disagreement with the professional opinions of Brooks and Yu regarding his medical needs, and he therefore does not have a reasonable probability of prevailing on the merits of his litigation.
1. We decline to take judicial notice of pages 7-8, 18-42 and 45-48 of Bradford's December 21, 2015 motion for judicial notice. We grant Bradford's request as to pages 9-17 and 43-44. We deny Bradford's January 19, 2016 motion to file a supplemental brief. We also deny Bradford's December 28, 2015 motion for appointment of counsel.
2. Given Wolfe and California's long line of cases upholding California's vexatious litigant requirements as constitutional, Wolfe, 486 F.3d at 1125, we reject Bradford's contention that because he was permitted to proceed in forma pauperis, Bradford v. Vella-Lopez, 486 F. App'x 643 (9th Cir. 2012), it would be unconstitutional to require him to post security.
3. Dr. Robert Peppercorn was a named defendant in Bradford's second amended complaint and the district court granted summary judgment in his favor. Bradford does not appeal that ruling; instead, the only issue he raised on appeal relates to the posting of security and his vexatious litigant status. His passing reference without argument in his reply brief does not fix the problem. Therefore, he abandoned any issue vis-à -vis Dr. Peppercorn. See United States v. Kama, 394 F.3d 1236, 1238 (9th Cir. 2005) (“Generally, an issue is waived when the appellant does not specifically and distinctly argue the issue in his or her opening brief.”).


Supreme Tribunal of the Apostolic Signatura, Information Sheet Concerning Administrative Recourse, 2 January 1997.
This text is taken from an information sheet prepared by the Apostolic Signatura to provide basic information to persons who make recourse to the Signatura or at least indicate an interest in doing so. It is written for persons who do not have a technical knowledge of canon law and is not intended to be a complete treatment of this subject. Furthermore, it is written for persons who are of the Latin Church and thus does not cite the Code of Canons for the Eastern Churches.
Furthermore, “in addition to the judgment regarding illegitimacy of the acts, it can also adjudicate, at the request of the recurrent party, [the person making recourse], the reparation of damages caused by the illegitimate act” (art. 123, §2). Such a question would be subordinate to the principal question.
For the purpose of illustration, the following information will refer to individual administrative acts of a diocesan bishop and to decisions of a Congregation of the Roman Curia, but the reader should understand that other persons in authority (such as major religious superiors) can issue individual administrative acts and that the Roman Curia includes other Dicasteries (such as Pontifical Councils).
a. The recourse must be against one or more individual administrative acts, that is, acts arising from the exercise of administrative or executive power in the Church (e.g., on the part of the diocesan bishop).
Thus, it cannot concern an act of judicial power (e.g., the decision of a tribunal) or of legislative power (e.g., statutes issued by a diocesan bishop).
b. The individual administrative acts must be either issued by a Dicastery (Congregation or other organ) of the Roman Curia, or else must have been approved by such.
Thus one cannot have recourse directly to the Apostolic Signatura against an administrative act of a diocesan bishop; one would have to first make recourse to the competent Congregation (the competence is determined by the nature of the decision).
If the Congregation confirms the original decision, recourse could then be made to the Signatura against the act as approved by the Congregation.
If the Congregation issues another decision, recourse can be made to the Signatura against the decision of the Congregation by whichever party feels aggrieved by the new decision (for example, by the diocesan bishop whose decision was overturned, or by the original recurrent party who is dissatisfied with the decision of the Congregation). In particular, if the Congregation decided to reject the recourse because it was made after the time limits set by law had expired or because the person making recourse lacked legal standing, recourse to the Apostolic Signatura could only concern that decision and not yet the original decision.
c. Recourse to the Apostolic Signatura must concern a violation of the law.
This element is fairly clear concerning alleged violations of the law in regard to the procedure followed (in procedendo): the diocesan bishop — or the Congregation — either followed by procedures required by canon law or did not. However, if the Apostolic Signatura decides that it has been proven that he did violate the law in this way, it is possible that he could repeat his decision, this time observing the correct procedure. For this reason, persons contemplating recourse to the Apostolic Signatura against an administrative act of a diocesan bishop as confirmed by a Congregation of the Roman Curia should realize that, if their recourse concerns only an alleged violation of the law in procedendo, in the end the outcome may not have been changed, but only delayed.
a person disagree with the decision in question, even for reasons which appear to be sound.
While a Congregation can make a judgment regarding the opportuneness, relative wisdom, prudence, etc., of the administrative act in question, and has the power not only to confirm or nullify but also to amend the decision (c. 1739), the Apostolic Signatura is competent only to decide whether or not the law was violated.
On the other hand, it if could be proven that the reasons given by the bishop for the decision were substantially unfounded, there could be some basis for an alleged violation of the law in decernendo.
Likewise, if canon law requires specific reasons for a particular type of decision (see, for example, cc. 1740-1741), concerning the removal of a pastor), and it could be proven that such requirements were not observed, there could be some basis for an alleged violation of the law in decernendo.
2. Who Can Make a Recourse?
The question of who has legal standing to make recourse is not simple. For example, someone who is not personally and directly affected by an administrative act cannot make recourse against it.
Furthermore, if the recourse is made against an administrative act subsequently confirmed by a Congregation, only a person who had first made recourse to the Congregation against that act can subsequently make recourse to the Apostolic Signatura against the decision of the Congregation.
Moreover, a group or organization of the Christian faithful which lacks the recognition mentioned in canon 299, §3, is not a “juridic person” in the Church, and cannot make recourse as a group or organization as such. It is possible, however, that members of the group could make recourse as individuals, even if a number of them join together for this purpose.
While a person can present an initial recourse in his or her name, from that point on the recurrent party can participate in the contentious-administrative process only through a qualified procurator-advocate, that is, one admitted to the practice before this Tribunal in such cases. Once the advocate has been named, all further information should be sought from (and all communication with the Apostolic Signatura should be made through) that legal representative. A list of qualified advocates can be obtained from the Apostolic Signatura. The fees for the procurator-advocate are to be paid by the recurrent party directly.
When a Congregation has made a decision, an aggrieved party who wishes to challenge that decision must first, within ten days of receiving official notice of the decision, ask the Congregation to revoke or modify its decision (Regolamento Generale della Curia Romana, art. 119, §1).
In any case, recourse can be presented to the Apostolic Signatura within the period of thirty useful days of receiving an official communication of the decision of the Congregation (ibid., art. 119, §2, and Pastor Bonus, art. 123, §1).
–	the reasons for the recourse (the alleged violations of the law).
A document sent by fax is not accepted as a signed, original document; thus if a copy of the recourse is sent by fax, the original document must still be sent within the time period.
Whenever a recourse is sent to the Signatura, it should be sent in such a way that the recurrent party retains proof that it was sent within the time limit (for example, by registered mail or a courier service).
The classification of this time period of thirty days as “useful” or “available” time means that the time does not run when the person is prevented from acting, e.g., by serious illness (c. 201, §2). This does not mean that the period extends for thirty “working days” (since the time normally runs even on Sundays and holidays); nonetheless, should the last day of this period fall on a day when it is impossible to present the recourse because the Signatura itself or the local post office is closed, then the time limit is extended to include the next day when it is possible to present the recourse.
Furthermore, “useful” or “available” time does not run when the person is ignorant, e.g. of the right to make recourse to the Apostolic Signatura, but ignorance would have this effect only in those rare cases when it can be proven both that the person was truly ignorant and that the person was not negligent in any way in seeking the necessary information. Ignorance of the law, and thus of the right to have recourse to the Apostolic Signatura, or of the time limit established by law for doing so, is not presumed (c. 15, §2).
The burden of proof rests with the person who is alleging that the law was violated (c. 1526, §1).
party or whether he or she will have to pay an additional sum.
If the recurrent party does not have the means to pay the deposit in full, he or she can ask that the deposit be waived entirely, or reduced or paid in installments. Such a request should be made with the recourse and should be supported by proof of financial condition.
Likewise, if the recurrent party cannot afford to pay for a procurator-advocate, a request can be made for the favor of gratuitous legal assistance, that is, for the appointment of an ex officio procurator-advocate without cost to the recurrent party. Such a request should also be supported by proof of financial condition.
–	the recourse has some foundation — in other words, it is not obviously futile.


text:
Tomilova D. I., Karpov Yu. A., Lopukhova V. V.
Aim. To evaluate the occurence of cardiovascular events (CVE) and influence of lipid parameters on it, as other clinical and instrumental factors of coronary heart disease (CHD) patients during 5 years after selective percutaneous coronary intervention (PCI) with drug eluting stenting (DES).
Material and methods. In the study, 574 patients included, with stable angina (81% males, mean age 60,3 y. o.), hospitalized to the FSBI RCSPC of MHRF for selective PCI with implantation of DES. Patients were prescribed the therapy according to stable angina guidelines, including statins. The analysis was done, of various clinical and instrumental and laboratory parameters for evaluation of prognostic significance. The endpoints were assessed: lethal cases from cardiovascular, as from all causes, non-fatal myocardial infarction (MI), non-fatal stroke, repeated coronary revascularization, that happened after discharge.
Results. During the entire follow-up (average 53,5 months), CVE were registered in 24% cases. Totally, died 29 patients (5,1%), of those 4 (0,7%) — from non-cardiac causes, and repeat revascularization was done in 84 (14,6%) patients, non-fatal MI and stroke developed in 17 (3,0%) and 8 (1,3%), respectively. The risk factors were defined, that are related with the rate of fatal outcomes: smoking, brachiocephalic atherosclerosis, stroke in anamnesis, significant lesion of circumflex artery (CA) and its branches. Non-fatal stroke developed more oftenly in patients with higher body mass index (BMI) (32,2±2,56 versus 28,15±4,22, p=0,0164). Non-fatal MI more oftenly registered in patients with higher number and length of implanted stents (p=0,0018 and p<0,0001, resp.). By the end of follow-up, there were 66,2% patients on statins treatment. Target low density lipoproteides cholesterol (LDL-C) level (<1,8 mM/L) was found in 8,7%, median LDL-C level was 2,8 mM/L. There were no significant differences in LDL-C between those taking statins and discontinued, during 5 years. There was no significant relation of lipid profile values with CVE as well. The number of fatal cases was higher in the group of patients with lower baseline high density lipoproteide cholesterol.
Conclusion. Adverse events were found in about quarter of patients. Most of patients did not reach the target LDL-C. There was no significant relation in baseline LDL-C and its level in 5 years, with the occurence of MI, stroke, repeat revascularizations, all cause deaths. This can be explained by the absence of significant differences in LDL-C levels in patients continuing and discontinued statins during the follow-up, and is related to the use of insufficient statins dosages and low adherence to statin treatment.
Key words: percutaneous coronary intervention, long term follow-up, cholesterol of high density lipoproteides, statins.
Russian Cardiological Research-and-Production Complex of the Ministry of Health, Institute of Clinical Cardiology named after A. L. Myasnikov, Moscow, Russia.
Kamenskaya O. V., Loginova I. Yu., Doronin D. V., Chernyavsky A. M., Karaskov A. M.
Aim. Evaluation of prognostic significance of the parameters of cardiopulmonary exercise test in life quality improvement for the post-cardiac transplantation patients.
Material and methods. Into the study, 40 patients included, with severe chronic heart failure (CHF), included in the waiting list for cardiac transplantation. Before and after orthotopic heart transplantation (OHT), clinical status was evaluated, cardiopulmonary exercise testing parameters (CET) and life quality by SF-36.
Results. After OHT the significant life quality improvement noted, by the scale “Physical health” from 36 (32-45) points before surgery to 52 (49-55) points (p<0,05) and “Psychological health” from 38 (34-50) to 51 (50-56) points. In 13% cases life quality improvement was not noted. Among the CET parameters, significant relation with life quality improvement by “Physical” scale showed the preoperation level of exercise tolerance (ОR 2,10 (1,08-9,80), p=0,001), peak of oxygen consumption (OR 1,20 (0,97-2,61), p=0,037), efficacy of oxygen consumption in exertion (OR 0,68 (0,36-1,27), p=0,047). Also, it was shown that life quality increase after OHT depends on efficacy of oxygen consumption baseline return in first minute (OR 1,13 (1,02-1,27), p=0,024). Any relations of CET with “Psychological” life quality by SF-36 were not noted.
Conclusion. Exercise tolerance, peak oxygen consumption, exertion ventilator efficacy, efficacy of oxygen consumption baseline return after exercise, by CET in severe CHF patients, have high predictive value in evaluation of probability of life quality improvement by the scale “Physical health” of SF-36 after cardiac transplantation.
Key words: orthotopic cardiac transplantation; cardiopulmonary exercise test; life quality.
Babokin V. E., Pronina V. P., Mishchenko Yu. V., Ananko V. A., Martakov M. A.
Modern times, surgeons of the entire world utilize the technics of left ventricular reconstruction (LVR) developed by professor Dor V. However, oftenly the left ventricle (LV) presents with a spheric shape in postoperation period, by echocardiography. When, normally, geometry of the LV is conceptualized as a stretched ellipse with longitudinal axis directed from apex to the base of the heart.
Aim. To evaluate effectiveness of modified LVR using Z-suture to create the LV apex in patients with postinfarction heart aneurysms.
correction was assessed by echocardiography data in short term period till 1 month after the operation, comparing with pre-surgery data.
Results. In all patients surgery proceeded successfully. Sphericity index significantly decreased in diastolic phase at basal level from 0,83±0,17 to 0,63±0,11 (p=0,05) and at apical level from 0,56±0,12 to 0,37±0,09 (p=0,01). Conical index increased at basal level from 1,26±0,06 to 1,67±0,40 (p=0,05), at middle-apical level from 1,34±0,30 to 1,4±0,34 (p=0,05).
Conclusion. The modified left ventricular reconstruction with Z-suture forms the ellipsoid heart shape and is an effective method of surgery of postinfarction LV aneurysm.
Moscow Regional Research and Clinical Institute (MONIKI), Moscow, Russia.
Mamchur I. N., Chichkova T . Yu., Mamchur S . E., Bokhan N. S ., Romanova M. P., Khomenko E. A.
Aim. To assess and compare mechanical functioning of the left atrium before and just after cryoballoon or radiofrequency ablation.
Material and methods. Totally, 43 patients included, with sympthomatic atrial fibrillation resistant to drug treatment. Of those 21 — for cryoballoon ablation (mean age 57,8±8,7 y. o., 11 males and 10 females) and 22 candidates for radiofrequency ablation, at the age 54,4±11 y. o., 16 males and 6 females. Before procedure, just after and on the 5th day, transthoracal echocardiography was performed, with measurement of Doppler parameters of intracardiac hemodynamics, as mechanical function of the left atrium assessment, including 3D imaging.
Results. By the data from transthoracal echocardiography and direct intraoperation manometry, the significant disorders of the left atrium (LA) mechanical function were found in both treatment groups, with some differences. Pulmonary veins (PV) isolation by any method does not influence diastolic and systolic function of the left ventricle, that confirmed by invasive measurements of the end-diastolic pressure in LV, as the changes of volumes and ejection fraction by echocardiography. Therefore transmitral blood flow dynamics, as PV and pulmonary artery flow, related to PV isolation procedure, is a result of the LA functioning disorder due to its passive dilatability and active contractility decrease, dysfunction of the PV sleeves, increase of pulmonary vascular resistance. The significant decrease found in LA pumping function, more prominent in radiofrequency group just after the procedure, with further improvement to the 5th day after procedure. Also, mean pulmonary artery pressure increase, and till the 5th day in radiofrequency group it was significantly higher than in cryoablation group.
Conclusion. Both cryo and radio ablation procedures of PV isolation significantly impact on the mechanical functioning of the LA, however cryo ablation leads to less severe disorder at short follow-up.
Key words: atrial fibrillation, cryoablation, radiofrequency ablation, pulmonary veins isolation, left atrium, mechanical function, contractility.
Ayrapetian M. A., Luchinkina E. E., Gordeev I. G., Taratukhin E. O.
Aim. To assess the specifics of psychoemotional state of adult patients with non ST elevation acute coronary syndrome (NSTEACS) in 6 months post hospitalization.
Material and methods. Totally, 101 patient included, with non-obstructive lesion of coronary flow. Groups were formed by gender: group 1 — 51 females, group 2 — 50 males. Mean age: women 50,5±4,7 y. o., men 46,7±6,8 y. o. Patients were also selected to subgroups by NSTEACS type: subgroup A — unstable angina (UA), subgroup B — myocardial infarction. Patients were questionned by phone in 6 months after discharge. The questionnaire included key points about health, emotional balance, physical activity and life quality.
Results. There are gender differences in life quality constituents between men and women. In questions on general health state 6% of women replied that are not satisfied with their health, in men — 2%; satisfactorily graded their health state 27% of women and 38% of men, good — 47% and 46%, excellent — 20% and 14%, respectively. Pre-morbid physical activity at work was saved in 45% of men and 32% of women; active life style retained 47% of women and 42% of men. Men more often felt hopelessness (43% and 12%; p<0,01), as women mostly pointed on irritability and sleeplessness (35% and 28%; p>0,05) and were unsatisfied with their psychological state (31% and 6%; p<0,05). In both groups patients experienced the feeling of lost worth of living, women — more often (7% and 4%; p>0,05), however men noted loss of interest to former habits (13% и 22%; р>0,05). The specifics in subtypes of NSTEACS was also noted.
Conclusion. Regardless an individuality of the meanings of life quality, experiences, coping, there is gender specifics, as specifics in NSTEACS subtype. The specifics can be included as a part of patient-centered work with post-ACS patients.
Key words: myocardial infarction, gender differences, CHD in women, life quality, psychoemotional state, risk factors, patient-centered medicine.
Aim. To investigate on clinical, hemodynamic and laboratory specifics of heart failure course in diabetes mellitus type 2 (DM2) patients and non-diabetic, hospitalized due to acute decompensation of chronic heart failure (CHF).
Material and methods. Totally, 134 patients included, hospitalized to cardiology. All patients were selected to 2 groups: I (CHF and DM2, n=66; age 61,8±7,2 y. o., 28 males, 38 females), and group II (CHF non-DM, n=68; 62,3±7,7 y. o., 33 males, 35 females). Symptom assessments were done, with the score of clinical state in CHF (SCSC), electrocardiography (ECG) resting in 12 leads; transthoracal echocardioscopy; laboratory blood tests; chest x-ray; 6-minute walking test.
Results. Patients with CHF and DM2 were characterized by comparatively high functional class of CHF, severity of symptoms (by SCSC 13,7±2,2 versus 11,1±2,2 points, p<0,05) and more prominent morphofunctional changes of the heart: significant decrease in ejection fraction of the left ventricle (LV) by 5,5% and increase of deceleration time in early diastolic filling, followed by the decrease of E/A. The specifics found was followed by disordered biochemical parameters in DM2. Anamnesis of CHF and DM2 in the cohort made it to find out an insufficient (less than 80%) control of glycemia among CHF and DM2 patients regardless long lasting course of glycemia disorder.
Conclusion. Results of the conducted study demonstrate negative character of impact of DM2 on CHF course of ischemic and non-ischemic origin.
Key words: chronic heart failure, diabetes mellitus, clinical condition, left ventricle functioning.
1National Research Center for Preventive Medicine of the Ministry of Health, Moscow; 2Domodedovskaya Central City Hospital, Domodedovo, Russia.
Aim. Comparison of efficacy of stents coated with sirolimus (group I — 116 patients), and bare metallic stents (group II — 117 patients) in treatment of diffuse (long) atherosclerotic lesions in coronary arteries.
Material and methods. The groups were comparable by main parameters. Diabetes was found in 19% and 13,7%, respectively; multivessel lesion in 87,1% and 80,4%; vessel caliber less than 2,75 mm — 46,5% and 23,9%, respectively. Length of the lesion was 25,9±6,6 mm (28-93 mm) in group I and 22,1±7,8 mm (26-102 mm) in group II. Totally, 473 stents implanted into 232 arteries (2,1 per artery): group I — 184 stents in 116 arteries (overlap of 2> stents in 87,9% cases) and 289 in 117 in group II (superposition of stents in 87,1%).
Results. The direct success at short term was noted in 113 patients in group I (97,4%) and in 116 in group II (99,1%) (p=0,74). In both groups there were no cases of acute thrombosis of stents. Subacute thrombosis (in 1-3 weeks) was noted in 2 patients (1,7%) in group I and in 1 (0,85%) in group II (p=0,47). Long term angiographic restenosis was noted in 12 patients from group I (10,6%) and in 66 in group II (56,9%) (p<0,0025). Also, in group II 47 patients from 66 had diffuse restenosis (71,2%), as in group I there was no diffuse restenosis. Survival rate with no MACE or angina in 12 months was 79,8% in group I, and 31% in group II.
Key words: diffuse atherosclerosis, long lesions of coronary arteries, drug eluting stents, sirolimus.
1The Center of Endosurgery and Lithotripsy, Moscow; 2Moscow Regional Research and Clinical Institute (MONIKI), Moscow; 3I.M. Sechenov First Moscow State Medical University of the Ministry of Health, Moscow, Russia.
Bogachev-Prokofiev A. V., Sharifulin R. M., Zubarev D. D., Zhuravleva I. Yu., Karaskov A. M.
Aim. Transcatheter replacement of the aortic valve with transfemoral approach is the procedure of choice in patients with aortic valve defects and high to very high operatrional risk. If transfemoral approach is not applicable, alternative approaches implemented. The most rarely used is transaortal approach. The data was analyzed, of the direct transaortal approach for aortic valve replacement.
Material and methods. During the years 2015-2017, 11 procedures performed, of transcatheter aortic valve replacement, with transaortal approach. In 10 cases, the operation was done with the right-sided anterior minithoracotomy, in 1 — with ministernotomy.
Results. Thirty-day mortality was 9,1%. There were no conversions of surgical approach. In one patient (9,1%) there was paraprosthesis regurgitation, in the other — no such regurgitation, or non-significant. There were no hemorrhagic complications or complications of the surgery. One patient received permanent pacemaker for developed complete atrioventricular block.
Conclusion. Direct transaortal approach makes it to safely and effectively perform transcatheter implantation of aortic valve and might be an alternative in the cases of impossible transfemoral approach.
Key words: aortic valve, aortal stenosis, transcatheter aortic valve replacement.
Loginova I. Yu., Kamenskaya O. V., Chernyavsky A. M., Novikova N. V., Lomivorotov V. V., Karaskov A. M..
Material and methods. Totally, 131 patient included, with CPH, who had undergone thrombo-endarterectomy from the branches of pulmonary artery. Before the surgery, together with standard investigation, the following methods were applied: body pletismography, lung diffusion capacity assessment, ventilation efficiency assessment. The relation was analyzed, of the parameters of pulmonary functional tests with the results of surgical treatment of CPH patients.
Davtian K. V., Kalemberg A. A., Simonian G. Yu., Shatakhtsian V. S ., Topchian A. G.
Aim. To evaluate the possibility of hybrid procedure that includes single-moment cryoballoon isolation of pulmonary veins (PV) ostia and implantation of occluder into the left atrium appendage (LAA) in patients of high thromboembolic and hemorrhagic risk and prominent symptoms in atrial fibrillation (AF) paroxysms.
Material and methods. From 2012 to 2016 y., 72 procedures performed, of LAA occluder implantation for patients with high thromboembolic and hemorrhagic risk (mean age 68±7,4 y. o., 48 females, 24 males, mean rate by CHA2DS2VASc 4,82±1,48 points), of those 3 underwent single-moment cryoballoon isolation of the PV ostia without electrical isolation of LAA. The parameters of the intervention were assessed, and prevalence of intra-operation complications in AF patients that included single-moment catheter cryoballoon isolation of PV ostia and implantation of LAA occluding device, in comparison with isolated LAA occluder implantation.
Results. Occluding device implantation was successful in 100% cases. Periprocedural efficacy of PV ostia isolation was 100%. In both groups, intraoperational complications were absent. Mean heparin time and dosage of contrast in the hybrid intervention group were higher: 94,3±6,8 min vs 59,7±19,95 min (p<0,05), 196,8±20,82 mL vs 124,6±30,24 mL (p<0,05), respectively.
Conclusion. Performing of the hybrid intervention that includes single-moment catheter isolation of PV ostia and implantation of the occluding device into LAA increases mean procedure duration and contrast load in comparison to isolated LAA occluder implantation, with no operational risk increase.
Key words: atrial fibrillation, left atrium appendage, stroke prevention, cryoballoon ablation, anticoagulation therapy.
Fomichev A. V., Chernyavsky A. M., Tarkova A. R., Ibragimov R. U., Kareva Yu. E., Minin S . M., Nikitin N. A.
Aim. To evaluate perfusion and functioning of myocardium in occluded coronary artery with various types of collateral blood flow.
Material and methods. Ninety patients with three-vessel disease and obligate occlusion of the right coronary artery (RCA) according to the type of collateral flow development, were selected to 2 groups: first — 44 patients (49%) with I and II grades by Rentrop, second — 46 patients (51%) with grade III Rentrop collaterals. Perfusion scintigraphy data was analysed, with echocardiography and tissue Doppler.
Results. Worsening of perfusion of myocardium inferior wall was found in patient of group 2 with non-significant defect of perfusion in 1st group patient. Stable perfusion defect in group 1 was 9,8±3,5%, in group 2 — 4,1±1,7%. While comparing tissue Doppler values, change in longitudinal deformation of inferior wall in the group with worse collaterals was -4,1±2,6, in group 2 -6,8±2,7. While assessing segmentary contractility of the inferior wall of the left ventricle, lower number of hypokinesis segments was found in group 2.
Conclusion. Chronic occlusion of coronary artery with a weak collaterals is followed by worse parameters of local perfusion and function of myocardium. In a good condition of collaterals, regardless the non-significant perfusion disorders in myocardium at rest, there are prominent stress-defects and local contractility disorders of myocardium.
Key words: coronary heart disease, collateral blood supply, chronic occlusion of coronary arteries.
Aim. Comparative analysis of the acquired with EchoCG method parameters of the left chambers of the heart and of mitral valve in normal state and in restrictive type of failure with further building up three-dimensional models of these variants of the fibrous anulus geometry, and of the left atrium, left ventricle and its outgoing tract.
Material and methods. The study was done using 3D transthoracal and transesophageal EchoCG on Philips iE33 (Philips Healthcare, USA) in 30 patients with unchanged mitral valve (n=15) and in ischemic mitral regurgitation (n=15). Spatial configuration of the anulus fibrosus was investigated, and mitral valve, spatial and volumetric parameters of the left atrium and left ventricle. Data was processed in SciLab 4.1.2 software and exported to CATIA 5 modelling system, where the acquired curves were combined to 2 solid thin-wall models, and after linking of the surfaces — to a hard-bodied model with required thickness of the walls.
Results. All studied parameters revealed significant differences (p<0,001) in groups comparison. In restrictive type of insufficiency, sizes of fibrous anulus increase: intercomissural diameter by 22%, front-back — by 13%, perimeter — by 28%, surface — by 79%. End systolic and diastolic volumes of the LV increase more than 2 times, which is related with more prominent sphericity of the LV, than normally. Increase of LA more than 1,5 times also combines with its geometry change towards sphere. Three dimensional computer model of the left heart chambers changed as a result of ischemic mitral failure, is created. The model can be implemented in creation, analysis and prediction of medical devices for the position and/or realized as the full-sized mockups, test systems and phantoms for development and education.
Conclusion. The investigation of mitral valve characteristics and of the left heart chambers by method of 3D transthoracal and transesophageal echocardiography makes it to obtain the baseline data necessary for creation of 3D computed models of the anatomic area normal and disordered. Such models can be implemented in the development of implanted devices constructions, preliminary tests of medical devices and in training.
Key words: left chambers of the heart, three-dimensional models, transcatheter valves.
1E.N. Meshalkin Novosibirsk Scientific-Research Institute of Circulation Pathology, Novosibirsk; 2LLC “TESIS”, Moscow, Russia.
Orshanskaya V. S., Kamenev A. V., Belyakova L. A., Mikhaylov E. N., Lebedev D. S .
Aim. To evaluate an extent of left arrial (LA) electroanatomical substrate (EAS) by the method of high density contact mapping in patients with atrial fibrillation (AF) and estimate its impact on recurrence rate following circular radiofrequency pulmonary veins (PV) isolation in prospective observational study.
Material and methods. Totally 181 high symptomatic subjects with paroxysmal (142 pts) and persistent (39 pts) AF, who underwent circular RF PVI were enrolled. We created and prospectively analyzed LA electroanatomical high density bipolar maps. Bipolar signals ≤0.75mV, associated with local conduction velocity delay <1 m/s were tagged on LA maps and considered as EAS. Relative EAS areas outside PV ostia were consistently measured. All of the patients were followed up at least for 3 years and AF recurrence rate and redo procedures were recorded.
Results. A mean relative EAS area was 13.8±10.3% and 32.6±18.5% in patients with paroxysmal and persistent AF, respectively (P=0,02). During a mean follow-up of 32±7 months, AF recurrence was diagnosed in 69 (38%) of patients. Following a redo ablation in 51 (28%) of patients, subsequent AF recurrence developed in 31 pts (19%). Multivariate analysis showed that only relative EAS areas was independently associated with AF recurrence (HR 1.05, CI 95% 1.02-1.09, P=0.002) and ach 10% increase in the extent of relative EAS area was associated with a 1.6-fold elevation of AF recurrence rate after the index ablation. But the impact of the EAS on clinical outcome after redo ablation was even higher (HR =1,09, p=0,0018) and each 10% increase in the extent of relative EAS area was associated with a 2.4-fold elevation of AF recurrence rate after a redo ablation.
Conclusion. The present study suggests that an extent of LA EAS in patients undergoing PVI — is a significant and independent predictor of AF recurrence. This data can have important role for further development and personalization of strategy of interventional treatment in patients with AF.
Key words: atrial fibrillation, circular isolation of pulmonary veins, risk of atrial fibrillation relapse, high density contact mapping, electroanatomical substrate.
Parmon E. V., Gordeeva M. S ., Kurilenko T . A., Berngardt E. R.
Aim. To investigate on the QRS complex fragmentation (fQRS) in patients with idiopathic ventricular arrhythmias (VA) .
Material and methods. Totally, 125 patients, selected into 2 groups: 1st group — 100 patients (mean age 46,4±14,1 y., 69 females) with idiopathic VRD. Patients had predominating daytime arrhythmia (63%), more oftenly — monomorphic ventricular exstrasystolic complexes (VE) (59%), in 39% patients — paroxysms of nonsustained ventricular tachicardia. Structural pathology of myocardium was ruled out based on electrocardiography data, echocardiography, in some cases — magnetic resonance. Second, control group — 25 pts. (69,0±11 y. o., 12 females) with VRD of ischemic origin (coronary heart disease, myocardial infarction in anamnesis). In this group, polymorphic (84%) daytime (68%) VE predominated, and in 25% — nonsustained ventricular tachicardia. Analysis was done with Holter ECG in 12 leads (“KTResult 2”, “Inkart” JSC).
Results. In the 1st group, fQRS of sinus complexes was registered in 2 patients (2%) and was transient. Relations in 24-hour dynamics of fQRS were not found. FQRS in VE was registered in 25 patients (25%). One patient had fQRS of sinus complexes as well as fQRS in VE. In 17 patients (68%) fQRS was found in VE. In controls, fQRS of sinus complexes was found in 6 patients (24%), fQRS of VE — in 23 (92%) and was permanent.
Conclusion. The phenomenon of fQRS can be found during routine instrumental investigation (standard ECG or Holter ECG), and is more common for CHD patients, being significant criteria for repolarization processes evaluation. Looking for fQRS in patients with idiopathic VRD, probably, is related to dysbalance of autonomous nervous regulation that leads to electrical instability of myocardium. It cannot be ruled out that fQRS might be an early marker of cardiomyopathies. It is necessary to investigate on this phenomenon further and to find its place in risk stratification of sudden cardiac death of patients with no structural heart pathology.
Key words: QRS fragmentation, electrical instability of myocardium, depolarization, ECG, Holter monitoring,. ventricular arrhythmias (VA).
Recent guidelines it is permitted to continue aspirin before coronary bypass operation (CBG) (Class I, Level B). Nevertheless, absence of randomized multicenter studies makes it possible not to follow these in routine practice as the only. Practive of aspirin discontinuation before CBG is quite common due to anticipated risks of post-surgery complications.
Aim. To evaluate the safety of CBG with continued aspirin.
Material and methods. For the safety assessment of aspirin before CBG, we conducted prospective randomized study. Patients with stable coronary heart disease were included, who underwent CBG with continued aspirin (aspirin group), and another group included those who had aspirin discontinued (controls). Totally, 74 patients randomized. Treatment group included 37 patients, and 37 controls. Follow-up lasted for 5 minutes. As primary endpoint, the volume of operational blood loss was taken, during the next 24 hours post-surgery. As the second endpoint, the combination was taken as any cardiovascular adverse event: cardiac death, perioperational myocardial infarction, ischemic stroke.
Results. There was noted, the comparability of intraoperational blood loss in comparison groups (p=0,166). Summary blood loss in 24 hours of postoperational blood loss showed statistical significance between groups (mean difference 100 mL, 95% CI 0-110 mL, p=0,027). This amount of blood loss is clinically non-significant. In aspirin group, there were 2 cases of perioperational myocardial infarction, by cardiac enzymes elevation, not statistically significant.
Conclusion. Results of the study witness for the safety of CBG operations under continued aspirin as well as discontinued at least 5 days before surgery.
Key words: cardiovascular system, coronary bypass grafting, aspirin.
1E.N. Meshalkin Novosibirsk Scientific-Research Institute of Circulation Pathology, Novosibirsk; 2Institute of Computational Mathematics and Mathematical Geophysics, Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia.
COMBINATION OF AZILSARTAN MEDOXOMIL AND CHLORTHALIDONE: IS IT POSSIBLE TO FIGHT SYSTEMIC HYPERTENSION AND OBESITY TOGETHER?
Vasyuk Yu. A., Shupenina E. Yu., Nesterova E. A., Golubkova E. I., Nesvetov V. V.
Arterial hypertension (AH) and obesity are the main risk factors of chronic noncommunicable diseases. Adipous tissue is not only a depot for energetic compounds, but is an active endocrine organ synthetizing biologically active substances that facilitate development of AH. Patients with AH and obesity are in the high cardiovascular risk group and demand effective combination antihypertension therapy. One of such drugs is the fixed combination of azilsartan medoxomil and chlorthalidone, which safety and efficacy are confirmed by various trials. Our clinical case demonstrates positive action of Edarbi Сlo on office and 24-hour blood pressure (BP), main parameters of aorta stiffness and structural and functional condition of myocardium at rest, as in exertion in patient with AH and obesity.
Key words: arterial hypertension, obesity, aortic stiffness, diastolic dysfunction, exercise tolerance.
Aim. To investigate on the ways antihypertension drugs (AD) prescription, including, firstly, combinational therapy, in real conditions, by the data from two outpatient registries done in district polyclinics of Ryazan city (RECVASA) and in specialized scientific center in Moscow (PROFILE).
Material and methods. To the RECVAZA registry, 3690 patients were included, with cardiovascular diseases, and in 3648 (98,9%) arterial hypertension was diagnosed. Among 1531 patient’s data included into PROFILE registry during August 2011 — August 2015, hypertension was diagnosed in 1230 (80,3%). Mean age of RECVASA and PROFILE patients was 66,3±12,8 и 63,7±11,4, respectively. In overall data, males and females ratio were 28% and 72%, respectively, in RECVASA, and 54% and 46%, resp., in PROFILE.
Results. In comparative analysis of the registries, it was found that RECVASA patients were older, and women predominated (72%). Hypertension was diagnosed in almost 100%, was more severe and more comorbid. By the number of prescribed AD, both registries were almost identical: every third patient was prescribed 2 drugs, every fourth — 3, every fifth was taking 1 drug. Fixed combinations of AD were used in 15%, in both registries. The target blood pressure profile was reached in 26,1% of hypertension patients in RECVASA and in 37,6% in PROFILE; in hypertension of 3rd degree — in 21,9% and 34,2% cases, respectively.
Conclusion. In generally analogical approaches to AD, matching with current clinical guidelines, final result of treatment in terms of reached target blood pressure values, was significantly better in specialized cardiological center. This, probably, reflects better adherence to therapy in PROFILE patients.
Key words: outpatients registries, arterial hypertension, combination antihypertension therapy, fixed combinations.
1National Research Center for Preventive Medicine of the Ministry of Health, Moscow; 2Ryazansky State Medical University named after I. P. Pavlov, Ryazan, Russia.
Workgroup of the PROFILE registry: Voronina V. P., Dmitrieva N. A., Zakharova A. V., Zagrebelny A. V., Kutishenko N. P., Lerman O. V., Lukina Yu. V., Tolpygina S . N., Martsevich S . Y.
Workgroup of the RECVASA registry: Vorobyev A. N., Zagrebelniy A. V., Kozminsky A. N., Lukina Yu. V., Lukyanov M. M., Moseichuk K. A., Nikulina N. N., Pereverzeva K. G., Pravkina E. A., Boitsov S . A., Martsevich S. Yu., Yakushin S. S.
The review focuses on the gathered data related to preconditioning phenomenon and, particularly, pharmacological preconditioning of myocardium. The information presented, on the activator of ATP-dependent potassium channels nicorandil. Mechanism of action is discussed, as efficacy and safety data. The evidence shows that, recently, nicorandil is not an obligatory medication to follow percutaneous intervention on coronary arteries, though clinical trials data confirm the possibility of periprocedural myocardium damage risk reduction, if the drug is prescribed in advance. The data presented, on positive influence of nicorandil on myocardial contractility and clinical outcomes.
Key words: pharmacological preconditioning of myocardium, nicorandil, activator of ATP-dependent potassium channels, percutaneous coronary interventions, cardiac enzymes.
1National Medical Research Center for Cardiology, Moscow; 2Moscow Regional Research and Clinical Institute (MONIKI), Moscow, Russia.
Osiev A. G., Gegenava B. B., Paleev F. N., Grigoryeva N. M.
Alcohol septal ablation was introduced in 1994 as an alternative for surgical septal myectomy in patients with obstructive hypertrophic cardiomyopathy refractory to drug treatment. The procedure decreases symptoms of the disease creating targeted localized infarction focus of the upper part of interventricular spetum leading to increase of outgoing tract diameter, decrease of pressure gradient at the level of outgoing left ventricle tract and hypertrophy regression caused by overload. Such clinical improvement can be achieved in most cases. Main complication of the alcohol-based ablation — complete atrioventricular block with necessity, in some patients, of permanent cardiostimulator. Contrast echocradiography during alcohol septal ablation makes it to localize infarction, to use less amount of alcohol and, therefore, to decrease complications rate.
Key words: alcohol-based septal ablation, obstructive hypertrophic cardiomyopathy, atrioventricular block, contrast echocardiography, coronary arteriography.

matches: V. V. V. V. V. V. V. V. V. V.


Attorney Timothy D. McGonigle has successfully represented numerous clients in appellate matters in California's state and federal courts. From his office in Los Angeles, he handles appeals throughout Los Angeles County and across the state. He has several reported decisions covering a broad span of litigation topics.
Mr. McGonigle understands the differences in procedure between the state and federal courts, and he knows the criteria they use to review appeals. From notifying the court of the intent to appeal to submitting the appellate brief and delivering oral arguments when appropriate, attorney McGonigle possesses the ability and the skill to navigate every aspect of the appellate process.
Flora Dolnikov v. Dikran Ekizian, et al: In this case, Flora Dolnikov, an owner of dominant tenement sought damages for interference with her easement, injunctive relief, and a declaration of the parties' rights and duties under the easement. The servient tenement owner cross-complained seeking damages for, among other things, trespass, negligence, and nuisance. When Superior Court Judge Robert L. Hess entered judgment on jury verdict in favor of Flora Dolnikov was awarded, among other things, $713,927.96 in damages and interest.
The Court of Appeals upheld Judge Hess' ruling on grounds that Mr. McGonigle had successfully demonstrated at oral argument: (1) his client was entitled to build a retaining wall in furtherance of her rights and her full enjoyment of the easement and (2) the servient tenement owners' refusal to sign documents constituted an unreasonable interference with Flora's use and enjoyment of the easement.
Apex, LLC v. Sharing World, Inc.: Securing a sweeping victory, Timothy McGonigle successfully appealed a trial court's verdict in a case involving Defendant Sharing World, Inc.'s refusal to pay his client, Apex LLC, for cottonseed based on an enforceable oral agreement. The trial court had found in favor of Sharing World, Inc., holding that there was no evidence of mutual assent due to lack of certain contract terms. However, in accordance with Mr. McGonigle's reasoning, the Appellate Court reversed the erroneous trial court decision, holding that, since both parties clearly intended to enter into the contracts, the Uniform Commercial Code provided gap fillers to cover the terms left open by the parties' oral agreement.
Mordechai Kachlon, et al. v. Donald J. Markowitz: Timothy McGonigle secured a precedent-setting victory for his client, Donald J. Markowitz, in a wrongful foreclosure case brought against his client's residence. The Court of Appeals adopted Mr. McGonigle's argument and held in a published opinion that Civil Code §2924 deems the statutorily required mailing, publication, and delivery of notices in nonjudicial foreclosure, and the performance of statutory nonjudicial foreclosure procedures, to be privileged communications under the qualified, common-interest privilege of Civil Code §47(c)(1).
Mt. Holyoke Homes L.P. v. Jeffer Mangels Butler & Mitchell, LLP: Timothy McGonigle won a resounding victory for his clients, Mt. Holyoke Homes, L.P. and Darla Jones, when he successfully filed an appeal to vacate an arbitration award in a legal malpractice action. The Court of Appeals adopted Mr. McGonigle's argument that the trial court should have granted Mt. Holyoke Homes L.P.'s motion to vacate the arbitration award due to the arbitrator's failure to timely disclose a prior relationship with a partner of the defendant law firm. The Court of Appeals' opinion reversed the arbitrator's award and awarded Mr. McGonigle's clients all costs for appeal.
You are invited to contact Mr. McGonigle to discuss your appellate law matter. You can schedule an appointment with a lawyer by calling 310-478-7110. You may also contact the firm via email.