Health Care System Distrust, Race, and Surrogate Decision-Making Regarding Code Status.

Purpose: Previous studies have shown that black patients are more likely to prefer life-sustaining treatments such as cardiopulmonary resuscitation at end-of-life (EOL) compared to non-Hispanic white patients. Given prior racial disparities in health care, distrust has been proposed to explain these preferences. As many hospitalized older adults require surrogates to make medical decisions, we explored surrogates' code status preferences and the role of trust in these decisions. Methods: We conducted secondary analyses of an observational study of patient/surrogate dyads admitted to three hospitals in a Midwest metropolitan area. Distrust was assessed using the Revised Health Care System Distrust Scale. A single item asked the surrogate which code status they thought was best for the patient, full code or do not resuscitate. Results: We enrolled 350 patient/surrogate dyads (101 black; 249 white). In bivariate analysis, higher proportion of black surrogates preferred full code (62.4% vs. 38.3%, p=0.0001). After adjusting for trust and sociodemographic and psychological covariates, race was still significantly associated with preference for full code (adjusted odds ratio=2.13; 95% confidence interval: 1.16-3.92; p=0.0153). Surrogate race was not associated with distrust in bivariate or multivariable analysis, adjusting for sociodemographic and psychological covariates (p=0.3049). Conclusion: Although black race was associated with preferences for full code status, we observed no association between race and distrust. Differences in code status preference may be due to other factors related to race and culture. To ensure that patients are receiving EOL care that is consistent with their values, more work is needed to understand the cultural complexities behind EOL care preferences.

Atom Economical Multi-Substituted Pyrrole Synthesis from Aziridine.

Multi-substituted pyrroles are synthesized from regiospecific aziridine ring-opening and subsequent intramolecular cyclization with a carbonyl group at the γ-position in the presence of Lewis acid or protic acid. This method is highly atom economical where all the atoms of the reactants are incorporated into the final product with the removal of water. This new protocol is applied to the synthesis of various pyrroles, including natural products.

Quantitative assessment of Aß peptide in brain, cerebrospinal fluid and plasma following oral administration of γ-secretase inhibitor MRK-560 in rats.

The ß-amyloid peptides (Aß) are thought to play a critical role in the pathophysiology of Alzheimer's disease. One therapeutic strategy aimed to reduce or eliminate the production of Aß peptides is inhibition of the γ-secretase enzyme, which cleaves amyloid precursor protein to form Aß peptides. We studied the in vivo effects of the potent, orally bioavailable and brain penetrant γ-secretase inhibitor (GSI), MRK-560, on both Aßx-40 and Aßx-42 in multiple compartments (plasma, the brain and cerebrospinal fluid) of rat. Although there were differences in the time course and magnitude of the changes, the results showed that MRK-560 caused marked inhibition of both Aßx-40 and Aßx-42 in all three compartments. We identified good correlations between plasma Aßx-40 versus brain Aßx-40 (r = 0.84), and plasma Aßx-40 versus CSF Aßx-40 (r = 0.85), indicating that these pools of Aß are related dynamically. These results suggest that central Aß changes that occur following acute dosing with MRK-560 can be predicted based on plasma Aß changes and could thus serve as a useful biomarker to help accelerate decision-making during early clinical development.

Comparison of robot-assisted and conventional total knee arthroplasty: a controlled cadaver study using multiparameter quantitative three-dimensional CT assessment of alignment.

INTRODUCTION: A functional total knee replacement has to be well aligned, which implies that it should lie along the mechanical axis and in the correct axial and rotational planes. Incorrect alignment will lead to abnormal wear, early mechanical loosening, and patellofemoral problems. There has been increased interest of late in total knee arthroplasty with robotic assistance. This study was conducted to determine whether robot-assisted total knee arthroplasty is superior to the conventional surgical method with regard to the precision of implant positioning. MATERIALS AND METHODS: Twenty knee replacements, comprising ten robot-assisted procedures and ten conventional operations, were performed on ten cadavers. Two experienced surgeons performed the surgeries. Both procedures on each cadaver were performed by the same surgeon. The choice of which procedure was to be performed first was randomized. Following implantation of the prosthesis, the mechanical axis deviation, femoral coronal angle, tibial coronal angle, femoral sagittal angle, tibial sagittal angle, and femoral rotational alignment were measured via 3D CT scanning. These variables were then compared with the preoperatively planned values. RESULTS: In the knees that underwent robot-assisted surgery, the mechanical axis deviation ranged from -1.94° to 2.13° (mean: -0.21°), the femoral coronal angle from 88.08° to 90.99° (mean: 89.81°), the tibial coronal angle from 89.01° to 92.36° (mean: 90.42°), the tibial sagittal angle from 81.72° to 86.24° (mean: 83.20°), and the femoral rotational alignment from 0.02° to 1.15° (mean: 0.52°) in relation to the transepicondylar axis. In the knees that underwent conventional surgery, the mechanical axis deviation ranged from -3.19° to 3.84° (mean: -0.48°), the femoral coronal angle from 88.36° to 92.29° (mean: 90.50°), the tibial coronal angle from 88.15° to 91.51° (mean: 89.83°), the tibial sagittal angle from 80.06° to 87.34° (mean: 84.50°), and the femoral rotational alignment from 0.32° to 4.13° (mean: 2.76°) in relation to the transepicondylar axis. In the conventional knee replacement group, there were two instances of outliers outside the range of 3° varus/valgus for the mechanical axis deviation. The robot-assisted knee replacements showed significantly superior femoral rotational alignment results compared with conventional surgery (p = 0.006). There was no statistically significant difference between robot-assisted and conventional total knee arthroplasty with regard to the other variables. All the measurements showed high intra-observer and inter-observer reliability. CONCLUSION: Robot-assisted total knee arthroplasty showed excellent precision in the sagittal and coronal planes of the 3D CT scan. In particular, the robot-assisted technique showed better accuracy in femoral rotational alignment compared to the conventional surgery, despite the fact that the surgeons who performed the operations were more experienced and familiar with the conventional method than with robot-assisted surgery. It can thus be concluded that robot-assisted total knee arthroplasty is superior to conventional total knee arthroplasty.