The facilitated values history: helping surrogates make authentic decisions for incapacitated patients with advanced illness

Many patients who develop incapacitating illness have not expressed clear treatment preferences. Therefore, surrogate decision makers are asked to make judgments about what treatment pathway is most consistent with the patient's values. Surrogates often struggle with such decisions. The difficulty arises because answering the seemingly straightforward question, "What do you think the patient would choose?" is emotionally, cognitively, and morally complex. There is little guidance for clinicians to assist families in constructing an authentic picture of the patient's values and applying them to medical decisions, in part because current models of medical decision making treat the surrogate as the expert on the patient's values and the physician as the expert on technical medical considerations. However, many surrogates need assistance in identifying and working through the sometimes conflicting values relevant to medical decisions near the end of life. We present a framework for clinicians to help surrogates overcome the emotional, cognitive, and moral barriers to high-quality surrogate decision making for incapacitated patients.     

HIV positive pregnant women who do not follow the prenatal prophylaxis

This is an exploratory study based on a qualitative approach. The objective was to investigate why HIV positive pregnant women do not follow the treatment which is recommended by the Health Ministry during the prenatal period. The individuals participating of this investigation were seven HIV positive women who, during their pregnancy, did not follow the prophylaxis treatment currently recommended. The data were collected by means of semi-structured interviews. Categories based on what these individuals reported were then stipulated and the results showed that women are in a vulnerable position regarding the negotiation of safe sex with their partners. Moreover, low social and economical conditions and lack of affection lead women to become victims of HIV/AIDS.     

Answer to “REPLY to Association between Plasmatic Oxidative Stress and Thrombosis in Primary Antiphospholipid Syndrome”

Journal of Thrombosis and Thrombolysis - Left atrial appendage (LAA), a blind pouch, accounts for more than 90% of the source of cardiac thrombus formation. Contrast retention (CR) in the LAA has...     

Radiosynthesis and biological evaluation of an 18F-labeled derivative of the novel pyrazolopyrimidine sedative-hypnotic agent indiplon

INTRODUCTION: Gamma amino butyric acid type A (GABA(A)) receptors are involved in a variety of neurological and psychiatric diseases, which have promoted the development and use of radiotracers for positron emission tomography imaging. Radiolabeled benzodiazepine antagonists such as flumazenil have most extensively been used for this purpose so far. Recently, the non-benzodiazepine pyrazolopyrimidine derivative indiplon with higher specificity for the alpha(1) subtype of the GABA(A) receptor has been introduced for treatment of insomnia. The aim of this study was the development and biological evaluation of an (18)F-labeled derivative of indiplon. METHODS: Both [(18)F]fluoro-indiplon and its labeling precursor were synthesized by two-step procedures starting from indiplon. The radiosynthesis of [(18)F]fluoro-indiplon was performed using the bromoacetyl precursor followed by multiple-stage purification using semipreparative HPLC and solid phase extraction. Stability, partition coefficients, binding affinities and regional brain binding were determined in vitro. Biodistribution and radiotracer metabolism were studied in vivo. RESULTS: [(18)F]Fluoro-indiplon was readily accessible in good yields (38-43%), with high purity and high specific radioactivity (>150 GBq/micromol). It displays high in vitro stability and moderate lipophilicity. [(18)F]Fluoro-indiplon has an affinity to GABA(A) receptors comparable to indiplon (K(i)=8.0 nM vs. 3.4 nM). In vitro autoradiography indicates high [(18)F]fluoro-indiplon binding in regions with high densities of GABA(A) receptors. However, ex vivo autoradiography and organ distribution studies show no evidence of specific binding of [(18)F]fluoro-indiplon. Furthermore, the radiotracer is rapidly metabolized with high accumulation of labeled metabolites in the brain. CONCLUSIONS: Although [(18)F]fluoro-indiplon shows good in vitro features, it is not suitable for in vivo imaging studies because of its metabolism. Structural modifications are needed to develop derivatives with higher in vivo stability.     

A comparative study of IgG second- and third-generation anti-cyclic citrullinated peptide (CCP) ELISAs and their combination with IgA third-generation CCP ELISA for the diagnosis of rheumatoid arthritis

To compare IgG anti-cyclic citrullinated peptide (CCP) enzyme-linked immunosorbent assays (ELISAs) of second (anti-CCP2) and third generations (anti-CCP3) for the diagnosis of rheumatoid arthritis (RA), an IgA CCP3 ELISA was also evaluated. Combinations of the use of the three tests were evaluated. Anti-CCP2 IgG, anti-CCP3 IgG, and anti-CCP3 IgA antibody levels were determined by ELISAs in the serum of 70 patients with rheumatoid arthritis, 34 patients with systemic lupus erythematosus (SLE), and 54 normal subjects. We evaluated the serum levels, diagnostic performance, and the use of a combination of tests for RA diagnosis. Statistical analyses include receiver operating curves (ROCs) and others. The serum levels were higher in RA patients. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio (LR), and negative LR were, respectively, 78.6%, 94.3%, 91.7%, 84.7%, 13.8, and 0.23 for anti- CCP2 IgG and 82.9%, 93.2%, 90.6%, 87.2%, 12.2, and 0.18 for anti-CCP3 IgG. These values were better than the same statistical tests for anti-CCP3 IgA. ROC analysis showed that anti-CCP2 IgG and anti-CCP3 IgG had good performance and similar areas. Measuring both IgG and IgA anti-CCP tests increases the specificity if both tests were positive and increases the sensitivity if either test were positive. In our population, anti-CCP2 IgG and anti-CCP3 IgG had good diagnostic performance. Anti-CCP3 IgG had 4.3% more sensitivity than the anti-CCP2 IgG test while sustaining high specificity. This and other studies suggest the development of a dual test—CCP3 IgG and IgA that may be a potential diagnostic tool.