Dying in the ICU: perspectives of family members

OBJECTIVE: To describe the perspectives of family members to the care provided to critically ill patients who died in the ICU. DESIGN: Multicenter, prospective, observational study. SETTING: Six university-affiliated ICUs across Canada. METHODS: Patients who received mechanical ventilation for > 48 h and who died in the ICU were eligible for this study. Three to four weeks after the patient's death, we mailed a validated questionnaire to one selected family member who made at least one visit to the patient in the ICU. We obtained self-rated levels of satisfaction with key aspects of end-of-life care, communication, and decision making, and the overall ICU experience. Main results: Questionnaires were mailed to 413 family members; 256 completed surveys were returned (response rate, 62.0%). In the final hours before the death of the patient, family members reported that patients were "totally comfortable" (34.8%), "very comfortable" (23.8%), or "mostly comfortable" (32.0%). Family members felt "very supported" (57.0%) and "supported" (30.7%) by the health-care team. Most (82.0%) believed that the patient's life was neither prolonged nor shortened unnecessarily. Most family members (90.4%) preferred some form of shared decision making. Overall, 52% of families rated their satisfaction with care as "excellent," 31% rated care as "very good," 10% as "good," 4% as "fair," and 2% as "poor." Overall satisfaction with end-of-life care was significantly associated with completeness of information received by the family member, respect and compassion shown to patient and family member, and satisfaction with amount or level of health care received. CONCLUSIONS: The majority of families of patients who died in participating ICUs were satisfied with the end-of-life care provided. Adequate communication, good decision making, and respect and compassion shown to both the dying patient and their family are key determinants to family satisfaction.     

Quality of life perceived by chronic haemodialysis patients and family members

In this study quality of life perceived by 100 haemodialysis patients with family members' viewpoints on the patients' quality of life was studied. The SF-36 was used as the main measurement tool. According to the findings of the study the quality of life scores, perceived by patients, usually ranged between average and below average. The family members perceived patients' social functioning and functional status in the SF-36 more pessimistically but vitality and well-being in the SF-36 more optimistically, when compared to the patients. In the light of the findings obtained from the study, it is suggested to periodically assess the quality of life of haemodialysis patients considering the viewpoints of family members on the patients' quality of life.     

Quality of dying and death in two medical ICUs: perceptions of family and clinicians

OBJECTIVE: We compared perceptions of the quality of dying and death in the ICU across nurses, resident physicians, attending physicians, and family members. The aim was to obtain a surrogate assessment of the quality of the dying process and examine differences in the perceptions of different types of raters. DESIGN: Cross-sectional survey of family members and ICU clinicians conducted following the death of enrolled patients. SETTING: Two medical ICUs at academic tertiary care medical centers. PATIENTS: Patients dying in the ICU (n = 68). MEASUREMENTS AND RESULTS: The previously validated Quality of Dying and Death (QODD) instrument was modified for use in the ICU. Within 48 h of the time of death, the nurse, resident, and attending physician caring for the patient were asked to complete the QODD. One month following the death, a designated family member was contacted and the QODD was administered on the telephone. Family members and attending physicians gave the most favorable ratings of death, while nurses and residents provided less favorable ratings. Significant differences between these groups were notable (p < 0.01) on items related to patient autonomy: maintaining dignity, being touched by loved ones, and the overall quality of death. CONCLUSIONS: The perception of dying and death in the ICU varies considerably between nurses, attending physicians, resident physicians, and family members. Further studies are needed to explain these differences and determine the utility of the ICU QODD instrument for assessing and improving the quality of end-of-life care in the ICU.     

Liver histology in ICU patients dying from sepsis：A clinico-pathological study

AIM：To determine end-stage pathologic changes in the liver of septic patients dying in the intensive care unit.
METHODS： Needle liver biopsies obtained immediately after death from 15 consecutive patients with sepsis and no underlying liver disease were subjected to routine histological examination. Liver function tests and clinical monitoring measurements were also recorded.
RESULTS： Liver biochemistries were increased in the majority of patients before death. Histology of liver biopsy specimens showed portal inflammation in 73.3%, centrilobular necrosis in 80%, lobular inflammation in 66.7%, hepatocellular apoptosis in 66.6% and cholangitis/cholangiolitis in 20% of patients. Mixed hepatitic/ cholestatic type of liver injury was observed in 6/15 （40%） patients and hepatitc in 9/15 （60%）. Steatosis was observed in 11/15 （73.3%） patients affecting 5%-80% of liver parenchyma. Among the histological features, the presence of portal inflammation in liver biopsy was associated with increased hospitalization in the ICU prior death （P = 0.026）.
CONCLUSION： Features of hepatitis and steatosis arethe main histological findings in the liver in the majority of patients dying from sepsis.     

家庭聚集性人附红体病暴发的病例报告

我国自１９８０年开始对人畜附红细胞体（下简称附红体）感染进行研究以来至今未见家庭聚集性人附红体病暴发的病例报告。我们在今年开展人附红体病流行病学调查中发现一户５口家庭全部感染附红体且有４人在１１天内先后发病,以庆大或强力霉素治愈。现报告如下。　　例１,患儿林某,女,１１岁,１９９８年８月２０日因发热５天不退就诊于县医院,以可疑副伤寒收住儿科。入院查体：急性病容神清,肝脾未触及,浅表淋巴结未扪及,体温４０℃～４０．５℃,实验室检查：ＷＢＣ、ＲＢＣ正常,ＨＢ９８ｇ／Ｌ,ＨＣＴ０．２９５ｌ／Ｌ,白细胞…     

The forgotten members of the glucagon family

From proglucagon, at least six final biologically active peptides are produced by tissue-specific post-translational processing. While glucagon and GLP-1 are the subject of permanent studies, the four others are usually left in the shadow, in spite of their large biological interest. The present review is devoted to oxyntomodulin and miniglucagon, not forgetting glicentin, although much less is known about it. Oxyntomodulin (OXM) and glicentin are regulators of gastric acid and hydromineral intestinal secretions. OXM is also deeply involved in the control of food intake and energy expenditure, properties that make this peptide a credible treatment of obesity if the question of administration is solved, as for any peptide. Miniglucagon, the C-terminal undecapeptide of glucagon which results from a secondary processing of original nature, displays properties antagonistic to that of the mother-hormone glucagon: (a) it inhibits glucose-, glucagon- and GLP-1-stimulated insulin release at sub-picomolar concentrations, (b) it reduces the in vivo insulin response to glucose with no change in glycemia, (c) it displays insulin-like properties at the cellular level using only a part of the pathway used by insulin, making it a good basis for developing a pharmacological workaround of insulin resistance.     

Plasmid transfer into members of the family Legionellaceae

The plasmids RP4 and pPH1JI::Mu::Tn5 were transferred with moderate frequency from Escherichia coli to Legionella pneumophila (strain Bloomington 2) and Fluoribacter (Legionella) bozemanae (strain WIGA). The frequency of transfer to Tatlockia (Legionella) micdadei (strain Tatlock) was much lower. In these transconjugant strains the plasmids were maintained following at least 10 nonselective passages. However, the introduced plasmids could not be transferred from these strains to several other strains of Legionella or Tatlockia with a detectable frequency, yet they could be transferred to a restriction-modification deficient (rm-) E. coli strain with moderate frequency. This suggests not only that the expression of transfer genes may be repressed but that the legionellae are poorer recipients than are the rm- E. coli.     

Vitamin A hepatotoxicity in multiple family members

Three of five family members experienced symptoms and biochemical evidence of hepatitis that could not be explained on the basis of infectious, metabolic or immunologic disorders of the liver. A history of prolonged ingestion of moderate amounts of vitamin A (20,000 to 45,000 IU per day for 7 to 10 years) was obtained in each of the three family members and was absent in the remaining two unaffected individuals. A liver biopsy performed in one family member confirmed the diagnosis of vitamin A toxicity. This report emphasizes the finding that even moderate amounts of vitamin A, when ingested over a prolonged period of time, can cause significant hepatocellular injury.     

Epidermal growth factor family members: endogenous mediators of the ovulatory response

Previous studies showed that epidermal growth factor (EGF) and TGFalpha mimic the action of LH on the resumption of oocyte maturation. We tested whether EGF-like agents, such as amphiregulin (AR), epiregulin (ER), and betacellulin (BTC), also mediate the LH stimulation of the ovulatory response in the rat. LH induced transient follicular expression of AR, ER, and BTC mRNA, reaching a maximum after 3-h incubation. Furthermore, the addition of ER, AR, and BTC to the culture medium could mimic some of LH actions. AR and ER fully simulated LH-induced resumption of meiosis in vitro, whereas BTC was less effective. To study the putative involvement of EGF-like factors in mediation of LH signal, the effect of the EGF receptor kinase inhibitor AG1478 was tested. When added with LH, AG1478, but not its inactive analog AG43, reduced EGF receptor phosphorylation and oocyte maturation compared with follicles treated with LH only. In addition to the inhibition of resumption of meiosis, AG1478 administration into the bursa (3 microg/bursa) resulted in 51% (P < 0.0005) inhibition of ovulation in the treated ovaries, compared with the untreated contralateral ones, as well as to the vehicle-treated ovaries (P < 0.02). LH, as well as ER, induced the expression of genes associated with the ovulatory response like rat hyaluronan synthase-2, cyclooxygenase-2, and TNFalpha-stimulated gene 6 mRNA, whereas AG1478 inhibited this effect of LH. Release of EGF-like factors from the membrane is dependent on activated metalloproteases. Indeed, Galardin, a broad-spectrum metalloprotease inhibitor, but not a specific matrix metalloprotease 2 and 9 inhibitor, suppressed meiotic maturation induced by LH. Conversely, meiotic maturation induced by ER was not affected by Galardin, thus, supporting the notion that LH releases follicular membrane-bound EGF-like agents. In summary, EGF-like factors such as ER, AR, and BTC seem to mediate, at least partially, the LH stimulation of oocyte maturation, ovulatory enzyme expression, and ovulation.     

Familial monoclonal gammopathy: hyper-responsive B cells in unaffected family members

Background: In Iceland, eight families have been identified with multiple cases of monoclonal gammopathies (MG) and other lymphoproliferative diseases. In one of these families with several cases of monoclonal gammopathy of undetermined significance (MGUS) and Waldenströms macroglobulinemia, in vitro stimulation with poke‐weed mitogen revealed hyper‐responsive B cells showing increased immunoglobulin production in one‐third of disease‐free family members. Design and methods: In this study, the families were further traced and the list of names produced was compared with The Icelandic Cancer Registry (ICR) to find all recent cases of lymphoproliferative diseases. First‐degree relatives and descendants older than 20 yrs of age (n = 350) were selected for screening for paraprotein. Selected family members were tested for B‐cell hyper‐responsiveness and the lymphocyte phenotype was analysed by flow cytometry. Results: Comparison of the total list of 4370 family members with the ICR revealed 22 new cases and screening for serum paraprotein identified nine new cases of MG, eight being first‐degree relatives of known probands. Sixty cases of lymphoproliferative diseases are currently known within the eight families, five of them containing both IgG/A and IgM disorders. Twelve hyper‐responders (HR) were identified in four families, eight from one family, of whom four were known already. Stimulated B cells from HR had a significantly higher proportion of CD27⁺ memory/plasma cells than controls. Conclusion: Identification of new affected family members by screening confirms a hereditary predisposition to B‐cell proliferative diseases. Contrary to most studies, IgG/A and IgM disorders occurred together in five families. In four families, enhanced B‐cell responsiveness was found in healthy subjects clustered around cases.     

Modulation of smooth muscle cell migration by members of the low-density lipoprotein receptor family

Low-density lipoprotein receptor family members (LRs) play a key role in the catabolism of many membrane-associated proteins, such as complexes between proteinases and their receptors, in addition to being involved in lipoprotein metabolism as suspected by the hitherto well-established functions of low-density lipoprotein receptor, in a variety of tissues. Recent studies using receptor-deficient or -overexpressing animals and cells have suggested that certain LRs are important regulators of the migration (and proliferation) of vascular smooth muscle cells (SMCs). LR expression is markedly induced in intimal or medial SMCs during the formation of atherosclerotic lesions. Because LRs can modulate the activity of the urokinase-type plasminogen activator (uPA) receptor and possibly of the platelet-derived growth factor (PDGF) receptor, LRs may influence the migration of SMCs through functional modulation of these membrane receptors. Therefore, SMC migration may be regulated by time-restricted expression of LRs. In agreement with the concept of functional interaction between LRs and membrane signaling receptors, a negative regulator of uPA receptor protein catabolism, LR11, has been identified. Statins modulate the PDGF-induced migration of intimal SMCs via the LR11/uPA receptor cascade. Selective modification of the LRs/uPA receptor/PDGF receptor systems in SMCs may be important for suppression of atherosclerotic plaque formation as well as for preventing intimal thickening after angioplasty.