Automated image analysis of Euglena gracilis Klebs (Euglenophyta) for measuring sublethal effects of three model contaminants

The short-term impacts of atrazine (herbicide), tributyltin (organometal) and copper on the behaviour of Euglena gracilis Klebs (Euglenophyta) were assessed. First, the ECOTOX automated image analysis system was used, which measured swimming velocity, cell shape, percentage of cells swimming upwards, and randomness of swimming. Next, visual observation by microscopy was used to measure percentage of cell motility and cell shape. Behavioural changes can be used as an indicator of stress in less than 24 h, potentially making them suitable for inclusion in early-warning systems for water quality. Findings indicate that E. gracilis is a very sensitive organism to copper, showing inhibition of motility with visual observation at 0.8 μmol/L within 1 h. The image analysis system was in general less sensitive than visual observation for detecting behavioural changes after incubation in copper. In contrast, after exposure to organic contaminants atrazine and tributyltin, the ECOTOX system detected small changes in the number of cells swimming upwards (antigravitactic behaviour) at higher concentrations.

Health-related quality of life in patients reliant upon mitrofanoff catheterisation

OBJECTIVE

Aim of the study was determine health care outcomes from the patients' perspective in patients reliant on Mitrofanoff catheterisation for bladder emptying.

SUBJECTS/PATIENTS

Patients over the age of 16 dependent on Mitrofanoff catheterisation for bladder emptying were asked to complete a health care outcome questionnaire, the SF-36 (®) Health Survey v2. Quality of life measures for 8 health concepts were compared against published data for the normal population.

RESULTS

Out of a total of 25 patients who were eligible for enrolment into our study, we were able to contact 19 patients. The norm-based score for Physical Functioning (PF=50.4), Role Physical (RP=53.8), Bodily Pain (BP=55.6), Vitality (VT=56.9), Social Functioning (SF=51.5), Role Emotional (RE=52.2), and Mental Health (MH=54.6) were all higher than those reported within the normal population (normal=50.0). Physical and mental component summary measures were higher than in the normal population. When compared against age-matched norms our patient group scored higher than the normal population for all measures except Physical Functioning (50.4 vs. 53.4) and physical component summary (51.9 vs. 53.5). The self-reported scores for Vitality, Mental Health and the mental component summary were all statistically significantly better than those seen in the age-matched control population (p<0.01).

CONCLUSIONS

Quality of life in patients dependent on Mitrofanoff catheterisation for bladder emptying is good. The SF-36 measures 8 major health care outcomes and in our patients these measures of health were similar to those seen in the general population, rather than the poorer outcomes reported in patients with other chronic medical conditions.

What is the effect of circumcision on risk of urinary tract infection in boys with posterior urethral valves?

PURPOSE

Boys with posterior urethral valves (PUV) have increased risks of urinary tract infection (UTI) voiding dysfunction and ongoing renal damage. Circumcision has been shown epidemiologically to reduce UTIs, but no trial has yet confirmed this in PUV. Circumcision is not routinely performed in boys with PUV in our unit, but one quarter of our patients are circumcised for religious reasons. It may be hypothesized that circumcision reduces the risk of subsequent urinary tract infection in boys with PUV. This study aims to test this hypothesis by comparing the risk of UTI, and subsequent renal outcome, in PUV in uncircumcised boys with those who were circumcised.

METHODS

A retrospective cross-sectional case note review of boys with PUV was performed, and the following were documented: age at presentation, method of diagnosis, method of treatment, initial renal status, and timing of treatment; use and timing of urinary tract diversion; timing of circumcision; and UTIs-date, organism, and treatment.

RESULTS

Seventy-eight patients were identified, mean age 6.7 years (range, 1-18). These boys experienced 78 UTIs in the uncircumcised state. Subsequently, 27 were circumcised, experiencing 8 UTIs. Eighteen boys were diverted. The incidence of UTI was reduced from 0.50 +/- 0.14 (mean +/- SEM) UTIs annually uncircumcised to 0.09 +/- 0.02 (mean +/- SEM) circumcised (P < .01, Student's t test).

CONCLUSION

In PUV, circumcision reduces the incidence of UTI by 83%, every circumcision prevents 1 UTI on average. Early circumcision in all PUV is beneficial, but a larger randomised control trial should be considered to confirm this.

Frequency of risk factors that potentially increase harm from medications in older adults receiving primary care

BACKGROUND

Many circumstances elevate patients, especially older adults, risk for drug-related morbidity and misadventures. Understanding the frequency of these situations can help with the design of initiatives to address or alter these circumstances with the aim of reducing medication therapy-related concerns and associated expenditures.

OBJECTIVE

To describe the frequency of circumstances that may place older adults at higher risk for drug-related morbidity and misadventures in a large sample of elderly patients visiting family medicine clinics.

METHODS

Elderly adults at 7 family medicine practices across Ontario self-completed the 10-item Medication Risk Questionnaire (MRQ).

RESULTS

Surveys were completed by 907 patients, with a mean age of 72.4 (SD 10.7) years and a mean number of 4.8 medical conditions (SD 2.3; min-max: 0-14). Many subjects were taking multiple medications (mean 6.9 (SD 3.8; min-max: 0-21)) and over 90% of respondents reported at least one indicator that potentially increases their risk of drug-related morbidity.

CONCLUSION

Number of medications, number of medical conditions and number of daily medication doses were the most frequently observed risks for medication-related issues in this large sample of elderly patients visiting family medicine clinics.

A sticky case of intestinal obstruction

The cause of intestinal obstruction in children can occasionally be obscure although history and examination usually directs the clinician to the correct diagnosis. Pica, the ingestion of non-nutrient material, however can be surreptitious and escape detection. A case report is presented of a 9-year-old child with an extensive and complicated surgical history. Following lengthy investigation and progression of sub-acute to acute intestinal obstruction over a long period, the cause was finally found to be due to persistent ingestion of Blu-Tack -- a common household putty-like adhesive.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is a relatively common personality disorder with a major impact on health services as those affected often present in crisis, often self-harming.

OBJECTIVES

To evaluate the effects of psychological interventions for people with borderline personality disorder.

SEARCH STRATEGY

We conducted a systematic search of 26 specialist and general bibliographic databases (December 2002) and searched relevant reference lists for further trials.

SELECTION CRITERIA

All relevant clinical randomised controlled trials involving psychological treatments for people with BPD. The definition of psychological treatments included behavioural, cognitive-behavioural, psychodynamic and psychoanalytic.

DATA COLLECTION AND ANALYSIS

We independently selected, quality assessed and data extracted studies. For binary outcomes we calculated a standard estimation of the risk ratio (RR), its 95% confidence interval (CI), and where possible the number need to help/harm (NNT/H). For continuous outcomes, endpoint data were preferred to change data. Non-skewed data from valid scales were summated using a weighted mean difference (WMD).

MAIN RESULTS

We identified seven studies involving 262 people, and five separate comparisons. Comparing dialectical behaviour therapy (DBT) with treatment as usual studies found no difference for the outcome of still meeting SCID-II criteria for the diagnosis of BPD by six months (n=28, 1 RCT, RR 0.69 CI 0.35 to 1.38) or admission to hospital in previous three months (n=28, 1 RCT, RR 0.77 CI 0.28 to 2.14). Self harm or parasuicide may decrease at 6 to 12 months (n=63, 1 RCT, RR 0.81 CI 0.66 to 0.98, NNT 12 CI 7 to 108). One study detected statistical difference in favour of people receiving DBT compared with those allocated to treatment as usual for average scores of suicidal ideation at 6 months (n=20, MD -15.30 CI -25.46 to -5.14). There was no difference for the outcome of leaving the study early (n=155, 3 RCTs, RR 0.74 CI 0.52 to 1.04). For the outcome of interviewer-assessed alcohol free days, skewed data are reported and tend to favour DBT. When a substance abuse focused DBT was compared with comprehensive validation therapy plus 12-step substance misuse programme no clear differences were found for service outcomes (n=23, 1 RCT, RR imprisoned 1.09 CI 0.64 to 1.87) or leaving the study early (n=23, 1 RCT, RR 7.58 CI 0.44 to 132.08). When dialectical behaviour therapy-oriented treatment is compared with client centred therapy no differences were found for service outcomes (n=24, 1 RCT, RR admitted 0.33 CI 0.08 to 1.33). However, fewer people in the DBT group displayed indicators of parasuicidal behaviour (n=24, RR 0.13 CI 0.02 to 0.85, NNT 2 CI 2 to 11). There were no differences for outcomes of anxiety and depression (n=24, 1 RCT, RR anxiety BAI >/=10 0.60 CI 0.32 to 1.12; RR depression HDRS >/=10 0.43 CI 0.14 to 1.28) but people who received DBT had less general psychiatric severity than those in the control (MD BPRS at 6 months -7.41 CI -13.72 to -1.10). Finally this one relevant study reports skewed data for suicidal ideation with considerably lower scores for people allocated to DBT. When psychoanalytically oriented partial hospitalization was compared with general psychiatric care the former tended to come off best. People who received treatment in a psychoanalytic orientated day hospital were less likely to be admitted into inpatient care when measured at different time points (e.g. n=44, RR admitted to inpatient 24 hour care >18 to 24 months 0.05 CI 0.00 to 0.77, NNT 3 CI 3 to 10) Fewer people in psychoanalytically oriented partial hospitalization needed day hospital intervention in the 18 months after discharge (n=44, 1 RCT, RR 0.04 CI 0.00 to 0.59, NNT 2 CI 2 to 8). More people in the control group took psychotropic medication by the 30 to 36 month follow-up, than those receiving psychoanalytic treatment (n=44, 1 RCT, RR 0.44 CI 0.25 to 0.80, NNT 3 CI 2 to 7). Anxiety and depression scores were generally lower in the psychoanalytically oriented partial hospitalization group (n=44, 1 RCT, RR >/=14 on BDI 0.52 CI 0.34 to 0.80, NNT 3 CI 3 to 6), as are global severity scores. People receiving psychoanalytic care in a day hospital had better social improvement in social adjustment using the SAS-SR at 6 to 12 months compared with people in general psychiatric care (MD -0.70 CI -1.08 to -0.32). Rates of attrition were the same (n=44, 1 RCT, RR leaving the study early 1.00 CI 0.23 to 4.42).

AUTHORS' CONCLUSIONS

This review suggests that some of the problems frequently encountered by people with borderline personality disorder may be amenable to talking/behavioural treatments but all therapies remain experimental and the studies are too few and small to inspire full confidence in their results. These findings require replication in larger 'real-world' studies.

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

Borderline Personality Disorder (BPD) is prevalent (2% in the general population, 20% among psychiatry in-patients) and has a major impact on health facilities as those affected often present in crisis but then make poor use of further attempts to help them.

OBJECTIVES

To evaluate the effects of pharmacological interventions for people with borderline personality disorder.

SEARCH STRATEGY

We conducted a systematic search of 26 specialist and general bibliographic databases (October 2002) and searched relevant reference lists for further trials.

SELECTION CRITERIA

We included all randomised clinical trials comparing any psychoactive drugs with any other treatment for people with borderline personality disorder.

DATA COLLECTION AND ANALYSIS

We independently selected, quality assessed and data extracted studies. For binary outcomes we calculated a standard estimation of the risk ratio (RR), its 95% confidence interval (CI), and where possible the number need to help/harm (NNT/H). For continuous outcomes, endpoint data were preferred to change data. Non-skewed data from valid scales were synthesised using a weighted mean difference (WMD).

MAIN RESULTS

We found ten small (total n=554), short, randomised studies involving eight comparisons from which we could extract usable data. Studies comparing antidepressants with placebo were small (total n=79, 2 RCTs) but for ratings of anger fluoxetine may offer some improvement for those on antidepressant therapy over placebo (n=22, 1 RCT, RR anger not improved 0.30 CI 0.10 to 0.85, NNT 2 CI 2 to 9). The one small study investigating the important outcome of attempted suicide found no difference between mianserin and placebo (n=38, 1 RCT, RR 0.82 CI 0.44 to 1.54). Haloperidol may be better than antidepressants for symptoms of hostility and psychotism. There were few differences between MAOIs and placebo except that people given MAOIs were less hostile (n=62, 1 RCT, MD -9.19 CI -16.12 to -2.26). Although some ratings were statistically significant the comparison of MAOIs with antipsychotics did not show convincing differences. Antipsychotics may effect some mental state symptoms more effectively than placebo but results are difficult to interpret clinically and there is little evidence of advantage of one antipsychotic over another. Finally mood stabilisers such as divalporex may help mental state (n=16, 1 RCT, RR no improvement in mental state 0.58 CI 0.36 to 0.94, NNT 3 CI 2 to 17) but data are far from conclusive.

AUTHORS' CONCLUSIONS

Pharmacological treatment of people with BPD is not based on good evidence from trials and it is arguable that future use of medication should be from within randomised trials. Current trials suggest that the positive effect of antidepressants, in particular, could be considerable. Well designed, conducted and reported clinically meaningful trials are possible and needed with, perhaps, the question of antidepressant versus placebo being addressed first.

Tau phosphorylation increases in symptomatic mice overexpressing A30P alpha-synuclein

Mice overexpressing mutant alpha-synuclein develop a progressive loss of motor function associated with the accumulation of aggregated alpha-synuclein in neurons of the brainstem. Recent reports suggest that tau pathology might also be associated with Parkinson disease (PD) and aggregation of alpha-synuclein. We now report that mice overexpressing A30P alpha-synuclein develop abnormally phosphorylated tau in parallel with the accumulation of aggregated alpha-synuclein. Enhanced phosphorylation of tau occurs only in symptomatic mice that also harbor abundant aggregated alpha-synuclein. The increased phosphorylation of tau occurs at S396/404 and S202 as shown by immunoblotting and immunocytochemical studies with the antibodies PHF-1 and AT8. Neurons that accumulated alpha-synuclein occurred in the dorsal brainstem and did not show strong colocalization with neurons that showed abnormal tau phosphorylation, which largely occurred in the ventral brainstem. Aggregation of alpha-synuclein and phosphorylation of tau are associated with increased levels of phosphorylated c-jun kinase (JNK), which is a stress kinase known to phosphorylate tau protein. These results suggest that alpha-synuclein pathology can stimulate early pathological changes in tau.

MEK5 overexpression is associated with metastatic prostate cancer, and stimulates proliferation, MMP-9 expression and invasion

The novel mitogen/extracellular-signal-regulated kinase kinase 5/extracellular signal-regulated kinase-5 (MEK5/ERK5) pathway has been implicated in the regulation of cellular proliferation. MEK5 expression has been detected in prostate cancer cells, although the significance of the MEK5/ERK5 pathway in human prostate cancer has not been tested. We examined MEK5 expression in 127 cases of prostate cancer and 20 cases of benign prostatic hypertrophy (BPH) by immunohistochemistry and compared the results to clinical parameters. We demonstrated that MEK5 expression is increased in prostate cancer as compared to benign prostatic tissue. Strong MEK5 expression correlates with the presence of bony metastases and less favourable disease-specific survival. Furthermore, among the patients with high Gleason score of 8-10, MEK5 overexpression has an additional prognostic value in survival. MEK5 transfection experiments confirm its ability to induce proliferation (P < 0.0001), motility (P = 0.0001) and invasion in prostate cancer cells (P = 0.0001). MEK5 expression drastically increased MMP-9, but not MMP-2 mRNA expression. Luciferase report assays suggest that the -670/MMP-9 promoter is upregulated by MEK5 and electromobility shift assay further suggests the involvement of activator protein-I (AP-1), but not the NF-kappa B, binding site in the MMP-9 promoter. Using an AP-1 luciferase construct, activation of MEK5 was confirmed to enhance AP-1 activities up to twofold. Taken together, our results establish MEK5 as a key signalling molecule associated with prostate carcinogenesis. As the MEK5/ERK5 interaction is highly specific, it represents a potential target of therapy.

Opioids, opioid receptors, and the immune response

It is now clear that opioid receptors participate in the function of the cells of the immune system, and evidence suggests that opioids modulate both innate and acquired immune responses. We review literature here which establishes that mu-, kappa-, and delta-opioid compounds alter resistance to a variety of infectious agents, including the Human Immunodeficiency Virus (HIV). The nature of the immunomodulatory activity of the opioids has been the subject of a great deal of research over the last ten years. There is increasing evidence that effects of opioids on the immune response are mediated at several levels. Modulation of the inflammatory response appears to be a target of these compounds, including effects on phagocytic activity, as well as the response of cells to various chemoattractant molecules. Moreover, findings from several laboratories have demonstrated the impact of opioid treatment on antibody responses, and the molecular basis for this effect is likely due, at least in part, to the modulation of both cytokine and cytokine receptor expression. Future research should provide a clearer understanding of the cellular and molecular targets of opioid action within the immune system.

Expression of functional mu-opioid receptors during T cell development

We have examined the chemotactic responsiveness of thymocytes to selective mu-, kappa-, and delta-opioid agonists. Our results show that developing T cells migrate in response to mu-, but not kappa- or delta-opioids. The mu-opioid response appears to be dependent on the classical mu-opioid receptor (MOR-1) since the chemotactic response is blocked by a selective mu-opioid antagonist, and is absent in thymocytes from MOR-1-deficient mice. Flow cytometric analysis of the mu-opioid responsive cells shows that these cells consist predominantly of highly immature CD4- CD8- T cells. These results represent the first demonstration of the functional expression of mu-opioid receptors by developing T cells.

Organ donation in children: role of the pediatric intensive care unit

OBJECTIVES

Children waiting for organ transplants continue to die because of the shortage of available organs. Studies of organ donation in children are scarce. The evaluation of the organ donation experience in a pediatric tertiary care hospital may identify factors that influence actual organ donation rates and lead to strategies to improve pediatric organ donation.

DESIGN

Retrospective study.

SETTING

Pediatric intensive care unit in a Canadian pediatric referral center.

PATIENTS

All children with brain death over an 8-yr period (1990-1997).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 199 children who fulfilled the criteria for brain death, 153 were medically suitable for organ donation. Families were approached for consent to organ donation in 128 (84%) of the 153 suitable cases. Consent was obtained in 63% (81/128) of those asked. Brain death caused by acute neurosurgical lesions was highly correlated to medical suitability and consent. Families identified as ethnic minorities were significantly more likely to refuse. After consent was granted, organs were procured from 63 (78%) of 81 donors, for an average of 3.6 organs transplanted per donor. There was a failure to procure organs in 22% (18/81) of cases after consent had been granted, primarily as a result of cardiocirculatory instability while in the intensive care unit.

CONCLUSIONS

Despite an encouraging 63% consent rate for organ donation when families are approached, only 41% of potential donors proceeded to actual donation. Strategies for a prospective pediatric study should focus on mandatory request, multicultural issues, and aggressive postconsent medical management and procurement. The pivotal role of the pediatric intensive care unit practitioner should be emphasized.

Efficacy and safety of OK-432 sclerotherapy for giant cystic hygroma in a newborn

BACKGROUND

OK-432, a lyophilised incubation mixture of group A Streptococcus pyogenes of human origin, was used as a sclerosant for the involution of a giant cervical cystic hygroma in a newborn.

RESULTS

There were no systemic side effects. Blood tests and double immune diffusion tests showed no systemic infection or generalised inflammatory response, or antibody production. Cellular and cytokine-induced localised inflammatory reaction within the cystic hygroma, was observed on analysis of the intracystic fluid.

CONCLUSIONS

The leucocytosis induced and activated by OK-432 probably increases the endothelial permeability of the lymphatics. This probably accelerated lymph drainage leading to involution of the cystic hygroma. Intralesional injection of OK-432 was safe and effective therapy for cystic hygroma in this newborn as its inflammatory reaction was localised.

Poppies in a wheat field: exploring the lives of rural lesbians

Many believe that lesbian identity is predicated upon the availability of opportunities in urban life to find information, support, and like others (Bell and Valentine 1995a). Indeed, exploring one's lesbian sense of self often involves identifying with a visible reference group, seeking out social arenas where there are other gays and lesbians, connecting with a local community, and taking part in gay and lesbian oriented activities. For rural residents, these opportunities are mostly unavailable, and the lack of access to information, to a public meeting space, and to connections with other lesbians further hinders the development of social group identity. Given that gay and lesbian identity has as its basis a social reference group, how might rural lesbians develop and sustain their sense of personal and group lesbian identity? With few exceptions (D'Augelli 1989; D'Augelli et al. 1987; Kramer 1995; Krieger 1982) the empirical research conducted on the lives of gays and lesbians has utilized urban and suburban samples. Likewise, research on rural life has omitted the experiences of gay and lesbian residents. Either way, information about rural lesbian life remains mostly uncovered. This pilot study attempts to provide new information about the experiences of rural lesbians. Utilizing focus group interviews, the challenges of sustaining lesbian identity in a rural setting are explored. The data show that for this sample, although rural lesbians initially felt isolated and unsure of how to develop a sense of group identity, the opportunity to connect with a small informal network of friends and acquaintances helped alleviate these problems. Further, because these women have little access to information, public gathering space, or to local gay culture, this network was said to be crucial. Without it, the women feel invisible and isolated, that is, their identity remains unseen.

The adjuvant combination monophosphoryl lipid A and QS21 switches T cell responses induced with a soluble recombinant HIV protein from Th2 to Th1

The induction of protective immunity with recombinant vaccines is dependent on the identification of adjuvant or delivery systems that can augment immune responses, especially cellular immune responses, to soluble protein antigen. In this study we demonstrate that an adjuvant formulation comprising QS21, a purified form of saponin and 3D-monophosphoryl lipid A (MPL), a nontoxic derivative of lipopolysaccharide (LPS), enhances cellular and humoral immune responses to a recombinant HIV protein. Analysis of cytokine secretion by antigen-specific T-cells from the spleen demonstrated that QS21 augmented Th1 and Th2 responses, whereas addition of 3D-MPL resulted in preferential induction of type 1 T-cells. Furthermore, analysis of the subclass of the IgG antibody in the serum in mice immunized with gp120 with the combined adjuvant formulation confirmed the selective activation of Th1 cells in vivo. 3D-MPL was found to enhance B7-1 expression and IL-12 production by macrophages, which are known to be involved in the LPS-induced enhancement of Th1 responses. Thus 3D-MPL appears to act as an adjuvant, without the toxicity associated with LPS, by controlled and selective potentiating effects on antigen presentation and T-cell activation.

Characterization of whole genome radiation hybrid mapping resources for non-mammalian vertebrates

Radiation hybrid panels are already available for genome mapping in human and mouse. In this study we have used two model organisms (chicken and zebrafish) to show that hybrid panels that contain a full complement of the donor genome can be generated by fusion to hamster cells. The quality of the resulting hybrids has been assessed using PCR and FISH. We confirmed the utility of our panels by establishing the percentage of donor DNA present in the hybrids. Our hybrid resources will allow inexpensive gene mapping and we expect that this technology can be transferred to many other species. Such successes are providing the basis for a new era of mapping tools, in the form of whole genome radiation hybrid panels, and are opening new possibilities for systematic genome analysis in the animal genetics community.

Pertussis toxin potentiates Th1 and Th2 responses to co-injected antigen: adjuvant action is associated with enhanced regulatory cytokine production and expression of the co-stimulatory molecules B7-1, B7-2 and CD28

Pertussis toxin (PT) is a major virulence factor of Bordetella pertussis which exerts a range of effects on the immune system, including the enhancement of IgE, IgA and IgG production, delayed-type hypersensitivity reactions, and the induction of experimental autoimmune diseases. However, the mechanism by which PT mediates adjuvanticity remains to be defined. In this investigation we have shown that PT can potentiate antigen-specific T cell proliferation and the secretion of IFN-gamma, IL-2, IL-4 and IL-5 when injected with foreign antigens. A chemically detoxified PT and a genetic mutant with substitutions/deletions in the S-1 and B oligomer components that abrogate enzymatic and binding activity displayed no adjuvant properties. In contrast, a non-toxic S-1 mutant devoid of enzymatic activity but still capable of receptor binding retained its adjuvanticity, augmenting the activation of both Th1 and Th2 subpopulations of T cells. In an attempt to address the mechanism of T cell activation, we found that PT stimulated the production of IFN-gamma and IL-2 by naive T cells and IL-1 by macrophages. Therefore potentiation of distinct T cell subpopulations may have resulted in part from the positive influence of IFN-gamma on the development of Th1 cells and the co-stimulatory role of IL-1 for Th2 cells. Furthermore, PT augmented expression of the co-stimulatory molecules B7-1 and B7-2 on macrophages and B cells, and CD28 on T cells, suggesting that the adjuvant effect may also be associated with facilitation of the second signal required for maximal T cell activation. This study demonstrates that the immunopotentiating properties of PT are largely independent of ADP-ribosyltransferase activity, but are dependent on receptor binding activity and appear to involve enhanced activation of T cells.

A retrospective review of a large cohort of patients undergoing the process of withholding or withdrawal of life support

OBJECTIVES

To determine the proportion of patients who died as a result of the withdrawal or withholding of life support (WD/WHLS) in the intensive care units (ICUs) of three teaching hospitals and to describe the process involved by determining: a) why the decision was made to withdraw support (WDLS); b) when WDLS took place; and c) how the WDLS process was conducted.

DESIGN

Retrospective cohort study.

SETTING

Three university-affiliated ICUs.

PATIENTS

Four hundred nineteen patients who died in one of three academic, tertiary care ICUs over a 1-yr period.

INTERVENTIONS

Retrospective chart review. Data collected included age, gender, admitting diagnoses, comorbid disease, Acute Physiology and Chronic Health Evaluation II score, and mode of death (brain death, death due to withholding of life support, death due to WDLS, or death despite ongoing therapy). For those patients dying due to WDLS, the reason for WDLS, person initiating discussion, timing of WDLS, degree of organ dysfunction, order of withdrawal of life support modalities, and the use of sedatives and analgesics were recorded.

MEASUREMENTS AND MAIN RESULTS

Seventy percent of patients died by WD/WHLS and 8.4% were brain dead. Patients undergoing WD/WHLS were older and had a longer length of stay than patients dying from other causes. Poor prognosis was the most common reason given for WDLS, reflected by significant organ dysfunction at the time of WDLS. Future quality of life was a less frequently cited reason. Most patients undergoing WDLS did so early in their ICU stay, although time to WDLS appeared to reflect diagnostic group. Few meetings occurred before WDLS and death occurred soon after initiating WDLS. There was a preference of withdrawing mechanical ventilation last and large amounts of morphine (mean 21 +/- 33 [SD] mg/hr) and benzodiazepines (mean 8.6 +/- 11 mg/hr) were used. Little variability in practice was apparent among the studied ICUs.

CONCLUSIONS

Similar to other studies, WD/WHLS was the most common cause of death in academic ICUs and poor patient prognosis was considered the most important factor in deciding on WDLS. However, in contrast to other studies, future quality of life was not as frequently cited a reason for WDLS and larger amounts of morphine were used during WDLS. These discrepancies suggest areas for potential future research.