Half the family members of intensive care unit patients do not want to share in the decision-making process: A study in 78 French intensive care units*

OBJECTIVE

To evaluate the opinions of intensive care unit staff and family members about family participation in decisions about patients in intensive care units in France, a country where the approach of physicians to patients and families has been described as paternalistic.

DESIGN

Prospective multiple-center survey of intensive care unit staff and family members.

SETTING

Seventy-eight intensive care units in university-affiliated hospitals in France.

PATIENTS

We studied 357 consecutive patients hospitalized in the 78 intensive care units and included in the study starting on May 1, 2001, with five patients included per intensive care unit.

INTERVENTIONS

We recorded opinions and experience about family participation in medical decision making. Comprehension, satisfaction, and Hospital Anxiety and Depression Scale scores were determined in family members.

MEASUREMENTS AND MAIN RESULTS

Poor comprehension was noted in 35% of family members. Satisfaction was good but anxiety was noted in 73% and depression in 35% of family members. Among intensive care unit staff members, 91% of physicians and 83% of nonphysicians believed that participation in decision making should be offered to families; however, only 39% had actually involved family members in decisions. A desire to share in decision making was expressed by only 47% of family members. Only 15% of family members actually shared in decision making. Effectiveness of information influenced this desire.

CONCLUSION

Intensive care unit staff should seek to determine how much autonomy families want. Staff members must strive to identify practical and psychological obstacles that may limit their ability to promote autonomy. Finally, they must develop interventions and attitudes capable of empowering families.

A systematic comparison of methods to measure HIV-1 specific CD8 T cells

Several methods are now available to evaluate the frequencies of virus-specific CD8 T cells but require a systematic comparison to help at choosing the best strategy for evaluation. First, we compared the ELISpot-IFNgamma assay, intracellular IFNgamma staining and HLA class I tetramer-binding assay to quantify the HIV-specific CD8 T cells. Second, we determined the frequency of recognition of HIV antigens and evaluated whether the mode of antigen presentation might influence the results: We compared HIV antigen presentation in the same ELISpot-IFNgamma assays by using recombinant vaccinia viruses (rVVs) encoding for HIV-LAI Gag, Pol, Env, Nef, Tat and Vif proteins, or a panel of 49 synthetic 8-11 amino acid length peptides tested either individually or pooled. Third, we compared the antigens recognized by memory CTL analysis using chromium release assay (CRA) on CTL lines and by effector CD8 cell analysis using ELISpot assay. Our results show that: (1) Flow cytometry and ELISpot assay measuring IFNgamma production give the same frequency of HIV-specific CD8 T cells; (2) tetramer-binding assay detects more HIV-specific CD8 T cells than other methods; (3) pools of optimal peptides and sum frequencies of individual optimal peptides give similar results in ELISpot assay; (4) ELISpot assays using peptides are more sensitive than those using rVV; and (5) CRA and ELISpot assay when using rVV provide a comparable profile of HIV antigen recognition by memory CTLs (CRA) and effector CTLs (ELISpot) in two thirds cases. These results have important implications for the choice of immunological methods to evaluate CD8 T cells responses to vaccines.

Study of different coupling agents in the conjugation of a V3-based synthetic MAP to carrier proteins

The conjugation of synthetic peptides to carrier proteins is a widely used method for immunological studies. Different coupling agents have been described to form the conjugate with carrier proteins. In this paper, we demonstrate that the antibody response toward V3-based synthetic MAPs derived from HIV-1, JY1 isolate, conjugated to two different carrier proteins using either m-maleimidobenzoyl-N-hydroxysuccinimide ester (MBS) or beta-maleimidopropionic acid N-hydroxysuccinimide ester (MPS), or succinic anhydride (SA) show different behaviors. An excellent anti-JY1 response without a strong response to the coupling agent is observed in the case of succinic anhydride spacer. In contrast, MBS produces total abrogation of the antibody response with a high response toward the coupling agent.

A phase I clinical trial of a multi-epitope polypeptide TAB9 combined with Montanide ISA 720 adjuvant in non-HIV-1 infected human volunteers

A phase I clinical trial was performed to examine the safety and immunogenicity of a multi-epitope polypeptide comprising the central 15 amino acids of the V3 loop from six HIV-1 isolates. This protein called TAB9 was emulsified in Montanide ISA720 (Seppic, Paris) and administered intramuscularly at doses of 0, 0.2 and 1 mg to 24 healthy, HIV-1 seronegative adult males. Three immunisations were given at months 0, 1 and 6 in a randomised, double blind, placebo controlled clinical trial. The placebo was generally well tolerated. However, severe local reactions were observed in TAB9 vaccinated subjects after the second and third inoculations. Seven out of eight volunteers from the lower dose group showed moderate or severe local inflammation, while four out of eight subjects from the higher dose group developed granulomas and sterile abscesses. In general, the reactogenicity depended on the number of inoculations given and the dose of TAB9. Both doses were immunogenic, all immunised volunteers seroconverted and antibodies were broadly reactive against the V3 peptides included in the protein. All vaccine's sera reacted against gp120 in Western blot and 50% of them also neutralised at least one out of five laboratory isolates tested. No differences between doses were found. Anti TAB9 lymphoproliferative responses were observed, being more intense in the high dose group. Due to the strong local reactions that were found in this study, a change in the formulation will be required for further trials with this vaccine candidate in humans.

Isolates from four different HIV type 1 clades circulating in Cuba identified by DNA sequence of the C2-V3 region

According to the epidemiology of human immunodeficiency virus infection in Cuba, the main sources of infection have been persons coming from foreign countries, mainly from Africa, and individuals who have had sexual contacts with foreigners in Cuba. However, the first Cuban HIV-1 isolates sequenced have been all classified as subtype B. In this note we report the sequence of the gp120 C2/V3 region from 11 HIV-1 isolates from Cuban patients. DNA was isolated either directly from blood PBMC or from primary isolates, PCR amplified and sequenced. Six isolates were classified as subtype B and three of them had the atypical sequences GRGR, GWGR, and TPGR on the tip of the V3 loop. Besides, two other sequences were classified as subtype A, two as subtype H, and one as subtype C. These results confirm that although subtype B seems to be predominant, HIV-1 isolates from various subtypes do circulate in Cuba.

Immunogenicity comparison of a multi-antigenic peptide bearing V3 sequences of the human immunodeficiency virus type 1 with TAB9 protein in mice

The multiple antigenic peptide system (MAP) has been proposed as a novel and valuable approach for eliciting antibodies for peptides and developing synthetic vaccines. Multi-epitope polypeptides (MEP) have also been developed as an alternative to the recombinant approach for vaccines. The V3 loop from the HIV type 1 (HIV-1) external glycoprotein (gp120) contains the principal neutralization domain (PND). Antibodies against this region neutralize HIV-1 in vitro and in vivo. In this work, a novel presentation of di-epitope MAP was synthesized. A monomeric MAP carrying two identical JY1 V3 sequences as B-cell epitopes and the 830-843 region of tetanus toxoid as a T-helper cell epitope was synthesized. This basic structure was covalently linked to produce a four-JY1-branched homodimer (JY1-MAP4). Additionally, six different monomeric MAPs, bearing four copies of V3 from isolates LR150, JY1, RF, MN, BRVA and IIIB, were synthesized. These monomers were conveniently linked among themselves to produce homodimeric and heterodimeric MAPs of eight V3 branches (V3-MAP8). JY1-MAP8 elicited higher antibody titers in Balb/c mice than JY1-MAP4. The immunogenicity of two different, hexavalent V3-MAP8 mixtures and the MEP TAB9, which tandems the same six V3 sequences in a single molecule, were compared. The antibody response against the mixtures of the heterodimeric MAP showed a wider recognition pattern of the V3 region, while the homodimeric cocktail showed an intermediate pattern. Antibodies elicited by TAB9 recognized only the JY1, LR150 peptides. These results emphasize the influence of V3 epitope presentation upon the characteristics of the antibody response generated.

Quantitation of nifedipine in human plasma by on-line solid-phase extraction and high-performance liquid chromatography

An analytical methodology for nifedipine quantitation in plasma by on-line solid-phase extraction (SPE) and high-performance liquid chromatography (HPLC) is described. The SPE cartridges contain C2 and the analytes nifedipine and nitrendipine (internal standard) are separated on a C18 column with a mobile phase consisting of acetonitrile-13 mM phosphate buffer pH 7 (65:35, v/v) followed by UV detection at 338 nm. Validation of the method demonstrated good recoveries (>90%), sensitivity (limit of quantification, 2 ng/ml), based on a 500 microl sample volume, accuracy and precision (<5.5% in concentrations greater than the limit of quantitation). This methodology has been used for bioequivalence studies.

[Unusual cause of severe alveolar hypoventilation]

Mesenteric panniculitis is a rare disease of the adipose tissue of mesentery. Ascites is an unusual presentation. We report a case of panniculitis whose initial presentation was an obesity-hypoventilation syndrome with pulmonary hypertension. Respiratory disorders were related to abundant ascites. Panniculitis cure and ascites disappearance allowed return to normal pulmonary function and pulmonary artery pressure.

Nandrolone decanoate is a good alternative for the treatment of anemia in elderly male patients on hemodialysis

OBJECTIVE

To assess the efficiency of nandrolone decanoate (ND) in the control of anemia in elderly male patients on hemodialysis (HD), and to determine its influence on nutritional parameters.

DESIGN

A prospective 6-month study with randomization of patients on recombinant human erythropoietin (rHuEPO) therapy into two groups. Group A: rHuEPO was stopped before starting treatment with ND. Group E: rHuEPO was continued.

SETTING

Renal unit, tertiary-care center.

PATIENTS

14 male patients in Group A and 19 patients, 12 males and 7 females, in Group E.

INTERVENTIONS

In Group A rHuEPO was stopped and ND 200 mg/I.M. weekly was given over six months.

RESULTS

The increase in hemoglobin and hematocrit levels was progressive with ND, and significant differences (p < 0.003) were evident after six months (9.6 +/- 1.0 vs 11.0 +/- 1.4 and 28.9 +/- 4.7 vs 33.0 +/- 4.7, respectively), which remained unmodified in Group E. Group A showed a significant increase in serum creatinine, total protein, transferrin and anthropometric parameters. These parameters remained stable and even presented a tendency to decrease in Group E. There was a significant rise in the concentration of triglycerides and a significant decrease in both HDL-cholesterol and apolipoprotein A-1 in Group A. However, lipoprotein (a) decreased significantly. No significant changes were detected in Group E.

CONCLUSIONS

The use of ND would allow us an acceptable treatment of anemia as well as a better nutritional condition in elderly male patients on dialysis.

Characterisation of the lpdA gene from Neisseria meningitidis by polymerase chain reaction, restriction fragment length polymorphism and sequencing

P64k protein from Neisseria meningitidis is well recognised in sera from individuals convalescent from meningococcal disease or vaccinated with the Cuban antimeningococcal vaccine VA-MENGOC-BC. The presence of the protein in more than 80 meningococcal strains has also been verified. It is immunogenic in animal models and the antibodies elicited show bactericidal activity against meningococci. To further investigate at the molecular level whether lpdA, the gene coding for P64k protein, is conserved among different N. meningitidis strains, a total of 20 strains isolated from different geographic areas were differentiated on the basis of restriction fragment length polymorphism (RFLP) patterns after polymerase chain reaction (PCR) amplification of the lpdA gene and restriction endonuclease digestion with HpaII. Although a total of five different PCR-RFLP patterns were present, nucleotide sequence determination showed that identity levels were as high as 93-99% among the N. meningitidis strains analysed.

p53 oncoprotein as a prognostic indicator in patients with breast cancer

p53 is a tumor suppressor gene located on the human chromosome 17 that is thought to regulate (suppress) the proliferation of normal cells. The mutant protein accumulates in the nuclei of tumor cells that may then have a proliferative advantage over normal cells. The purpose of this study was to investigate the relationship between levels of mutant p53 expression and the clinical outcome of patients with node-positive and node-negative breast cancer. Expression of mutant p53 was evaluated in 655 human breast carcinomas (349 node-positive and 306 node-negative patients) with long-term clinical follow-up by immunohistochemistry in sections from paraffin embedded tumors.

RESULTS

Immunoreactivity was found in 37.3% of breast tumors. There was no significant correlation between the expression of p53 and tumor size, nodal involvement, age or histological type. However, p53 overexpression was clearly related to histological grade and steroid receptors, with a trend to higher overexpression in ER-tumors or in those with a high histological grade (p < 0.01). On univariate analysis positive tumors were associated with reduced DFS in the total group (p < 0.001) as well as in node-positive patients (p < 0.05) and in node-negative patients (p < 0.01). In conclusion, these results suggest that the immunoreactivity of p53 may be a biologic marker of prognostic significance in both node-positive and node-negative patients.