Provider Perceptions for Withdrawing Life Sustaining Therapies at a Large Pediatric Hospital

CONTEXT

More than 74% of pediatric deaths occur in an intensive care unit (ICU), with 40% occurring after withdrawal of life-sustaining therapies (WOLST). No needs assessment has described provider needs or suggestions for improving the WOLST process in pediatrics.

OBJECTIVES

This study aims to describe interdisciplinary provider self-reported confidence, needs, and suggestions for improving the WOLST process.

METHODS

A convergent parallel mixed-methods design was used. An online survey was distributed to providers involved in WOLSTs in a quaternary children's hospital between January and December 2018. The survey assessed providers' self-reported confidence in their role, in providing guidance to families about the WOLST, experiences with the WOLST process, areas for improvement, and symptom management. Kruskal-Wallis testing was used for quantitative data analysis with P values <0.05 considered significant. Analysis was performed with SPSS v27. Qualitative data were thematically analyzed using Atlas.ti.8 and NVivo.

RESULTS

A total of 297 surveys were received (48% survey completion) that consisted of multiple choice, Likert-type, and yes/no questions with options for open-ended responses. Mean provider self-rated confidence was high and varied significantly between disciplines. Qualitative analysis identified four areas for refining communication: 1) between the primary team and family, 2) within the primary team, 3) between the primary team and consulting providers, and 4) logistical challenges.

CONCLUSIONS

While participants' self-rated confidence was high, it varied between disciplines. Participants identified opportunities for improved communication and planning before a WOLST. Future work includes development and implementation of a best practice guideline to address gaps and standardize care delivery.

The Drosophila Eip78C gene is not vital but has a role in regulating chromosome puffs

We have generated a number of chromosomal aberrations that disrupt the early-late ecdysone-induced 78C puff gene (Eip78C, ecdysone-induced protein, FlyBase name for the E78 gene of Stone and Thummel 1993), which encodes the two members of the nuclear hormone receptor superfamily Eip78C-A and Eip78C-B. The aberrations include deletions of the ligand-binding/dimerization domain of both, inversions that split Eip78C-A but retain residual Eip78C-B expression, and a small deletion specific for Eip78C-B. We find that wild-type Eip78C functions are completely dispensable for normal development under laboratory conditions. However, we show that Eip78C-B is required for the maximal puffing activity of a subset of late puffs (63E and 82F) since these puffs are reduced in size in Eip78C-B mutant backgrounds. Paradoxically the same late puffs are reduced, as well as at least one other, when the Eip78C-B cDNA is overexpressed from a heat shock promoter. These data indicate either that Eip78C function is redundant or that it plays a subtle modulating role in the regulation of chromosome puffing.

Egalitarian and the choice of cell fates in Drosophila melanogaster oogenesis

Oogenesis in Drosophila females begins with the formation of a cyst of 16 interconnected sister cells, one of which eventually becomes the definitive oocyte. The other 15 become nurse cells, performing nutritive roles for the oocyte. There are four alternative developmental pathways in each cyst: winning pro-oocyte, losing pro-oocyte and cells with three ring canals, all of which enter meiosis, and the twelve obligate pro-nurse cells, which do not. In flies homozygous for the female-sterile mutation egalitarian (egl) all 16 cells follow the same intermediate pathway. All nuclei enter meiosis (shown by their attainment of synaptonemal complex of at least mid-zygotene levels and by their attainment of pachytene numbers and locations of recombination nodules), then all exit it and become morphologically indistinguishable from nurse cells in wild-type flies. The wild-type allele of egl therefore performs two active but opposite roles in cell fate choice. Early on it is necessary for inhibition of meiotic entry in the 'obligate' pro-nurse cells; later it is necessary for meiotic maintenance in the 'winning' pro-oocyte. One can account for both roles from a single function by invoking gradients through the early cyst; the egl+ function appears to be required for the normal function of these gradients.

Stereochemical studies on the formation of melanin by monophenol monooxygenase

The oxidation of tyrosine by monophenol monooxygenase (tyrosinase: EC 1.10.3.1) to melanin has been studied by a combination of ultraviolet, circular dichroism, and nuclear magnetic resonance techniques. It is demonstrated that the chiral intermediate (dopachrome) is generated stereoselectively in this enzymic reaction.

Are there morphologically abnormal early recombination nodules in the Drosophila melanogaster meiotic mutant mei-218?

Early recombination nodules have been suggested to perform a role in meiotic gene conversion recombination events. The meiotic recombination-defective mutant mei-218 greatly reduces the frequency of meiotic crossover (reciprocal) recombination events and reduces the number of late recombination nodules to the same extent. However, it does not reduce the frequency of simple gene conversion events, although they are abnormal in having shorter coconversion tracts than controls. The original cytological study yielded somewhat fewer early nodules in mei-218 than in controls, although very abnormal ones might have been missed. The present study failed to identify a mei-218 specific abnormal category. However, because recombination nodules are at present recognizable only by their morphology, a definitive answer to this question must await a specific probe for recombination nodules. Moreover, the possibility remains that early nodules in mei-218 are more ephemeral than are early nodules in wild type.

The effect of sequence homozygosity on the frequency of X-chromosomal exchange in Drosophila melanogaster females

The repair of mismatched heteroduplex DNA has been implicated in the normal resolution of meiotic exchange events. Although sequence microheterogeneity over defined intervals of homologous chromosomes has been correlated with local effects on recombination, this correlation has not previously been extended to effects on chromosomal levels of exchange. In order to determine the role of microheterogeneity in normal exchange between homologs, a system was devised for monitoring exchange between isogenic X chromosomes. Lack of microheterogeneity did not significantly alter the frequency of exchange along the isogenic X chromosomes relative to controls or to previously reported values. There were, however, characteristic levels of exchange intrinsic to the cloned X chromosomes in each of the lines tested.

Recombination nodules and the mechanism of crossing-over in Drosophila

Meiotic recombination involves a complex sequence of regulated enzymatic and structural functions. These functions and their possible interrelations are discussed using evidence mainly from studies on Drosophila.

Mismatch repair, gene conversion, and crossing-over in two recombination-defective mutants of Drosophila melanogaster

Recombination-defective mutants at two loci that are known to decrease drastically the frequency of meiotic crossing-over do not decrease the frequency of gene conversion at the rosy locus. mei-9 mutant alleles produce frequent postmeiotic segregants manifested as mosaic progeny whereas controls and mei-218 mutants produce none. It is concluded that (i) recombination in Drosophila involves a biparental DNA intermediate and (ii) correction of heteroduplex DNA or recognition of biparental DNA or both is necessary, but not sufficient, for this intermediate to result in crossing-over of flanking markers. It is therefore likely, at least in Drosophila, that the isomerization step in Meselson-Radding type molecular models of recombination is under genetic control.

ON THE CONTROL OF THE DISTRIBUTION OF MEIOTIC EXCHANGE IN DROSOPHILA MELANOGASTER

The effects of eight recombination-defective meiotic mutants on crossing over within the X heterochromatin were examined. Since none permit substantial frequencies of exchange within heterochromatin although six lessen or abolish constraints on the location of exchanges within euchromatin, the systems that prohibit exchange within heterochromatin and that govern where exchanges will occur in euchromatin are under separate genetic control.—A minor component of the effects of mei-218 is the production of nonhomologous exchanges; of mei-9 is the recovery of deleted chromatids; and of mei-41 is the recovery of deleted chromatids and/or a low frequency of heterochromatic exchanges.

EM autoradiographic evidence that DNA synthesis occurs at recombination nodules during meiosis in Drosophila melanogaster females

Serial section electron microscopic autoradiography was used to examine the relationship between recombination nodules and 3H-thymidine incorporation during pachytene in Drosophila melanogaster females. For both ellipsoidal and spherical recombination nodules, the number of nodules that are associated with an autoradiographic grain is higher than that expected by chance; this observation is consistent with the hypotheses that recombination involves DNA synthesis and that recombination nodules are the sites of meiotic recombination. Moreover, general DNA replication (S-phase) and synapsis (synaptonemal complex formation) were found to be temporally distinct events, contrary to previous reports; Drosophila females therefore are not exceptional in this regard.

Effects of recombination-deficient and repair-deficient loci on meiotic and mitotic chromosome behavior in Drosophila melanogaster

The results of recent genetic and cytological studies on recombination-defective and repair-defective mutants of Drosophila melanogaster are summarized. These studies show that there is substantial overlap between the functions used in various aspects of DNA metabolism in Drosophila. Most loci first identified by either recombination-defective or mutagen-sensitive mutants have been shown also to function in nonmutagenized mitotic cells where their action is necessary to maintain the integrity of the genome: mutants at particular loci produce elevated frequencies of chromosome breakage, mitotic exchange, mutation, and/or chromosome loss. Genetic studies of meiotic recombination show that many of the loci identified by recombination-defective mutants restrict where along the chromosome arms exchange may occur. Recent EM studies suggest that the products of at least some of these loci are components of recombination nodules. Region-specific control of DNA metabolism is also indicated by the finding of nonrandom patterns of chromosome breakage in some mutagen-sensitive mutants. Recombination-defective mutants at two loci have been studied for their effects on sister chromatid exchanges (SCEs) and x-ray induced aberrations. Mutants at both loci are defective in steps necessary for the production of symmetrical chromatid interchanges but have little effect on SCEs.

Synaptonemal complex and recombination nodules in wild-type Drosophila melanogaster females

Electron microscope serial section reconstruction analysis of all zygotene-pachytene nuclei of meiotic cells from three wild-type germaria (a subunit of the ovary containing the early meiotic stages arrayed in temporal developmental sequence) of Drosophila melanogaster females corroborates and extends earlier observations (Carpenter 1975a) on the nature and sequence of ultrastructural events occurring during the time of meiotic recombination. Emphasis has been placed on (1) the time of appearance and disappearance of the synaptonemal complex (SC) and the changes in its dimensions that accompany a cell's progression through pachytene, and (2) the appearance, disappearance, number and chromosomal locations of recombination nodules (Carpenter 1975b). For both the SC and the recombination nodule the availability of several developmental series has provided an estimate of the biological variability in the properties of these recombination-associated structures. The much more extensive data presented here substantiate the earlier hypothesis that recombination nodules occur at sites where reciprocal meiotic recombination will occur, has occurred, or is occurring. A second morphological type of recombination nodule is reported; it is suggested that the presence of the latter type of nodule may correlate with sites of gene conversion. The hypothesis that there may be two types of meiotic recombination processes is discussed.

Recombination nodules and synaptonemal complex in recombination-defective females of Drosophila melanogaster

The cytological effects of mutant alleles of the mei-9, mei-218, and mei-41 loci during prophase I have been examined by electron microscopy. None of these mutants affect synaptonemal complex structure, continuity, or temporal behavior. Both the precondition-defective mutants mei-218 and mei-41 affect both number and morphology of spherical recombination nodules and apparently affect at least the numbers of ellipsoidal recombination nodules, whereas in the exchange-defective mutant mei-9 the numbers and morphologies of both ellipsoidal and spherical recombination nodules are normal. The parallel effects of mei-218 and mei-41 on meiotic recombination and on recombination nodules indicate that spherical recombination nodules at least mark the site of exchange events; the effects of these mutants on nodule morphology suggest that the nodule performs an active role in the recombination process. The nodule phenotype of mei-9 indicates that spherical nodules are present, and presumably functioning, well before the concluding stages of the recombination event. The parallel effects of all 3 mutants on ellipsoidal and spherical nodules indicate that these are indeed related structures but does not ellucidate the nature of the relationship. It is suggested that all aspects of meiotic recombination are under the aegis of recombination nodules.

THE UTILIZATION DURING MITOTIC CELL DIVISION OF LOCI CONTROLLING MEIOTIC RECOMBINATION AND DISJUNCTION IN DROSOPHILA MELANOGASTER

To inquire whether the loci identified by recombination-defective and disjunction-defective meiotic mutants in Drosophila are also utilized during mitotic cell division, the effects of 18 meiotic mutants (representing 13 loci) on mitotic chromosome stability have been examined genetically. To do this, meiotic-mutant-bearing flies heterozygous for recessive somatic cell markers were examined for the frequencies and types of spontaneous clones expressing the cell markers. In such flies, marked clones can arise via mitotic recombination, mutation, chromosome breakage, nondisjunction or chromosome loss, and clones from these different origins can be distinguished. In addition, meiotic mutants at nine loci have been examined for their effects on sensitivity to killing by UV and X rays.—Mutants at six of the seven recombination-defective loci examined (mei-9, mei-41, c(3)G, mei-W68, mei-S282, mei-352, mei-218) cause mitotic chromosome instability in both sexes, whereas mutants at one locus (mei-218) do not affect mitotic chromosome stability. Thus many of the loci utilized during meiotic recombination also function in the chromosomal economy of mitotic cells.—The chromosome instability produced by mei-41 alleles is the consequence of chromosome breakage, that of mei-9 alleles is primarily due to chromosome breakage and, to a lesser extent, to an elevated frequency of mitotic recombination, whereas no predominant mechanism responsible for the instability caused by c(3)G alleles is discernible. Since these three loci are defective in their responses to mutagen damage, their effects on chromosome stability in nonmutagenized cells are interpreted as resulting from an inability to repair spontaneous lesions. Both mei-W68 and mei-S282 increase mitotic recombination (and in mei-W68, to a lesser extent, chromosome loss) in the abdomen but not the wing. In the abdomen, the primary effect on chromosome stability occurs during the larval period when the abdominal histoblasts are in a nondividing (G2) state.—Mitotic recombination is at or above control levels in the presence of each of the recombination-defective meiotic mutants examined, suggesting that meiotic and mitotic recombination are under separate genetic control in Drosophila.—Of the six mutants examined that are defective in processes required for regular meiotic chromosome segregation, four (l(1)TW-6cs, cand, mei-S332, ord) affect mitotic chromosome behavior. At semi-restrictive temperatures, the cold sensitive lethal l(1)TW-6cs causes very frequent somatic spots, a substantial proportion of which are attributable to nondisjunction or loss. Thus, this locus specifies a function essential for chromosome segregation at mitosis as well as at the first meiotic division in females. The patterns of mitotic effects caused by cand, mei-S332, and ord suggest that they may be leaky alleles at essential loci that specify functions common to meiosis and mitosis. Mutants at the two remaining loci (nod, pal) do not affect mitotic chromosome stability.

Genetic controls of meiotic recombination and somatic DNA metabolism in Drosophila melanogaster

Recombination-defective meiotic mutants and mutagen-sensitive mutants of D. melanogaster have been examined for their effects on meiotic chromosome behavior, sensitivity to killing by mutagens, somatic chromosome integrity, and DNA repair processes. Several loci have been identified that specify functions that are necessary for both meiotic recombination and DNA repair processes, whereas mutants at combination and DNA repair processes, whereas mutants at other loci appear to be defective in only one pathway of DNA processing.

Electron microscopy of meiosis in Drosophila melanogaster females: II. The recombination nodule--a recombination-associated structure at pachytene?

The recombination nodule is a transient structure present during pachytene in intimate association with the synaptonemal complex. The total numbers of these structures per nucleus and their locations along the bivalents correspond to the total numbers and distributions of genetic exchanges. It is suggested that this structure may be involved in the recombination process.

Electron microscopy of meiosis in Drosophila melanogaster females. I. Structure, arrangement, and temporal change of the synaptonemal complex in wild-type

Complete reconstruction of the synaptonemal complex in 12 pachytene (defined here as that stage in which the synaptonemal complex is continuous throughout the bivalents) nuclei from one wild-type germarium has permitted the following observations. 1) Drosophila melanogaster bivalents at pachytene exhibit a chromocentral arrangement; the pericentric heterochromatin of all bivalents lies in one region of the nucleus, the chromocenter. Telomeric ends do not appear to abutt the nuclear envelope. 2) Synaptonemal complex is present in the pericentric heterochromatin; however, it is morphologically distinct from that present in the euchromatic portion of thesynaptonemal complex of the bivalent arms is greatest at early pachytene; the synaptonemal complex then becomes progressively shorter. Minimum length is approximately one-half of the maximum. 4) Decrease in length of synaptonemal complex is accompanied by an increase in thickness. Reconstruction of 20 pachytene nuclei from an additional 8 germaria suggests that these observations are typical. Correlations between these cytological observations and genetic observations (e.g., patterns of crossing-over) are discussed.

On recombination-defective meiotic mutants in Drosophila melanogaster

The genetic effects of four recombination-defective meiotic mutants in D. melanogaster on recombination, segregation and the relationship between the two have been examined. The results suggest the following. (1) The anomalous meiotic segregation observed in females carrying recombination-defective meiotic mutants is a normal consequence of the reduction in exchange; each recombination-defective mutant can, therefore, be defined by a single lesion in the control of recombination. (2) Of the operations used to date to characterize this lesion, the most informative is whether the decrease in recombination is uniform along the chromosome arm or nonuniform; in particular, if the formation of recombinants is visualized as a two-step process consisting of the establishment of possible exchange points (exchange preconditions) followed by exchange itself, then mutants that uniformly decrease crossing over involve defects in the second step while mutants that result in a nonuniform decrease involve defects in the establishment of exchange preconditions. (3) Of the fourteen loci identified by recombination-defective meiotic mutants, only one (with two alleles) is involved in exchange itself; the others all reduce recombination most drastically in distal regions, suggesting that the establishment of exchange preconditions involves polar processes. (4) A very general description of the polar establishment of exchange preconditions is presented; this description has the property that if a precondition meiotic mutant affects interference, the coefficient of coincidence will be increased in proportion to the decrease in recombination which is what is observed for all recombination-defective meiotic mutants studied to date.

A meiotic mutant defective in distributive disjunction in Drosophila melanogaster

The female meiotic mutant no distributive disjunction (symbol: nod) reduces the probability that a nonexchange chromosome will disjoin from either a nonexchange homolog or a nonhomolog; the mutant does not affect exchange or the disjunction of bivalents that have undergone exchange. Disjunction of nonexchange homologs was examined for all chromosome pairs; nonhomologous disjunction of the X chromosomes from the Y chromosome in XXY females, of compound chromosomes in females bearing attached-third chromosomes with and without a Y chromosome, and of the second chromosomes from the third chromosomes were also examined. The results suggest that the defect in nod is in the distributive pairing process. The frequencies and patterns of disjunction from a trivalent in nod females suggest that the distributive pairing process involves three separate events-pairing, orientation, and disjunction. The mutant nod appears to affect disjunction only.

Genetic analysis of sex chromosomal meiotic mutants in Drosophilia melanogaster

A total of 209 ethyl methanesulfonate-treated X chromosomes were screened for meiotic mutants that either (1) increased sex or fourth chromosome nondisjunction at either meiotic division in males; (2) allowed recombination in such males; (3) increased nondisjunction of the X chromosome at either meiotic division in females; or (4) caused such females, when mated to males heterozygous for Segregation-Distorter (SD) and a sensitive homolog to alter the strength of meiotic drive in males.-Twenty male-specific meiotic mutants were found. Though the rates of nondisjunction differed, all twenty mutants were qualitatively similar in that (1) they alter the disjunction of the X chromosome from the Y chromosome; (2) among the recovered sex-chromosome exceptional progeny, there is a large excess of those derived from nullo-XY as compared to XY gametes; (3) there is a negative correlation between the frequency of sex-chromosome exceptional progeny and the frequency of males among the regular progeny. In their effects on meiosis these mutants are similar to In(1)sc(4L)sc(8R), which is deleted for the basal heterochromatin. These mutants, however, have normal phenotypes and viabilities when examined as X/0 males, and furthermore, a mapping of two of the mutants places them in the euchromatin of the X chromosome. It is suggested that these mutants are in genes whose products are involved in insuring the proper functioning of the basal pairing sites which are deleted in In(1)sc(4L)sc(8R), and in addition that there is a close connection, perhaps causal, between the disruption of normal X-Y pairing (and, therefore, disjunction) and the occurrence of meiotic drive in the male.-Eleven mutants were found which increased nondisjunction in females. These mutants were characterized as to (1) the division at which they acted; (2) their effect on recombination; (3) their dominance; (4) their effects on disjunction of all four chromosome pairs. Five female mutants caused a nonuniform decrease in recombination, being most pronounced in distal regions, and an increase in first division nondisjunction of all chromosome pairs. Their behavior is consistent with the hypothesis that these mutants are defective in a process which is a precondition for exchange. Two female mutants were allelic and caused a uniform reduction in recombination for all intervals (though to different extents for the two alleles) and an increase in first-division nondisjunction of all chromosomes. Limited recombination data suggest that these mutants do not alter coincidence, and thus, following the arguments of Sandler et al. (1968), are defective in exchange rather than a precondiiton for exchange. A single female mutant behaves in a manner that is consistent with it being a defect in a gene whose functioning is essential for distributive pairing. Three of the female meiotic mutants cause abnormal chromosome behavior at a number of times in meiosis. Thus, nondisjunction at both meiotic divisions is increased, recombinant chromosomes nondisjoin, and there is a polarized alteration in recombination.-The striking differences between the types of control of meiosis in the two sexes is discussed and attention is drawn to the possible similarities between (1) the disjunction functions of exchange and the process specified by the chromosome-specific male mutants; and (2) the prevention of functional aneuploid gamete formation by distributive disjunction and meiotic drive.

Segmental aneuploidy and the genetic gross structure of the Drosophila genome

By combining elements of two Y-autosome translocations with displaced autosomal breakpoints, it is possible to produce zygotes heterozygous for a deficiency for the region between the breakpoints, and also, as a complementary product, zygotes carrying a duplication for precisely the same region. A set of Y-autosome translocations with appropriately positioned breakpoints, therefore, can in principle be used to generate a non-overlapping set of deficiencies and duplications for the entire autosomal complement.-Using this method, we have succeeded in examining segmental aneuploids for 85% of chromosomes 2 and 3 in order to assess the effects of aneuploidy and to determine the number and location of dosage-sensitive loci in the Drosophila genome (Figure 5). Combining our data with previously reported results on the synthesis of Drosophila aneuploids (see Lindsley and Grell 1968), the following generalities emerge.-1. The X chromosome contains no triplo-lethal loci, few or no haplo-lethal loci, at least seven Minute loci, one hyperploid-sensitive locus, and one locus that is both triplo-abnormal and haplo-abnormal. 2. Chromosome 2 contains no triplo-lethal loci, few or no haplo-lethal loci, at least 17 Minute loci, and at least four other haplo-abnormal loci. 3. Chromosome 3 contains one triplo-lethal locus that is also haplo-lethal, few or no other haplo-lethal loci, at least 16 Minute loci, and at least six other haplo-abnormal loci. 4. Chromosome 4 contains no triplo-lethal loci, no haplo-lethal loci, one Minute locus, and no other haplo-abnormal loci.-Thus, the Drosophila genome contains 57 loci, aneuploidy for which leads to a recognizable effect on the organism: one of these is triplo-lethal and haplo-lethal, one is triplo-abnormal and haplo-abnormal, one is hyperploid-sensitive, ten are haplo-abnormal, 41 are Minutes, and three are either haplo-lethals or Minutes. Because of the paucity of aneuploid-lethal loci, it may be concluded that the deleterious effects of aneuploidy are mostly the consequence of the additive effects of genes that are slightly sensitive to abnormal dosage. Moreover, except for the single triplo-lethal locus, the effects of hyperploidy are much less pronounced than those of the corresponding hypoploidy.