Parental experience of end-of life care in the pediatric intensive care unit

BACKGROUND

There is a considerable variability among European countries regarding the management of end-of-life (EOL) care in the pediatric critical care setting. In Italy, recommendations on these issues are available but no study has investigated the parents' experience. The aim of this study was to explore parents' experience of EOL care in a Pediatric Intensive Care Unit (PICU) in Italy.

METHODS

The study was conducted in a 6-bed PICU of a university affiliated hospital in Milan. Parents of children who died between 2007-2010 after a stay of at least 24 hours were eligible to participate. Through semi-structured interviews, parents were asked to describe the story of their child's stay in the PICU, including his/her final moments. The interviews were audio-recorded, transcribed verbatim and analyzed according to the hermeneutic-phenomenology approach.

RESULTS

Twelve parents of 8 children were interviewed. Four themes emerged that described the parents' experience: 1) loss of parental role; 2) lack of physical intimacy with their child; 3) ambivalence about end-of-life decisions; and 4) reclaiming the dying process.

CONCLUSION

Our findings suggest that in order to improve pediatric EOL care we need to better integrate medical and parental priorities, in a shared process that allows parents to preserve their role and relationship with their child. The most critical aspect for parents was not related to the involvement (or not) in EOL decisions, but rather to the possibility of staying connected with their child during the hospitalization and at the time of death.

Neutralization sensitivity and accessibility of continuous B cell epitopes of the feline immunodeficiency virus envelope

Antibodies elicited during natural infection of domestic cats by the feline immunodeficiency virus (FIV) recognize continuous epitopes in nine domains of the virus envelope glycoproteins. Whereas antibodies directed against the V3 envelope region can neutralize laboratory-adapted virus, neutralization of FIV has been shown to depend upon cellular substrate, and virus adaptation to laboratory cell lines may alter sensitivity to neutralizing antibodies. We therefore undertook a systematic analysis of the continuous B cell epitopes of the envelope of a primary FIV isolate, Wo. The capacity of feline antisera elicited against nine envelope domains to neutralize primary and laboratory-adapted virus was evaluated in feline peripheral blood mononuclear cells (PBMC). The laboratory-adapted strain Petaluma was used to compare neutralization in PBMC and Crandell feline kidney cells (CrFK). Antibodies specific for the V3 region neutralized both primary and laboratory-adapted virus whether residual infectivity was measured in CrFK or in feline PBMC. However, a large discrepancy in the efficiency of neutralization was observed in these ex vivo models of infection, perhaps reflecting diversity in the interaction between virus and different cellular targets. We also examined the accessibility of epitopes on the functional oligomeric envelope complex of FIV. Most of the epitopes were poorly exposed on native envelope glycoproteins at the surface of live infected cells. The most accessible domain was the only domain sensitive to neutralizing antibodies. These results suggest that inaccessibility on oligomeric envelope glycoproteins may frequently underlie the insensitivity of diverse lentivirus B cell epitopes to neutralization.

Structure and variations of feline immunodeficiency virus envelope glycoproteins

We report the characterization of the env gene of a feline immunodeficiency virus isolate from France (FIV Wo). FIV Wo gag and env genes were cloned directly from cat peripheral blood mononuclear cells, using polymerase chain reaction. The env molecular clone was shown to be functional and to express antigenically relevant envelope glycoproteins in vitro. Alignment of FIV Wo sequences with available FIV sequences and application of a regionalization algorithm resulted in delineation of variable and conserved domains of FIV Env. These data were used to build a schematic folding model of FIV envelope glycoproteins. The Env molecular clone, variability map, and structural model constitute helpful tools for future studies of FIV envelope aimed at the determination of structure-function relationships or design of diagnostics or vaccine reagents.