American Thoracic Society Journal news tips for April 2005 (second issue)

April 15, 2005

IMPROVING END-OF-LIFE CONFERENCES

A study in 4 intensive care units (ICUs) aimed at family conferences to discuss the withholding or withdrawing of life-sustaining therapy in critically ill patients showed that in 15 of 51 conferences physicians missed opportunities to provide either support or information to the family. All 51 family conferences were audio-taped with permission from the family. Along with family members, they involved 226 clinicians, including 36 physicians who led the conferences; 50 nurses; 25 social workers; and 12 chaplains, priests, or nuns. The conferences ranged in length from 7 to 74 minutes, with the average lasting about 32 minutes.

According to the investigators, the majority of deaths that occur in the intensive care unit in North America involve withholding or withdrawing life-sustaining therapy. When this occurs, most patients are unable to communicate for themselves, so decision-making is delegated to family members and clinicians. In this setting, say the researchers, communication with the family is complicated by the fact that family members report significant financial and health burdens as a result of their loved one's critical illness, as well as a major load of anxiety and depression.

The missed opportunities to communicate fell into three categories: opportunities to listen and respond to the family; to acknowledge and address emotions; and to pursue key principles of medical ethics and palliative care, including explanations of patient preferences, surrogate decision-making, and affirmation of non-abandonment. They said that the most common missed opportunity occurred when clinicians failed to listen and respond appropriately and directly to comments made by family members. Sometimes, the doctors involved answered a different question than that posed by the family member. The study appears in the second issue for April 2005 of the American Thoracic Society's peer-reviewed American Journal of Respiratory and Critical Care Medicine.

REVEALING HOW THE BODY'S IMMUNE RESPONSE DIFFERS IN SARS PATIENTS

Chinese investigators have revealed that the early presence of interferon-inducible protein 10 (IP-10), an immunoregulatory protein, is a prominent characteristic of the body's immune reaction to the coronavirus that causes severe acute respiratory syndrome (SARS). The disease itself differs from other non-SARS viral infections that cause no increase in IP-10. The researchers believe that levels of the protein could make a difference in both diagnosis and the development of an effective treatment for the disease.

The investigators screened 14 cytokines/chemokines (immunoregulatory proteins) in the blood of 23 patients with SARS and 25 non-SARS patients with atypical pneumonia. The SARS patients were separated into 4 groups, according the disease's course: early stage---2 days after onset of fever; progressive stage--10 to 20 days after onset; end stage--the day before death; and convalescent stage--15 to 30 days after discharge from the hospital.

They said that IP-10 was markedly elevated in the blood during the early stage of SARS, and remained at a high level during convalescence. Also, they said that IP-10 was highly expressed in both lung and lymphoid tissues.

The investigators pointed out that immunopathologic injury of host cells triggered by the immune response to virus plays a key role in the pathogenesis of virus infections. Many cytokines/chemokines released from activated immune cells not only take part in the process of antiviral immune response, but are also involved in cell damage and development of organ dysfunction. Determination of these soluble factors in the blood should aid their understanding of the immunologic processes of SARS and enable differential diagnosis of SARS from other atypical pneumonias that require quite different approaches to the management of patients.

The study was published in the second issue for April 2005 of the American Thoracic Society's peer-reviewed American Journal of Respiratory and Critical Care Medicine.
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American Thoracic Society

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