Handling End-of-Life Situations in Small Animal Practice: What Strategies do Veterinarians Contemplate During their Decision-Making Process?

This study researched end-of-life (EoL) decision-making processes in small animal practices in the Netherlands, focusing on strategies veterinarians contemplate during this process. Fourteen veterinarians were interviewed about animal end-of-life decision-making. The results of these interviews show that the decision-making process consists of three steps. The first step is to assess the animal's health and welfare. During the second step, veterinarians consider the position of the owner. Based on steps 1 and 2, veterinarians decide in step 3 whether their advice is to a) euthanize or b) contemplate one or more strategies to come to a decision or potentially alter the decision. These results can support members of the veterinary profession to reflect on their decision-making process. If veterinarians know what strategies their peers use to deal with EoL situations, this can help to reduce the stress they experience in such situations. In addition, veterinarians may find inspiration for new strategies in the study results. For the veterinary profession itself, the current results can be used as a starting point for describing best practices for EoL decision-making in small animal practice.

Overexpression of the orphan nuclear receptor NR2F6 is associated with improved survival across molecular subgroups in endometrial cancer patients.

INTRODUCTION: NR2F6 (nuclear receptor subfamily 2 group F member 6, also called Ear-2) is known to be an orphan nuclear receptor that has been characterized as an intracellular immune checkpoint in effector T cells and, therefore, may control tumor development and growth. The prognostic impact of NR2F6 in endometrial cancers is evaluated in this study. MATERIALS AND METHODS: Expression analysis of NR2F6 in 142 endometrial cancer patients was performed by immunohistochemistry of primary paraffin­embedded tumor samples. Staining intensity of positive tumor cells was automatically assessed semi-quantitatively, and results were correlated with clinicopathological characteristics and survival. RESULTS: Forty five of 116 evaluable samples (38.8%) showed an overexpression of NR2F6. This leads to an improvement of the overall survival (OS) and progression-free survival (PFS). In NR2F6-positive patients, the estimated mean OS was 156.9 months (95% confidence interval (CI) 143.1-170.7) compared to 106.2 months in NR2F6-negative patients (95% CI 86.2-126.3; p = 0.022). The estimated PFS differed by 63 months (152 months (95% CI 135.7-168.4) vs. 88.3 months (95% CI 68.5-108.0), p = 0.002). Furthermore, we found significant associations between NR2F6 positivity, MMR status, and PD1 status. A multivariate analysis suggests NR2F6 to be an independent factor influencing the OS (p = 0.03). CONCLUSION: In this study, we could demonstrate that there is a longer progression-free and overall survival for NR2F6-positive patients with endometrial cancer. We conclude that NR2F6 might play an essential role in endometrial cancers. Further studies are required to validate its prognostic impact.

The mediator of cellular immunity. 3. Lymphocyte traffic from the blood into the inflamed peritoneal cavity.

A substantial portion of the lymphocyte-like cells in induced peritoneal exudates derive from cells which enter the blood by way of the thoracic duct. The migrant cells have been identified as large and medium lymphocytes, but they may also include short-lived small lymphocytes derived from them. Small lymphocytes which have a potentially long circulating life-span are excluded from exudates, although cells of this type predominate in thoracic duct lymph. The results imply that many (perhaps all) of the small round cells in inflamed tissue are members of a line of rapidly proliferating lymphocytes. Specifically committed lymphocytes with precisely these properties are added to the blood of rats infected with Listeria monocytogenes. The localization of committed lymphocytes in inflammatory foci could be the crucial event which enables the host to focus his cellular defenses at sites of bacterial implantation.

The mediator of cellular immunity. I. The life-span and circulation dynamics of the immunologically committed lymphocyte.

Thoracic duct cells from rats which have survived an infection with Listeria monocytogenes can confer a high level of antimicrobial resistance upon normal recipients. The cells which confer protection appear in the thoracic duct during the 1st wk of the immunizing infection, at a time when newly formed lymphocytes are being added to the lymph in substantially increased numbers. The protective cells differ in at least two respects from the majority of small lymphocytes in central lymph: they have a rapid turnover rate and a short life-span in the circulation. Evidence was also obtained that lymphopoiesis affecting the long-lived small lymphocyte, which belongs to the recirculating pool, is not increased during an acute Listeria infection.

The mediator of cellular immunity. II. Migration of immunologically committed lymphocytes into inflammatory exudates.

Peritoneal exudates from rats which have survived an infection with L. monocytogenes can protect cyclophosphamide-treated recipients against a Listeria challenge. They are more effective in this respect than cells obtained from the spleen or thoracic duct lymph. Since exudate cells from normal rats and inocula prepared from the resident peritoneal cell populations of infected donors are unable to inhibit the challenge infection, the protective cells must belong to a class of lymphocytes that emerges from the blood in response to inflammation. It is significant therefore that thoracic duct lymphocytes formed during an acute Listeria infection can move into exudates induced by a variety of inflammatory stimuli. The affinity of newly formed lymphocytes for inflamed tissue points to a mechanism whereby the host marshalls its cellular defenses at sites of bacterial invasion. The tendency of short-lived lymphocytes to leave inflamed vessels might also explain their short-circulating life-span.

Prostaglandins from human T suppressor/cytotoxic cells modulate natural killer antibacterial activity.

We have recently described potent antibacterial activity of purified human NK cells. Here we show that this function is regulated by T cytotoxic/suppressor CD8+ cells. Thus, coculture of NK and CD8+ cells for 3 h or longer times abrogated the expression of the NK antibacterial activity, and of two activation markers IL-2R and transferrin receptor (Tf-R). The suppressive activity was mediated by PGE2 as demonstrated by direct PGE2 determination in CD8+ cell free supernatants, and by inhibition of CD8+ cell suppression with indomethacin or piroxicam in vitro. We also found that resting T cytotoxic/suppressor cells purified by negative selection produce higher amounts of PGE2 than adherent cells like monocytes and macrophages, and that these concentration levels are in the range of concentrations known to suppress a significant number of in vitro immunologic functions.

Antibacterial activity of human natural killer cells.

The in vitro effects of human NK cells on viability of Gram-negative and Gram-positive bacteria was investigated. PBLs depleted of glass-adherent cells showed a significant antibacterial activity that was increased as the concentration of NK cells became higher. Leu-11-enriched cells exhibited the most efficient bactericidal activity. Stimulation of NK cells with staphylococcal enterotoxin B for 16 h produced a significant increase in the antibacterial activity of all NK cells tested. The antibacterial activity of monocyte-depleted cells and Leu-11-enriched cells was also enhanced after culturing in vitro for 16-24 h without exogenous cytokines. Dependence of the antibacterial activity on the presence of serum in the culture medium was not found. Ultrastructural studies revealed close contact between NK cell membranes and bacteria, no evidence of phagocytosis, and extracellular bacterial ghosts, after incubation at 37 degrees C. Supernatants from purified NK cells exhibited potent bactericidal activity with kinetics and target specificity similar to that of effector cells. These results document the potent antibacterial activity of purified NK cells and suggest an extracellular mechanism of killing.

Antiinflammatory effects of reconstituted high-density lipoprotein during human endotoxemia.

High-density lipoprotein (HDL) has been found to neutralize LPS activity in vitro and in animals in vivo. We sought to determine the effects of reconstituted HDL (rHDL) on LPS responsiveness in humans in a double-blind, randomized, placebo-controlled, cross-over study. rHDL, given as a 4-h infusion at 40 mg/kg starting 3.5 h before endotoxin challenge (4 ng/kg), reduced flu-like symptoms during endotoxemia, but did not influence the febrile response. rHDL potently reduced the endotoxin-induced release of TNF, IL-6, and IL-8, while only modestly attenuating the secretion of proinflammatory cytokine inhibitors IL-1ra, soluble TNF receptors and IL-10. In addition, rHDL attenuated LPS-induced changes in leukocyte counts and the enhanced expression of CD11b/CD18 on granulocytes. Importantly, rHDL infusion per se, before LPS administration, was associated with a downregulation of CD14, the main LPS receptor, on monocytes. This effect was biologically relevant, since monocytes isolated from rHDL-treated whole blood showed reduced expression of CD14 and diminished TNF production upon stimulation with LPS. These results suggest that rHDL may inhibit LPS effects in humans in vivo not only by binding and neutralizing LPS but also by reducing CD14 expression on monocytes.

Rat thoracic duct lymphocytes: types that participate in inflammation.

Newly formed small lymphocytes with a short life-span in the blood are the only cells from thoracic duct lymph which accumulate in acutely inflamed tissue. This conclusion is drawn from studies in which rats with induced peritonieal exudates were injected intravenously with radioactively labeled thoracic duct cells. Radioactivity, originally vested in newly formed donor small lymphocytes, was found later in a small number of similar exudate cells. Small lymphocytes generated 10 days or more before the thoracic ducts were cannulated failed to localize in peritoneal exudates, although the cells moved in large numbers from the blood in to lymph nodes.

Cytokine profile in cases with premature elevation of progesterone serum concentrations during ovarian stimulation.

The aim of this study was to investigate the concentrations of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), leptin, tumor necrosis factor-alpha, interleukin (IL)-1beta and IL-6, in cycles with a premature rise of serum progesterone. 25 intracytoplasmic sperm injection (ICSI) cycles with (Group 1) and 25 ICSI cycles without a premature progesterone elevation (Group 2) were included. The cut-off value of serum progesterone on the day of human chorionic gonadotropin (hCG) administration was 0.9 ng/ml. The indication for ICSI was male factor infertility exclusively. On the day of hCG injection, serum IL-6, VEGF and bFGF were significantly higher in Group 1 (7.7+/-24.5 pg/ml, 290.2+/-161.4 pg/ml and 15.7+/-8.2 ng/ml respectively) than in Group 2 (1.7+/-0.7 pg/ml, 175.2+/-92.1 pg/ml, and 9+/-1.6 ng/ml respectively). On the day of follicular puncture, serum cytokine concentrations were similar in the two groups. IL-6 intrafollicular concentrations were higher in Group 1 (14.7+/-20.7 pg/ml) than in Group 2 (9+/-9.3 pg/ml, p=0.031). There were no differences regarding the ICSI outcome. Patients with serum progesterone above 0.9 ng/ml, have elevated serum concentrations of IL-6, VEGF, and bFGF, as well as elevated intrafollicular concentrations of IL-6. The outcome of ICSI cycles is not associated with premature elevation of progesterone when the cut-off value is set at 0.9 ng/ml.

The power of communication. Modifying behaviour: effectively influencing nutrition patterns of patients.

Every year 7000 people die from obesity and another 13,000 people die by wrong diets in The Netherlands. Part of this problem can be solved when the communication between general practitioners (GPs) and patients about nutrition and diets improves. There are four activities that can contribute greatly to the communication between GPs and their patients. (1) GPs can ask nonjudgemental questions that help to understand their patients' perspective on the illness, its causes and possible treatments. (2) GPs can listen carefully to their patients' replies and try to pick up clues to their understanding as well as their ability to adhere to a recommended treatment. (3) GPs can work with patients and family members to set realistic and achievable goals for behavioural change. (4) GPs can involve their patients in active problem solving. The role that practitioners play in changing patients' behaviour to healthy lifestyles is more similar to a coach. They should be along the sideline, empowering patients, helping them develop their own healthy lifestyles. When GPs apply these principles in daily practice, they will find out that they can effectively influence the nutrition patterns of their patients.

Disseminated macronodular cutaneous candidiasis in chronic alcoholism.

Disseminated candidiasis usually occurs in profoundly immunocompromised hosts. We described a case of disseminated macronodular cutaneous candidiasis in a man with no known risk for immunosuppression other than alcoholic liver disease and a second case of multiple macronodular cutaneous abscesses in an alcoholic man who had no evidence of systemic dissemination. One patient had testicular candidiasis, a previously unreported site of infection in disseminated candidiasis. Tests showed neutrophil and lymphocyte function to be normal; however, a marked defect in serum opsonization was demonstrated in one patient. It is postulated that chronic alcoholism with alcoholic liver disease resulted in impaired serum opsonization, which, in turn, predisposed these patients to candidal infection.

Discriminators between hantavirus-infected and -uninfected persons enrolled in a trial of intravenous ribavirin for presumptive hantavirus pulmonary syndrome.

To provide a potentially therapeutic intervention and to collect clinical and laboratory data during an outbreak of hantavirus pulmonary syndrome (HPS), 140 patients from the United States with suspected HPS were enrolled for investigational intravenous ribavirin treatment. HPS was subsequently laboratory confirmed in 30 persons and not confirmed in 105 persons with adequate specimens. Patients with HPS were significantly more likely than were hantavirus-negative patients to report myalgias from onset of symptoms through hospitalization, nausea at outpatient presentation, and diarrhea and nausea at the time of hospitalization; they were significantly less likely to report respiratory symptoms early in the illness. The groups did not differ with regard to time from the onset of illness to the point at which they sought care; time from onset, hospitalization, or enrollment to death was significantly shorter for patients with HPS. At the time of hospitalization, patients with HPS more commonly had myelocytes, metamyelocytes, or promyelocytes on a peripheral blood smear, and significantly more of them had thrombocytopenia, hemoconcentration, and hypocapnia. Patterns of clinical symptoms, the pace of clinical evolution, and specific clinical laboratory parameters discriminated between these 2 groups.

Recovery of cellular immune competence during treatment of protein-calorie malnutrition.

Fifty Bangladeshi children with severe protein-calorie malnutrition were randomly allocated at admission to four groups and sensitized to dinitrochlorobenzene either immediately or after 1, 2, or 3 wk of protein-calorie replacement therapy. Ability to initiate cutaneous hypersensitivity to dinitrochlorobenzene on admission was impaired when the total serum proteins was less than 5.5 g/dl, but uniformly recovered after 1 wk of feeding. Three severely malnourished children with total serum proteins less than 4.5 g/dl in whom sensitization was attempted before refeeding failed to respond despite repeated challenge, suggesting immunological tolerance to dinitrochlorobenzene. The data support the concept of a threshold serum protein level, at least as an indicator, below which cellular immunity may be temporarily, or even permanently, impaired.

Cellular immune competence and diarrheal morbidity in malnourished Bangladeshi children: a prospective field study.

A year-long prospective study of 152 Bangladeshi children with mild to moderate protein-calorie malnutrition related nutritional status and cellular immune defects to morbidity due to diarrheal, respiratory, and febrile diseases. In children older than 36 mo, wasting correlated with skin test anergy to three recall antigens and with inability to initiate hypersensitivity to dinitrochlorobenzene. In this older age group, anergy was associated with a 58% increased attack rate and an 83% increased duration of diarrheal diseases but not with febrile or respiratory infections. In stepwise regression analysis, this anergy effect was independent of the small negative impact of poorer nutritional status on morbidity. Ninety-three percent of diarrheal illnesses lasting at least 14 d were among anergic children. Cellular immune incompetence, indicated by anergy of unknown etiology, is associated with increased diarrheal morbidity and may promote the vicious cycle of repeated infections and deteriorating nutritional status.

PIP: A year long prospective study of 152 Bangladeshi children with mild to moderate protein-calorie malnutrition related nutritional status and cellular immune defects to morbidity due to diarrheal, respiratory, and febrile diseases. In children older than 36 months, wasting correlated with skin test anergy to 3 recall antigens and with inability to initiate hypersensitivity to dinitrochlorobenzene. In this older age group, anergy was associated with a 58% increased attack rate and an 83% increased duration of diarrheal diseases but not with febrile or respiratory infections. In stepwise regression analysis, this anergy effect was independent of small negative impact of poorer nutritional status on morbidity. 93% of diarrheal illnesses lasting at least 14 days were among anergic children. Cellular immune incompetence, indicated by anergy of unknown etiology, is associated with increased diarrheal morbidity and may promote the vicious cycle of repeated infections and deteriorating nutritional status.

Anthropometric, metabolic, and immunological effects of recombinant human growth hormone in AIDS and AIDS-related complex.

Metabolic and anthropometric changes induced by "pharmacological" versus "physiological" doses (5.0 vs. 2.5 mg, every other day) of recombinant human growth hormone (rhGH) were compared in 10 human immunodeficiency virus-positive patients with AIDS or AIDS-related complex. Five patients were randomly assigned to each treatment schedule in a 3-month prospective, double-blind clinical trial. Three of the 10 patients, none taking zidovudine and all with low initial CD4 counts, were withdrawn during the study due to acute opportunistic infections. During treatment, insulin-like growth factor-1 (IGF-1) levels increased significantly (p < 0.05) in the pharmacological hGH treatment group, whereas no significant change was observed in IGF-1 in the physiological dose rhGH group. In the pharmacological hGH treatment group, weight loss preceding the study was reversed (p < 0.05) in each of the four patients who completed the study. This weight gain was associated with increases (p < 0.05) in lean body mass and total body water, with concomitant decreases in fat mass (p < 0.05) and urinary nitrogen excretion. Muscle power and endurance, as assessed by standardized omnikinetic dynamometry, also improved. All four patients lost weight again (p < 0.05) 6 weeks after completion of the study and termination of rhGH treatment. Minor positive changes in body composition were also observed in the physiologic-dose hGH group. The pharmacological dose of hGH was associated with minor increments (p < 0.05) in fasting plasma glucose, insulin, and C-peptide concentrations, which were of negligible clinical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous ribavirin for hantavirus pulmonary syndrome: safety and tolerance during 1 year of open-label experience. Ribavirin Study Group.

Intravenous ribavirin was provided non-selectively for investigational open-label use among persons with suspected hantavirus pulmonary syndrome (HPS) in the United States between 4 June 1993 and 1 September 1994. Therapy was initiated prior to laboratory confirmation of hantavirus infection because most deaths from HPS occur within 48 h of hospitalization. Thirty patients with confirmed HPS, 105 patients without HPS and 5 patients without adequate diagnostic testing for HPS were enrolled. This observational study arguably provides the most complete information available on ribavirin-associated adverse effects. Although ribavirin was generally well tolerated, 71% of recipients became anaemic and 19% underwent transfusion. An apparent excess of hyperamylasaemia/pancreatitis was either therapy-associated or due to enrollment bias. The 30 enrolled HPS patients had a case-fatality rate of 47% (14/30). It is not possible to assess efficacy with this study design. However, comparison of survival curves for the 30 enrolled HPS patients and 34 patients who developed HPS during the same time period but were not enrolled did not suggest an appreciable drug effect. A randomized, placebo-controlled trial that enrolls patients during the prodrome phase would be necessary to assess the efficacy and further define the safety of intravenous ribavirin for HPS.

The maximum conjugate frequency (alpha max) characterizes killer cell populations.

A quantitative procedure to characterize NK cell populations based on the dependence of the frequency of conjugation (alpha) on the effector-to-target ratio (R) is shown. To this end, a detailed study of the influence exerted by: (a) the value of R; (b) the number of effector and target cells (N, T); and (c) the source (donor) and enrichment of the effector cell population on the frequency of conjugation between NK effector and K562 target cells has been performed. This has demonstrated that for a given value of R large differences in the values of alpha can be obtained for different donors and/or N values. Hence, the usual practice of reporting the frequency of conjugation at a given value of R cannot be used as a valid criterion for comparison, and this could explain the differences in the alpha values reported in the literature for the same effector-target system. Moreover, the frequency of conjugation depends on the enrichment of the effector cell populations, although it has been shown that in all cases a plot of 1/alpha vs. R for N = constant is always linear with intercept 1/alpha max.alpha max represents the maximum frequency of conjugation for an effector-target system and remains constant for all values of R and N, and is also independent on the donor of the cell source. These characteristics make that the values of alpha max can be used as an easy criterion to determine with accuracy conjugate frequencies in an effector-target system, and could also be applied to characterize the activation or inhibition of effector cell populations by monoclonal antibodies or other agents. This criterion was applied to characterize the enrichment of NK cell populations and so, a value of alpha max = 58 +/- 3% has been obtained when highly purified (greater than or equal to 99%) NK effector cells obtained by panning with the monoclonal antibodies Leu-2, Leu-3 and Leu-4 are used. However, the corresponding value for MDC (14% NK cells) was lowered to 26 +/- 1%.

Alterations in lymphocyte cell surface markers during various human infections.

Peripheral blood lymphocyte cell surface markers were studied in 146 patients with various forms of acute infection using B cell identification with antisurface immunoglobulin and T cell subset enumeration with hybridoma T cell subpopulation reagents. Significant depression was recorded in total numbers of T cells and T cell helper-inducer and suppressor-cytotoxic subsets in pneumonia, acute pyelonephritis, and severe generalized sepsis. In addition, proportions of T cells being the OKT4 helper-inducer phenotype were reduced only in patients over the age of 60 with pneumonia or sepsis. Patients with severe infection frequently had multiple T cell phenotypic surface marker abnormalities. In some instances, when depressions of total T cell numbers as well as respective helper-inducer or suppressor-cytotoxic T cells were noted in the face of generalized sepsis, lack of improvement in these abnormalities during the course of treatment was associated with rapid clinical deterioration and death. On the contrary, in patients with a successful response to appropriate therapy, initial depressions of total T cell numbers and subsets improved progressively with clinical resolution of sepsis and illness.

Hantavirus pulmonary syndrome in the United States: a pathological description of a disease caused by a new agent.

An outbreak of an acute respiratory disease in the southwestern United States has led to the recognition of a new hantaviral illness. This report describes a unique spectrum of antemortem and postmortem pathological findings seen in a case series of nine surviving patients and 13 who died. Clinical, laboratory, and autopsy findings were derived from a consecutive series of individuals confirmed to have hantavirus pulmonary syndrome. Laboratory studies included chemical, hematological, and bone marrow analyses as well as flow cytometric and immunohistochemical phenotyping. Autopsy tissues were examined by routine histological stains, immunohistochemical methods, and transmission electron microscopy. The lung is the primary target organ in this illness. Pulmonary abnormalities include pleural effusions, alveolar edema and fibrin, and an interstitial mononuclear cell infiltrate. Large immunoblast type cells are seen in the lungs, blood, bone marrow, lymph nodes, liver, and spleen. A tetrad of hematological findings includes left-shifted neutrophilic leukocytosis, thrombocytopenia, hemoconcentration in severe cases, and circulating immunoblasts. In contrast to previously described nephropathic hantaviral syndromes, hantavirus pulmonary syndrome is characterized by a unique constellation of pulmonary, hematological, and reticuloendothelial pathological findings. The pulmonary findings are distinguishable from fatal adult respiratory distress syndrome. The data suggest a capillary leak syndrome restricted to the pulmonary circulation. Likewise, the hematological picture is unique and may be valuable in the rapid identification of cases for further diagnostic studies.