"We want to include him in that journey": A qualitative descriptive study of parental experiences and considerations for sibling inclusion in the paediatric ICU

OBJECTIVES

Siblings are an important yet often forgotten part of the paediatric intensive care unit (PICU) family experience. Commonly, siblings are supported through the experience by their parents; however, very little is known about parental experiences of providing this support. This study aims to explore parental experiences of supporting sibling inclusion in PICU.

RESEARCH METHODOLOGY/DESIGN

This study utilised a qualitative descriptive approach to conduct semi-structured interviews with 6 parents of 5 children with congenital heart disease who had spent time in PICU. Data were analysed using reflexive thematic analysis.

SETTING

Australian PICUs.

FINDINGS

Parental considerations and experiences for sibling inclusion were identified across three key phases: Pre-inclusion, The PICU visit, and Post-inclusion. Prior to including siblings in PICU, parents considered various ways of sharing information with siblings, and weighed up the risks and benefits of bringing siblings into PICU. Parents also recounted a number of challenges and facilitators to a positive sibling experience in PICU, including supportive staff and fun activities. Finally, parents, identified that siblings require ongoing support after their inclusion in PICU and made suggestions for ongoing availability of information and supportive resources.

CONCLUSIONS

This study has illuminated key parental experiences when supporting sibling inclusion in PICU before, during and after their visit. By understanding these parental experiences, PICU staff can work with and support parents where needed, helping to achieve a positive sibling inclusion experience.

IMPLICATIONS FOR CLINICAL PRACTICE

Parents need ongoing support to explain the PICU to siblings of critically ill children and may benefit from specific visual resources to aid communication. In addition, PICUs should aim to ensure the physical layout is supportive of sibling needs, with dedicated spaces for siblings to play and take time out during their experience.

Palliative care for children with complex cardiac conditions: survey results

OBJECTIVE

To explore perspectives of paediatric cardiac and palliative care professionals on providing palliative care to children with complex cardiac conditions.

DESIGN

A national survey including closed-ended and open-ended questions as well as clinical scenarios designed to capture referral practices, attitudes towards palliative care, confidence delivering key components of palliative care and perspectives on for whom to provide palliative care. Responses to closed-ended questions and scenarios were analysed using descriptive statistics. Open-ended responses were analysed thematically.

PARTICIPANTS

Paediatric cardiac and palliative care professionals caring for children with complex cardiac conditions in the UK.

RESULTS

177 professionals (91 cardiac care and 86 palliative care) responded. Aspects of advance care planning were the most common reasons for referral to palliative care. Palliative care professionals reported greater confidence than cardiac colleagues with such discussions. Clinicians agreed that children with no further surgical management options, comorbid genetic disorders, antenatal diagnosis of a single ventricle, ventricular device in situ, symptomatic heart failure and those awaiting heart transplantation would benefit from palliative care involvement.

CONCLUSIONS

Components of palliative care, such as advance care planning, can be provided by cardiac care professionals alongside the disease-directed care of children with complex cardiac conditions. Further research and training are needed to address confidence levels in cardiac care professionals in delivering components of palliative care as well as clarification of professional roles and parent preferences in delivery of family-centred care for children with complex cardiac conditions.

Insights into the perception that research ethics committees are a barrier to research with seriously ill children: A study of committee minutes and correspondence with researchers studying seriously ill children

BACKGROUND

Research ethics committees are commonly perceived as a 'barrier' to research involving seriously ill children. Researchers studying seriously ill children often feel that committees view their applications more harshly compared to applications for research with other populations. Whether or not this is the case in practice is unknown.

AIM

The aim of this study was to explore committees' concerns, expectations and decisions for research applications involving seriously ill children submitted for review in the United Kingdom.

DESIGN

Content analysis of committee meeting minutes, decision letters and researcher response letters.

SETTING/PARTICIPANTS

Chief investigators for National Institute of Health Research portfolio studies involving seriously ill children were contacted for permission to review their study documents.

RESULTS

Of the 77 applications included in this study, 57 received requests for revisions at first review. Committee expectations and concerns commonly related to participant information sheets, methodology, consent, recruitment or formatting. Changes were made to 53 of these studies, all of which were subsequently approved.

CONCLUSION

Our findings suggest that committees review applications for research involving seriously ill children with the same scrutiny as applications for research with other populations. Yet, the perception that committees act as a barrier to this type of research persists. We suggest that this perception remains due to other factors including, but not limited to, the high levels of formatting or administrative revisions requested by committees or additional study requirements needed for research involving children, such as multiple versions of consent forms or participant information sheets.

Bereaved parents' experiences of research participation

Background

As understandings of the impacts of end-of-life experiences on parents’ grief and bereavement increase, so too does the inclusion of bereaved parents into research studies exploring these experiences. However, designing and obtaining approval for these studies can be difficult, as guidance derived from bereaved parents’ experiences of the research process are limited within the current literature.

Methods

We aimed to explore bereaved parents’ experiences of research participation in a larger grounded theory study exploring experiences of the death of a child in the paediatric intensive care unit. Data were obtained during follow-up phone calls made to 19 bereaved parents, five of whom provided data from their spouse, 1 week after their participation in the study. Participants were asked to reflect on their experiences of research participation, with a focus on recruitment methods, timing of research contact, and the location of their interview. Parents’ responses were analysed using descriptive content analysis.

Results

Our findings demonstrate that despite being emotionally difficult, parents’ overall experiences of research participation were positive. Parents preferred to be contacted initially via a letter, with an opt in approach viewed most favourably. Most commonly, participants preferred that research contact occurred within 12–24 months after their child’s death, with some suggesting contact after 6 months was also appropriate. Parents also preferred research interviews conducted in their own homes, though flexibility and parental choice was crucial.

Conclusions

Findings from this study offer further insight to researchers and research review committees, to help ensure that future studies are conducted in a way that best meets the unique needs of bereaved parents participating in research.

Gradually Disengaging: Parent-Health care Provider Relationships After a Child's Death in the Pediatric Intensive Care Unit

When a child dies in the intensive care unit, many bereaved parents want relationships with their child's health care staff to continue in the form of follow-up care. However, the nature of these relationships and how they change across the parents' bereavement journey is currently unknown. This article explores early and ongoing relationships between parents and health care staff when a child dies in intensive care. Constructivist grounded theory methods were used to recruit 26 bereaved parents from four Australian pediatric intensive care units into the study. Data were collected via audio-recorded, semistructured interviews and analyzed using the constant comparative methods and theoretical memoing. Findings show that these relationships focus on Gradually disengaging, commonly moving through three phases after the child dies: Saying goodbye, Going home, and Seeking supports. These findings provide guidance to health care staff on what families need as they leave the intensive care unit and move through bereavement.

Critical care nurses' experiences of caring for a dying child: A qualitative evidence synthesis

AIM

To synthesize qualitative research examining the experience of critical care nurses caring for a dying child.

BACKGROUND

Caring for a dying child remains one of the most difficult aspects of nursing, potentially leading to personal and professional distress. A thorough understanding of this experience for critical care nurses allows for improved delivery of care and support for the nurse.

DESIGN

A qualitative evidence synthesis was undertaken, informed by Thomas and Harden's thematic synthesis methodology.

DATA SOURCES

Studies were retrieved from CINAHL Plus, Scopus, OVID Medline, and Embase, alongside hand-searching reference lists in February 2016.

REVIEW METHODS

Two reviewers independently assessed each study using a multistep screening process and performed critical appraisal of each included study. Data were extracted onto a predeveloped tool and analysed using thematic analysis.

RESULTS

There is a blurred line between the role of the nurse as a person or a professional while caring for the child and family throughout hospitalization and during and after the death. Each stage of care involves tasks and emotions that highlight the changing dominance of the nurse as either a person or professional.

CONCLUSION

Personal, interpersonal, and contextual factors affect delivery of care and impact of the death of the child on the critical care nurse. Reviewing individual and institutional practices could improve provision of care, interprofessional collaboration, and support provided to staff involved.

Becoming a Team: The Nature of the Parent-Healthcare Provider Relationship when a Child is Dying in the Pediatric Intensive Care Unit

PURPOSE

To explore bereaved parents' perspectives of parent and staff roles in the pediatric intensive care unit when their child was dying, and their relationships with healthcare staff during this time.

DESIGN AND METHODS

Constructivist grounded theory was used to undertake this study. Semi-structured interviewers were conducted with 26 bereaved parents recruited from four Australian pediatric intensive care units. The constant comparative method, coupled with open, focused, and theoretical coding were used for data analysis.

RESULTS

Becoming a team explores the changes that occurred to the parent-healthcare provider relationship when parents realized their child was dying and attempted to become part of their child's care team. When the focus of care changed from 'life-saving' to 'end-of-life', parents' perspectives and desires of their and the healthcare providers' roles changed. Parents' attempted to reconstruct their roles to match their changing perspectives, which may or may not have been successful, depending on their ability to successfully negotiate these roles with healthcare providers.

CONCLUSIONS

Findings offer insights into parental understandings of both the parental and healthcare provider roles for parents of dying children in intensive care, and the ways in which the parent-healthcare provider relationships can influence and be influenced by changes to these roles.

PRACTICE IMPLICATIONS

Successful parent-healthcare provider relationships require an understanding of the parental and healthcare provider role from the parents' perspective. The meanings of the parental and healthcare provider roles should be explored with parents of dying children, and supported as much as possible to enable the development of a collaborative relationship.

Bereaved parents' experiences of the police in the paediatric intensive care unit

BACKGROUND

A child's death in the intensive care unit is often sudden and unexpected, requiring the involvement of the state coroner to investigate both the cause and the circumstances surrounding the death. This process often involves the police, who arrive in intensive care to identify the body and collect statements from the parents. At present, very little is known about parents' experiences of this process.

OBJECTIVES

To explore bereaved parents' experiences of police presence in intensive care, as part of routine coronial investigations. The findings arose from a larger study on bereaved parents' experiences of the death of a child in the intensive care unit.

METHODS

Secondary analysis of incidental data from a larger grounded theory study. Nine bereaved parents from two paediatric intensive care units (PICUs) mentioned police presence in the PICU during their original audio-recorded, semistructured interviews. These data were extracted, and thematic analysis techniques were used to identify key themes.

RESULTS

Three main concepts were identified with the parents' experiences: (i) timing of police interviews; (ii) the impacts of police presence; and (iii) the demeanour of the officers. Overall, the parents' experiences of police presence were negative. They felt that police arrived too soon after their child's death and took too long taking their statements, hindering their ability to say goodbye. The presence of police officers also made parents feel as though they were being accused of involvement in their child's death. Finally, several participants also experienced inappropriate or unsympathetic attitudes from the police officers attending their child's death.

CONCLUSIONS

Findings from our study indicate that parents' experiences of police presence in the PICU as part of a coronial investigation may be negative, leaving lasting impressions on their experiences of their child's death. These findings provide areas for improvements in care delivery and the treatment of newly bereaved parents during the early phases of a coronial investigation.

Welcoming expertise: Bereaved parents' perceptions of the parent-healthcare provider relationship when a critically ill child is admitted to the paediatric intensive care unit

BACKGROUND

Entering the paediatric intensive care unit with a critically ill child is a stressful experience for parents. In addition to fearing for their child's well-being, parents must navigate both a challenging environment and numerous new relationships with healthcare staff. How parents form relationships with staff and how they perceive both their own and the healthcare providers' roles in this early stage of their paediatric intensive care journey is currently unknown.

PURPOSE

This paper explores bereaved parents' perceptions of their role and their relationships with healthcare providers when their child is admitted to the intensive care unit, as part of a larger study exploring their experiences when their child dies in intensive care.

METHODS

A constructivist grounded theory approach was utilised to recruit 26 bereaved parents from 4 Australian intensive care units. Parents participated in audio-recorded, semi-structured interviews lasting 90-150min. All data were analysed using the constant comparative analysis processes, supported by theoretical memos.

RESULTS

Upon admission, parents viewed healthcare providers as experts, both of their child's medical care and of the hospital system. This expertise was welcomed, with the parent-healthcare provider relationship developing around the child's need for medical care. Parents engaged in 2 key behaviours in their relationships with staff: prioritising survival, and learning 'the system'. Within each of these behaviours are several subcategories, including 'Stepping back', 'Accepting restrictions' and 'Deferring to medical advice'.

CONCLUSIONS

The relationships between parents and staff shift and change across the child's admission and subsequent death in the paediatric intensive care unit. However, upon admission, this relationship centres around the child's potential survival and their need for medical care, and the parent's recognition of the healthcare staff as experts of both the child's care and the hospital system.

Learning style preferences of Australian accelerated postgraduate pre-registration nursing students: A cross-sectional survey

Graduate entry programs leading to registration are gaining momentum in nursing. These programs attract student cohorts with professional, cultural, gender and age diversity. As a consequence of this diversity, such accelerated programs challenge traditional pedagogical methods used in nursing and require different approaches. To date, however, there has been limited research on the learning styles of students undertaking these programs to inform academics involved in their delivery. Kolb's Experiential Learning model has been used widely in a variety of educational settings because it is based on the theory of experiential learning. More recently VARK (Visual, Aural, Read/write and Kinaesthetic) model has become popular. The aim of this study was to investigate the learning styles of two cohorts of graduate entry nursing students undertaking an accelerated masters-level program. This was a cross-sectional survey of two cohorts of Master of Nursing Practice students enrolled at a large Australian university. The students were more inclined toward converging (practical) and least toward concrete experience (experiencing) learning styles. The majority of students were more inclined toward kinaesthetic and least toward aural learning style. Findings have implications for academics engaged in teaching graduate entry nursing students.

Ethical and Practical Realities of Using Letters for Recruitment in Bereavement Research

Recruitment of participants into bereavement research may present many challenges for the research team. At present, there is little consensus for researchers and ethics committees on the most appropriate method of recruitment. There is some evidence that participants prefer to be contacted about research studies via letters. However, recruitment involving the use of a letter can occur in a number of ways, each with ethical and practical benefits and limitations. In a study of the experiences of bereaved parents, we used letters in three ways: direct mailing from the research team with an opt-out option; permission to mail letters obtained by social workers from a hospital-based follow-up program during routine contact; and letters mailed from the hospital's PICU research nurse at the hospital with instruction on how to opt in. In this paper, the practical and ethical realities of each method are highlighted, using examples from our own experiences. Nineteen parents also provided reflections in follow-up phone calls. While direct researcher contact is perhaps the most feasible for researchers, ethical concerns may render it unacceptable. While contact via a known member of a follow-up program is more ethically appropriate for participants, it also presents significant practical issues. We suggest that contact via a representative of the healthcare institution provides the best balance of ethical and practical acceptability for both participants and the research team, but responsiveness to the ethical and practical requirements of the study is crucial in ensuring it can be successfully undertaken. © 2017 Wiley Periodicals, Inc.

Researching people who are bereaved: Managing risks to participants and researchers

Conducting qualitative research, especially in areas considered 'sensitive', presents many challenges. The processes involved in such research often expose both participants and the research team to a vast array of risks, which may cause damage to their personal, professional, social and cultural worlds. Historically, these risks have been considered independent of each other, with most studies exploring only the risks to participants or only risks to researchers. Additionally, most researchers only consider risks during data collection, frequently overlooking risks that might be present during other phases of the research project. We aim, therefore, to bring together this fractured literature to enable an integrated exploration of the current academic discourse relating to risks to participants with the literature exploring risks to researchers across all phases of the research process. This article draws on personal experiences to highlight ethical issues and risks encountered by both participants and researchers throughout all phases of a research project. Beginning in recruitment, we discuss the risk of secondary distress in participants arising from researcher contact and then explore the concept of informed consent during grief and bereavement research. We then focus on risks present during data collection, examining risks for participants, such as emotional distress, and potential safety risks for the research team. Finally, we consider the risks which arise in data analysis, including both confidentiality and the possibility of researcher burnout. Previous recommendations are summarised, with new management strategies suggested based on lessons learned along the way.

CHOP Contributes to, But Is Not the Only Mediator of, IAPP Induced β-Cell Apoptosis

The islet in type 2 diabetes is characterized by β-cell loss, increased β-cell apoptosis, and islet amyloid derived from islet amyloid polypeptide (IAPP). When protein misfolding protective mechanisms are overcome, human IAPP (h-IAPP) forms membrane permeant toxic oligomers that induce β-cell dysfunction and apoptosis. In humans with type 2 diabetes (T2D) and mice transgenic for h-IAPP, endoplasmic reticulum (ER) stress has been inferred from nuclear translocation of CCAAT/enhancer-binding protein homologous protein (CHOP), an established mediator of ER stress. To establish whether h-IAPP toxicity is mediated by ER stress, we evaluated diabetes onset and β-cell mass in h-IAPP transgenic (h-TG) mice with and without deletion of CHOP in comparison with wild-type controls. Diabetes was delayed in h-TG CHOP(-/-) mice, with relatively preserved β-cell mass and decreased β-cell apoptosis. Deletion of CHOP attenuates dysfunction of the autophagy/lysosomal pathway in β-cells of h-TG mice, uncovering a role for CHOP in mediating h-IAPP-induced dysfunction of autophagy. As deletion of CHOP delayed but did not prevent h-IAPP-induced β-cell loss and diabetes, we examined CHOP-independent stress pathways. JNK, a target of the IRE-1pTRAF2 complex, and the Bcl-2 family proapoptotic mediator BIM, a target of ATF4, were comparably activated by h-IAPP expression in the presence and absence of CHOP. Therefore, although these studies affirm that CHOP is a mediator of h-IAPP-induced ER stress, it is not the only one. Therefore, suppression of CHOP alone is unlikely to be a durable therapeutic strategy to protect against h-IAPP toxicity because multiple stress pathways are activated.

Family Experience and PICU Death: A Meta-Synthesis

BACKGROUND AND OBJECTIVES

The PICU is the most common site for inpatient pediatric deaths worldwide. The impact of this clinical context on family experiences of their child's death is unclear. The objective of the study was to review and synthesize the best available evidence exploring the family experience of the death of their child in the PICU.

METHODS

Studies were retrieved from CINAHL Plus, OVID Medline, Scopus, PsycINFO, and Embase. Gray literature was retrieved from greylit.com, opengrey.edu, Trove, Worldcat, and Google scholar. Study selection was undertaken by 4 reviewers by using a multistep screening process, based on a previously developed protocol (International Prospective Register of Systematic Reviews 2015:CRD42015017463). Data was extracted as first-order constructs (direct quotes) or second-order constructs (author interpretations) onto a predeveloped extraction tool. Data were analyzed by thematic synthesis.

RESULTS

One main theme and 3 subthemes emerged. "Reclaiming parenthood" encompasses the ways in which the parental role is threatened when a child is dying in the PICU, with the subthemes "Being a parent in the PICU," "Being supported," and "Parenting after death" elucidating the ways parents work to reclaim this role. The review is limited by a language bias, and by the limitations of the primary studies.

CONCLUSIONS

When a child dies in a PICU, many aspects of the technology, environment, and staff actions present a threat to the parental role both during and after the child's death. Reclaiming this role requires support from health care providers and the wider community.

Pancreas volumes in humans from birth to age one hundred taking into account sex, obesity, and presence of type-2 diabetes

Our aims were (1) by computed tomography (CT) to establish a population database for pancreas volume (parenchyma and fat) from birth to age 100 years, (2) in adults, to establish the impact of gender, obesity, and the presence or absence of type-2 diabetes on pancreatic volume (parenchyma and fat), and (3) to confirm the latter histologically from pancreatic tissue obtained at autopsy with a particular emphasis on whether pancreatic fat is increased in type-2 diabetes. We measured pancreas volume in 135 children and 1,886 adults (1,721 nondiabetic and 165 with type-2 diabetes) with no history of pancreas disease who had undergone abdominal CT scan between 2003 and 2006. Pancreas volume was computed from the contour of the pancreas on each CT image. In addition to total pancreas volume, parenchymal volume, fat volume, and fat/parenchyma ratio (F/P ratio) were determined by CT density. We also quantified pancreatic fat in autopsy tissue of 47 adults (24 nondiabetic and 23 with type-2 diabetes). During childhood and adolescence, the volumes of total pancreas, pancreatic parenchyma, and fat increase linearly with age. From age 20–60 years, pancreas volume reaches a plateau (72.4 ± 25.8 cm³ total; 44.5 ± 16.5 cm³ parenchyma) and then declines thereafter. In adults, total (∼32%), parenchymal (∼13%), and fat (∼68%) volumes increase with obesity. Pancreatic fat content also increases with aging but is not further increased in type-2 diabetes. We provide lifelong population data for total pancreatic, parenchymal, and fat volumes in humans. Although pancreatic fat increases with aging and obesity, it is not increased in type-2 diabetes. Clin. Anat. 20:933–942, 2007. © 2007 Wiley-Liss, Inc.

Modestly increased beta cell apoptosis but no increased beta cell replication in recent-onset type 1 diabetic patients who died of diabetic ketoacidosis

AIMS/HYPOTHESIS

Type 1 diabetes is characterised by a deficit in beta cell mass thought to be due to immune-mediated increased beta cell apoptosis. Beta cell turnover has not been examined in the context of new-onset type 1 diabetes with diabetic ketoacidosis.

METHODS

Samples of pancreas were obtained at autopsy from nine patients, aged 12 to 38 years (mean 24.3+/-3.4 years), who had had type 1 diabetes for less than 3 years before death due to diabetic ketoacidosis. Samples of pancreas obtained at autopsy from nine non-diabetic cases aged 11.5 to 38 years (mean 24.2+/-3.4 years) were used as control. Fractional beta cell area (insulin staining), beta cell replication (insulin and Ki67 staining) and beta cell apoptosis (insulin and TUNEL staining) were measured.

RESULTS

In pancreas obtained at autopsy from recent-onset type 1 diabetes patients who had died of diabetic ketoacidosis, the beta cell deficit varied from 70 to 99% (mean 90%). The pattern of beta cell loss was lobular, with almost all beta cells absent in most pancreatic lobules; islets in lobules not devoid of beta cells had reduced or a near-normal complement of beta cells. Beta cell apoptosis was increased in recent-onset type 1 diabetes, but to a surprisingly modest degree given the marked hyperglycaemia (30 mmol/l), acidosis and presumably high NEFA. Beta cell replication, scattered pancreatic beta cells and beta cells in exocrine ducts were not increased in recent-onset type 1 diabetes.

CONCLUSIONS/INTERPRETATION

These findings do not support the notion of active beta cell regeneration by replication in new-onset type 1 diabetes under conditions of diabetic ketoacidosis. The gluco-lipotoxicity reported in isolated human islets may be less evident in vivo.

Increased islet beta cell replication adjacent to intrapancreatic gastrinomas in humans

AIMS/HYPOTHESIS

Type 1 and type 2 diabetes are characterised by a beta cell deficit. Islet hyperplasia has been described in patients with Zollinger-Ellison syndrome secondary to gastrin-producing tumours (gastrinomas), and gastrin therapy has increased beta cell mass in rodents and human islets in vitro. In the present studies we addressed the following questions: (1) In pancreas specimens from gastrinoma cases, is the fractional beta cell area increased? (2) If so, is this restricted to tumour-adjacent islets or also present in tumour-distant islets? (3) Is new beta cell formation (beta cell replication and islet neogenesis) increased and beta cell apoptosis decreased in pancreas specimens from gastrinoma cases?

METHODS

Pancreas was obtained at surgery from four patients with Zollinger-Ellison syndrome caused by pancreatic gastrinomas and 15 control subjects at autopsy.

RESULTS

Islet fractional beta cell area (p<0.001), islet size (p<0.001) and beta cell replication (Ki67 staining) (p<0.05) were increased in islets adjacent to the tumours, but not in tumour-distant pancreas, compared with control subjects. We did not observe any differences in beta cell apoptosis or in the number of insulin-positive cells in ducts either adjacent to or distant from the tumour.

CONCLUSIONS/INTERPRETATION

One or more factors released by human gastrinomas increase beta cell replication in islets immediately adjacent to the tumour, but not in tumour-distant islets. While these findings demonstrate that adult human beta cells can be driven into the cell cycle, they caution against the therapeutic usefulness of gastrin, since islets located >1 cm away from the gastrinomas did not exhibit changes in beta cell turnover, despite markedly elevated systemic gastrin levels sufficient to cause severe gastrointestinal symptoms.

Direct evidence of attempted beta cell regeneration in an 89-year-old patient with recent-onset type 1 diabetes

AIMS/HYPOTHESIS

We investigated whether there was evidence of attempted beta cell regeneration in the pancreas obtained from a patient with recent-onset type 1 diabetes, and if so by what mechanism this occurred.

SUBJECTS, MATERIALS AND METHODS

We examined pancreas tissue from a lean 89-year-old patient (BMI 18.0 kg/m(2)) with recent-onset type 1 diabetes who had had a distal pancreatectomy to remove a low-grade pancreatic intraepithelial neoplasia.

RESULTS

In the tumour-free tissue, the fractional beta cell area was 0.54+/-0.2% of pancreas area (about one-third of that in non-diabetic humans). CD3-positive T lymphocytes and macrophages had infiltrated the majority of the islets. Subclassification of the T cell population revealed a predominance of CD8-positive cells over CD4-positive cells. Beta cell apoptosis (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labelling [TUNEL] staining) was greatly increased, consistent with ongoing immune-mediated beta cell destruction. There was also a marked increase (more than approximately 100-fold) in the frequency of beta cell replication (0.69+/-0.15% Ki67-positive beta cells) in all blocks examined.

CONCLUSIONS/INTERPRETATION

The present report provides direct evidence of attempted beta cell regeneration through the mechanism of beta cell replication in a case of newly diagnosed type 1 diabetes, and affirms that beta cell apoptosis is an important mechanism for beta cell loss in type 1 diabetes.

Sustained beta cell apoptosis in patients with long-standing type 1 diabetes: indirect evidence for islet regeneration?

AIMS/HYPOTHESIS

Type 1 diabetes is widely held to result from an irreversible loss of insulin-secreting beta cells. However, insulin secretion is detectable in some people with long-standing type 1 diabetes, indicating either a small population of surviving beta cells or continued renewal of beta cells subject to ongoing autoimmune destruction. The aim of the present study was to evaluate these possibilities.

MATERIALS AND METHODS

Pancreatic sections from 42 individuals with type 1 diabetes and 14 non-diabetic individuals were evaluated for the presence of beta cells, beta cell apoptosis and replication, T lymphocytes and macrophages. The presence and extent of periductal fibrosis was also quantified.

RESULTS

Beta cells were identified in 88% of individuals with type 1 diabetes. The number of beta cells was unrelated to duration of disease (range 4-67 years) or age at death (range 14-77 years), but was higher (p<0.05) in individuals with lower mean blood glucose. Beta cell apoptosis was twice as frequent in type 1 diabetes as in control subjects (p<0.001), but beta cell replication was rare in both groups. The increased beta cell apoptosis in type 1 diabetes was accompanied by both increased macrophages and T lymphocytes and a marked increase in periductal fibrosis (p<0.001), implying chronic inflammation over many years, consistent with an ongoing supply of beta cells.

CONCLUSIONS/INTERPRETATION

Most people with long-standing type 1 diabetes have beta cells that continue to be destroyed. The mechanisms underlying increased beta cell death may involve both ongoing autoimmunity and glucose toxicity. The presence of beta cells despite ongoing apoptosis implies, by definition, that concomitant new beta cell formation must be occurring, even after long-standing type 1 diabetes. We conclude that type 1 diabetes may be reversed by targeted inhibition of beta cell destruction.

Islet amyloid polypeptide in human insulinomas. Evidence for intracellular amyloidogenesis

Amyloid deposits that characteristically form in the pancreatic islets of patients with non-insulin-dependent diabetes mellitus (NIDDM) and in insulinomas are both derived from islet amyloid polypeptide (IAPP). Evidence from previous studies has suggested that deposition of IAPP-derived amyloid is related to inherent amyloidogenic sequences present within normal human IAPP, together with an increased production and local concentration of IAPP. However, whether the aggregation of IAPP to form amyloid fibrils is primarily an intra- or extracellular event is not clear. To address this question, we studied 20 human insulinomas by light and electron microscopy. By light microscopy, amyloid deposits were demonstrated in 13 of 20 (65%) human insulinomas. Furthermore, evaluation of Congo red-stained tumor sections showed small, globular or irregular, congophilic amyloid deposits within the cytoplasm of many tumor cells in 10 of 13 (77%) amyloid-containing insulinomas. Dense, punctate areas of IAPP immunoreactivity within tumor cells corresponded with the congophilic intracellular deposits. Ubiquitin immunoreactivity also was observed as punctate intracellular labeling and within large extracellular amyloid deposits. Among the 10 insulinomas available for electron microscopic evaluation, pathological IAPP-immunoreactive (immunogold) deposits were found in 3 of 5 insulinomas in which amyloid was demonstrated by light microscopy and in none of 5 tumors found negative for amyloid by light microscopy. Morphology of IAPP-immunoreactive deposits varied from those with the classical distinct 7- to 10-nm diameter nonbranching fibrils to those with distinct but faint fibrillarity to those without discernable fibrils.(ABSTRACT TRUNCATED AT 250 WORDS)

Lymphocytic mastopathy associated with infiltrating lobular breast carcinoma

A case of lymphocytic mastopathy (LM) and concomitant infiltrating lobular breast carcinoma is described. The inflammatory infiltrate cuffed areas of carcinoma. The LM changes also affected lobules that had not been infiltrated by the carcinoma, although adjacent areas contained both in situ and infiltrating tumour. A minor portion of the inflammation was distributed throughout the ducts. The striking lobulocentricity of the inflammatory infiltrate corresponds to previous reports of LM, and distinguishes this case from the inflammatory response commonly associated with breast carcinomas. It is highly likely that the breast carcinoma induced the LM changes in lobules not yet harbouring tumour.

Analysis of lymphoepithelioma and lymphoepithelioma-like carcinomas for Epstein-Barr viral genomes by in situ hybridization

Lymphoepithelioma of the nasopharynx has a strong association with Epstein-Barr virus (EBV). To test the hypothesis that lymphoepithelioma-like carcinomas occurring at other sites are also associated with EBV virus, we used in situ hybridization to analyze 20 cases of lymphoepithelioma and histologically similar lesions and five basaloid squamous cell carcinomas for evidence of EBV genomes. EBV genomes were demonstrated in six of six lymphoepitheliomas of the nasopharynx but in none of five basaloid squamous cell carcinoma. Only one of 14 lymphoepithelioma-like carcinomas was found to contain EBV genomes. The single positive lymphoepithelioma-like carcinoma occurred in the lung of an Asian patient, suggesting that ethnic or geographic influences may be important in determining whether EBV is associated with these nonnasopharyngeal neoplasms. Despite their histologic similarity, most lymphoepithelioma-like carcinomas probably have a different pathogenesis from nasopharyngeal lymphoepithelioma.

Lymphoepithelioma-like carcinoma of the lung

Originally described in the nasopharynx, lymphoepitheliomas are undifferentiated carcinomas with prominent lymphoid infiltration. Recently this tumor has been described in a number of other sites. An association with prior infection by the Epstein-Barr virus has been recognized in cases from the nasopharynx. We report four cases of lymphoepithelioma-like carcinoma arising in the lung. Epstein-Barr virus serology indicated prior infection in two cases, one of which was also found by in situ hybridization to have the virus genome. Lymphoepithelioma-like carcinoma must be considered in the differential diagnosis of primary lung tumors, particularly when an extensive infiltrate by lymphoid tissue is present and may even suggest lymphoma.

Evidence for a 15;17 translocation in every patient with acute promyelocytic leukemia

Cytogenetic specimens were obtained from blood or bone marrow in 27 patients with acute promyelocytic leukemia, including four with the microgranular variant. A 15;17 translocation was identified in 21 to 100 percent of metaphase cells from all 27 patients. The structural rearrangement was identical in every case, and the breakpoints were assigned to 15q22 and 17q21.1. Twelve patients had complete remission, and two (both with the microgranular variant) have had unmaintained continuous remission longer than four years. These data indicate that the 15;17 translocation may be found in every patient with acute promyelocytic leukemia if optimal chromosome analysis is performed.

Ultrastructural characterization of de novo and secondary leukemias

Cells from 95 patients with acute leukemia were studied by cytochemistry, light microscopy, and transmission electron microscopy (TEM), and were classified according to the French-American-British (FAB) guidelines. This group included 63 patients with acute nonlymphocytic leukemia (ANLL) de novo, 18 with acute lymphocytic leukemia (ALL), and 14 with ANLL as a second malignancy. In addition, 13 cases of chronic myelocytic leukemia in blast crisis were studied. Ultrastructural examination resulted in reclassification of 6 cases of ANLL de novo; two of these were reclassified from M2 (myeloblastic leukemia with maturation) to M3 variant (microgranular variant of hypergranular promyelocytic leukemia). The classification of the cases of CML in blast crisis was identical by light microscopy and TEM. IN 1 case of myeloblastic crisis, however, basophilic granules were demonstrated by TEM but were not appreciated by light microscopy. Classification of the cases of secondary leukemia was possible by light microscopy and cytochemistry in all 14 cases, but was often difficult since the cytochemical reactions were usually less intense than in de novo ANLL. This was particularly true in those cases classified as M1, and in such cases, TEM was required to confirm the diagnosis.