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Calton BA, Rabow MW, Branagan L, Dionne-Odom JN, Parker Oliver D, Bakitas MA, Fratkin MD, Lustbader D, Jones CA, Ritchie CS. Top Ten Tips Palliative Care Clinicians Should Know About Telepalliative Care. J Palliat Med 2019; 22:981-985. [PMID: 31237467 DOI: 10.1089/jpm.2019.0278] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The field of telehealth is rapidly growing and evolving across medical specialties and health care settings. While additional data are needed, telepalliative care (the application of telehealth technologies to palliative care) may help address important challenges inherent to our specialty, such as geography and clinician staffing; the burden of traveling to brick-and-mortar clinics for patients who are symptomatic and/or functionally limited; and the timely assessment and management of symptoms. Telepalliative care can take many forms, including, but not limited to, video visits between clinicians and patients, smartphone applications to promote caregiver well-being, and remote patient symptom-monitoring programs. This article, created by experts in telehealth and palliative care, provides a review of the current evidence for telepalliative care and potential applications and practical tips for using the technology.
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Affiliation(s)
- Brook Anne Calton
- 1Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Michael W Rabow
- 1Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Linda Branagan
- 2Telehealth Resource Center, University of California, San Francisco, San Francisco, California
| | | | - Debra Parker Oliver
- 4Department of Family and Community Medicine, School of Medicine, University of Missouri, Columbia, Missouri
| | - Marie A Bakitas
- 3University of Alabama at Birmingham, School of Nursing, Birmingham, Alabama.,5University of Alabama at Birmingham, Division of Gerontology, Geriatrics, and Palliative Care, Birmingham, Alabama
| | | | - Dana Lustbader
- 7Department of Palliative Care, ProHEALTH Care, Lake Success, New York
| | - Christopher A Jones
- 8Department of Medicine and Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christine S Ritchie
- 9Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
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Lustbader D, Mudra M, Romano C, Lukoski E, Chang A, Mittelberger J, Scherr T, Cooper D. The Impact of a Home-Based Palliative Care Program in an Accountable Care Organization. J Palliat Med 2016; 20:23-28. [PMID: 27574868 PMCID: PMC5178024 DOI: 10.1089/jpm.2016.0265] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: People with advanced illness usually want their healthcare where they live—at home—not in the hospital. Innovative models of palliative care that better meet the needs of seriously ill people at lower cost should be explored. Objectives: We evaluated the impact of a home-based palliative care (HBPC) program implemented within an Accountable Care Organization (ACO) on cost and resource utilization. Methods: This was a retrospective analysis to quantify cost savings associated with a HBPC program in a Medicare Shared Savings Program ACO where total cost of care is available. We studied 651 decedents; 82 enrolled in a HBPC program compared to 569 receiving usual care in three New York counties who died between October 1, 2014, and March 31, 2016. We also compared hospital admissions, ER visits, and hospice utilization rates in the final months of life. Results: The cost per patient during the final three months of life was $12,000 lower with HBPC than with usual care ($20,420 vs. $32,420; p = 0.0002); largely driven by a 35% reduction in Medicare Part A ($16,892 vs. $26,171; p = 0.0037). HBPC also resulted in a 37% reduction in Medicare Part B in the final three months of life compared to usual care ($3,114 vs. $4,913; p = 0.0008). Hospital admissions were reduced by 34% in the final month of life for patients enrolled in HBPC. The number of admissions per 1000 beneficiaries per year was 3073 with HBPC and 4640 with usual care (p = 0.0221). HBPC resulted in a 35% increased hospice enrollment rate (p = 0.0005) and a 240% increased median hospice length of stay compared to usual care (34 days vs. 10 days; p < 0.0001). Conclusion: HBPC within an ACO was associated with significant cost savings, fewer hospitalizations, and increased hospice use in the final months of life.
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Affiliation(s)
- Dana Lustbader
- 1 Department of Palliative Care, ProHEALTH Care , Lake Success, New York
| | - Mitchell Mudra
- 2 Optum Center for Palliative and Supportive Care , Eden Prairie, Minnesota
| | - Carole Romano
- 3 ProHEALTH Medical Management, An Optum Company , Lake Success, New York
| | - Ed Lukoski
- 3 ProHEALTH Medical Management, An Optum Company , Lake Success, New York
| | - Andy Chang
- 3 ProHEALTH Medical Management, An Optum Company , Lake Success, New York
| | - James Mittelberger
- 2 Optum Center for Palliative and Supportive Care , Eden Prairie, Minnesota
| | - Terry Scherr
- 4 Healthcare Analytics , OptumCare, Eden Prairie, Minnesota
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Boss R, Nelson J, Weissman D, Campbell M, Curtis R, Frontera J, Gabriel M, Lustbader D, Mosenthal A, Mulkerin C, Puntillo K, Ray D, Bassett R, Brasel K, Hays R. Integrating palliative care into the PICU: a report from the Improving Palliative Care in the ICU Advisory Board. Pediatr Crit Care Med 2014; 15:762-7. [PMID: 25080152 PMCID: PMC4184991 DOI: 10.1097/pcc.0000000000000209] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE This review highlights benefits that patients, families and clinicians can expect to realize when palliative care is intentionally incorporated into the PICU. DATA SOURCES We searched the MEDLINE database from inception to January 2014 for English-language articles using the terms "palliative care" or "end of life care" or "supportive care" and "pediatric intensive care." We also hand-searched reference lists and author files and relevant tools on the Center to Advance Palliative Care website. STUDY SELECTION Two authors (physicians with experience in pediatric intensive care and palliative care) made final selections. DATA EXTRACTION We critically reviewed the existing data and tools to identify strategies for incorporating palliative care into the PICU. DATA SYNTHESIS The Improving Palliative Care in the ICU Advisory Board used data and experience to address key questions relating to: pain and symptom management, enhancing quality of life, communication and decision-making, length of stay, sites of care, and grief and bereavement. CONCLUSIONS Palliative care should begin at the time of a potentially life-limiting diagnosis and continue throughout the disease trajectory, regardless of the expected outcome. Although the PICU is often used for short term postoperative stabilization, PICU clinicians also care for many chronically ill children with complex underlying conditions and others receiving intensive care for prolonged periods. Integrating palliative care delivery into the PICU is rapidly becoming the standard for high quality care of critically ill children. Interdisciplinary ICU staff can take advantage of the growing resources for continuing education in pediatric palliative care principles and interventions.
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Affiliation(s)
- Renee Boss
- 1Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD. 2Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. 3Center to Advance Palliative Care, Icahn School of Medicine at Mount Sinai, New York, NY. 4Center for Health Research, College of Nursing, Wayne State University, Detroit, MI. 5Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA. 6Cerebrovascular Center, Cleveland Clinic, Cleveland, OH. 7VA Palo Alto Health Care System, Palo Alto, CA. 8Section of Palliative Care, North Shore-Long Island Jewish Health System, Manhasset NY. 9Department of Surgery, New Jersey Medical School-University of Medicine and Dentistry of New Jersey, Newark, NJ. 10Hartford Hospital, Hartford, CT. 11Department of Physiological Nursing, University of California, San Francisco, CA. 12Lehigh Valley Health Network, Allentown, PA. 13Boise, Meridian, & Mountain States Tumor Institute, St. Luke's Hospital, Boise, ID. 14Departments of Surgery and Health Policy, Medical College of Wisconsin, Milwaukee WI 15Departments of Rehabilitation Medicine, Pediatrics and Bioethics & Humanities, University of Washington School of Medicine, Seattle, WA
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Puntillo K, Nelson JE, Weissman D, Curtis R, Weiss S, Frontera J, Gabriel M, Hays R, Lustbader D, Mosenthal A, Mulkerin C, Ray D, Bassett R, Boss R, Brasel K, Campbell M. Palliative care in the ICU: relief of pain, dyspnea, and thirst--a report from the IPAL-ICU Advisory Board. Intensive Care Med 2014; 40:235-248. [PMID: 24275901 PMCID: PMC5428539 DOI: 10.1007/s00134-013-3153-z] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 10/31/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Pain, dyspnea, and thirst are three of the most prevalent, intense, and distressing symptoms of intensive care unit (ICU) patients. In this report, the interdisciplinary Advisory Board of the Improving Palliative Care in the ICU (IPAL-ICU) Project brings together expertise in both critical care and palliative care along with current information to address challenges in assessment and management. METHODS We conducted a comprehensive review of literature focusing on intensive care and palliative care research related to palliation of pain, dyspnea, and thirst. RESULTS Evidence-based methods to assess pain are the enlarged 0-10 Numeric Rating Scale (NRS) for ICU patients able to self-report and the Critical Care Pain Observation Tool or Behavior Pain Scale for patients who cannot report symptoms verbally or non-verbally. The Respiratory Distress Observation Scale is the only known behavioral scale for assessment of dyspnea, and thirst is evaluated by patient self-report using an 0-10 NRS. Opioids remain the mainstay for pain management, and all available intravenous opioids, when titrated to similar pain intensity end points, are equally effective. Dyspnea is treated (with or without invasive or noninvasive mechanical ventilation) by optimizing the underlying etiological condition, patient positioning and, sometimes, supplemental oxygen. Several oral interventions are recommended to alleviate thirst. Systematized improvement efforts addressing symptom management and assessment can be implemented in ICUs. CONCLUSIONS Relief of symptom distress is a key component of critical care for all ICU patients, regardless of condition or prognosis. Evidence-based approaches for assessment and treatment together with well-designed work systems can help ensure comfort and related favorable outcomes for the critically ill.
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Affiliation(s)
| | | | | | | | - Stefanie Weiss
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Ross Hays
- University of Washington, Seattle, WA, USA
| | - Dana Lustbader
- North Shore-Long Island Jewish Health System, Hyde Park, NY, USA
| | - Anne Mosenthal
- University Medical and Dental of New Jersey, Newark, NJ, USA
| | | | - Daniel Ray
- Lehigh Valley Health Network, Allentown, PA, USA
| | | | - Renee Boss
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Brasel
- Medical College of Wisconsin, Milwaukee, WI, USA
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Affiliation(s)
- Dana Lustbader
- Dana Lustbader is an intesivist and the section head of Palliative Medicine, Critical Care Medicine at the North Shore-LIJ Health System in Manhasset, New York
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Lustbader D, Goldstein MJ. Organ Donation after Cardiac Death #242. J Palliat Med 2011; 14:966-7. [DOI: 10.1089/jpm.2011.9659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Lustbader D, O'Hara D, Wijdicks EFM, MacLean L, Tajik W, Ying A, Berg E, Goldstein M. Second brain death examination may negatively affect organ donation. Neurology 2010; 76:119-24. [PMID: 21172836 DOI: 10.1212/wnl.0b013e3182061b0c] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Little is known about the impact of the requirement for a second brain death examination on organ donation. In New York State, 2 examinations 6 hours apart have been recommended by a Department of Health panel. METHODS We reviewed data for 1,229 adult and 82 pediatric patients pronounced brain dead in 100 New York hospitals serviced by the New York Organ Donor Network from June 1, 2007, to December 31, 2009. We reviewed the time interval between the 2 clinical brain death examinations and correlated this brain death declaration interval to day of the week, hospital size, and organ donation. RESULTS None of the patients declared brain dead were found to regain brainstem function upon repeat examination. The mean brain death declaration interval between the 2 examinations was 19.2 hours. A 26% reduction in brain death examination frequency was seen on weekends when compared to weekdays (p = 0.0018). The mean brain death interval was 19.9 hours for 0-750 bed hospitals compared to 16.0 hours for hospitals with more than 750 beds (p = 0.0015). Consent for organ donation decreased from 57% to 45% as the brain death declaration interval increased. Conversely, refusal of organ donation increased from 23% to 36% as the brain death interval increased. A total of 166 patients (12%) sustained a cardiac arrest between the 2 examinations or after the second examination. CONCLUSION A single brain death examination to determine brain death for patients older than 1 year should suffice. In practice, observation time to a second neurologic examination was 3 times longer than the proposed guideline and associated with substantial intensive care unit costs and loss of viable organs.
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Affiliation(s)
- D Lustbader
- New York University School of Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA.
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Lustbader D, Meier DE. Branding Our Field. J Palliat Med 2010; 13:1053. [DOI: 10.1089/jpm.2010.9767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dana Lustbader
- Hofstra Medical School, North Shore LIJ Health System, Manhasset, New York
| | - Diane E. Meier
- Lilian and Benjamin Hertzberg Palliative Care Institute, Department of Geriatrics and Adult Development, Department of Medicine, Center to Advance Palliative Care, Mount Sinai Medical School, New York, New York
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Lustbader D. When death is certain. J Palliat Med 2010; 13:609-10. [PMID: 20491553 DOI: 10.1089/jpm.2009.0367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dana Lustbader
- Department of Palliative Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA.
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Dlugacz YD, Stier L, Lustbader D, Jacobs MC, Hussain E, Greenwood A. Expanding a performance improvement initiative in critical care from hospital to system. Jt Comm J Qual Improv 2002; 28:419-34. [PMID: 12174407 DOI: 10.1016/s1070-3241(02)28042-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Concern about the expense and effects of intensive care prompted the development and implementation of a hospital-based performance improvement initiative in critical care at North Shore University Hospital, Manhasset, New York, a 730-bed acute care teaching hospital. THE HOSPITAL-BASED PERFORMANCE IMPROVEMENT INITIATIVE IN CRITICAL CARE: The initiative was intended to use a uniform set of measurements and guidelines to improve patient care and resource utilization in the intensive care units (ICUs), to establish and implement best practices (regarding admission and discharge criteria, nursing competency, unplanned extubations, and end-of-life care), and to improve performance in the other hospitals in the North Shore-Long Island Jewish Health System. In the medical ICU, the percentage of low-risk (low-acuity) patients was reduced from 42% to 22%. ICU length of stay was reduced from 4.6 days to 4.1 days. IMPLEMENTING THE CRITICAL CARE PROJECT SYSTEMWIDE A system-level critical care committee was convened in 1996 and charged with replicating the initiative. By and large, system efforts to integrate and implement policies have been successful. The critical care initiative has provided important comparative data and information from which to gauge individual hospital performance. DISCUSSION Changing the critical care delivered on multiple units at multiple hospitals required sensitivity to existing organizational cultures and leadership styles. Merging organizational cultures is most successful when senior leadership set clear expectations that support the need for change. The process of collecting, trending, and communicating quality data has been instrumental in improving care practices and fostering a culture of safety throughout the health care system.
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Affiliation(s)
- Yosef D Dlugacz
- North Shore-Long Island Jewish Health System, 150 Community Drive, Great Neck, NY 11021, USA
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Abstract
Novel therapies for the next decade include hyperbaric oxygen, nitric oxide, and extracorporeal membrane oxygenation. Hyperbaric oxygen delivers oxygen at a pressure greater than one atmosphere and has been used in diseases ranging from decompression sickness to carbon monoxide poisoning. Inhaled nitric oxide, a potent vasodilator, has been used in the acute respiratory distress syndrome and for the diagnosis and treatment of pulmonary hypertension. Extracorporeal membrane oxygenation (ECMO) has been used to provide cardiopulmonary bypass support, particularly in the pediatric and neonatal population.
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Affiliation(s)
- D Lustbader
- Center for Pulmonary and Critical Care Medicine, North Shore University Hospital, Manhasset, New York 11030, USA.
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Abstract
It is likely that greater on-site intensivist coverage in critical care units will be observed in the future. Regionalization of critical care services will make this a financial reality because this level of expertise cannot realistically be provided to all hospitals. Perhaps units above a certain size will warrant this level of coverage and smaller community hospitals will transfer patients in need of a very high level of service, which can be provided only by intensivists on site. Community hospitals may rely on specially trained nurse practitioners or physician assistants to provide more on-site coverage during off hours. As technology advances, telemedicine will play a greater role in providing intensivist coverage to ICUs during off hours or to community hospitals in remote areas. Advanced technology and reorganization of critical care services offer opportunities for creative and nontraditional ways to deliver improved care to patients.
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Affiliation(s)
- D Lustbader
- New York University School of Medicine, Division of Pulmonary and Critical Care Medicine, North Shore University Hospital-Manhasset, USA.
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Pavlakis SG, Kingsley PB, Kaplan GP, Stacpoole PW, O'Shea M, Lustbader D. Magnetic resonance spectroscopy: use in monitoring MELAS treatment. Arch Neurol 1998; 55:849-52. [PMID: 9626777 DOI: 10.1001/archneur.55.6.849] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Sodium dichloroacetate has been used to treat patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and strokelike episodes (MELAS). Magnetic resonance spectroscopy (MRS) has been used to assess cerebral metabolism in MELAS, but to our knowledge, the findings of serial MRS studies performed after therapeutic intervention of strokelike episodes have not been reported. METHODS Proton MRS was serially used to measure brain metabolites in strokelike regions and in clinically uninvolved brain regions in a patient with MELAS. PATIENT A patient with MELAS and a strokelike episode clinically improved after treatment with sodium dichloroacetate. An elevated lactate-creatine ratio in the "stroke" region decreased on MRS studies after treatment. After a second episode, the lactate-creatine ratio increased from baseline in a region of the brain that was normal on magnetic resonance imaging scans. CONCLUSIONS To our knowledge, this is the first study to assess the response to treatment of a MELAS strokelike episode and the first to show an increase in the lactate-creatine ratio in a brain region that was associated with a clinical abnormality, even though it appeared normal on magnetic resonance imaging. We conclude that MRS may help to monitor therapeutic efficacy in mitochondrial encephalomyopathies.
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Affiliation(s)
- S G Pavlakis
- Department of Neurology, North Shore University Hospital, Manhasset, NY 11030, USA
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Astiz M, Saha D, Lustbader D, Lin R, Rackow E. Monocyte response to bacterial toxins, expression of cell surface receptors, and release of anti-inflammatory cytokines during sepsis. J Lab Clin Med 1996; 128:594-600. [PMID: 8960643 DOI: 10.1016/s0022-2143(96)90132-8] [Citation(s) in RCA: 106] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Exposure to endotoxin produces a state of macrophage hyporesponsiveness on subsequent stimulation. Monocytes in patients with septic shock demonstrate a similar hyporesponsiveness to endotoxin. The purpose of this study was to examine whether this state of hyporesponsiveness extends to other inflammatory stimuli and the relationship of this state to cell surface receptor expression and the release of anti-inflammatory cytokines. Twelve normal volunteers, 10 patients with severe sepsis, and 9 patients with septic shock were included in the study. Monocytes from each subject were isolated and stimulated with lipopolysaccharide (LPS), staphylococcal enterotoxin B (SEB), and phorbol myristate acetate (PMA). Tumor necrosis factor-alpha (TNF-alpha) and interleukin-1beta (IL-1beta) were measured in the supernatants by enzyme-linked immunosorbent assay (ELISA). Serum levels of transforming growth factor-beta1 (TGF-beta1), prostaglandin E2 (PGE2), and interleukin-10 (IL-10) were also measured by ELISA. The expression of monocyte CD14 and HLA-DR in whole blood were measured by flow cytometry. Patients with septic shock demonstrated significantly decreased TNF-alpha and IL-1beta release as compared with normal subjects in response to LPS. In response to SEB, patients with sepsis and patient with septic shock demonstrated significantly decreased release of TNF-alpha and IL-1beta. Significant decreases in TNF-alpha release were found in the patients with septic shock after PMA stimulation. There were no significant differences in the monocyte response to the different stimuli between patients with gram-positive sepsis and gram-negative sepsis. HLA-DR expression was significantly decreased in patients with septic shock (58 +/- 9 fluorescence units (flU)) as compared with normal subjects (102 +/- 14 flU) (p < 0.05). No differences in CD14 expression were observed. IL-10 levels were significantly increased in patients with sepsis (16 +/- 4 pg/ml) and in patients with septic shock (42 +/- 15 pg/ml) and were detectable in 1 normal subject. TGF-beta1 levels were decreased in patients with septic shock (25 +/- 6 pg/ml) as compared with those in normal subjects (37 +/- 2 pg/ml)(p < 0.05). PGE2 levels were significantly increased in patients with septic shock and patients with sepsis. These data are consistent with a more generalized monocyte hyporesponsiveness to bacterial toxins that may be related to altered cell surface receptor expression and the release of anti-inflammatory cytokines.
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Affiliation(s)
- M Astiz
- St. Vincent's Hospital and Medical Center, New York, NY 10011, USA
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