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The objectives of this study were to develop an instrument to assess the satisfaction of family members with withdrawal of life support (WLS), and to determine which factors are associated with greater levels of satisfaction. To do this, we developed a self-administered questionnaire that was sent to the next-of-kin of intensive care unit (ICU) patients dying following WLS. Over a six-month period, 69 patients died following WLS in the ICU. Three letters were returned "address unknown", 33 did not respond, and 33 responded, of whom 29 agreed to participate (29/66 = 44% of those contacted). Of these, 24 (83%) strongly agreed with the patient's death being compassionate and dignified, one moderately agreed, one mildly agreed, one was neutral and two strongly disagreed. Items associated with greater satisfaction included: the process of WLS being well explained, WLS proceeding as expected, patient appearing comfortable, family/friends prepared for the decision, appropriate person initiating discussion, adequate privacy during WLS, chance to voice concerns. The study suggests factors that are important to consider in ensuring family comfort with the process of withdrawing life support.

The glucocorticoid receptor (GR) mediates glucocorticoid stimulation of surfactant production by fetal mammalian lung. In many other tissues, glucorticoids decrease expression of GR, thereby reducing responsiveness to these hormones. We therefore determined whether there is a similar effect of exogenous glucocorticoids on GR in fetal rat whole lung, and in the principal cell types involved in the stimulation of surfactant, the fibroblasts and the epithelial cells. The ontogeny of GR in late gestation lung differed between the two cell types, with maximal levels occurring in fibroblasts on gestational d 19, and on d 20 in epithelial cells. Administration of dexamethasone (1 mg/kg) to the mother on gestational d 18 or 19 (term = 22 d) increased specific GR binding activity in whole lung 24 h later. Furthermore, in vitro, incubation of cultured fibroblasts of gestational d 20 with 10(-7) M cortisol increased GR immunoreactive protein and binding activity in a dose- and time-dependent manner, without affecting cellular levels of GR mRNA. However, identical treatment of d 20 distal airway epithelial cells was followed by decreased GR protein without significant change in cellular GR mRNA. Surfactant protein-A protein levels, taken as assessments of lung maturation, were increased in response to the same treatment. Our findings suggest that hormonal regulation of GR in fetal lung cells occurs at a posttranscriptional level, and is cell-specific. In the context of substantial increases in circulating glucocorticoid concentrations during late gestation, these findings may be of physiologic importance to the biochemical maturation of the antenatal lung.

To further study the role of platelet-derived growth factor (PDGF) in fetal lung development, the distribution of the PDGF homodimers PDGF-AA and PDGF-BB was examined by immunohistochemistry in embryonic and fetal rat lung from d 12 to 22 of gestation (term = 22 d). PDGF-AA and PDGF-BB were localized to airway epithelial cells as early as d 12 of gestation, 2 d before their appearance in mesenchymal cells. Both PDGF homodimer immunoreactivities increased until the late pseudoglandular stage of lung development, followed by fluctuations in reactivity during the canalicular stage. Only weak immunoreactivity to either PDGF homodimer was evident during the saccular stage of lung development. Immunodetection by Western blotting revealed that PDGF-AA and PDGF-BB homodimer protein concentrations were high during the embryonic and pseudoglandular stage of lung development and decreased with advancing gestation. We conclude that the presence of PDGF in both developing airway epithelial cells and mesenchymal cells, as well as gestation-dependent changes of PDGF homodimers, is compatible with a role for this growth factor during fetal lung development.

Fifty-one focal nodular hyperplasia lesions from 36 patients were examined histologically. Serial sections and three-dimensional models were studied in selected cases. Lesions were multiple in 19% of patients. Thirty-four patients were female. One case had 11 focal nodular hyperplasia lesions and 7 hemangiomata in the liver. Three had astrocytoma and one had anomalous pulmonary venous drainage. Morphometric analysis revealed that the lesions were supplied by an anomalous artery larger than expected for the locale in the liver. This artery branched to form a spider-like structure and was usually not accompanied by a portal vein or duct. Each terminal arterial branch supplied a separate nodule 1 mm in diameter; adjacent nodules coalesced to form the focal nodular hyperplasia lesion. The arterial blood appeared to drain directly into the sinusoids of the nodule. We propose that focal nodular hyperplasia is an hyperplastic response of the hepatic parenchyma to a preexisting arterial spider-like malformation. The frequent coexistence of focal nodular hyperplasia with other vascular and neuroendocrine anomalies suggest that the malformations are developmental in origin. The basic requirement for development of hepatic hyperplasia may be greater blood flow to a region compared to the adjacent parenchyma. This requirement appears to be met in the other forms of nodular transformation of the liver, i.e., nodular regenerative hyperplasia and partial nodular transformation.