***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background —We investigated the immunoinflammatory profile of patients successfully resuscitated after cardiac arrest , representing a model of whole-body ischemia/reperfusion syndrome . Methods and Results —Plasma cytokine , endotoxin , and ex vivo cytokine production in whole-blood assays was assessed in 61 , 35 , and 11 patients , respectively . On admission , high levels of plasma interleukin (IL)-6 , IL-8 , IL-10 , and soluble tumor necrosis factor ( TNF ) receptor type II could discriminate between survivors and nonsurvivors . Among nonsurvivors , the initial need for a vasopressor agent was associated with higher levels of IL-1 receptor antagonist , IL-10 , and IL-6 on day 1 . Plasma endotoxin was detected in 46 % of the analyzed patients within the 2 first days . Endotoxin-induced TNF and IL-6 productions were dramatically impaired in these patients compared with healthy control subjects , whereas an unaltered production was observed with heat-killed Staphylococcus aureus . In contrast , IL-1 receptor antagonist productions were enhanced in these patients compared with healthy control subjects . The productions of T-cell – derived IL-10 and interferon-&ggr ; were also impaired in these patients . Finally , using in vitro plasma exchange between healthy control subjects and patients , we demonstrated that the endotoxin-dependent hyporeactivity was an intrinsic property of patients ’ leukocytes and that an immunosuppressive activity was also present in their plasma . Conclusions —Altogether , the high levels of circulating cytokines , the presence of endotoxin in plasma , and the dysregulated production of cytokines found in these patients recall the immunological profile found in patients with sepsis STUDY OBJECTIVE The critical care community has used st and ard criteria for defining the sepsis syndromes and organ dysfunction for more than 15 years ; however , these criteria are not well vali date d in the emergency department ( ED ) setting . The study objectives in our ED population of patients admitted to the hospital are to determine the prevalence of the sepsis syndromes , quantify inhospital mortality and 1-year survival associated with the sepsis syndromes , and assess the inhospital and 1-year survival associated with organ dysfunctions . METHODS This was a prospect i ve , observational , cohort study from February 1 , 2000 , to February 1 , 2001 in an urban university hospital ED with 50,000 annual visits . There were 3,102 ( 96 % of eligible ) consecutive adult patients ( aged 18 years or older ) with suspected infection ( as indicated by the clinical decision to obtain a blood culture ) who were enrolled . Patients were screened for  systemic inflammatory response syndrome ( SIRS ) ( 2 or more indicators of inflammatory response ) , sepsis ( SIRS plus suspected infection ) , severe sepsis ( sepsis plus organ dysfunction ) , septic shock ( sepsis plus hypotension refractory to an initial fluid challenge ) , and number of organs with acute dysfunction . Main outcome measure was inhospital and 1-year mortality . RESULTS Overall inhospital mortality was 4.1 % and 1-year mortality was 22 % . The inhospital mortality rates were suspected infection without SIRS 2.1 % , sepsis 1.3 % , severe sepsis 9.2 % , and septic shock 28 % . Compared to suspected infection without SIRS , adjusted risks of inhospital mortality were severe sepsis ( odds ratio [ OR ] 4.0 ; 95 % confidence interval [ CI ] 2.6 to 6.3 ) and septic shock ( OR 13.8 ; 95 % CI 6.6 to 29 ) . Severe sepsis ( OR 2.2 ; 95 % CI 1.8 to 2.6 ) and septic shock ( OR 3.5 ; 95 % CI 2.3 to 5.3 ) also predicted 1-year mortality . The presence of SIRS criteria alone had no prognostic value for either endpoint . Each additional organ dysfunction increased the adjusted 1-year mortality hazard by 82 % ( pulse rate : 1.82 , 95 % CI 1.7 to 2.0 ) . CONCLUSION Immediate identification of acute organ dysfunction in ED patients with suspected infection may help select patients at increased short- and long-term mortality risk . SIRS criteria offered no additional prognostic value , whereas each additional organ dysfunction increased the 1-year mortality risk BACKGROUND Cardiac arrest outside the hospital is common and has a poor outcome . Studies in laboratory animals suggest that hypothermia induced shortly after the restoration of spontaneous circulation may improve neurologic outcome , but there have been no conclusive studies in humans . In a r and omized , controlled trial , we compared the effects of moderate hypothermia and normothermia in patients who remained unconscious after resuscitation from out-of-hospital cardiac arrest . METHODS The study subjects were 77 patients who were r and omly assigned to treatment with hypothermia ( with the core body temperature reduced to 33 degrees C within 2 hours after the return of spontaneous circulation and maintained at that temperature for 12 hours ) or normothermia .  The primary outcome measure was survival to hospital discharge with sufficiently good neurologic function to be discharged to home or to a rehabilitation facility . RESULTS The demographic characteristics of the patients were similar in the hypothermia and normothermia groups . Twenty-one of the 43 patients treated with hypothermia ( 49 percent ) survived and had a good outcome --that is , they were discharged home or to a rehabilitation facility -- as compared with 9 of the 34 treated with normothermia ( 26 percent , P=0.046 ) . After adjustment for base-line differences in age and time from collapse to the return of spontaneous circulation , the odds ratio for a good outcome with hypothermia as compared with normothermia was 5.25 ( 95 percent confidence interval , 1.47 to 18.76 ; P=0.011 ) . Hypothermia was associated with a lower cardiac index , higher systemic vascular resistance , and hyperglycemia . There was no difference in the frequency of adverse events . CONCLUSIONS Our preliminary observations suggest that treatment with moderate hypothermia appears to improve outcomes in patients with coma after resuscitation from out-of-hospital cardiac arrest Objectives : Tissue Pco2 reflects metabolic alterations due to circulatory failure during circulatory shock . This study addresses simultaneous changes in gastric and buccal tissue Pco2 with changes in microcirculatory blood flow in a rat model of circulatory shock induced by cecal ligation and puncture .  Design : Prospect i ve controlled laboratory study . Setting : University-affiliated research laboratory . Subjects : Male breeder Sprague-Dawley rats . Interventions : Induction of polymicrobial , abdominal sepsis by cecal ligation and puncture . Measurements and Main Results : Tissue Pco2 was continuously measured with the aid of a miniature carbon dioxide electrode . Using orthogonal polarization spectral imaging , recordings of the microcirculation were taken at baseline and hourly intervals until death and compared with sham-operated animals . Gastric and buccal tissue Pco2 values progressively increased in animals after cecal ligation and puncture and terminated in death . Microcirculatory blood flow in vessels > 20 & mgr;m was well preserved during progression of shock , whereas there was an early and progressive decrease in microcirculatory blood flow in vessels < 20 & mgr;m , mostly representing capillaries . Tissue Pco2 , the tissue Pco2-Paco2 gradient , and blood flow in vessels < 20 & mgr;m were highly correlated . This contrasted with sham control animals in which no significant hemodynamic , blood gas , lactate , microcirculatory , and tissue Pco2 abnormalities were observed . Conclusions : These observations suggest that microcirculatory failure in capillaries appears as an early defect in close association with anaerobic metabolism during progression of circulatory shock in an animal model of septic peritonitis ObjectiveS epsis mortality is closely linked to multi-organ failure , and impaired microcirculatory blood flow is thought to be pivotal in the pathogenesis of sepsis-induced organ failure . We hypothesized that changes in microcirculatory flow during resuscitation are associated with changes in organ failure over the first 24 h of sepsis therapy . Design Prospect i ve observational study . Setting Emergency Department and Intensive Care Unit . Participants Septic patients with systolic blood pressure < 90 mmHg despite intravenous fluids or lactate ≥4.0 mM/L treated with early goal -directed therapy ( EGDT ) .  Measurements and results We performed Sidestream Dark Field ( SDF ) videomicroscopy of the sublingual microcirculation <3 h from EGDT initiation and again within a 3–6 h time window after initial . We imaged five sites and determined the mean microcirculatory flow index ( MFI ) ( 0 no flow to 3 normal ) blinded to all clinical data . We calculated the Sequential Organ Failure Assessment ( SOFA ) score at 0 and 24 h , and defined improved SOFA a priori as a decrease ≥2 points . Of 33 subjects ; 48 % improved SOFA over 0–24 h. Age , APACHE II , and global hemodynamics did not differ significantly between organ failure groups . Among SOFA improvers , 88 % increased MFI during EGDT , compared to 47 % for non-improvers ( P = 0.03 ) . Median change in MFI was 0.23 for SOFA improvers versus −0.05 for non-improvers ( P = 0.04 ) . Conclusions Increased microcirculatory flow during resuscitation was associated with reduced organ failure at 24 h without substantial differences in global hemodynamics . These data support the hypothesis that targeting the microcirculation distinct from the macrocirculation could potentially improve organ failure in sepsis Objective : To evaluate sublingual microcirculatory and peripheral tissue perfusion parameters in relation to systemic hemodynamics during and after therapeutic hypothermia following out-of-hospital cardiac arrest . Design : Prospect i ve observational study . Setting : Intensive cardiac care unit at a university teaching hospital . Subjects : We followed 80 patients , of whom 25 were included after out-of-hospital cardiac arrest . Intervention : In all patients , we induced therapeutic hypothermia to 33 ° C during the first 24 hrs of admission . Measurements and Main Results : Complete hemodynamic measurements were obtained directly on intensive cardiac care unit admission ( baseline ) , during induced hypothermia ( T1 ) , directly after rewarming ( T2 ) , and another 24 hrs later ( T3 ) . In addition , the sublingual microcirculation was observed using sidestream dark-field imaging , and peripheral tissue perfusion was monitored with the peripheral perfusion index , capillary refill time , tissue oxygen saturation , and forearm-to-fingertip skin temperature gradient . During hypothermia , all sublingual microcirculatory parameters decreased significantly together with peripheral capillary refill time and the peripheral perfusion index , followed by a significant increase at T2 . Changes in sublingual and peripheral tissue perfusion parameters were significantly related to changes in central body temperature , but not to changes in systemic hemodynamic variables such as cardiac index or mean arterial pressure . Surprisingly , these parameters were significantly lower in nonsurvivors ( n = 6 ) at admission and after rewarming . Persistent alterations in these parameters were related with the prevalence of organ dysfunction and were highly predictive of mortality . Conclusions : Following out-of-hospital cardiac arrest , the early postresuscitation phase is characterized by abnormalities in sublingual microcirculation and peripheral tissue perfusion , which are caused by vasoconstriction due to induced systemic hypothermia and not by impaired systemic blood flow . Persistence of these alterations is associated with organ failure and death , independent of systemic hemodynamics 
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Pochard F , Azoulay E , Chevret S , et al : Symptoms of anxiety and depression in family members of intensive care unit patients : Ethical hypothesis regarding decision-making capacity .
Majesko A , Hong SY , Weissfeld L , et al : Identifying family members who may struggle in the role of surrogate decision maker .
Daly BJ , Douglas SL , O’Toole E , et al : Effectiveness trial of an intensive communication structure for families of long-stay ICU patients .
Mack JW , Block SD , Nilsson M , et al : Measuring therapeutic alliance between oncologists and patients with advanced cancer : The Human Connection Scale .
Mack JW , Weeks JC , Wright AA , et al : End-oflife discussion s , goal attainment , and distress at the end of life : Predictors and outcomes of receipt of care consistent with preferences .