Association between perceived coercion and perceived level of information in involuntarily admitted patients: Results from a multicenter observational study in Switzerland

BACKGROUND

Involuntary admissions (IA) to psychiatric hospitals are controversial because they interfere with people's autonomy. In some situations, however, they appear to be unavoidable. Interestingly, not all patients perceive the same degree of coercion during IA. The aim of this study was to assess whether the level of knowledge about one's own IA is associated with perceived coercion.

METHODS

This multicenter observational study was conducted on n = 224 involuntarily admitted patients. Interviews were conducted at five study centers from April 2021 to November 2021. The Macarthur Admission Experience Survey was administered to assess perceived coercion. Knowledge of involuntary admission, perceptions of information received, and attitudes towards legal aspects of involuntary admission were also assessed.

RESULTS

We found that higher levels of knowledge about IA were negatively associated with perceived coercion at admission. Perceived coercion did not differ between study sites. Only half of the patients felt well informed about their IA, and about a quarter found the information they received difficult to understand.

DISCUSSION

Legislation in Switzerland requires that patients with IA be informed about the procedure. Strategies to improve patients' understanding of the information given to them about IA might be helpful to reduce perceived coercion, which is known to be associated with negative attitudes towards psychiatry, a disturbed therapeutic relationship, avoidance of psychiatry, and the risk of further coercion.

Mental health service areas in Switzerland

OBJECTIVES

Small area analysis is a health services research technique that facilitates geographical comparison of services supply and utilization rates between health service areas (HSAs). HSAs are functionally relevant regions around medical facilities within which most residents undergo treatment. We aimed to identify HSAs for psychiatric outpatient care (HSA-PSY) in Switzerland.

METHODS

We used HSAr, a new and automated methodological approach, and comprehensive psychiatric service use data from insurances to identify HSA-PSY based on travel patterns between patients' residences and service sites. Resulting HSA-PSY were compared geographically, demographically and regarding the use of inpatient and outpatient psychiatric services.

RESULTS

We identified 68 HSA-PSY, which were reviewed and validated by local mental health services experts. The population-based rate of inpatient and outpatient service utilization varied considerably between HSA-PSY. Utilization of inpatient and outpatient services tended to be positively associated across HSA-PSY.

CONCLUSIONS

Wide variation of service use between HSA-PSY can hardly be fully explained by underlying differences in the prevalence or incidence of disorders. Whether other factors such as the amount of services supply did add to the high variation should be addressed in further studies, for which our functional mapping on a small-scale regional level provides a good analytical framework.

Detailing the effects of polypharmacy in psychiatry: longitudinal study of 320 patients hospitalized for depression or schizophrenia

Current treatment standards in psychiatry are oriented towards polypharmacy, that is, patients receive combinations of several antidepressants, antipsychotics, mood stabilizers, anxiolytics, hypnotics, antihistamines, and anticholinergics, along with other somatic treatments. In tandem with the beneficial effects of psychopharmacological drug treatment, patients experience significant adverse reactions which appear to have become more frequent and more severe with the rise of ubiquitous polypharmacy. In this study, we aimed to assess today's acute inpatient treatment of depressive and schizophrenic disorders with focus on therapeutic strategies, medications, adverse side effects, time course of recovery, and efficacy of treatments. Of particular interest was the weighing of the benefits and drawbacks of polypharmacy regimens. We recruited a total of 320 patients hospitalized at three residential mental health treatment centers with a diagnosis of either schizophrenic (ICD-10: "F2x.x"; n = 94; "F2 patients") or depressive disorders (ICD-10: "F3x.x"; n = 226; "F3 patients"). The study protocol included (1) assessment of previous history by means of the SADS Syndrome Check List SSCL-16 (lifetime version); (2) repeated measurements over 5 weeks assessing the time course of improvement by the Hamilton Depression Scale HAM-D and the Positive and Negative Syndrome Scale PANSS, along with medications and adverse side effects through the Medication and Side Effects Inventory MEDIS; and (3) the collection of blood samples from which DNA and serum were extracted. Polypharmacy was by far the most common treatment regimen (85%) in this study. On average, patients received 4.50 ± 2.68 medications, consisting of 3.30 ± 1.84 psychotropic drugs, plus 0.79 ± 1.13 medications that alleviate adverse side effects, plus 0.41 ± 0.89 other somatic medications. The treating psychiatrists appeared to be the main determining factor in this context, while «previous history» and «severity at baseline» played a minor role, if at all. Adverse drug reactions were found to be an inherent component of polypharmacy and tended to have a 2-3 times higher incidence compared to monotherapy. Severe adverse reactions could not be attributed to a particular drug or drug combination. Rather, the empirical data suggested that severe side effects can be triggered by virtually all combinations of drugs, provided patients have a respective vulnerability. In terms of efficacy, there were no advantages of polypharmacy over monotherapy. The results of this study underlined the fact that polypharmacy regimens are not equally suited for every patient. Specifically, such regimens appeared to have a negative impact on treatment outcome and to obfuscate the "natural" time course of recovery through a multitude of interfering factors. Evidence clearly speaks against starting just every therapeutic intervention in psychiatry with a combination of psychopharmaceuticals. We think that it is time for psychiatry to reconsider its treatment strategies, which are far too one-sidedly fixated on psychopharmacology and pay far too little attention to alternative approaches, especially in mild cases where psychotherapy without concurrent medication should still be an option. Also, regular exercises and sports can definitely be an effective therapeutic means in a considerable number of cases. General practitioners (GPs) are particularly in demand here.

Physical and mental health impact of COVID-19 on children, adolescents, and their families: The Collaborative Outcomes study on Health and Functioning during Infection Times - Children and Adolescents (COH-FIT-C&A)

BACKGROUND

The COVID-19 pandemic has altered daily routines and family functioning, led to closing schools, and dramatically limited social interactions worldwide. Measuring its impact on mental health of vulnerable children and adolescents is crucial.

METHODS

The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT - www.coh-fit.com) is an on-line anonymous survey, available in 30 languages, involving >230 investigators from 49 countries supported by national/international professional associations. COH-FIT has thee waves (until the pandemic is declared over by the WHO, and 6-18 months plus 24-36 months after its end). In addition to adults, COH-FIT also includes adolescents (age 14-17 years), and children (age 6-13 years), recruited via non-probability/snowball and representative sampling and assessed via self-rating and parental rating. Non-modifiable/modifiable risk factors/treatment targets to inform prevention/intervention programs to promote health and prevent mental and physical illness in children and adolescents will be generated by COH-FIT. Co-primary outcomes are changes in well-being (WHO-5) and a composite psychopathology P-Score. Multiple behavioral, family, coping strategy and service utilization factors are also assessed, including functioning and quality of life.

RESULTS

Up to June 2021, over 13,000 children and adolescents from 59 countries have participated in the COH-FIT project, with representative samples from eleven countries.

LIMITATIONS

Cross-sectional and anonymous design.

CONCLUSIONS

Evidence generated by COH-FIT will provide an international estimate of the COVID-19 effect on children's, adolescents' and families', mental and physical health, well-being, functioning and quality of life, informing the formulation of present and future evidence-based interventions and policies to minimize adverse effects of the present and future pandemics on youth.

The collaborative outcomes study on health and functioning during infection times in adults (COH-FIT-Adults): Design and methods of an international online survey targeting physical and mental health effects of the COVID-19 pandemic

BACKGROUND

. High-quality comprehensive data on short-/long-term physical/mental health effects of the COVID-19 pandemic are needed.

METHODS

. The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT) is an international, multi-language (n=30) project involving >230 investigators from 49 countries/territories/regions, endorsed by national/international professional associations. COH-FIT is a multi-wave, on-line anonymous, cross-sectional survey [wave 1: 04/2020 until the end of the pandemic, 12 months waves 2/3 starting 6/24 months threreafter] for adults, adolescents (14-17), and children (6-13), utilizing non-probability/snowball and representative sampling. COH-FIT aims to identify non-modifiable/modifiable risk factors/treatment targets to inform prevention/intervention programs to improve social/health outcomes in the general population/vulnerable subgrous during/after COVID-19. In adults, co-primary outcomes are change from pre-COVID-19 to intra-COVID-19 in well-being (WHO-5) and a composite psychopathology P-Score. Key secondary outcomes are a P-extended score, global mental and physical health. Secondary outcomes include health-service utilization/functioning, treatment adherence, functioning, symptoms/behaviors/emotions, substance use, violence, among others.

RESULTS

. Starting 04/26/2020, up to 14/07/2021 >151,000 people from 155 countries/territories/regions and six continents have participated. Representative samples of ≥1,000 adults have been collected in 15 countries. Overall, 43.0% had prior physical disorders, 16.3% had prior mental disorders, 26.5% were health care workers, 8.2% were aged ≥65 years, 19.3% were exposed to someone infected with COVID-19, 76.1% had been in quarantine, and 2.1% had been COVID 19-positive.

LIMITATIONS

. Cross-sectional survey, preponderance of non-representative participants.

CONCLUSIONS

. Results from COH-FIT will comprehensively quantify the impact of COVID-19, seeking to identify high-risk groups in need for acute and long-term intervention, and inform evidence-based health policies/strategies during this/future pandemics.

Relationship of Internalized Transnegativity and Protective Factors With Depression, Anxiety, Non-suicidal Self-Injury and Suicidal Tendency in Trans Populations: A Systematic Review

Discrimination heavily impacts the lives of trans populations and causes adverse mental health outcomes. As stated by the Gender Minority Stress Model self-stigmatization could play an important role in this process. The aim of this systematic review is to investigate whether there is a positive association between self-stigmatization and mental health and to identify mediation factors. Studies which quantitatively investigated the association between internalized transnegativity and selected mental health outcomes (depression, anxiety, non-suicidal self-injury, suicidal tendency) in self-identified trans populations were included. Comprehensive search of 5 large databases in June 2020 and the following screening and selection procedure, performed by two researchers separately, identified 14 studies which met criteria. The relationship to be studied was reported with correlation and/or mediation analysis of cross-sectional data. IT was directly positively associated with depression, anxiety and suicidal tendency in most of the reviewed studies. Data indicates links between self-stigmatization and other general mental health stressors such as rumination and thwarted belongingness. Community connectedness showed to be the strongest protective factor for mental health impairments. These results should be considered in transition counseling. More research is needed to better understand the underlying mechanisms of the GMSM and to address unsolved operationalization and measurement issues.

[Entrustable Professional Activities in Graduate Medical Education in Psychiatry: A Promising Concept]

Entrustable Professional Activities in Graduate Medical Education in Psychiatry: A Promising Concept Abstract. Entrustable Professional Activities (EPAs) are competency-based learning goals derived from observable clinical activities. In undergraduate medical education, they have now been adopted throughout Switzerland as part of the so-called PROFILES catalog (Principal Relevant Objectives and Framework for Integrated Learning and Education in Switzerland). The nine core EPAs to be mastered in undergraduate medical education can serve as a basis for introducing EPAs in graduate medical education as well. We will discuss this approach in the context of graduate medical education in psychiatry and psychotherapy from the perspective of different training contexts and a pilot example. In this position paper, we describe a promising opportunity to improve graduate medical training through the implementation of EPAs, both in terms of the quality of training and thus of patient care, as well as in terms of the attractiveness of the specialty for future residents.

Inflammatory processes linked to major depression and schizophrenic disorders and the effects of polypharmacy in psychiatry: evidence from a longitudinal study of 279 patients under therapy

Over the past 2 decades, polypharmacy has become the de-facto standard of acute treatment in psychiatry where patients with psychiatric disorders receive a multiple medication regimen. There is growing evidence for a potential link between major psychiatric disorders and inflammatory processes. Combining these two aspects aims at avoiding polypharmacy attempts among patients with inflammatory activation through alternative treatment strategies. In this study, we addressed the following questions: (1) to what extent can polypharmacy be explained through the factors "diagnosis", "previous history", "severity at baseline", "age", "gender", and "psychiatrist in charge"; (2) what are the differences between polypharmacy and monotherapy regarding efficacy and side effect profiles; and (3) what amount of between-patient variance is explainable by the natural antibody immunoglobulin M (IgM) within each diagnostic group. This naturalistic longitudinal study was comprised of 279 patients under therapy with a clinical diagnosis of depressive (ICD-10: "F3x.x"; n = 195) or schizophrenic disorders (ICD-10: "F2x.x"; n = 84). The study protocol included (1) assessment of previous history by the SADS Syndrome Check List SSCL-16 (lifetime version); (2) repeated measurements over 5 weeks assessing the time course of improvement by the Hamilton Depression Scale HAM-D and the Positive and Negative Syndrome Scale PANSS, along with medication and unwanted side effects through the Medication and Side Effects Inventory MEDIS; and (3) the collection of blood samples from which DNA and serum were extracted. The association between inflammatory response system and psychiatric disorders was detailed by fitting multi-layer Neural Net (NN) models to the observed data ("supervised learning"). The same approach was used to set up prediction models of side effects. Our data showed that polypharmacy was omnipresent. Yet the various polypharmacy regimens had no advantage over monotherapy: we even found slightly larger baseline score reductions under monotherapy, independent of primary diagnoses and for comparable baseline severities. Most patients experienced unwanted side effects. The close link between side effects and treatment regimen was revealed by a linear model in which the mere number of drugs explained a significant (p < 0.001) proportion of the observed variance. As to the inflammatory response system: For the F2 patients, our NN model identified a 22.5% subgroup exhibiting a significant correlation of r = 0.746 (p = 0.0004) between global schizophrenia scores and IgM levels, along with a correct prediction of response of 94.4%, thus explaining 55.7% of the observed between-patient variance. For the F3 patients, our NN model identified a 19.6% subgroup exhibiting a significant correlation of r = 0.644 (p = 0.00003) between global depression scores and IgM levels, along a correct prediction of response of 89.6%, thus explaining 41.4% of the observed between-patient variance. Polypharmacy is omnipresent in today's acute treatment of psychiatric disorders. Given the large proportion of patients with unwanted side effects and the strong correlation between side effects and the number of drugs, polypharmacy approaches are not equally suited for every patient. In terms of efficacy, there are no advantages of polypharmacy over monotherapy. Most notably, our study appears to have cleared the way for the reliable identification of a subgroup of patients for whom the inflammatory response system is a promising target of therapeutic intervention.

Fifteen years of heroin-assisted treatment in a Swiss prison-a retrospective cohort study

Background

In the context of the current US opioid crisis and the compelling fact that a quarter to a third of all those addicted to heroin pass through its prisons and jails each year, the care of incarcerated opioid-using individuals (OUI) needs to be improved.

Aims

Little has been published on the effectiveness or outcomes of heroin-assisted treatment (HAT), a treatment option for severely dependent OUI delivered in a prison setting. The aim of this study was therefore to evaluate such treatment since its implementation. The primary objective was to investigate whether heroin-assisted treatment was associated with severe detrimental health outcomes. The secondary objective was to compare the heroin-assisted treatment group with the general prison population in terms of occupational functioning.

Design

Retrospective cohort study

Setting

An open prison with 120 places

Subjects

Data on 1885 male prisoners with a total of 2239 imprisonment periods between 2000 and 2015 was available. Ninety-seven inmates in heroin-assisted treatment were compared with 1788 inmates from the general prison population (reference group).

Measurements

Mortality, medical complications (including overdoses), and work performance (days worked, sick days, and monthly wages earned).

Findings

Inmates receiving HAT were on average 1 year younger (33.8 vs. 34.9 years), had longer prison stays (7.3 vs. 3.0 months), were more often of Swiss nationality (68.0% vs. 28.9%), and had committed more drug- and property-related offenses (49.5% vs. 23.2% and 63.9% vs. 38.3%, respectively) compared to the reference group. No serious heroin-related medical complication occurred during the 15-year window of observation among inmates with heroin-assisted treatment. Their work performance was comparable to that of the reference group.

Conclusions

This study shows that heroin-assisted treatment can be a valuable treatment option for severely dependent OUI during imprisonment, can be delivered safely by prison health staff over extended periods of time, and allows OUI in treatment to achieve work performance rates comparable to that of the general prison population.

Reducing recidivism using the Reasoning and Rehabilitation program: a pilot multi-site-controlled trial among prisoners in Switzerland

OBJECTIVES

This study evaluated whether the Reasoning and Rehabilitation (R&R2) program was effective in reducing recidivism, minimizing dropout rates, and improving outcomes related to attitudes, behaviors, and personality among people living in detention.

METHODS

Data were collected in eight Swiss German-speaking prisons among males detained for violent offenses using a quasi-experimental controlled design (R&R2: n = 129, treatment as usual [TAU]: n = 84). Measures included recidivism, dropout rate, and self-report questionnaires (hostile attribution bias, aggressiveness, interpersonal problems, and willingness to accept responsibility). Data were analyzed using mixed-effect models.

RESULTS

Participants in the R&R2 group were less likely to reoffend in comparison with the TAU group in the intention-to-treat (n = 51, odds ratio = 0.75, p = .060) and the per-protocol (excluding dropouts; n = 38, odds ratio = 0.65, p = .068) analyses. They also had lower self-reported scores of spontaneous and reactive aggressiveness (p = .047 and p = .070) and excitability (p = .086).

CONCLUSIONS

The findings of this pilot project were promising, with the R&R2 program leading to reduced recidivism and dropout rate. Even though these results should be considered preliminary, the R&R2 program appeared to be a relevant approach in reducing recidivism after prison.

The Accessibility of Opioid Agonist Treatment and Its Forced Discontinuation in Swiss Prisons-Attitudes, Perceptions and Experiences of Defense Lawyers in Dealing With Detained Persons Using Opioids

BACKGROUND

Opioid agonist treatment (OAT) is an important pillar in the treatment of individuals using opioids and its continuation during imprisonment is recommended. Despite this knowledge access to and continuation of OAT is still limited in many countries. The forced discontinuation during pre-trial detention can cause severe withdrawal symptoms, which in turn may significantly impair the defendant's ability to exercise granted procedural participation rights. Furthermore, it can be argued that forced discontinuation of a desired treatment represents a form of a compulsory intervention.

AIMS

The present study was developed against the backdrop of a recent ruling by the European Court of Human Rights (Wenner vs. Germany). It intended to examine how defense lawyers dealing with detained persons using opioids view and assess the accessibility of OAT in pre-trial detention as well as during imprisonment in different parts of Switzerland.

METHODS

Using a qualitative approach, we interviewed 11 defense lawyers from three different cantons of Switzerland with multiple years of experience in providing legal representation to more than 220 defendants using heroin. The interviews were analyzed with QSR NVIVO 11 for Windows. A qualitative content analysis approach was used to evaluate findings.

RESULTS

Defenders who had been exposed to the opioid crisis during the course of their legal career had adopted a positive attitude towards OAT and associated it with a stabilizing influence on their clients, an improvement in criminal prognosis, and a reduction in recidivism. They were generally of the opinion that access to OAT had improved, however identified a considerable variance in different penitentiaries, which were mediated by attitudes of staff and authorities. Based on the assessments of the defense lawyers, it can be estimated that the initiation of OAT especially during pre-trial detention is challenging. The predominant aim of OAT in a variety of Swiss prisons still seems to focus on a discontinuation, mediated by a forced reduction of medication. Some of the interventions reported are not in line with the principle of equivalence and strongly contrast the recommendations of the Council of Europe.

Perceptions and Attitudes of Correctional Staff Toward ADHD-A Challenging Disorder in Everyday Prison Life

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is associated with risk-taking behaviors, poor self-control, and interpersonal difficulties. Affected individuals have an increased probability of involvement with the criminal justice system, contributing to a higher rate of arrest, and imprisonment compared with the general population; they are also inadequately treated once sentenced. Because prison staff play a central role in the identification of inmates with mental disorders, they could well be key to improving provision of care. There is however little knowledge of the conceptions, perceptions, and attitudes of prison staff toward ADHD. Such information could help to identify starting points for awareness training and further implementation of specific ADHD treatment. To bridge this gap, we undertook a study based on a qualitatively-driven mixed methods design, combining qualitative data collection in the form of narrative interviews with 19 prison staff from a Swiss correctional facility with quantitative data collection in the form of a survey that included the Attitudes toward Prisoners scale. The interviews were analyzed with QSR NVIVO 11 and a qualitative content analysis approach was used to evaluate findings. Prison staff were generally aware of ADHD and its symptomology, believing it to a be "real," but "fashionable" disorder and favoring hereditary-genetic or biological explanatory models for its development. They viewed inmates with ADHD rather negatively, as complicating correctional efforts, and perceived them as sticking out, as tying up more resources and as frequently being involved in confrontations. Our findings suggest that difficulties in pragmatic aspects of communication and language comprehension may be perceived "as not listening or following instructions," creating additional tensions. Consequently, inmates with ADHD are more often exposed to disciplinary sanctions, such as solitary confinement-an intervention deemed "necessary" by staff. Therefore, staff training on ADHD might need to cover evidence on adverse effects. Non-pharmacological interventions for treatment were preferred and considered to be highly efficacious. Skepticism toward pharmacological treatment prevailed, even when benefits from stimulant medication were described. Interestingly, this skepticism was not the result of negative experiences with the misuse and diversion of stimulants. Acceptance of multimodal treatment among prison staff may require customized strategies.

[Influence of an "Open Door Policy" on Ward Climate: Impact on Treatment Quality]

OBJECTIVE

To compare the ward atmosphere, safety, therapeutic hold, and patients' coherence on recently opened (1 year), opened (4 years) and open (> 20 years) psychiatric wards in a longitudinal naturalistic study design. The question was if a patient shift from formerly locked to open wards might deteriorate the ward atmosphere on the open and opened wards.

METHODS

Ward atmosphere on two recently opened (n = 2), opened (n = 2) and open (n = 2) wards was examined using the Essen Climate Evaluation Schema (EssenCES) in a follow-up study after 4 years. Structural as well as clinical data were extracted.

RESULTS

Global ward atmosphere, safety, and patients' coherence on the recently opened wards was significantly increased; on always opened wards and long-term opened wards it remained unchanged. Coercive measures and discharges against medical advice decreased during the open door process.

CONCLUSION

Opening locked psychiatric wards can help to establish a positive therapeutic atmosphere without changing the therapeutic climate on the other already open wards. A better ward atmosphere might be connected with a better therapeutic quality.

Differences in short and long sleep durations between blacks and whites attributed to emotional distress: analysis of the National Health Interview Survey in the United States

OBJECTIVES

The current study examined the role of emotional distress in explaining racial/ethnic differences in unhealthy sleep duration.

DESIGN

Data from the 2004-2013 National Health Interview Survey were analyzed using SPSS 20.

SETTING

Data were collected through personal household interviews in the United States.

PARTICIPANTS

Of the total 261,686 participants (age≥18 years), 17.0% were black, 83.0% were white, and the mean age was 48 years (SE=0.04).

MEASUREMENTS

To ascertain total sleep duration, participants were asked, "How many hours of sleep do you get on average in a 24-hour period?" Sleep duration was coded as short sleep (<7hours), average sleep (7-8hours), or long sleep (>8hours). Emotional distress-feeling sad, nervous, restless, hopeless, worthless, and burdened over a 30-day period-was measured using Kessler-6, a 6-item screening scale.

RESULTS

Of the participants reporting significant emotional distress (4.0% black, 3.5% white), χ² analyses revealed that a higher percentage of blacks, compared with whites, reported unhealthy sleep durations. Relative to Whites, Blacks had increased prevalence of short sleep (prevalence ratio=1.32, P<.001) or long sleep (odds ratio =1.189, P<.001). The interaction between race/ethnicity and emotional distress was significantly associated with short (prevalence ratio=0.99, P<.001) and long sleep (odds ratio=0.98, P<.001) durations.

CONCLUSIONS

Individuals of the black race/ethnicity or those reporting greater levels of emotional distress are more likely to report short or long sleep duration. Emotional distress might partially explain racial/ethnic differences in unhealthy sleep duration between blacks and whites.

Vaccination for Parkinson's disease

Idiopathic Parkinson's disease (PD) is, like other neurodegenerative diseases such as Alzheimer's disease (AD) considered a proteinopathy. Thus, a disease that is driven by the accumulation and aggregation of misfolded proteins, in case of PD α-synuclein (aSyn) is incriminated. Accordingly, removal of aSyn is assumed of having the potential to modify the course of the disease. Both active and passive aSyn targeting immunotherapy were found to modify disease in mice overexpressing human aSyn and recapitulating various aspects of synucleopathies. Translating immunotherapy to humans needs to consider the issue of potential autoimmunity. PD vaccines developed by AFFiRiS integrate the safety concept as applied for the company's AD vaccine candidates. This includes the use of short antigens, precluding activation of aSyn-specific T cells and, thus, cellular autoimmunity. Moreover, the selection of AFFITOPES® for clinical development is based on the principle of exclusive aSyn reactivity of vaccine-induced Abs excluding crossreactivity to β-synuclein (bSyn), which is ensured by the AFFITOME® platform technology. PD01, the first in class aSyn vaccine developed by AFFiRiS is about to enter the clinical phase of development.

Development of AFFITOPE vaccines for Alzheimer's disease (AD)--from concept to clinical testing

Based on the notion that cerebral accumulation of certain Abeta species is central to AD pathogenesis and endowed with the knowledge that emerged during clinical testing of the first human Alzheimer vaccine, AN1792, we designed a new generation of Alzheimer vaccines. Rather than relying on full-length Abeta itself or fragments thereof, AFFITOPE vaccines use short peptides, mimicking parts of the native Abeta sequence, as their antigenic component. The technology created to identify these peptides, termed AFFITOPE-technology, at the same time provides the basis for the multi-component safety concept realized in AFFITOPE vaccines. First, as they are nonself, AFFITOPES don't need to break tolerance typically established against self proteins. This allows us to use aluminium hydroxide, the agent first approved as immunological adjuvant for human use and, thus, exhibiting an excellent safety profile. Second, AFFITOPES employed in Alzheimer vaccines are only 6 amino acids in length, which precludes the activation of Abeta-specific autoreactive T cells. Third, and above all, the AFFITOPE technology allows for controlling the specificity of the vaccine-induced antibody response focusing it exclusively on Abeta and preventing crossreactivity with APP. In a program based on two AFFITOPES allowing neoepitope targeting of Abeta (free N-terminus), this approach was taken all the way from concept to clinical application. Early clinical data support the safety concept inherent to AFFITOPE Alzheimer vaccines. Further clinical testing will focus on the identification of the optimal vaccine dose and immunization schedule. Together, result of these trials will provide a solid basis for clinical POC studies.

Apheresis products of the Amicus™ and the AS.TEC 204® cell separators are comparable with regard to dendritic cells derived from the mononuclear cell collection

BACKGROUND

In this study, we investigated the quality of autologous mononuclear cells (MNC) collected with two different cell separators using standard MNC-apheresis procedure modalities. MNCs were purified by density gradient centrifugation and cultured according to standard protocols to generate dendritic cells (DC) and 1 x 10(7)/ml immature DCs were pulsed with tumour lysate for 3 days and subsequently characterized by fluorescent-activated cell sorter analysis.

RESULTS

No difference was found in the monocyte content of either apheresis product (P = 0.07) and in the overall yield of MNCs (P = 0.7). Mature DCs as defined by their phenotype revealed also no significant difference: Amicus, 118 x 10(6) cells +/- 91 vs. AS.TEC 204, 128 x 10(6) cells +/- 137 (P = 0.55), respectively, although the contamination with platelets (threefold) and red cells (twofold) was significantly higher in the AS.TEC 204 group (P < 0.05) than in the Amicus group.

CONCLUSION

The Amicus and the AS.TEC 204 are equally capable in providing MNCs for the generation of DCs and the amount of concomitantly collected red cells and platelets had no impact on the final DC yield.

Successful use of acitretin in conjunction with narrowband ultraviolet B phototherapy in a child with severe pustular psoriasis, von Zumbusch type

Severe pustular psoriasis von Zumbusch type is a therapeutic challenge not only in adults, but even more in children. We report a 3(1/2)-year-old boy who developed a generalized flare of diffusely scattered pustules on erythematous skin which rapidly progressed to large exuding areas. The clinical presentation and investigations including histopathological examination of a biopsy and negative bacterial cultures were consistent with the diagnosis of pustular psoriasis von Zumbusch type. Upon initial treatment with methylprednisolone, acitretin and antibiotics the extent of the disease declined. However, several attempts to reduce the dose of the oral corticosteroid were followed by immediate severe flares. Additional treatment with narrowband ultraviolet B (NB-UVB, 311-313 nm UVB) resulted in a rapid arrest of disease activity and allowed the corticosteroid to be tapered off. After 10 irradiations the patient was both off steroid and disease free. NB-UVB therapy was subsequently reduced to twice-weekly exposures and acitretin gradually diminished to a maintenance dose of 0.3 mg kg(-1) daily. We conclude that NB-UVB in conjunction with acitretin is a potent therapeutic regimen for the treatment of severe pustular psoriasis von Zumbusch type in childhood.

Linguistic analysis of the speech output of schizophrenic, bipolar, and depressive patients

Using speech samples of 100 patients suffering from schizophrenia, bipolar illness and major depression, we addressed the question of the extent to which the linguistic abnormalities in the speech of these patients represent diagnosis-specific characteristics or constitute independent, syndrome-like dimensions of the illnesses. All speech samples were transcribed by a professional linguist who was blind to both identity and diagnosis of the patients. The majority of the deviant linguistic variables was found to be common to all three diagnostic groups under comparison, while only a few linguistic variables exhibited statistically significant between-group differences. On the other hand, when the respective variables were analysed as a multivariate entity, the variety of subtle between-group differences allowed us to discriminate between the diagnostic groups at an overall performance of 72.7% correctly classified patients. There was an almost complete lack of association between linguistic abnormalities and psychopathology syndromes. In particular, we found no correlation between the syndrome 'formal thought disorder' and the large variety of linguistic variables used in this investigation. In consequence, we conjecture that linguistically deviant speech characteristics represent an independent syndrome complex manifested at varying intensities across mental illnesses, and that this syndrome complex deserves greater attention, not only with respect to the principal understanding of the underlying disturbances, but also as a potential target of therapeutical intervention.

Ion selectivity of the cytoplasmic binding sites of the Na,K-ATPase: II. Competition of various cations

In the E1 state of the Na,K-ATPase all cations present in the cytoplasm compete for the ion binding sites. The mutual effects of mono-, di- and trivalent cations were investigated by experiments with the electrochromic fluorescent dye RH421. Three sites with significantly different properties could be identified. The most unspecific binding site is able to bind all cations, independent of their valence and size. The large organic cation Br2-Titu3+ is bound with the highest affinity (<microM), among the tested divalent cations Ca2+ binds the strongest, and Na+ binds with about the same equilibrium dissociation constant as Mg2+ (approximately 0.8 mM). For alkali ions it exhibits binding affinities following the order of Rb+ approximately equals K+ > Na+ > Cs+ > Li+. The second type of binding site is specific for monovalent cations. its binding affinity is higher than that of the first type, for Na+ ions the equilibrium dissociation constant is < 0.01 mM. Since binding to that site is not electrogenic it has to be close to the cytoplasmic surface. The third site is specific for Na+, no other ions were found to bind, the binding is electrogenic and the equilibrium dissociation constant is 0.2 mM.

Intracutaneous genetic immunization with autologous melanoma-associated antigen Pmel17/gp100 induces T cell-mediated tumor protection in vivo

Using the differentiation antigen Pmel17/gp100 to genetically immunize C57BL/6 mice (H-2(b)), we and colleagues noticed that only mice that had received the human homolog but not animals injected with the murine counterpart were protected against the growth of syngeneic B16 melanoma cells. The goal of this study was to determine whether the state of nonresponsiveness to the autoantigen Pmel17/gp100 can be broken by immunization with a plasmid DNA construct encoding the autologous form of the molecule. A construct containing the murine form of Pmel17 was administered intradermally to DBA/2 mice (H-2(d)), which were then investigated for the presence of Pmel17/gp100-specific immunity. We show that administration of plasmid DNA coding for the autologous melanoma-associated antigen Pmel17/gp100 protects DBA/2 mice against the growth of Pmel17-positive M3 melanoma cells but not against Pmel17-negative M3 melanoma cells or unrelated P815 mastocytoma cells. Cell depletion experiments demonstrated that this protective effect is mediated by T lymphocytes. The notion that Pmel17/gp100 represents the biologically relevant target in this system was supported by the observations (i) that recipients of Pmel17/gp100 DNA mount an antigen-specific cytotoxic T lymphocyte response and (ii) that M3 tumors growing in mice immunized with autologous Pmel17/gp100 had lost expression of this melanoma-associated antigen whereas M3 melanomas appearing in control-vector-treated animals were still Pmel17/gp100-positive. These results indicate that intracutaneous genetic immunization with autologous melanoma-associated antigen Pmel17/gp100 encoding plasmid DNA can lead to protection against melanoma cells as a result of the induction of a melanoma-associated antigen-specific and protective T-cell-mediated immune response. J Invest Dermatol 115:1082-1087 2000

What is the most promising strategy for the treatment of metastasizing melanoma?

The treatment of patients with metastasizing melanoma, still one of the most deadly diseases in modern medicine, ranks among the greatest challenges that a clinician has to face. Metastatic melanoma also is one of the most profound sources of clinical frustration, since it provides far more ultimately defeating experiences than clinical victories. At the same time, the fascinating biology of melanoma has invited the study of this neuroectodermal tumor as a model system for dissecting many of the key problems of modern oncology, ranging from molecular oncogenesis via the controls of tumor proliferation, apoptosis, invasion, metastasis, and angiogenesis to tumor immunosurveillance and tumor drug resistance. Together with the dire need to develop more effective treatment modalities for improving both life expectancy and quality of life of affected patients, this has made metastatic melanoma a favorite model for the exploration of innovative strategies for tumor management. Encouragingly, many of these have already generated very promising results in animal models. However, this impressive level of research progress in conquering melanoma in the animal room contrasts rather pitifully with the actual progress made on the ward. This CONTROVERSIES feature, therefore, critically and soberly reviews the state of the art of treating metastatic melanoma today (distinguishing between nodal and distant metastases), and sharply defines unresolved or comparatively neglected key problems. In addition, this feature highlights several novel, provocative, hitherto underappreciated, yet potentially promising treatment approaches that deserve systematic exploration. Hopefully, this will offer further inspiration for the design and pursuit of innovative anti-melanoma strategies off-the-beaten-track.

Management of malignant melanoma: new developments in immune and gene therapy

Thus far, the use of classical anti-cancer treatment modalities had only rarely a beneficial impact on the prognosis of patients with metastatic melanoma. We as physicians have therefore the obligation as well as the chance to develop and test new therapeutic strategies. Our growing knowledge about the genetic basis of melanoma provides one platform to fulfil this task. Another one comes from our increasing understanding of the molecular and cellular mechanisms involved in the induction/modulation of immune responses, as well as the progress made in the field of identification of melanoma antigens, and allows for the development of a new generation of vaccines. The aim of this article is to discuss several of these new concepts towards the use of immune and gene therapy of melanoma.

Entrance port for Na(+) and K(+) ions on Na(+),K(+)-ATPase in the cytoplasmic loop between trans-membrane segments M6 and M7 of the alpha subunit. Proximity Of the cytoplasmic segment of the beta subunit

Based on the following observations we propose that the cytoplasmic loop between trans-membrane segments M6 and M7 (L6/7) of the alpha subunit of Na(+),K(+)-ATPase acts as an entrance port for Na(+) and K(+) ions. 1) In defined conditions chymotrypsin specifically cleaves L6/7 in the M5/M6 fragment of 19-kDa membranes, produced by extensive proteolysis of Na(+),K(+)-ATPase, and in parallel inactivates Rb(+) occlusion. 2) Dissociation of the M5/M6 fragment from 19-kDa membranes is prevented either by occluded cations or by competitive antagonists such as Ca(2+), Mg(2+), La(3+), p-xylylene bisguanidinium and m-xylylene bisguanidinium, or 1-bromo-2,4, 6-tris(methylisothiouronium)benzene and 1,3-dibromo-2,4,6-tris (methylisothiouronium)benzene (Br(2)-TITU(3+)). 3) Ca(2+) ions raise electrophoretic mobility of the M5/M6 fragment but not that of the other fragments of the alpha subunit. It appears that negatively charged residues in L6/7 recognize either Na(+) or K(+) ions or the competitive cation antagonists. Na(+) and K(+) ions are then occluded within trans-membrane segments and can be transported, whereas the cation antagonists are not occluded and block transport at the entrance port. The cytoplasmic segment of the beta subunit appears to be close to or contributes to the entrance port, as inferred from the following observations. 1) Specific chymotryptic cleavage of the 16-kDa fragment of the beta subunit to 15-kDa at 20 degrees C (Shainskaya, A., and Karlish, S. J. D. (1996) J. Biol. Chem. 271, 10309-10316) markedly reduces affinity for Br(2)-TITU(3+) and for Na(+) ions, detected by Na(+) occlusion assays or electrogenic Na(+) binding, whereas Rb(+) occlusion is unchanged. 2) Na(+) ions specifically protect the 16-kDa fragment against this chymotryptic cleavage.

The tumorigenicity of IL-2 gene-transfected murine M-3D melanoma cells is determined by the magnitude and quality of the host defense reaction: NK cells play a major role

Transfection of a variety of tumor lines with the IL-2 gene strongly reduces their tumorigenic potential when applied to either euthymic or athymic animals. To elucidate the mechanisms underlying this phenomenon, we inoculated IL-2-transfected M-3D melanoma (M-3D-IL-2) cells into DBA/2 mice immunosuppressed by gamma-irradiation. Animals thus treated developed pigmented tumors, suggesting that IL-2 transfection of melanoma cells, instead of altering their neoplastic growth properties, renders them capable of evoking a tumoricidal host response. To define the critical effector cell, we injected M-3D-IL-2 and, for control purposes, nontransfected M-3D cells into DBA/2 recipients and analyzed the injection site. We found that 1) IL-2-expressing M-3D cells induce a much stronger inflammatory reaction than wild-type cells, 2) in both instances the infiltrate consists mainly of macrophages (40-60%) and granulocytes (30-40%), and 3) only the infiltrate of M-3D-IL-2 cell deposits contains a minor fraction of NK cells (approximately 1-2%). When we reconstituted sublethally irradiated animals with various leukocyte subsets, we found that unfractionated as well as macrophage-depleted peritoneal lavage cells but not NK cell-depleted peritoneal lavage cells were able to suppress the growth of IL-2-expressing M-3D cells. In vivo leukocyte depletion experiments showed that the NK cell-depleting asialo-GM1 antiserum, but not anti-macrophage and/or anti-granulocyte reagents, restored the tumorigenicity of M-3D-IL-2 cells. Our results indicate that the inflammatory tissue response evoked by IL-2-transfected cancer cells includes the attraction and/or activation of NK cells and that, in the experimental system used, these cells are critically needed for successfully controlling cancer growth in vivo.

Ion selectivity of the cytoplasmic binding sites of the Na,K-ATPase: I. Sodium binding is associated with a conformational rearrangement

To investigate Na+ binding to the ion-binding sites presented on the cytoplasmic side of the Na,K-ATPase, equilibrium Na+-titration experiments were performed using two fluorescent dyes, RH421 and FITC, to detect protein-specific actions. Fluorescence changes upon addition of Na+ in the presence of various Mg2+ concentrations were similar and could be fitted with a Hill function. The half-saturating concentrations and Hill coefficients determined were almost identical. As RH421 responds to binding of a Na+ ion to the third neutral site whereas FITC monitors conformational changes in the ATP-binding site or its environment, this result implies that electrogenic binding of the third Na+ ion is the trigger for a structural rearrangement of the ATP-binding moiety. This enables enzyme phosphorylation, which is accompanied by a fast occlusion of the Na+ ions and followed by the conformational transition E1/E2 of the protein. The coordinated action both at the ion and the nucleotide binding sites allows for the first time a detailed formulation of the mechanism of enzyme phosphorylation that occurs only when three Na+ ions are bound.

Partial reactions of the Na,K-ATPase: kinetic analysis and transport properties

The complex functions of the Na,K-ATPase can be described by reaction cycles based on the generally accepted "Post-Albers cycle". By appropriate experimental conditions various, partly overlapping partial reactions may be isolated which allow the investigation of specific reaction steps and their succession. From kinetic analysis rate constants and dielectric properties may be determined which characterize the function of the ion pump and allow the formulation of constraints with respect to structure-function relations. This is exemplified by two partial reactions which comprise (1) the ATP-driven Na+ transport, and (2) binding of Na+ ions to the cytoplasm sites. Equilibrium Na+ titration experiments were performed using the fluorescent dyes RH421 and FITC. Fluorescence changes upon addition of Na+ in the presence of various Mg2+ concentrations were similar and the half-saturation concentrations determined were almost identical. As RH421 responds to binding of Na+ to the neutral site whereas FITC monitors conformational changes, this result implies that electrogenic biding of the third Na+ is a trigger for a structural rearrangement of the ATP-binding moiety. This enables enzyme phosphorylation, which is accompanied with a fast occlusion of the Na+ ions and followed by the conformational transition E1/E2 of the protein. Current transients produced by the Na,K-ATPase could be induced by ATP-concentration jumps using DMB-caged ATP. The dependence of the maximum of the current transients on concentration of ADP was reproduced by mathematical simulations. They fit the data well on the assumption that the rate-limiting reaction step of the Na(+)-translocation partial reaction is the conformational transition E1/E2.

[General practice of lumbosacral peridural infiltrations in rheumatology: considerations based on a review of the literature]

Recommendations about the practice of epidural steroid injections for low back pain and sciatica are formulated based on an extensive review of the published literature. These infiltrations should be reserved to trained physicians observing strictly aseptic conditions. Their indications are limited to the few special situations where classical treatments have failed, and only after exclusion of an infectious or tumoral process. To the present time no conclusive data have been published to prove that these procedures reduced the need for surgery in the case of herniated nucleus pulposus or spinal stenosis. Their efficacy on the intensity of pain is also controversial. Some improvement on pain and functional scores may be observed for a few weeks but this positive effect disappears 2 or 3 months post-injection.

Immunologic host defense in melanoma: delineation of effector mechanisms involved and of strategies for the augmentation of their efficacy

There exists substantial evidence that the immune system plays an important role in the prevention and control of cancer. This evidence includes 1) the occasional clinical observation of spontaneous tumor regression, 2) the correlation of this phenomenon with the presence of tumor-infiltrating lymphocytes, and 3) the in vitro demonstration of the specificity of tumor-infiltrating lymphocytes for the autologous tumor. Because of the only weak immunogenicity of and the occurrence of active immunosuppression by the cancer, this response often does not suffice to combat the neoplasm successfully. One strategy for amplifying the anti-tumor immune response is vaccination of patients or experimental animals with cancer cells, the immunogenicity of which has been enhanced by the introduction of genes encoding immunostimulatory molecules. Several investigators have shown that transfection of certain types of cancer cells with the interleukin-2 gene reduces their tumorigenicity and that immunization with interleukin-2-transduced cancer cells protects animals from challenge with a tumorigenic dose of wild-type cancer cells. We have recently established a murine melanoma model (M-3) and have used it to elucidate the mechanism by which interleukin-2-transfected cancer cells can induce protective immunity. We will demonstrate the following: 1) that the mechanisms leading to the loss of tumorigenicity of interleukin-2-expressing cancer cells are somewhat different from those leading to the rejection of wild-type cancer cells in immunized animals, 2) that immunity resides within both CD4- and CD8-positive T cells, and 3) that host antigen-presenting cells are probably important in the induction of this protective anti-tumor immunity.

Priming of tumor-specific T cells in the draining lymph nodes after immunization with interleukin 2-secreting tumor cells: three consecutive stages may be required for successful tumor vaccination

Although both CD4+ and CD8+ T cells are clearly required to generate long-lasting anti-tumor immunity induced by s.c. vaccination with interleukin 2 (IL-2)-transfected, irradiated M-3 clone murine melanoma cells, some controversy continues about the site and mode of T-cell activation in this system. Macrophages, granulocytes, and natural killer cells infiltrate the vaccination site early after injection into either syngeneic euthymic DBA/2 mice or athymic nude mice and eliminate the inoculum within 48 hr. We could not find T cells at the vaccination site, which argues against the concept that T-cell priming by the IL-2-secreting cancer cells occurs directly at that location. However, reverse transcription-PCR revealed transcripts indicative of T-cell activation and expansion in the draining lymph nodes of mice immunized with the IL-2-secreting vaccine but not in mice vaccinated with untransfected, irradiated M-3 cells. We therefore propose that the antigen-presenting cells, which invade the vaccination site, process tumor-derived antigens and, subsequently, initiate priming of tumor-specific T lymphocytes in lymphoid organs. These findings suggest a three-stage process for the generation of effector T cells after vaccination with IL-2-secreting tumor cells: (i) tumor-antigen uptake and processing at the site of injection by antigen-presenting cells, (ii) migration of antigen-presenting cells into the regional draining lymph nodes, where T-cell priming occurs, and (iii) circulation of activated T cells that either perform or initiate effector mechanisms leading to tumor cell destruction.

Elicitation of a systemic and protective anti-melanoma immune response by an IL-2-based vaccine. Assessment of critical cellular and molecular parameters

We have established a model for the immunologic rejection of melanoma cells. Using a receptor-mediated, adenovirus-augmented gene delivery system (transferrinfection) we have shown that, upon transfection with an IL-2 gene construct, MHC class I+/class II- murine M-3 cells lose their tumorigenicity in both athymic and euthymic mice. More importantly, we found that these melanoma cells, which produce high levels of IL-2, can be used to induce a long-lasting anti-tumor immune response in syngeneic euthymic DBA/2 mice but not in athymic animals. This immune response, which can also be elicited by coadministration of nonmodified, irradiated M-3 cells and IL-2-transduced fibroblasts, results in the rejection of a subsequent challenge with M-3 cells or, in the elimination of preexisting M-3 cancer cell deposits. We found that transfer of T cell-enriched, but not of T cell-depleted, splenocytes from immunized mice conferred protection against M-3 cells, but not against unrelated KLN 205 cancer cells. Transfer of either CD4+ or CD8+ T cells led to only partial protection against challenge with wild-type M-3 cells. Our further observations that T cell-enriched, but not T cell-depleted splenocytes of immunized animals are capable of tumor-specific lytic activity and that this activity resides in the CD8+ cell population are compatible with the assumption that MHC class I-restricted T cell cytotoxicity is a biologically relevant effector mechanism in this model. That other mechanisms also contribute to melanoma cell destruction is evidenced by the presence of large numbers of macrophages and granulocytes in addition to T cells at the challenge sites of immunized mice.

Elicitation of a systemic and protective anti-melanoma immune response by an IL-2-based vaccine. Assessment of critical cellular and molecular parameters

We have established a model for the immunologic rejection of melanoma cells. Using a receptor-mediated, adenovirus-augmented gene delivery system (transferrinfection) we have shown that, upon transfection with an IL-2 gene construct, MHC class I+/class II- murine M-3 cells lose their tumorigenicity in both athymic and euthymic mice. More importantly, we found that these melanoma cells, which produce high levels of IL-2, can be used to induce a long-lasting anti-tumor immune response in syngeneic euthymic DBA/2 mice but not in athymic animals. This immune response, which can also be elicited by coadministration of nonmodified, irradiated M-3 cells and IL-2-transduced fibroblasts, results in the rejection of a subsequent challenge with M-3 cells or, in the elimination of preexisting M-3 cancer cell deposits. We found that transfer of T cell-enriched, but not of T cell-depleted, splenocytes from immunized mice conferred protection against M-3 cells, but not against unrelated KLN 205 cancer cells. Transfer of either CD4+ or CD8+ T cells led to only partial protection against challenge with wild-type M-3 cells. Our further observations that T cell-enriched, but not T cell-depleted splenocytes of immunized animals are capable of tumor-specific lytic activity and that this activity resides in the CD8+ cell population are compatible with the assumption that MHC class I-restricted T cell cytotoxicity is a biologically relevant effector mechanism in this model. That other mechanisms also contribute to melanoma cell destruction is evidenced by the presence of large numbers of macrophages and granulocytes in addition to T cells at the challenge sites of immunized mice.

A putative second cell-derived oncogene of the avian leukaemia retrovirus E26

The acute avian leukaemia retroviruses AMV and E26 both induce myeloblastosis in vivo and transform myeloblasts in vitro. Both viruses contain the oncogene v-myb first described for AMV. Unlike AMV, E26 has the additional capacity to induce erythroblastosis in vivo and to transform erythroblasts. Previous analyses indicated that the genome of E26 also contained nucleotide sequences distinct from v-myb and unrelated to viral replicative genes. Using a molecularly cloned E26 provirus, we have now identified a novel nucleotide sequence designated v-ets (for E-twenty-six specific) of approximately 1.5 kilobase pairs (kbp) located next to v-myb. v-ets possesses all the structural characteristics of a putative new oncogene: it has a conserved cellular counterpart c-ets which is transcribed in some normal chicken cells as a major 7.5-kb polyadenylated RNA. Although our results now await elucidation of their biological significance, we propose that v-ets could be a new oncogene accounting for the additional transforming properties of E26, or potentiating the transforming properties of the v-myb oncogene.