A prospective observational study of post-COVID-19 chronic fatigue syndrome following the first pandemic wave in Germany and biomarkers associated with symptom severity

A subset of patients has long-lasting symptoms after mild to moderate Coronavirus disease 2019 (COVID-19). In a prospective observational cohort study, we analyze clinical and laboratory parameters in 42 post-COVID-19 syndrome patients (29 female/13 male, median age 36.5 years) with persistent moderate to severe fatigue and exertion intolerance six months following COVID-19. Further we evaluate an age- and sex-matched postinfectious non-COVID-19 myalgic encephalomyelitis/chronic fatigue syndrome cohort comparatively. Most post-COVID-19 syndrome patients are moderately to severely impaired in daily live. 19 post-COVID-19 syndrome patients fulfill the 2003 Canadian Consensus Criteria for myalgic encephalomyelitis/chronic fatigue syndrome. Disease severity and symptom burden is similar in post-COVID-19 syndrome/myalgic encephalomyelitis/chronic fatigue syndrome and non-COVID-19/myalgic encephalomyelitis/chronic fatigue syndrome patients. Hand grip strength is diminished in most patients compared to normal values in healthy. Association of hand grip strength with hemoglobin, interleukin 8 and C-reactive protein in post-COVID-19 syndrome/non-myalgic encephalomyelitis/chronic fatigue syndrome and with hemoglobin, N-terminal prohormone of brain natriuretic peptide, bilirubin, and ferritin in post-COVID-19 syndrome/myalgic encephalomyelitis/chronic fatigue syndrome may indicate low level inflammation and hypoperfusion as potential pathomechanisms.

Endothelial dysfunction and altered endothelial biomarkers in patients with post-COVID-19 syndrome and chronic fatigue syndrome (ME/CFS)

Background

Fatigue, exertion intolerance and post-exertional malaise are among the most frequent symptoms of Post-COVID Syndrome (PCS), with a subset of patients fulfilling criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). As SARS-CoV-2 infects endothelial cells, causing endotheliitis and damaging the endothelium, we investigated endothelial dysfunction (ED) and endothelial biomarkers in patients with PCS.

Methods

We studied the endothelial function in 30 PCS patients with persistent fatigue and exertion intolerance as well as in 15 age- and sex matched seronegative healthy controls (HCs). 14 patients fulfilled the diagnostic criteria for ME/CFS. The other patients were considered to have PCS. Peripheral endothelial function was assessed by the reactive hyperaemia index (RHI) using peripheral arterial tonometry (PAT) in patients and HCs. In a larger cohort of patients and HCs, including post-COVID reconvalescents (PCHCs), Endothelin-1 (ET-1), Angiopoietin-2 (Ang-2), Endocan (ESM-1), IL-8, Angiotensin-Converting Enzyme (ACE) and ACE2 were analysed as endothelial biomarkers.

Results

Five of the 14 post-COVID ME/CFS patients and five of the 16 PCS patients showed ED defined by a diminished RHI (< 1.67), but none of HCs exhibited this finding. A paradoxical positive correlation of RHI with age, blood pressure and BMI was found in PCS but not ME/CFS patients. The ET-1 concentration was significantly elevated in both ME/CFS and PCS patients compared to HCs and PCHCs. The serum Ang-2 concentration was lower in both PCS patients and PCHCs compared to HCs.

Conclusion

A subset of PCS patients display evidence for ED shown by a diminished RHI and altered endothelial biomarkers. Different associations of the RHI with clinical parameters as well as varying biomarker profiles may suggest distinct pathomechanisms among patient subgroups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03346-2.

Medication use in pregnancy: a cross-sectional, multinational web-based study

OBJECTIVES

Intercountry comparability between studies on medication use in pregnancy is difficult due to dissimilarities in study design and methodology. This study aimed to examine patterns and factors associated with medications use in pregnancy from a multinational perspective, with emphasis on type of medication utilised and indication for use.

DESIGN

Cross-sectional, web-based study performed within the period from 1 October 2011 to 29 February 2012. Uniform collection of drug utilisation data was performed via an anonymous online questionnaire.

SETTING

Multinational study in Europe (Western, Northern and Eastern), North and South America and Australia.

PARTICIPANTS

Pregnant women and new mothers with children less than 1 year of age.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of and factors associated with medication use for acute/short-term illnesses, chronic/long-term disorders and over-the-counter (OTC) medication use.

RESULTS

The study population included 9459 women, of which 81.2% reported use of at least one medication (prescribed or OTC) during pregnancy. Overall, OTC medication use occurred in 66.9% of the pregnancies, whereas 68.4% and 17% of women reported use of at least one medication for treatment of acute/short-term illnesses and chronic/long-term disorders, respectively. The extent of self-reported medicated illnesses and types of medication used by indication varied across regions, especially in relation to urinary tract infections, depression or OTC nasal sprays. Women with higher age or lower educational level, housewives or women with an unplanned pregnancy were those most often reporting use of medication for chronic/long-term disorders. Immigrant women in Western (adjusted OR (aOR): 0.55, 95% CI 0.34 to 0.87) and Northern Europe (aOR: 0.50, 95% CI 0.31 to 0.83) were less likely to report use of medication for chronic/long-term disorders during pregnancy than non-immigrants.

CONCLUSIONS

In this study, the majority of women in Europe, North America, South America and Australia used at least one medication during pregnancy. There was a substantial inter-region variability in the types of medication used.

Serum analysis by 1H nuclear magnetic resonance spectroscopy: a new tool for distinguishing neuromyelitis optica from multiple sclerosis

BACKGROUND

Neuromyelitis optica (NMO) and multiple sclerosis (MS), two inflammatory demyelinating diseases, are characterized by different therapeutic strategies. Currently, the only biological diagnostic tool available to distinguish NMO from MS is the specific serum autoantibody that targets aquaporin 4, but its sensitivity is low.

OBJECTIVE

To assess the diagnostic accuracy of metabolomic biomarker profiles in these two neurological conditions, compared to control patients.

METHODS

We acquired serum spectra (47 MS, 44 NMO and 42 controls) using proton nuclear magnetic resonance ((1)H-NMR) spectroscopy. We used multivariate pattern recognition analysis to identify disease-specific metabolic profiles.

RESULTS

The (1)H-NMR spectroscopic analysis evidenced two metabolites, originating probably from astrocytes, scyllo-inositol and acetate, as promising serum biomarkers of MS and NMO, respectively. In 87.8% of MS patients, scyllo-inositol increased 0.15 to 3-fold, compared to controls and in 74.3% of NMO patients, acetate increased 0.4 to 7-fold, compared to controls. Using these two metabolites simultaneously, we can discriminate MS versus NMO patients (sensitivity, 94.3%; specificity, 90.2%).

CONCLUSION

This study demonstrates the potential of (1)H-NMR spectroscopy of serum as a novel, promising analytical tool to discriminate populations of patients affected by NMO or MS.

Whole-genome linkage scan for epilepsy-related photosensitivity: a mega-analysis

Photoparoxysmal response (PPR) is considered to be a risk factor for idiopathic generalised epilepsy (IGE) and it has a strong genetic basis. Two genome-wide linkage studies have been published before and they identified loci for PPR at 6p21, 7q32, 13q13, 13q31 and 16p13. Here we combine these studies, augmented with additional families, in a mega-analysis of 100 families. Non-parametric linkage analysis identified three suggestive peaks for photosensitivity, two of which are novel (5q35.3 and 8q21.13) and one has been found before (16p13.3). We found no evidence for linkage at four previously detected loci (6p21, 7q32, 13q13 and 13q31). Our results suggest that the different family data sets are not linked to a shared locus. Detailed analysis showed that the peak at 16p13 was mainly supported by a single subset of families, while the peaks at 5q35 and 8q21 had weak support from multiple subsets. Family studies clearly support the role of PPR as a risk factor for IGE. This mega-analysis shows that distinct loci seem to be linked to subsets of PPR-positive families that may differ in subtle clinical phenotypes or geographic origin. Further linkage studies of PPR should therefore include in-depth phenotyping to make appropriate subsets and increase genetic homogeneity.

[Is there a bridge between migraine and familial mesial temporal lobe epilepsy?]

Numerous reviews have emphasized the links between certain types of epilepsy and migraine. Historically, Gowers was one of the first, in 1907, to have drawn attention to a possible relationship between migraine headache and epilepsy in a period when no additional examination was available. In the last two decades, progress in molecular biology, electrophysiology, and neuro-imaging has enabled a better approach to the fundamental elements underlying the interrelationship between these two nosological domains. During this same time, a new term "channelopathy" has appeared in the literature. This term groups together affections involving a dysfunction of ion channels. In this article, the links between the different types of migraine and familial mesial temporal lobe epilepsy are illustrated by two case reports. This association does not appear to occur at random but would undoubtedly depend on a common genetic substratum, leading to a direct comorbidity. These occasional recurring symptoms would lie within the framework of a more general concept of "Primary Brain Channelopathies".

Is neuromyelitis optica associated with human leukocyte antigen?

BACKGROUND

To establish whether or not multiple sclerosis (MS) and neuromyelitis optica (NMO) are different pathological entities, we wondered whether MS patients and NMO patients share the same pattern of human leukocyte antigen (HLA) predisposition.

OBJECTIVE

To study a putative association between susceptibility to NMO and HLA class I or class II loci in Caucasians.

METHODS

A total of 39 unrelated Caucasian patients with NMO and six patients at a high risk of converting to NMO were studied. DNA genotyping of HLA class I and class II loci was assessed and allelic frequencies were reported at a high-resolution level. A case-control study by comparing the allelic distribution in the NMO patients with that of a French Caucasian MS group and a French Caucasian healthy group was carried out.

RESULTS

The frequencies of HLA-DQA1, DQB1, and HLA-DRB1 DR2 alleles in the NMO group were intermediate between the healthy control group and the MS group. The DPB1*0501 allele was not increased in the NMO group compared with the healthy control group. The distribution of HLA-DRB1 allele enabled to distinguish between NMO-IgG-positive patients and healthy controls (P = 0.01). NMO-IgG-negative patients presented an HLA II pattern closer to that of the MS group (P = 0.01).

CONCLUSION

In contrast to the reported results in Asian opticospinal MS, we found no association between the DPB1*0501 allele and NMO in our Caucasian patients. Moreover, we suggest that NMO-IgG-positive patients could represent a distinct NMO group in terms of their genetic susceptibility.

A Down syndrome female infant with partial trisomy of chromosome 21--abnormal nuchal translucency screening test

We describe a case of 24-year-old mother with abnormal nuchal translucency screening test. Standard G banding of chromosomes showed a normal prenatal karyotype. A Down syndrome female infant with partial duplication of the long arm of chromosome 21 was born resulted from a maternal pericentric inversion of region p1.1 to q22.1 of one of chromosome 21. As far as we know this case reports the first abnormal nuchal translucency screening test result due to partial trisomy of chromosome 21.

The operationalized psychodynamic diagnostics system: clinical relevance, reliability and validity

In this paper, we present a multiaxial system for psychodynamic diagnosis, which has attained wide usage in Germany in the last 10 years. First we will discuss the 4 operationalized psychodynamic diagnostics (OPD) axes: illness experience and treatment assumptions, relationships, mental conflicts, and structure, then clinical applications will be outlined. Focus psychodynamic formulations can be employed both with inpatients and with outpatients. Studies show good reliability in a research context and acceptable reliability for clinical purposes. Validity will be separately summarized as content, criterion, and construct validity. Validity studies indicate good validity for the individual axes. Numerous studies on the OPD indicate areas of possible improvement, for example for clinical purposes the OPD should be more practically formulated.

Neutron capture cross section measurement of 151Sm at the CERN neutron time of flight facility (n_TOF)

The151Sm(n,gamma)152Sm cross section has been measured at the spallation neutron facility n_TOF at CERN in the energy range from 1 eV to 1 MeV. The new facility combines excellent resolution in neutron time-of-flight, low repetition rates, and an unsurpassed instantaneous luminosity, resulting in rather favorable signal/background ratios. The 151Sm cross section is of importance for characterizing neutron capture nucleosynthesis in asymptotic giant branch stars. At a thermal energy of kT=30 keV the Maxwellian averaged cross section of this unstable isotope (t(1/2)=93 yr) was determined to be 3100+/-160 mb, significantly larger than theoretical predictions.

Prenatal diagnosis of a true fetal tetraploidy in direct and cultured chorionic villi

Prenatal diagnosis of a true fetal tetraploidy in direct and cultured chorionic villi: Tetraploidy is characterized by four complete sets of chromosomes (4n= 92). Although it has been frequently reported in spontaneous abortions, tetraploidy is extremely rare in term pregnancy. Most of late surviving patients are diploid/tetraploid mosaics and present severe mental and physical impairment. Up to date, only five tetraploidies were ascertained in the prenatal stage in amniocytes and/or fetal blood lymphocytes. No one has been reported in chorionic villi probably because tetraploidy is generally considered in this tissue as a false positive result due to confined placental mosaicism (CPM) or placental culture artefacts. We report here on a case of tetraploidy detected in chorionic villi because of fetal cystic hygroma. We discuss the reliability of this diagnosis and propose guidelines in the follow-up of tetraploidies detected after chorionic villus sampling (CVS). Thus a misdiagnosis of this poor condition will be avoided at best and an appropriate genetic counseling will be given to the parents.

[Therapeutic changes beyond the symptoms - effects of inpatient treatment according to the Heidelberg Structural Change Scale]

The question is discussed how changes concerning the patient's ability to recognize and obtain insight into dysfunctional relationship patterns, life-determining conflicts, and structural vulnerability as well as the readiness to take on the responsibility for the negative effects caused by these may be conceptualized. A model has been developed based on Operationalized Psychodynamic Diagnosis (OPD) in which individual problem areas for each patient may be chosen from a list of foci. Changes in these foci are evaluated using the Heidelberg Structural Change Scale which is presented and discussed in detail. This concept is applied to a sample of patients who had been treated in an in-patient setting. It is demonstrated that this method of measuring changes can be used reliably. Furthermore, the changes registered with the structural change scale correlate on an absolute level quite high to the global assessment of outcome through the therapeutic team; this correlation is even higher than the correlation between symptomatic changes and the global assessments. How this concept may be applied in planning, evaluating, and ensuring the quality of psychotherapy is presented in conclusion.

EEG criteria predictive of complicated evolution in idiopathic rolandic epilepsy

BACKGROUND

Although so-called "benign" epilepsy with centrotemporal spikes (BECTS) always has an excellent prognosis with regard to seizure remission, behavioral problems and cognitive dysfunctions may sometimes develop in its course. To search for clinical or EEG markers allowing early detection of patients prone to such complications, the authors conducted a prospective study in a cohort of unselected patients with BECTS.

METHODS

In 35 children with BECTS, academic, familial, neurologic, neuropsychological, and wake and sleep EEG evaluations were repeated every 6 to 12 months from the beginning of the seizure disorder up to complete recovery.

RESULTS

In 25 of 35 patients (72%), behavioral and intellectual functioning remained unimpaired. In 10 of 35 patients (28%), educational performance and familial maladjustment occurred. These sociofamilial problems were correlated with impulsivity, learning difficulties, attention disorders, and minor (7/35 cases, 20%) or serious (3/35 cases, 8%) auditory-verbal or visual-spatial deficits. Worsening phases started 2 to 36 months after onset and persisted for 9 to 39 months. Occurrence of atypical evolutions was significantly correlated with five qualitative and one quantitative interictal EEG pattern: intermittent slow-wave focus, multiple asynchronous spike-wave foci, long spike-wave clusters, generalized 3-c/s "absence-like" spike-wave discharges, conjunction of interictal paroxysms with negative or positive myoclonia, and abundance of interictal abnormalities during wakefulness and sleep. Clinical deterioration was not linked with seizure characteristics or treatment.

CONCLUSION

Different combinations of at least three of six distinctive interictal EEG patterns and their long-lasting (> or =6-month) persistence seem to be the hallmarks of patients with BECTS at risk for neuropsychological impairments.

A conserved sorting-associated protein is mutant in chorea-acanthocytosis

Chorea-acanthocytosis (CHAC, MIM 200150) is an autosomal recessive neurodegenerative disorder characterized by the gradual onset of hyperkinetic movements and abnormal erythrocyte morphology (acanthocytosis). Neurological findings closely resemble those observed in Huntington disease. We identified a gene in the CHAC critical region and found 16 different mutations in individuals with chorea-acanthocytosis. CHAC encodes an evolutionarily conserved protein that is probably involved in protein sorting.

Electrophysiological evidence of persisting unilateral auditory cortex dysfunction in the late outcome of Landau and Kleffner syndrome

OBJECTIVES

In the late outcome of Landau and Kleffner syndrome (LKS), a childhood-acquired epileptic aphasia, most patients show after complete recovery of epilepsy a permanent one-ear extinction on dichotic listening tests contralateral to the temporal cortex previously affected by the epileptic focus. The pathophysiological significance of this dichotic extinction is not yet understood. It may be a consequence of a permanent dysfunction in the auditory system due to epileptic activity during the maturing period of the auditory system. Evoked potentials were used to check this hypothesis and to localize the level of the dysfunction along the auditory pathways.

METHODS

Early, middle latency and late auditory evoked potentials were recorded in 5 right-handed children having recovered from LKS. They were compared with those of 5 control children paired for age and gender.

RESULTS

In all 5 LKS patients, early and middle latency auditory evoked potentials were normal. But the amplitude of N1c (arising from associative auditory areas) was strongly reduced at temporal electrodes contralateral to the extinguished ear, whereas latency and amplitude of N1b (related to primary auditory areas) were in the normal range.

CONCLUSIONS

Unilateral voltage reduction of late auditory evoked potentials over the temporal areas previously involved by epileptic discharges suggests a permanent dysfunction in the associative auditory cortex, the behavioral expression of which is the unilateral dichotic extinction.

[The use of evidence-based medicine in psychotherapeutic medicine]

This review article gives an overview of the state of the art of evidence-based medicine (EBM) which is contrasted with some central aspects of current psychotherapy research. In the first part, three meanings of EBM are discussed: EBM as a regulative idea, EBM as a codified method and EBM as a sociopolitical movement; it follows an evaluation of the advantages and disadvantages of randomized controlled trials (RCT). In the second part, the discussions surrounding the meta-analysis of Grawe, the "Consumer Reports" study and the so-called "Empirically Supported Treatments" are touched upon briefly; it follows a discussion of the specific problems of using RCTs in psychotherapy research and of the suggestions for more naturalistic studies in this field.

Dominant partial epilepsies. A clinical, electrophysiological and genetic study of 19 European families

Nineteen families with autosomal dominant partial epilepsy were analysed clinically and electrophysiologically in detail. Seventy-one patients were studied as well as 33 non-epileptic at-risk family members. We subdivided the families into those with autosomal dominant nocturnal frontal lobe epilepsy (ADNFLE) (n = 8), familial temporal lobe epilepsy (n = 7) and autosomal dominant partial epilepsy with variable foci (n = 4). However, the application of this nosology to certain families was difficult in cases of non-specific or conflicting clinical and electrophysiological evidence. This was underscored by the observation by depth electrode recordings in one patient that a so-called ADNFLE may originate in an extrafrontal area. The evolution of familial partial epilepsies, which exhibit great intrafamilial variability, is not always benign. The level of pharmacoresistance may reach 30%, close to that seen in classical cryptogenic partial epilepsies. The familial character of a partial epilepsy may be unrecognized in small families as some affected members may have only EEG abnormalities and are clinically asymptomatic, which reflects incomplete clinical penetrance. In view of the recent discoveries of mutations in the alpha4 nicotinic acetylcholine receptor subunit in a few families with ADNFLE, this genetic study focused on genes encoding nicotinic receptor subunits and a candidate region on chromosome 10q. No mutation was detected in the alpha4 and 012 nicotinic acetylcholine receptor subunits. Positive but not significant lod scores were obtained in four families with markers from the candidate region on chromosome 10q.

[Development of psychogenic disorders: an integrative model]

On the basis of clinical experience and empirically based data an integrative model of how psychogenic disorders develop is described in this article. The development-psychological steps of maturation from the uterine period to adolescence are examined with regard to the respective basic conflict to be derived from the step, and the disorder forms neurotization, structural disorder, and traumatisation are differentiated. Especially the process character of the respective development from the basic conflicts over the different coping strategies up to the symptom outbreak is emphasized.

[Brief report of working group OPD-CA (children and adolescents) Axis IV: structural standard]

Apart from the structural differentiation of the body and its functions, the enlargement of the child's repertoire of possibilities to make experiences and to act is a manifestation of the development of the child's psychic structure which, advancing in years, may be considered as a treasure of all the experiences one has made with oneself, with the world and with the others. Structure will develop along with the interactional experiences with the world around us and becomes manifest in one's behaviour which may be witnessed and observed. The description of the psychic structure comprises three dimensions (perception of the self and of the objects, control, communication and bonding) which will be described by certain capabilities and will be assessed with the help of an anchoring example typical for each age which serves the purpose of clinical illustration. The adaptational achievement may then be assessed on the basis of a structural standard independent of age and may be ranged on a structural level. It appears that the exemplary description of different scopes of tasks typically to be performed at certain ages which serves as a basis for the assessment of the adaptational competence during childhood and adolescence seems to be a good policy. The purpose of our studies is the development of a valid instrument which is easy to handle in practice and which has a high interrater-reliability.

Cerebral correlates of hemispheric lateralization during a pitch discrimination task: an ERP study in dichotic situation

OBJECTIVE

Electrophysiological correlates of perceptual asymmetry for dichotic pitch discrimination were investigated in 12 right-handed volunteers, whose dichotic listening performances attested the classical 'right ear advantage' in a verbal discrimination task.

METHODS

Event related potentials (ERPs), elicited by dichotic and binaural pairs of tones applied in a classical oddball paradigm including right ear targets, left ear targets and binaural targets (5% occurrence each) were recorded from medial and lateral scalp locations. Latencies and baseline to peak amplitudes were measured for P1, N1, P2, N2 and P3 components.

RESULTS

ERPs recorded in response to dichotic (compared with binaural) target pairs, exhibited delayed latencies for N2 and P3, correlated with prolonged RTs, probably linked to greater difficulty in identification of the target. They also displayed enhanced N1 and P2 voltages, which may reflect the simultaneous activation of two different populations of neurons in the auditory cortical areas. We observed specific lateralization effects for pitch discrimination with a left ear advantage on latency of early components.

CONCLUSIONS

Together with amplitude asymmetries in the N2 component, the findings bring strong electrophysiological support to Kimura's structural model for dichotic perceptions with a right hemisphere prevalence in a pitch discrimination task.

[Psychodynamic personality markers of psychotherapists in relation to therapy outcome]

In the Berlin psychotherapy study data were collected not only from the patients but also from the therapists. Thus, the influence of personality variables of the therapists on the multidimensionally registered therapy success could be studied. To this end a nonlinear k-sets canonical analysis was applied resulting in a sample-specific optimal scaling. The relationship pattern of the two sets of variables found was satisfactory as regards the internal criteria of the programme as well as its clinical meaningfulness. The results can be used in similar studies for specifying therapist-related hypotheses.

Chorea-acanthocytosis: genetic linkage to chromosome 9q21

Chorea-acanthocytosis (CHAC) is a rare autosomal recessive disorder characterized by progressive neurodegeneration and unusual red-cell morphology (acanthocytosis), with onset in the third to fifth decade of life. Neurological impairment with acanthocytosis (neuroacanthocytosis) also is seen in abetalipoproteinemia and X-linked McLeod syndrome. Whereas the molecular etiology of McLeod syndrome has been defined (Ho et al. 1994), that of CHAC is still unknown. In the absence of cytogenetic rearrangements, we initiated a genomewide scan for linkage in 11 families, segregating for CHAC, who are of diverse geographical origin. We report here that the disease is linked, in all families, to a 6-cM region of chromosome 9q21 that is flanked by the recombinant markers GATA89a11 and D9S1843. A maximum two-point LOD score of 7.1 (theta = .00) for D9S1867 was achieved, and the linked region has been confirmed by homozygosity-by-descent, in offspring from inbred families. These findings provide strong evidence for the involvement of a single locus for CHAC and are the first step in positional cloning of the disease gene.

Therapeutic alliance and transference: an exploratory study of their empirical relationship

Transference and the formation of a therapeutic alliance were studied in 126 patients from the Berlin psychotherapy project. The working hypothesis was that the internalized mother and father image would have an influence on the therapeutic alliance. The therapist rated the development of the therapeutic alliance at two points in time. When the parents' images and the therapist image were compared by using difference and similarity measures, four mother and four father types could be constructed of which some showed significant differences in the formation of therapeutic alliance. The introduction and the discussion are focused on the question as to what extent the psychoanalytic assumptions of transference can be useful in empirical therapy research for the construction of new variables and the explanation of social interactions between the two partners.

Induction of interferon regulatory factors 2'-5' oligoadenylate synthetase, P68 kinase and RNase L in chronic myelogenous leukaemia cells and its relationship to clinical responsiveness

The genes crucially determining the therapeutic response of chronic myelogenous leukaemia (CML) to interferon-alpha (IFN-alpha) are unknown. Recently, two independent IFN-alpha signalling pathways were identified: the classic pathway mediates induction of 2'-5' oligoadenylate synthetase (2-5 OAS), p68 kinase and IFN regulatory factor-2 (IRF-2), whereas the alternate pathway leads to activation of IFN regulatory factor-1 (IRF-1). We investigated whether deficient or imbalanced expression of components of these two pathways is associated with resistance of CML cells to antiproliferative action of IFN alpha/beta. Constitutive and IFN-induced transcript levels of IFN-dependent genes in mononuclear cells, granulocytes, monocytes, lymphocytes and CD34+ cells of chronic-phase CML and blast crisis patients were assessed by Northern blot techniques and were correlated with subsequent clinical responses to IFN therapy. Our results demonstrated that IFN-alpha or -beta treatment in vitro and in vivo leads to an enhanced expression of IRF-1, IRF-2. RNase L, p68 and 2-5 OAS which was independent of the degree of cellular differentiation and clonal evolution of CML. Neither the magnitude of induction of these genes nor the IRF-1/IRF-2 mRNA balance differed between chronic-phase CML patients responding or failing IFN-alpha therapy. These results indicate that failure of IFN-alpha treatment is not due to defects in mRNA induction of the above-mentioned candidate genes for the direct antiproliferative response to IFN type I.

DNA fragmentation and immediate early gene expression in rat striatum following quinolinic acid administration

Excitotoxic cell death is hypothesized to contribute to numerous neuropathologic conditions, including hypoxic/ischemic encephalopathy, hypoglycemia, Parkinson's disease, and Huntington's disease. Neuronal death from excitotoxic lesions has been shown to be an active process, with activation of immediate early gene transcription, resulting in secondary changes in gene expression. Another feature of neurotoxic cell death that has been examined is the presence of DNA fragmentation, which presumably indicates impending nuclear disintegration. A technique has been described for labeling fragmented DNA in situ, allowing precise determination of the anatomic and temporal distribution of neurons after an excitotoxic lesion. To investigate this phenomenon, we performed in situ nick translation on brain tissue from rats that have undergone stereotaxically placed intrastriatal quinolinic acid injections. Furthermore, in these same animals we analyzed the expression of c-fos mRNA to compare the time course and regional distribution of DNA fragmentation with immediate early gene activation after an excitotoxic lesion. Our analysis indicates that c-fos expression increases soon after quinolinic acid injection, is widespread in rat brain, but is effectively absent by 24 h postinjection. DNA fragmentation, however, is limited to striatum and is maximal at 24 h after injection. These results demonstrate the sensitivity of in situ nick translation for the detection of regional neuropathology and illustrate the temporal and spatial relationship of c-fos expression to excitotoxic neuronal death.

[Development of a model of operational psychodynamic diagnosis]

Since 1992 a working group called "Operationalized Psychodynamic diagnoses" conceptualized a model of operationalized psychodynamic diagnosis in Germany. This model includes the most important diagnostic dimensions from psychodynamic view which are: Axis I: Experience with illness and treatment preconditions. Axis II: Habituated relationships of the patient, Axis III: Intrapsychic conflicts of the patient, Axis IV: the structure of personality development of the patient, Axis V: The level of symptoms or syndromes. This axis is adapted to ICD-10. The development of these axis is done in special subgroups during 1992 and 1994 and in first empirical studies the reliability and other test-related dimensions of the model were proved. In this paper the essentials of the diagnostic model are shown and further developments are discussed.

[Methodological and statistical aspects of therapy evaluation exemplified by the Berlin psychotherapy study]

The answer to the question concerning the efficacy of psychotherapy is increasingly sought metaanalytically. For this purpose almost exclusively investigations are taken into consideration which have at least one control group. Using realistic data, the present paper refers to some basic considerations for the investigation and evaluation of therapeutic changes, which are however not always satisfyingly solved in metaanalytical studies. Investigations, therefore, especially of naturalistic samples, such as may be found in the context of outpatient or inpatient routine care, have a high clinical relevance for the evaluation of therapeutic changes even if they do not satisfy experimental requirements/standards. However, they do supplement experimental studies where the important aspect of external validity is concerned.

Divergent in vivo and in vitro antileukemic activity of recombinant interferon beta in patients with chronic-phase chronic myelogenous leukemia

It was the aim of this study to investigate the antileukemic activities of recombinant interferon beta (rIFN beta) in chronic-phase CML in vitro and in vivo. Nine patients in the early chronic-phase of CML were treated in a phase-II trial with escalating doses of rIFN beta. In parallel, antiproliferative and immunomodulatory activities of rIFN beta and rIFN alpha 2b were studied in vitro. rIFN beta exhibited a significantly higher antiproliferative activity on hematopoietic progenitor cells of CML patients in vitro than rIFN alpha 2b. In contrast, only very limited clinical antileukemic efficacy of rIFN beta was observed. None of the patients achieved a complete or partial hematologic response (0% response rate, 0-36% 95 C.I.). Primary resistance of CML patients to rIFN beta treatment was caused neither by antibody formation against the recombinant material nor by deficient IFN receptor targeting and/or signaling; Induction of serum levels of beta-2-microglobulin (beta-2-m) and neopterin after administration of rIFN beta was comparable to that seen after administration of rIFN alpha. However, rIFN beta treatment less effectively induced biosynthesis of interleukin-1 receptor antagonist protein (IL-1-Ra) than rIFN alpha 2b. Thus, we conclude that rIFN beta at doses up to 12 MU/day s.c. is ineffective for treatment of chronic-phase CML. Further investigations into divergent biologic responses to various type-I interferons might help to elucidate mechanisms crucial for IFN action in patients with CML.

Type-I interferons are potent inhibitors of interleukin-8 production in hematopoietic and bone marrow stromal cells

Interleukin-8 (IL-8) is produced by many cell types upon stimulation with bacterial products or inflammation-associated cytokines such as tumor necrosis factor-alpha and IL-1. Interferons (IFNs) represent another group of cytokines that are induced by similar stimuli in inflammatory reactions. We show now that type-I IFNs are potent inhibitors of IL-8 expression in vitro and in vivo. A significant reduction of both secretion of IL-8 protein and accumulation of IL-8 mRNA in vitro was observed in several cell types comprising peripheral blood mononuclear cells (PBMNC) from healthy donors and from patients with chronic myelogenous leukemia (CML), the myelomonocytic cell line THP-1, and bone marrow (BM) stromal cells as a representative model for BM microenvironment. By contrast, in lipopolysaccharide-stimulated polymorphonuclear phagocytes IFN failed to suppress IL-8 expression. In untreated patients with CML, a constitutive expression of IL-8 mRNA was detected in freshly isolated PBMNC that was markedly reduced 5 hours after therapeutic application of IFN-alpha. The mechanism of IL-8 downregulation was studied more in detail in the THP-1 cell line. The experiments showed that de novo protein synthesis was not required for the inhibitory effect. RNA decay analysis and nuclear run-on assays suggest that in THP-1 cell line the inhibition of IL-8 expression is predominantly regulated at the posttranscriptional level.

[The prognostic significance of the therapeutic working alliance from the perspective of the patient and therapist]

In general, the prognostic relevance of a working alliance for both the course and the outcome of psychotherapy is no longer a matter of dispute. Since a working alliance is conceived as an interactional variable, the results must be interpreted on the basis of several important dimensions: the perspective of the investigator and the time structure during the course of therapy. Using the data available from the Berlin Psychotherapy Study (Rudolf 1991), we investigated for the 238 patients (inpatients and outpatients who received psychoanalytically oriented therapy in the study) the prognostic relevance of diagnostic and therapy-related working alliance variables for the various outcomes investigated. A complex correlation-statistical method (latent-trait-model) was used to consider the investigator perspective with regard to the working alliance and the outcome as well as the time structure and the diagnostic variables. Our results emphasize the relevance of the therapist's perspective beginning with the diagnostic indication, the working alliance and finally the outcome. The patient's perspective, however, seems to be less relevant. The results are presented and discussed in relation to the relevant literature. One result we have found as a further important dimension is that the kind of therapy carried out must be taken into consideration. This implies that as in our study for all phases of the investigation therapy specific instruments must be applied. In this regard our results also contribute to the validation of the instrument used to measure the working alliance TAB.