Persuasion criteria in research and practice: Gathering more meaningful psychotherapy data

Psychotherapy research should ultimately benefit the psychotherapy client. Unfortunately, traditional psychotherapy research continues to have little influence on practicing clinicians and, therefore, does not benefit psychotherapy clients. As behavior analysts begin to show interest in this area of research, they may be in a position to improve its quality. We argue that traditional psychotherapy researchers have become prematurely wedded to a methodology that does not address the concerns of clinical audiences. Furthermore, we make a case for defining and evaluating psychotherapy data in terms of its capacity to influence both researchers and clinicians. We also suggest several alternative methods for gathering psychotherapy data based on the case formulation approach. We argue that this approach may be one of the most promising methods for gathering useful psychotherapy data.

Estimated risk of transmission of hepatitis C virus by blood transfusion

OBJECTIVE

The risk of transmitting hepatitis C (HCV) by transfusion of anti-HCV-negative screened blood was estimated for the blood donor population of Baden-Württemberg (southwestern Germany).

METHODS

The data from the blood donors screened for anti-HCV and for HBsAg during 1990-1995 were analyzed.

RESULTS

The prevalence of confirmed anti-HCV -positive blood donations decreased continuously during the last 5 years, reaching 121 per 100,000 blood donations. A higher anti-HCV prevalence rate was found in female than in male blood donors (p < 0.05). The estimated risk of transmitting HCV during the window period is 1:200,000 (1:97,000-1:1,400,000) for repeat donors. In 1995, the calculated risk for first-time donors was 1:20,000 (1:15,000-28,000). The incidence for HCV was 1.2 per 100,000 blood donations.

CONCLUSION

The risk of transmitting hepatitis C by blood transfusion is low. Additional tests to shorten the window period to detect antibodies to HCV might increase the safety of blood transfusion.

Research on dialectical behavior therapy for patients with borderline personality disorder

Research evidence to date indicates that, although DBT was developed for the treatment of patients with suicidal behavior, it can be adapted to treat BPD patients with comorbid substance-abuse disorder and be extended to other patient populations and the treatment of other disorders. Across studies, DBT seems to reduce severe dysfunctional behaviors that are targeted for intervention (e.g., parasuicide, substance abuse, and binge eating), enhance treatment retention, and reduce psychiatric hospitalization. Evidence suggests that additional research is warranted to examine which components of DBT contribute to outcomes. Although preliminary, skills coaching seems to be a crucial ingredient in producing reductions in parasuicidal behavior, and specific strategies (e.g., validation, balance of change, and acceptance interventions) may play an important role in positive behavioral change. Several investigators are evaluating the efficacy of DBT. For example, Asberg et al at the Karolinska Institute in Sweden have begun a pilot study comparing DBT for women who have made multiple suicide attempts to transference focus psychotherapy, a psychodynamic therapy developed by Kernberg. They have planned a randomized clinical trial to compare DBT and transference focus psychotherapy with TAU in the community. van den Bosch has completed a randomized clinical trial for women who met criteria for BPD and substance abuse comparing DBT-S with TAU. Lynch is conducting a randomized clinical trial examining the efficacy of DBT skills training plus medication versus medication only for the treatment of moderate to severe depression in the elderly. Results from these studies should become available over the next several years, providing further empiric evidence by which to evaluate the efficacy of DBT. Additional development of DBT seems warranted to improve its efficacy, and additional investigation is needed to establish its effectiveness in public health settings. Analyses from existing data sets of factors that predict treatment response and elements of the treatment that contribute to outcome are needed. Also, longitudinal follow-up studies to determine suicide rates and maintenance of treatment gains are needed. Because DBT has been adopted in a variety of clinical settings, effectiveness studies are needed. Given the difficulty of conducting treatment research with chronically suicidal individuals, perhaps the largest challenge to further treatment development is recruiting young investigators who are willing to conduct research in this area. Nevertheless, in the 6 years since the treatment manuals were published, DBT seems to be a step toward more effective treatment for severely multidisordered patients.

Experiences in HCV-NAT screening prior to releasing cellular components by the German Red Cross Blood Transfusion Service of Baden-Württemberg

In this report we present the accumulated data on nucleic acid testing (NAT) for hepatitis C virus (HCV) RNA of blood donations by the Blood Transfusion Service of Baden-Württemberg in the period between March 1997 and March 1999. An extra barcoded blood sample was collected from each donor. Samples were tested by NAT in mini-pools of maximally 96 samples. First-time and repeat donors were tested separately. RT/HCV-PCR was performed with the COBAS HCV Amplicortrade mark, versions 1.0 and 2.0 from Roche Diagnostic Systems. Many modifications have been introduced to the original protocol since the implementation of NAT screening aiming at an increase in the sensitivity and specificity of the assay. NAT positive pools containing serologically positive samples were detected. Initially, reactive pools were identified that could not be confirmed by secondary pooling and single testing procedures. So far, no serologically negative but NAT positive sample has been found.

Mini-pool screening by nucleic acid testing for hepatitis B virus, hepatitis C virus, and HIV: preliminary results

BACKGROUND

The purpose of this study was to evaluate the feasibility of nucleic acid testing (NAT) of mini-pools as a blood donation screening test.

STUDY DESIGN AND METHODS

The stepwise implementation of NAT of mini-pools began in January 1997. Since March 1997, all blood donations collected by the German Red Cross Blood Transfusion Service of Baden-Württemberg were tested for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV nucleic acids. An extra barcoded serum sample is collected from each blood donor for NAT-based screening, which is performed only on hepatitis B surface antigen-, anti-HCV-, anti-HIV-, and anti-Treponema pallidum-seronegative donations. Samples are pooled to a maximum of 96. Positive results are resolved through intersecting subpools (a chessboard design). NAT-based screening does not include a virus concentration step before nucleic acid extraction.

RESULTS

By the end of October 1997, 331, 783 donations in 3,779 pools had been screened. As yet, no viremic but seronegative blood donor has been found for the three markers.

CONCLUSION

It is feasible to incorporate NAT-based screening of mini-pools into the routine virus diagnostics of a large blood transfusion service. It remains to be determined whether screening blood donations by NAT will indeed increase the safety of blood supply.

Laparoscopic-assisted abdominoperineal resection in the prone position. An alternative technique

With the introduction of laparoscopic-assisted abdominoperineal resection (LAPR), the traditional Lloyd-Davies position with the Mayo two-team combined approach is being adapted. The Lloyd-Davies position allows two teams of surgeons to work simultaneously, minimizing operating time. The conditions required for laparoscopy restrict a simultaneous procedure. Since LAPR is typically performed as a two-stage procedure, we introduce an alternative position which facilitates the perineal dissection. We review the results and technique of LAPR in the prone position in three patients who were suitable candidates for this procedure. Three patients underwent LAPR. No operative or postoperative complications were encountered and the procedures were in keeping with oncologic principles of resection. Total anesthesia times were less than 3.5 h for these initial patients. No hemodynamic problems were encountered due to the choice of patient positioning. The prone jackknife position greatly increases visualization of deep structures, reduces blood loss, enhances dissection, and reduces the technical demands of the laparoscopic portion of the procedure.

Anti-HCV envelope prevalence in blood donors from Baden-Württemberg

We assess the diagnostic value of the recombinant antigens E1/E2 (heterodimer) and E2 for the screening of blood donors. For this purpose an ELISA assay was developed which used these recombinant glycoproteins as solid antigens on the microtiter plates. The anti-E1/E2 assay was able to detect 80% of the positive samples by Matrix and 87% of the PCR-positive samples. Anti-E2 was less sensitive. Fifteen percent of the indeterminate samples were anti-E1/E2 and 8% anti-E2 positive. In the case of the indeterminate samples there was no coincidence of results between these assays and the PCR. Fifty percent of seroconverters showed an anti-E1/E2-positive result with a previous indeterminate donation. We conclude that the recombinant envelope proteins, mainly anti-E1/E2, might be used in future in the diagnostics of HCV infection to increase the sensitivity of the currently used assays.

A component analysis of cognitive-behavioral treatment for depression

The purpose of this study was to provide an experimental test of the theory of change put forth by A. T. Beck, A. J. Rush, B. F. Shaw, and G. Emery (1979) to explain the efficacy of cognitive-behavioral therapy (CT) for depression. The comparison involved randomly assigning 150 outpatients with major depression to a treatment focused exclusively on the behavioral activation (BA) component of CT, a treatment that included both BA and the teaching of skills to modify automatic thoughts (AT), but excluding the components of CT focused on core schema, or the full CT treatment. Four experienced cognitive therapists conducted all treatments. Despite excellent adherence to treatment protocols by the therapists, a clear bias favoring CT, and the competent performance of CT, there was no evidence that the complete treatment produced better outcomes, at either the termination of acute treatment or the 6-month follow-up, than either component treatment. Furthermore, both BA and AT treatments were just as effective as CT at altering negative thinking as well as dysfunctional attributional styles. Finally, attributional style was highly predictive of both short- and long-term outcomes in the BA condition, but not in the CT condition.

Diagnosis of personality disorder: a radical behavioral alternative

From a radical behavioral perspective, a single, diagnostic system is unlikely to serve diverse purposes. Instead, ideal diagnostic systems should be developed to serve specific purposes. For example, the crucial proof required of a classification system designed to improve the outcome of psychosocial intervention would be that it enhance the clinician's influence on processes associated with client change. This means, in turn, that the change processes must be known or theoretically specified. As an illustration of this general approach to diagnostic classification, a specific behavioral theory is used to articulate processes of change in psychotherapy. The Axis II of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) is then evaluated with respect to its ability to enhance clinicians' influence of these processes, found problematic, and an alternative classification criterion is proposed.

A component analysis of cognitive-behavioral treatment for depression

The purpose of this study was to provide an experimental test of the theory of change put forth by A. T. Beck, A. J. Rush, B. F. Shaw, and G. Emery (1979) to explain the efficacy of cognitive-behavioral therapy (CT) for depression. The comparison involved randomly assigning 150 outpatients with major depression to a treatment focused exclusively on the behavioral activation (BA) component of CT, a treatment that included both BA and the teaching of skills to modify automatic thoughts (AT), but excluding the components of CT focused on core schema, or the full CT treatment. Four experienced cognitive therapists conducted all treatments. Despite excellent adherence to treatment protocols by the therapists, a clear bias favoring CT, and the competent performance of CT, there was no evidence that the complete treatment produced better outcomes, at either the termination of acute treatment or the 6-month follow-up, than either component treatment. Furthermore, both BA and AT treatments were just as effective as CT at altering negative thinking as well as dysfunctional attributional styles. Finally, attributional style was highly predictive of both short- and long-term outcomes in the BA condition, but not in the CT condition.

Ähnliche Prävalenz der Hepatitis-C-Virus-lnfektion bei Hämophilie-Patienten aus den alten und neuen Bundesländern

<i>Ziel: </i>Die Studie sollte die Infektionsrate mit dem Hepatitis-C-Virus (HCV) bei 2 Patientenkollektiven untersuchen, die vor 1991 in West- und Ostdeutschland substituiert worden waren. Da unterschiedliche Herstel-lungsverfahren der Faktorpräparate (groβe vs. kleine Plasmapools) den entscheidenden Unterschied darstellten, können diese Daten Hinweise auf die Bedeutung der Plasmapoolgröβe als Risikofaktor für die Infektiosität der Präparate geben. <i>Design: </i>Retrospektive Studie an Seren, die 1990 und 1991 entnommen wurden. <i>Rahmen: </i>Abteilungen für Innere Medizin und Transfusionsmedizin zweier Universitätskliniken (Ulm und Dresden) als Vertreter von Zentren in West- und Ostdeutschland. <i>Patienten: </i>86 sub-stitutionspflichtige erwachsene Patienten mit kongenitalen Gerinnungsstörungen aus West- (57 Patienten) und Ostdeutschland (29 Patienten). Kontrollgruppen: 16 Lebenspartner der westdeutschen Patienten, 6 nicht-transfundierte Patienten mit Willebrand-Jürgens-Syndrom und 42 gesunde westdeutsche Blutspender. <i>Interventionen: </i>Untersuchung der Seren auf HCV-Antikörper, virale RNA und Transaminasen. Vergleich der Infektionsrate mit HCV mit dem Schweregrad der Gerinnungsstörung, der Substitutionshäufigkeit und Markern für eine Infektion mit Hepatitis-B-Virus und HIV. <i>Ergebnisse: </i>Antikörper gegen HCV waren bei 81% der westdeutschen Patienten und 58% der ostdeutschen Patienten nachweisbar (p = 0,03); HCV-RNA fand sich im Serum von 55 bzw. 38% der Patienten (p = 0,1). Bei 82% der Patienten, in deren Serum neben HCV-Antikörpern auch HCV-RNA nachgewiesen wurde, war die SGPT erhöht; dagegen fanden sich nur bei 17% der Patienten mit alleinigem Nachweis von HCV-Antikörpern erhöhte SGPT-Werte. Die Infektionsrate korrelierte in beiden Patientengruppen mit der Zahl transfundierter, nichtvirusinaktivierter Gerinnungsfaktorpräparate und mit der Koinfektion mit Hepatitis B Virus. Seren von 16 Lebenspartnern der Patienten waren Antikörper- und RNA-negativ. In 3 von 41 zufällig ausgewählten Faktorkonzentraten, die 1987 bis 1991 in Ulm eingesetzt worden waren, war HCV-RNA nachweisbar. Im Gegensatz zu den westdeutschen Patienten (16% HIV-positiv) waren bei keinem der ostdeutschen Patienten, die ausschlieβlich mit Kleinpool-Präparaten behandelt worden waren, Marker einer HIV-Infektion nachweisbar. <i>Schlu</i>β<i>folgerungen: </i>Diese Daten zeigen, daβ das Risiko, eine HCV-Infektion zu erwerben, bis 1990 in den alten und neuen Bundesländern vergleichbar war. Bei den eingesetzten Substitutionsstrategien be-deutete somit der Einsatz kleiner Plasmapools eine ähnlich hohe Gefahr der Transmission von HCV wie die weltweit übliche Verwendung groβer Pools.

Low cytokine contamination in buffy coat-derived platelet concentrates without filtration

BACKGROUND

Cytokines (interleukin [IL]-1 beta, IL-6, and tumor necrosis factor [TNF]) generated by white cells during the storage of platelet concentrates can cause febrile nonhemolytic transfusion reactions. The high rate of febrile reactions reported in other studies was not observed in the patients in the authors' center. This discrepancy prompted the determination of cytokine levels in buffy coat-derived platelet concentrates.

STUDY DESIGN AND METHODS

Platelet concentrates were produced from buffy coats by a standard large-scale production process. Buffy coats were separated from the red cell and plasma components, and then platelets were recovered from the buffy coats by a soft-spin procedure. Levels of cytokines (IL-1 beta, IL-6, IL-8, and TNF) were determined with commercial enzyme-linked immunosorbent assays.

RESULTS

In platelet concentrates produced by the buffy coat method, IL-1 beta, IL-6, IL-8, and TNF were observed at or below the detection limit of current enzyme-linked immunosorbent assays after 5 days' storage at 22 +/- 2 degrees C. Therefore, prestorage filtration had no measurable effect on cytokine levels. In controls, IL-1 beta, IL-6, IL-8, and TNF were quantitatively detected after exogenous addition of recombinant cytokines or exposure to lipopolysaccharide.

CONCLUSION

Platelet concentrates prepared from buffy coats may be virtually free of cytokines (IL-1 beta, IL-6, IL-8, and TNF) during 5 days of storage. Filtration is not required to reduce the recipient's cytokine exposure via such platelet concentrates.

The serology of hepatitis C virus (HCV) infection: antibody crossreaction in the hypervariable region 1

We determined the NS1/E2 N-terminal sequence including the hypervariable region 1 (HVR1) from five individuals chronically infected with HCV: two from the Czech Republic and three from Germany. From each sequence, six 12-mer overlapping peptides were synthesized and used in a peptide scan to evaluate seroreactivity of each of those patients, as well as three anti-HCV positive blood donors to the different isolates. We could show the general presence of antibodies to multiple HVR1 specific sequences reflecting the existence of multiple variants in infected persons. Finally, we observed the persistance of HCV infections in all individuals despite an active humoral response directed against the virus.

Autologous platelet transfusion in alloimmunized patients with acute leukemia

Seventy-eight transfusions of autologous platelets were given to eight alloimmunized patients receiving curative chemotherapy for acute leukemia. Platelets were collected at regeneration of hematopoiesis after a chemotherapy cycle, cryopreserved with 5% dimethylsulfoxide in liquid nitrogen, and retransfused during bone marrow aplasia following the next treatment cycle. The in vitro platelet recovery after freezing, thawing, and washing was 85 +/- 4%. The in vivo corrected count increment 1 h after autologous platelet transfusions was 11 +/- 5 x 10(9)/l. With the exception of moderate urticaria and slight nausea each after one transfusion, no immediate or chronic side effects occurred. The bleeding time was shortened and hemorrhage during bone marrow aplasia was prevented in all alloimmunized patients by autologous platelet transfusions.

Human monoclonal antibodies for the immunological characterization of a highly conserved protein domain of the hepatitis C virus glycoprotein E1

Although both envelope glycoproteins of the hepatitis C virus, E1 and E2/NS1, show a high degree of sequence variation, the E1 protein includes a well conserved domain, which may be functionally important. We have analysed the human B cell response to a peptide fragment from amino acid residues 314-330 (EP3) covering the central conserved sequence of this domain. Anti-hepatitis C virus-positive blood donors were screened for anti-EP3 antibodies with an ELISA based on immobilized peptide. Thirty out of 92 (32%) RIBA-confirmed donors displayed a significant antibody response to EP3. From three of these blood donors we established four anti-EP3-producing heterohybridoma cell lines: Ul/F30 and Ul/F31 produced IgM-kappa, whereas Ul/F32 and Ul/F33 secreted the isotypes IgG1-lambda and IgG1-kappa, respectively. Epitope analysis with overlapping nonapeptides suggests the existence of different antigenic determinants within the EP3 fragment. Although both IgG antibodies Ul/F32 and Ul/F33 have dissociation constants to the peptide of approximately 10(-9) M, binding to recombinant E1 protein expressed in COS-7 cells was different. Only Ul/F33 detected envelope protein of approximately 24-35 kD in Western blot. This human MoAb will be useful for further investigations on the hepatitis C virus glycoprotein E1.

Quality of pooled platelet concentrates prepared from buffy coats and stored in an additive solution after filtration

Platelet concentrates prepared from buffy coat were pooled and stored for 6 days after removal of leukocytes by filtration. The platelets were stored in plasma or in an additive solution, Plasmalyte-A. In vitro platelet function was better preserved using Plasmalyte-A than plasma with regard to osmotic reversal and aggregation. No significant differences for the release of platelet markers beta-thromboglobulin, platelet factor 4, or lactate dehydrogenase pre- and post-filtration and storage in plasma or Plasmalyte-A was observed. Expression of the surface membrane glycoproteins Ib, Ia/IIa, IIb/IIIa, and IV measured by flow cytometry after binding of monoclonal antibodies did not change during storage. The expression of activation-dependent alpha-granula glycoprotein GMP140, the thrombospondin, and the glycoprotein 53 from the lysosomal granules was not different between platelet pools stored in plasma or in Plasmalyte-A. The in vitro quality of platelets stored as pools is comparable for plasma and the additive solution Plasmalyte-A.

Analysing the sequence diversity of the 5' NC-region of HCV-isolates found in southern Germany

In this study we compared the nucleotide sequence of the 5' NC-region of the HCV genome isolated from seven patients and two blood donors from Southern Germany. We could identify two very distinct groups of isolates: the first very similar to the HCV prototype sequence (HCV1) with homology ranging from 99.5% to 98.7%; the second showing 91.7% homology to the HCV1. Group 1 isolates could be found in five patients and the two blood donors. Group 2 isolates could be found in the two other patients. Finally, we could observe neither nucleotide insertion nor deletion in the isolates described here.

Isotype-specific immune response to a single hepatitis C virus core epitope defined by a human monoclonal antibody: diagnostic value and correlation to PCR

In this study we tested the seroreactivity of 223 selected anti-HCV-reactive blood donors to the human B-cell epitope N-VYLLPR-C (C34-39) of the hepatitis C virus core antigen. The epitope was recently identified and characterized by the human monoclonal IgG antibody Ul/F10 and is located within the amino acid residues 34-39 of the aminoterminal core region. The blood donor sera were selected from anti-HCV ELISA (Ortho, 2nd generation)-reactive samples. Sixty-seven of these sera were further reactive in RIBA (Ortho, 2nd generation). According to their RIBA pattern, these samples were divided into four groups. Samples in the first group (n = 18) reacted to all four recombinant HCV antigens. The samples of the second (n = 9) and third group (n = 8) reacted to c22-3/c33c and c22-3/c100-3, respectively. Sera from group 4 (n = 32) showed a RIBA indeterminate pattern with reactivity only to c22-3. All 223 samples were analyzed for anti-C34-39 antibodies by ELISA, and the 67 RIBA-reactive samples were additionally tested for the presence of HCV RNA by RT/PCR. In groups 1 and 2, over 80% of the samples showed anti-C34-39 reactivity which was restricted to the IgG1 isotype. In contrast, in groups 3 and 4, antibodies to the epitope C34-39 were detected in less than 10% of the samples. Interestingly, the anti-C34-39 response correlates with the presence of HCV RNA; 95.5% of the samples had coincident results in all subgroups. None of the RIBA-negative sera showed a specific seroreaction to the C34-39 peptide.

In vitro platelet function during storage in three different additive solutions

Three different synthetic media without glucose were studied for platelet storage. The first medium contained acetate and gluconate. The second contained acetate, gluconate and citrate. Finally the third contained phosphate and mannitol. The purpose of the study was to investigate whether there were differences among the various media in terms of preservation of platelet quality. Pools of platelet concentrates were prepared from buffy coats. In vitro function and metabolic parameters were measured during 5 days of storage in these additive solutions as well as in plasma. Platelet aggregation, hypotonic shock response and release of beta-thromboglobulin, platelet factor 4 and lactate dehydrogenase of the cytosol were equivalent in the media containing acetate compared to plasma storage. In vitro platelet functions and pH in these two media were better preserved compared to the medium with phosphate and mannitol. In addition bacteriological studies using platelets suspended in additive solutions or in plasma were carried out. Carryover of 20% of plasma to the synthetic media necessary for successful platelet storage in these additive solutions allows bacteriological growth. As shown, inoculation of 1 colony/ml Staphylococcus epidermidis leads to 10(6)-10(7) organisms/ml after 5 days of storage.

Hepatitis C virus infection is a risk factor for liver failure from veno-occlusive disease after bone marrow transplantation

The contribution of hepatitis C virus (HCV) infection to liver disease after bone marrow transplantation (BMT) was retrospectively evaluated in 61 patients treated with BMT. HCV genome, as well as antibodies to HCV, was analyzed in sera collected before and serially after BMT. Six patients had been infected with HCV before BMT and three patients acquired the infection during or shortly after BMT. All patients infected before BMT died within 10 weeks after transplantation. Five of these six patients (83%) died of veno-occlusive disease (VOD), compared with nine of 52 patients (17%) not infected with HCV (P < .005). Risk factors for VOD other than HCV were not more prevalent in these patients compared with uninfected patients. Parallel to the development of VOD, replication of HCV increased, as demonstrated by rising concentrations of viral RNA in serum. HCV infection acquired during or after BMT caused only mild acute hepatitis C, which progressed to chronic hepatitis C in one patient surviving 10 years after BMT. These data suggest that patients with liver disease caused by HCV infection are at high risk of developing lethal VOD after BMT.

Isolation and epitope characterization of human monoclonal antibodies to hepatitis C virus core antigen

In this study we describe the establishment of two hybridoma cell lines secreting human monoclonal antibodies to the 22-kD nucleocapsid protein (core, p22) of the hepatitis C virus (HCV). For this purpose we isolated B lymphocytes from an anti-HCV positive blood donor and infected them with Epstein-Barr (EBV). We obtained several lymphoblastoid cell clones secreting antibodies to the recombinant HCV core protein. The B-cell cultures were oligoclonally expanded and two of them were fused with the (mouse:human) heteromyeloma cell line K6H6/B5. The resulting stable hybridomas produce antibodies of the IgG1/kappa (U1/F10) and the IgM/kappa (Ul/F11) isotype reacting specifically with the recombinant core protein p22. To identify the epitopes recognized by these antibodies we synthesized overlapping peptides (13-mer and 6-mer) from the amino terminus of the core amino acid sequence. Antibody reactivity to these peptides was analyzed in an immunoblot assay. Finally, we were able to define a linear epitope recognized by the Ul/F10 antibody on the nucleocapsid protein. The antibody shows specificity to the sequence N-VYLLPR-C, which corresponds to the amino acids 34-39 of the core sequence.

Testing the integrity of a psychotherapy protocol: assessment of adherence and competence

Manipulation checks should be used in psychotherapy trials to confirm that therapists followed the treatment manuals and performed the therapy competently. This article is a review of some strategies that have been used to document treatment integrity; also, their limitations are discussed here. Recommendations for improving these checks are presented. Specific guidelines are offered regarding when and how to assess both therapist adherence to treatment protocols and competence.

Testing the integrity of a psychotherapy protocol: assessment of adherence and competence

Manipulation checks should be used in psychotherapy trials to confirm that therapists followed the treatment manuals and performed the therapy competently. This article is a review of some strategies that have been used to document treatment integrity; also, their limitations are discussed here. Recommendations for improving these checks are presented. Specific guidelines are offered regarding when and how to assess both therapist adherence to treatment protocols and competence.

[Risk of infection transmission by blood components]

OBJECTIVE

Assessment of the present risk of blood-borne infection associated with homologous blood transfusion in Central Europe with particular emphasis on HIV and HCV infections.

DATA SOURCES

The relevant literature in the English and German language and the authors' data.

STUDY SELECTION

No special study has been carried out for the present paper.

RESULTS

The recognition of the risk for transmitting HIV by transfusion has led to a bundle of measures which have improved the safety of blood supply in Germany. A stricter donor selection as well as screening for HIV 1 and HIV 2 have reduced the risk to transmit HIV to the order of 1 per 1 million units transfused. The transmission of hepatitis B is estimated to be in the order of 1:50,000. The anti-HCV testing, introduced in 1990, has markedly reduced the transmission of HCV to less than 1:5,000 per unit as judged from our own data. A further reduction is expected by an improved HCV screening in the near future. Fatal disease from bacterial contamination is rare, with an estimated risk of one in a million units. Syphilis transmitted by transfusion is virtually not occurring anymore. However, increased efforts should continue to enhance the safety of blood, bearing in mind that a zero risk is not achievable for effective therapies. The estimation of risks is a dynamic, time-dependent value which has to be estimated for a geographically defined population for a given time period.

CONCLUSIONS

The risk of transfusion-associated infection has been markedly reduced in recent years. Albeit there is a small but definitive risk, which is often overestimated. The risks have to be defined to estimate the risk/benefit ratio of the homologous as well as the autologous transfusion for the individual patient.

Prevalence of HCV-RNA-positive blood donors and correlation to ELISA and RIBA status

In Germany, transmission of hepatitis C virus by blood transfusion is prevented by screening the donations for anti-HCV and ALT. The specificity of the anti-HCV screening in low seroprevalence populations has been questioned. In order to evaluate this screening policy we wanted to estimate the prevalence of viremic and potentially infectious donors by the HCV-RNA polymerase chain reaction (PCR) in our donor population of southern Germany. Donors (n = 301) were divided into four subgroups according to anti-HCV status and ALT levels. HCV sequences were detected by nested PCR, using primers for the most conserved region of the viral genome. The recombinant immunoblot assay (RIBA-4) was applied to the same samples. PCR detected 4.2% HCV-RNA carriers in the subgroup anti-HCV-/ALT-; 3% in the subgroup anti-HCV-/ALT+; 19.4% in the subgroup anti-HCV+/ALT-; and 59.4% in the subgroup anti-HCV+/ALT+. It was concluded that, on the one hand, the lack of specificity of the anti-HCV ELISA gives rise to many false-positive results; on the other hand, a minority of infected donations will not be detected by the screening procedure. ALT in conjunction with anti-HCV improves the quality of screening for potentially infectious donors.

Das Risiko einer Infektionsübertragung durch Blutkomponenten

<i>Ziel: </i>Das aktuelle Risiko transfusionsassoziierter Infektionen, besonders mit dem Human Immunodeficiency Virus (HIV) und dem Hepatitis-C-Virus (HCV), für Mitteleuropa zu definieren. <i>Quellen: </i>Relevante neueste englische und deutsche Veröffentlichungen und eigene Daten. <i>Auswahlkriterien: </i>Keine spezielle Literaturrecherche über die Zeit. <i>Ergebnisse: </i>Durch verstärkte Spenderselektion, zusätzliches und verbessertes Labor-Screening und eine sich ändernde Epidemiologie ist das Risiko eine dynamische Gröβe, deren gegenwärtiger Stand immer wieder neu bestimmt werden muβ. Das Risiko einer HIV-Übertragung wird auf 1:1 Million per transfundierte Blutkomponente geschätzt. Durch die seit 1990 durchgeführte Testung aller Blutspenden auf Anti-HCV wurde die Posttransfusionshepatitis-C-(PTH-C-)Übertragung um 80% reduziert und nach eigenen Daten auf 1 per 5000 transfundierte Blutpräparate geschätzt. Eine zu erwartende Verbesserung des HCV-Screenings wird das Risiko, HCV durch Blut zu übertragen, weiter reduzieren. Das Risiko, Hepatitis B zu übertragen, liegt in der Gröβenordnung von 1 per 50000 transfundierte Blutkomponenten. <i>Schluβfolgerung: </i>Dieses in den letzten Jahren deutlich verminderte, aber häufig überschätzte Infektionsrisiko muβ bei einer Nutzen/Risiko-Abschätzung für alternative Methoden zur homologen Bluttransfusion für den einzelnen Patienten in Betracht gezogen werden.

Investigating the presence of HIV sequences and the distribution of virological markers in hemophiliacs and their sexual partners

In this study, we report the investigation of a hemophiliac cohort, in which the last HIV-1 seroconversion occurred in 1985. We wanted to evaluate whether 5 years later the results of serological screening and polymerase chain reaction (PCR) technology would match. We examined 61 German patients with congenital deficiencies of factors VII, VIII-c, and IX, and 16 sexual partners (15 partners of anti-HIV-1-negative hemophiliacs). Patients' and partners' anti-HIV-1 status was determined by ELISA and Western blot. Further, we applied the PCR to investigate the possible presence of HIV sequences in anti-HIV-1-negative individuals. Four sets of primers were used in four separated reactions to avoid false-negative results due to genetic variation, as well as false-positive results due to DNA carryover. The data by PCR were not different from the data attained by conventional serological methods. The prevalence of serological markers for HBV and HCV was determined.