Acceptance and commitment therapy group-treatment for non-responsive patients with personality disorders: An exploratory study

Patients with personality disorders who did not respond to previous outpatient treatment are among the most challenging patients to treat and are often referred to specialized settings. Acceptance and commitment therapy (ACT) is an innovative therapy that has shown effectiveness in treatment-resistant cases with chronic or recurrent depression with or without co-morbid personality disorders. The central role that ACT accords to positive values and experiential avoidance may enhance treatment responsivity in patients with personality disorders that did not respond to previous treatments. The current nonrandomized study explored the effectiveness of a 26-week ACT-based group treatment (n = 60) for personality disorders compared to treatment-as-usual (n = 21) based on cognitive behaviour therapy (CBT-TAU) at a specialized setting for patients with personality disorders. Individuals in both treatment conditions demonstrated small to moderate decreases in general psychological functioning and personality pathology. There was no main effect of therapy condition. Overall, results suggest that ACT is a possible treatment option for individuals with difficult-to-treat personality pathology and further outcome research is warranted.

Accelerometric assessment of different dimensions of natural walking during the first year after stroke: Recovery of amount, distribution, quality and speed of walking

OBJECTIVES

To describe the course of walking behaviour over a period of 1 year after stroke, using accelerometry, and to compare 1-year data with those from a healthy group.

DESIGN

One-year follow-up cohort study.

SUBJECTS

Twenty-three stroke patients and 20 age-matched healthy subjects.

METHODS

Accelerometer assessments were made in the participants' daily environment for 8 h/day during the 1st (T1), 12th (T2) and 48th (T3) weeks after stroke, and at one time-point in healthy subjects. Primary outcomes were: percentage of time walking and upright (amount); mean duration and number of walking periods (distribution); step regularity and gait symmetry (quality); and walking speed.

RESULTS

Time walking, time upright, and number of walking bouts increased during T1 and T2 (p < 0.01) and then levelled off (p > 0.30). Mean duration of walking periods showed no significant improvements (p > 0.30) during all phases. Step regularity, gait symmetry and gait speed showed a tendency to increase consistently from T1 to T3. At T3, amount and distribution variables reached the level of the healthy group, but significant differences remained (p < 0.02) in step regularity and gait speed.

CONCLUSION

In this cohort, different outcomes of walking behaviour showed different patterns and levels of recovery, which supports the multi-dimensional character of gait.

Recovery of the Sit-to-Stand Movement After Stroke: A Longitudinal Cohort Study

Background and Objective . To present quantitative data on sit-to-stand (STS)-related functioning and recovery during the first year after stroke. STS-related functioning was used to evaluate independent STS movement, rising speed, and actual STS performance during normal daily life. Methods. This was a prospective cohort study of 50 patients poststroke. Assessments were made at 0, 3, 6, 9, 12, 24, and 48 weeks poststroke. Actual STS performance was assessed at 0, 12, and 48 weeks. The main outcome measures were the following: ability to rise independently, rising speed (power chair stand up), number of STS movements, percentage of time walking and standing during daily life (using an activity monitor), and clinical outcomes, measured among others by the Barthel index (BI). Results. During year 1, the percentage of patients able to rise increased from 54% to 83%. Most improvements occurred during weeks 0 to 12, whereas no significant changes were observed during weeks 12 to 24. Rising speed similarly increased from 0.15 to 0.26 s− 1 during weeks 0 to 12 and to 0.30 s−1 at week 48. Gait speed and BI also significantly increased. The number of STS movements increased significantly during weeks 0 to 12 (from 10.6 to 17.7) but not during weeks 12 to 48. Conclusions. STS-related functioning improved significantly in the first year after stroke, with the most improvement occurring during the first 12 weeks. After 12 weeks, rising speed, gait speed, and BI continue to improve.

Neoadjuvant Intratumoral Injection of Dendritic Cells in Breast Cancer

Backround: Autologous intratumoral dendritic cell injections were used to modulate the tumor reduction effects of standard neoadjuvant chemotherapy. Dendritic cells are important in the regulation of T cell immunity and have been shown to have activity in cancer patients. The neoadjuavant combination therapy was designed to expose dendritic cells to tumor cell apoptosis leading to induction of tumor antigen-specific responses.Methods: Seventeen women with stage II or III breast cancer with breast tumors at least 3 cm in size and had a confirmed initial breast biopsy were entered into this trial from August 2007 through 2009. All patients participating in the clinical trial had tumors that expressed either carcinoembryonic antigen (CEA) or survivin and were HER2-neu negative. They received 4 cycles of paclitaxel at 175 mg/m2 followed by 4 cycles of doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 (AC) in a bi-weekly dose dense fashion. Pegfilgrastim 6 mg subcutaneous injection was administered 24 hours after each cycle of chemotherapy. Autologous intratumoral dendritic cell injections were administered one week following the first three paclitaxel treatments. All patients consented to a pre-treatment biopsy and a second tumor biopsy after 4 cycles of paclitaxel to evaluate responses to the intratumoral dendritic cell injections. The endpoints of this trial included assessment of clinical and pathologic response in the breast, safety of the intratumoral dendritic cell injection, evaluation of tumor response, and induction of T cell responses to tumor antigens.Results: Fourteen patients are evaluable for response. The median age was 51.5, the median tumor size was 5.6 cm, and 64 % were estrogen receptor positive. A complete clinical response was observed in 57%, a partial response in 36%, and one stable disease response. A pathologic complete response with no evidence of tumor in the breast was confirmed in 2 patients (14 %). Treatment was well tolerated with no incidence of toxicity observed related to the intratumoral dendritic cell injections. Grade 3/4 hematologic toxicity was as expected for the chemotherapy. Other grade 3/4 toxicity related to the chemotherapy included fatigue, hand-foot, infection, mucositis, and hypocalcemia.Discussion: Combination neoadjuvant therapy with dose-dense paclitaxel followed by AC and autologous intratumoral dendritic cell injections administered between the first three cycles of paclitaxel is safe with no toxicity observed related to the intratumoral dendritic cell injections. Immune response to the treatment is being evaluated by proliferation and interferon-gamma production by peripheral blood mononuclear cells in response to tumor cell lysates, survivin, and CEA. Initial evaluation indicates that treatment resulted in generation of tumor specific responses in more than half of all treated patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4128.

Autologous dendritic cell vaccine directed at wild type p53 in patients with high-risk breast cancer treated with adjuvant chemotherapy

Abstract #2152

Background: The tumor suppressor gene p53 is over-expressed in many human tumors, resulting in presentation of p53 epitopes in the MHC class I and II groove. This elicits antibodies to mutant and wt p53 and primes p53-specific T-cell responses to many p53 epitopes. Vaccination with dendritic cells (DCs) transduced with wt p53 using an adenovirus vector (Ad-p53) induces T-cell responses against wt p53 which can kill tumor cells that over-express wt or mutant p53. This vaccine in pts with extensive small cell lung cancer also appeared to enhance response to subsequent chemotherapy. Methods: Pts with breast cancers 4 cms or larger and/or involved 4 or more nodes and that stained &gt; 5% for p53 by immunohistochemistry were eligible. Pts were randomized to p53 DCs immunization (IMZ) during (early) or following (late) chemotherapy. Mononuclear cells collected with one apheresis, were divided and cryopreserved. Cells were thawed, matured into DCs and transduced with Ad-p53. The adjuvant therapy was dose-dense doxorubicin, cyclophosphamide (AC) followed by paclitaxel (P), then 33 doses of radiation (R). Early p53 DC IMZ was scheduled for 1 week post AC and 1, 15 and 21 weeks post P. Late p53 DC IMZ was scheduled 15,17,19 and 21 weeks post P. Each dose had approximately 5X107 DCs. Antigen specific immune assays included anti-p53 and anti-Ad antibodies and p53-specific T-cell response assays by interferon gamma ELISPOT in addition to flow cytometric analysis of cellular phenotypes were done on blood drawn before AC, each IMZ and 3, 6, and 12 mos after the last IMZ. Safety and immune responses were the primary endpoints. Results: Twenty-three pts (10 early, 13 late) have received a total of 88 IMZs of p53 DCs. The pts have been followed a median of 29 mos (range 5.5-50.5mos) from study entry. The only toxicity attributed to IMZ was grade 1 redness and itching at the IMZ site. One IMZ was held in a pt who had pre-IMZ thrombocytopenia that persisted. Two pts relapsed 8 and 23 months after diagnosis. T-cell CD-4 numbers declined following AC from an average of 4.9+0.5 x105/ml to 1.7+0.3x105/ml, but increased to an average of 2.7+ 0.3 x 105/ml, 21 weeks after P or 12 weeks after R. Antibody to adenovirus or p53 was not detected. In 14 pts evaluated at least 6 mos from last IMZ, T-cell response to p-53 was measured in all 7 early arm pts and 4 of 7 late arm pts. The median baseline response was 0.7 (range, 0-2) and median peak was 8.54 (range, 0.09-32.5). Post-IMZ responses in 2, 6 and 4 pts peaked at 3, 6 and 12 mos, respectively. Conclusions: The p53 DC IMZ is safe with CD-4 cells recovering 12 weeks after R. Although most IMZs were given when CD-4 cells were low, p53-specific T-cell responses were induced, appeared to peak at 6 mos and could persist 12 mos after the last IMZ. These studies suggest that IMZ strategies may be used with adjuvant chemotherapy and R.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2152.

Phase II trial of patients (pts) with extensive stage small cell lung cancer (ES-SCLC) immunized with p53-transduced dendritic cells (p53-DC): Immune sensitization to chemotherapy (CT)

3012

Background: Although ES-SCLC is initially, very responsive to CT, responses are not durable and relapse is characterized by chemoresistance. High incidence of p53 gene mutations, which prolong the protein’s half life, result in its frequent overexpression and enhanced detection in SCLC cells. This in turn allows for their recognition by p53-specific cytotoxic T cells. Here, we evaluated the clinical and immune response of a vaccine (vac) using p53-DC. Methods: Eligibility: Untreated, ES-SCLC pts. Age = 18 years. Performance status (PS) 0–2. Treated and controlled brain metastases. Adequate renal, hepatic and bone marrow function. Toxicity (T), survival (MST) and clinical and p53- specific immune responses were determined by CTCAE v2.0, Kaplan-Meier, RECIST and ELISPOT and tetramer staining respectively. Pts first received CT to best clinical response. Eight weeks later, those with minor progression (PD) or better, underwent leukapheresis. DC, generated from peripheral blood precursors, were infected with an adenoviral construct containing p53 (Advexin; Ad-p53) to produce the p53-DC vac. Each vaccination consisted of subcutaneous injections in 4 different nodal basins every 2 weeks x3 (2–5×106 p53-DC/dose). Results: Thirty-six pts received at least one vac; median age=58.8, (range=39–79), M/F=13/23, PS 0/1=16/20. All pts were evaluable for T and MST. Total vac=127 (median=3, range=2–6). Overall, vac was well tolerated (no > grade 2 toxicities detected). p53-specific immune response was positive in 11/21 (52.4%) pts; pending in 15 pts. After 3 vac doses, 10 (27.7%) pts. had stable disease (SD) and 26 (72.2%) had PD. Pts with SD were re-vaccinated (x3). Upon PD, all pts were offered further CT. Clinical response to post-vac CT was evaluated in 22 pts. Ten pts (45%) responded to post-vac CT (second line=7, third line=3) and 6 pts had SD. MST=473 days (95% CI: 380,534). Conclusions: ES-SCLC pts were treated safely with p53-DC vaccine and demonstrated significant immune response. The p53-DC vaccine appears to sensitize ES-SCLC to subsequent CT resulting in improved survival.

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The influence of staffing levels on the use of seclusion

This study focussed on the relationship between the use of seclusion and staff characteristics, such as number of nurses on shift, male-female staff ratio, level of education and level of work experience. A retrospective analysis of staff characteristics was applied to administrative data from ten wards in four mid-sized general psychiatric hospitals in the Netherlands. The data show that two variables were associated with seclusion rates: the male-female staff ratio and the variability in team's work experience. More female and less male nurses in a shift and less variability in team's work experience predicted an increase in seclusion rates.

Unusual phenomenology of autoerotic fatalities

Between 1983 and 2003 forty accidental autoerotic deaths (all males, 13-79 years old) have been investigated at the Institute of Legal Medicine in Hamburg. Three cases with a rather unusual scenery are described in detail: (1) a 28-year-old fireworker was found hanging under a bridge in a peculiar bound belt system. The autopsy and the reconstruction revealed signs of asphyxiation, feminine underwear, and several layers of plastic clothing. (2) A 16-year-old pupil dressed with feminine plastic and rubber utensils fixed and strangulated himself with an electric wire. (3) A 28-year-old handicapped man suffered from progressive muscular dystrophy and was nearly unable to move. His bizarre sexual fantasies were exaggerating: he induced a nurse to draw plastic bags over his body, close his mouth with plastic strips, and put him in a rubbish container where he died from suffocation.

Forensic aspects of 40 accidental autoerotic deaths in Northern Germany

Between 1983 and 2003, 40 accidental autoerotic fatalities have been investigated. in the Institute of Legal Medicine in Hamburg. Only 50% (n=20) were autopsied (13 legal autopsies, 6 for scientific purposes and 1 for an insurance company). All the victims were males, aged between 13 and 79 years (among them five children and adolescents, the deceased mainly between 20 and 40 years). The paraphiliacs utilized a great range of devices and props as fetishism, sexual aids or pain-stimulating agents, like intimate feminine garments, ropes, chains, bondages, locks, pornographic magazines, condoms, rubber items, and chemical anaesthetics. The cause of death was strangulation in 20 cases (17 x hanging, 3 x ligature strangulation), 11 x suffocation (8 x under plastic bags, 3 x with face-masks, 2 x thoracic compression, 1 x positional asphyxia, and 1 x cocaine intoxication). Five cases without autopsy remained unclear because of missing morphological and toxicological findings; it could not be differentiated between asphyxiation/intoxication/natural disease, although the scene characteristics seemed to be typical for autoerotic deaths. It is emphasized that the findings at the scene, the morphological and toxicological examination of the dead body (full autopsy as prerequisite) by experienced investigators and the personal history of the deceased have to be evaluated very carefully and intensely to reconstruct the accidental fatal autoerotic course accurately and undoubtedly (to exclude the possibility of sexual homicide, neglected killing, or suicide).

[Unintentional gunshot during police intervention]

33 cases of unintentional handgun use by police officers during operation since 1983 in Northern Germany have been evaluated. These cases have been selected from our own investigations and from prosecutors' and police departments' files and records. It was intended to find out criteria for forensic expertise. The unintended use of a handgun was always influenced in a decisive and causal manner by the behaviour of the delinquents (resistance, assault, escape). The confrontation of the police officer with the violence of aggressive offenders was of immediate importance for triggering the shot in various kinds of police operation. Sensorically caused, reflex muscle contractions as a consequence of a great effort, a loss of balance or fright when simultaneously protecting oneself with weapon in hand can be made responsible for the unvoluntary shot. In 10 cases (30%) persons were injured, 2 times lethally. As a whole, the consequences were of random nature, they could be explained by the series of actions in each case. The type and technical state of the weapons in use have not influenced the unintentional use. A behaviour of the police officers offending against the legally required care was stated in two of the investigated cases. Considering our investigations and the many policemen killed in duty we state that securing oneself in time with a weapon at the ready in critical phases of operations cannot be successfully replaced by any other method of self defense.

Adult bone marrow stromal cells differentiate into neural cells in vitro

Bone marrow stromal cells (BMSC) normally give rise to bone, cartilage, and mesenchymal cells. Recently, bone marrow cells have been shown to have the capacity to differentiate into myocytes, hepatocytes, and glial cells. We now demonstrate that human and mouse BMSC can be induced to differentiate into neural cells under experimental cell culture conditions. BMSC cultured in the presence of EGF or BDNF expressed the protein and mRNA for nestin, a marker of neural precursors. These cultures also expressed glial fibrillary acidic protein (GFAP) and neuron-specific nuclear protein (NeuN). When labeled human or mouse BMSC were cultured with rat fetal mesencephalic or striatal cells, a small proportion of BMSC-derived cells differentiated into neuron-like cells expressing NeuN and glial cells expressing GFAP.

Angiographic assessment of prospectively determined non-invasive reperfusion indices in acute myocardial infarction

OBJECTIVE

To investigate the value of non-invasive reperfusion indices in acute myocardial infarction, avoiding the possible need for acute coronary angiography and subsequent angioplasty.

DESIGN

In a prospective angiographic study, seven potential ECG or clinical markers of reperfusion were analysed in 230 patients with acute myocardial infarction. In all patients two 12 lead ECGs were used: the ECG on admission and the ECG immediately before coronary angiography. Non-invasive markers of reperfusion determined just before coronary angiography were prospectively correlated to thrombolysis in myocardial infarction (TIMI) flow. Data analysis correlated these non-invasive indices with coronary flow (analysis A: TIMI 2-3 v TIMI 0-1 flow; analysis B: TIMI 3 v TIMI 0-2 flow).

RESULTS

A sudden decrease in chest pain was the most common sign of reperfusion (36%), followed by reduction in ST segment elevation by >/= 50% (30%), and the development of a terminal negative T wave (20%) in the lead with the highest ST segment elevation. Reduction in ST segment elevation by > or = 50% and the appearance of an accelerated idioventricular rhythm (AIVR) had the highest positive predictive value for reperfusion. For analyses A and B, the positive predictive values were 85% and 66% for resolution of ST segment elevation, and 94% and 59% for AIVR, respectively. The presence of three or more non-invasive markers of reperfusion predicted TIMI 3 flow accurately in 80% of cases.

CONCLUSIONS

The prospective use of non-invasive indices of reperfusion is simple, practical, and can be of value in assessing coronary patency in patients admitted with acute myocardial infarction. Using these indices, discrimination between TIMI 0-1 and TIMI 2-3 flow can be made with good accuracy. However, TIMI 3 flow cannot be determined reliably. The use of such non-invasive indices depends on the goal of reperfusion.