Modified Treatment Strategies Research Articles

2758 – Personality and treatment dropout in depressed outpatients

Introduction Premature termination is common among patients treated for depression with either pharmacotherapy or psychotherapy. Yet little is known about factors associated with premature treatment termination among depressed patients. In other hand, there is conflicting evidence about the influence of personality disorder on outcome in depressive disorders. Aims The present study assesses whether personality may predict the dropout of a psychotherapy group for patients with depressive disorder. Methods A personality disorders (PDs) self-report questionnaire based on the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) was completed by 39 depressed outpatients. All patients attended a group-based CBT program for depression consisted of 10 weekly 90 minutes sessions. Patients were categorized in groups as completers vs. dropouts. Dropout was defined as attendance at less than 7 sessions. Differences between groups were tested using Student's t -test and in order to measure the specific contribution of personality on dropout a logistic regression analyses were performed. Results Comparing treatment completers (67%) vs. dropouts (33%), groups differed significantly on number of items in schizotypal, narcissistic and borderline PDs. The dropout group scored significantly higher on these PDs than the completer group. Scores on borderline personality disorder emerged as a significant predictor of dropout. Conclusions Depressed outpatients with comorbid borderline traits are at higher risk of premature termination and may require modified treatment strategies.

Prognostic Impact of Clinician-Based Interpretation of FDG-PET/CT Reports Obtained in Patients with Newly Diagnosed Diffuse Large B-Cell Lymphoma.

AbstractAbstract 2646▪▪This icon denotes a clinically relevant abstract Background:PET/CT scan is a widespread modality in both clinical settings and clinical trials in the evaluation of diffuse large B-cell lymphoma (DLBCL). The concordance among interpreters of PET/CT scan is important for basing clinical decisions on these results. In order to act properly on the results, the response evaluation according to interpretation of PET/CT reports has to correlate with specific clinical end points including outcome. As of today we have no evidence for that and clinical studies are only based on the assessment of nuclear medicine-physicians. Aim:To evaluate the clinician-based interpretation of PET/CT reports in newly diagnosed DLBCL at mid-therapy(I-PET) and end-therapy(E-PET) in terms of concordance and prognostic impact. Method:Patients were considered eligible for inclusion in this retrospective study if they fulfilled the following criteria: I) newly diagnosed with de novo DLBCL, II) age ≥15 years, III) treated with R-CHOP or R-CHOP like treatment with or without addition of CNS prophylaxis and radiotherapy and IV) evaluated with PET/CT at mid-therapy and/or end-therapy. Patients with primary CNS lymphoma and composite lymphoma histology, HIV-associated lymphoma and transplant related lymphoproliferative disease were excluded from this study. All DLBCL patients diagnosed between September 2005 and December 2009 at eight Danish hematology centers were screened for eligibility.Nine expert hematologists were asked to interpret PET/CT reports. Each report was independently evaluated by three hematologists. The assessments of reports were performed without any clinical information. PET/CT reports were labeled positive or negative if all three interpreters independently agreed. All others were considered indeterminate. Results:A total of 434 patients and 617 PET/CT reports were included in the study. The distribution of PET/CT report interpretation is shown in Table 1.The median follow-up time was 3.4 years (range 0.3 – 6.7 years). The progression free survival (PFS) and overall survival (OS) for the I-PET reports were not significantly different between the indeterminate and negative results (p=0.6). However, patients with an indeterminate result had a worse PFS and OS according to the E-PET reports (p=0.09 and p=0.006, respectively). Patients with a positive I-PET and/or E-PET report both had a significantly lower PFS (p<0.0001) and OS (p<0.0001) compared to the two other groups. Survival curves are shown in Figure 1. Discussion:PET/CT evaluation in newly diagnosed DLBCL needs not only acceptable predictive values for outcome prediction to reinforce the decision to modify treatment strategy, but also high concordance between the clinicians who make the decisions. Failing to achieve this will make PET an unsuitable tool for this purpose. In the present study, we found a high number of indeterminate evaluations according to both I-PET and E-PET reports. There was no significant prognostic difference between the negative and the indeterminate group of the I-PET. However, we observed a significant difference in outcome between patients with a negative and indeterminate E-PET. Patients with a positive E-PET and I-PET had a very poor prognosis.This study demonstrates that binary visual PET response criteria for de novo DLBCL leads to a considerable amount of indeterminate interpretations in the clinician based setting. The study also underlines the importance of consistent PET reports and a multidisciplinary approach for the evaluation of treatment response in DLBCL.Table 1:Distribution of 617 PET/CT reports by hematologist interpretationIndeterminateNegativePositiveI-PET (n=241)59% (n=142)30% (n=73)11% (n=26)E-PET (n=376)37% (n=186)41% (n=153)10% (n=37)Table 2:Survival estimates according to results of I-PET and E-PETI-PET (n=241)Indeterminate (n=142)Negative (n=73)Positive (n=26)2YRS PFS estimate (95% CI)85% (78-90%)90% (81-95%)52% (31-69%)2 YRS OS estimate (95% CI)87% (81-91%)89% (79-94%)58% (37-74%)E-PET (n=376)Indeterminate (n=186)Negative (n=153)Positive (n=37)2YRS PFS estimate (95% CI)86% (80-90%)95% (90-97%)36% (21-52%)2 YRS OS estimate (95% CI)89% (84-93%)97% (92-99%)41% (25-56%) [Display omitted] Disclosures:No relevant conflicts of interest to declare.

100% Human Monoclonal Antibodies in Oncology: Hype or Breakthrough?

Targeted therapies have dramatically modified treatment strategies in oncology since the early 2000's, especially for treating digestive cancers. These new biotherapies such as anti-VEGF (bevacizumab) or anti-EGFR (cetuximab) monoclonal antibodies have given oncologists new opportunities to use innovative treatment schedules or combinations with cytotoxics. Consequently, significant improvements in response rates, with trends to longer progression-free survival and/or overall survival have been achieved in patients with metastatic colorectal cancer (mCRC). Panitumumab is a novel, 100% human, anti-EGFR1 (HER1) antibody that has been approved in late 2007 for use as monotherapy in mCRC patients resistant to standard chemotherapy, provided that their tumor express EGFR and display wild-type K-Ras status. Panitumumab has been recently further approved in combination with chemotherapy in mCRC patients. However, owing to the fact that its mechanism of action for targeting EGFR is similar to that of chimeric cetuximab, picturing the specificities in pharmacological and pharmacokinetic properties of this 100% human antibody could help the oncologists to better define their strategies at the bedside.

Unique Patient Issues: Early Interventions and Management

Patient cases that present with recurring fertilization failure or complete abnormality in either the oocytes or sperm before fertilization are uncommon, yet they are devastating. This review presents several such instances, including oocyte maturation blocks, empty follicle syndrome, oocyte activation failures, defects in sperm phospholipase C isoform ζ, sperm structural anomalies, spontaneous oocyte activation, and unexplained cases. Diagnostic efforts have not only provided insight into possible etiologies but also have helped manage such challenging cases. Interventions may comprise cellular, molecular, or genetic analyses of gametes, as well as functional assays and/or modified treatment strategies. Consequently, infertility professionals can increasingly rely on evidence-based counseling with respect to prognosis and treatment options.

Sa1033 Oral Nutrition With a High Content of BCAA Improves the Liver Function and Major Symptoms of Decompensated Cirrhotic Patients Unresponsive to BCAA Granules Only

BACKGROUND: Spontaneous bacterial peritonitis (SBP) is a frequent and severe bacterial infection in patients with decompensated cirrhosis and ascites. Most organisms causing SBP are from intestinal microbial flora with Enterobacteriaceae and Escherichia coli being reported the most common organisms. However, studies of small series in recent years reported increasing frequency of SBP caused by Gram -positive bacteria in SBP. AIM: To evaluate microbial characteristics of ascitic fluid in cirrhotic patients with spontaneous bacterial peritonitis. METHODS: Medical records of 236 patients who underwent diagnostic paracentesis from July 1 2006 to July 1 2011 at Hershey Medical Center were reviewed. Pertinent data were collected and analyzed using SAS 1.1 software. RESULTS: One hundred ninety eight patients, age between 18-80 years old who had cirrhosis and ascites were included. The majority of the patients with end stage liver disease had either alcoholic liver disease or viral hepatitis or both. 145 (73.2%) were males and 53 (26.8 %) were females. Mean age was 54.8 years. Total 650 cultures were performed. 153 out of 650 cultures (23.5%) met criteria of spontaneous bacterial peritonitis based on absolute neutrophil count in ascitc fluid >250 cells/mm3. Bacteria grew in 86 cultures. 21 of the 86 cultures grew 2 or more micro-organisms, possible secondary to contamination, were excluded from this analysis. One culture grew candida. Fifty out of 64 (78.1%) cultures grew Gram-positive bacteria and 14/64 (21.9%) cultures grew Gram-negative bacteria. Most common organism isolated was coagulase negative Staphylococcus and the most common Gram-negative organism isolated was Klebsiella. Positive culture result of either Gram-positive or Gram-negative bacteria did not differ in age, MELD score, frequency of paracentesis, etiology of liver disease, or previous history of SBP. CONCLUSION: Our study shows increased frequency of Grampositive bacteria in patients with SBP which is a change in the pattern of SBP compared to current guideline. Larger prospective studies are needed to confirm this finding. The implication of such change is likely to modify treatment strategies particularly when empiric therapy is contemplated.

Prevalence & Prognosis Value of TET2 Gene Polymorphisms in Childhood Acute Myeloid Leukemia in Taiwan

Abstract 1551 Introduction:Acute myeloid leukemia (AML) is a phenotypically and genetically heterogeneous disease, accounts for 10% of childhood leukemia. The prognosis of children with AML has improved greatly over the past 30 years, and the Taiwan Pediatric Oncology group (TPOG) AML 97A and B protocols had been designed and explored in 1997 for the treatment of AML in Taiwan with complete remission (CR) and overall survival (OS) rates as high as 80–90% and 50–60%. In recent years, molecular research identified an increasing panel of genetic markers in AML, enhancing better risk stratification, modify treatment strategy and improving prognosis. The tet oncogene family member 2 (TET2) gene, a candidate tumor suppressor gene, and the mutations are found in adult AML with prevalence of around 10–20% and is associated to prognosis. However, the report in childhood AML is limited. Here, we assess the prevalence of TET2 gene alterations in childhood AML and to identify its association with prognosis. Method:We enrolled children who were diagnosed AML and visited national Taiwan university hospital between Jan, 1997 to June, 2010. The patients with APL (acute promyeloid leukemia) were excluded due to different treatment protocol. All the children were treated by TPOG AML 97 protocol. The induction therapy consist two courses of cytarabine (Ara-C) and idarubicin (IDR). Patients who achieved CR subsequently received four courses of consolidation therapy consisted of high-dose Ara-C and mitoxantrone or etoposide. The clinical characteristics, such as age, sex, laboratory data, cytogenetics information, relapse, survival time were all collected from TPOG database. DNA was isolated from bone marrow cells at diagnosis and sequence analysis was carried out for TET2 gene. The all data of eligible cases will be collected and analyzed for estimating EFS (event free survival), and OS (overall survival). Survival curves will be estimated by the Kaplan-Meier method. Comparisons were made by Chi-square test for binary variables and t test for continuous variables. For all analyses, the P-values were two-tailed, and a P < 0.05 was considered statistically significant. Results:Total of 56 pediatric AML patients were enrolled. The mean age is 9.07 ± 5.4 (0.01∼17.54) years. There are 34 (60.7%) males. Twenty-four (42.9%) patients had relapse and the overall survival rate is 44.6% (25/56). In this study, there was no nonsense or frameshift mutation, which is frequently identified in adult AML. Total 44 patients (78.6%) present TET2 SNP (single nucleotide polymorphism) and the details are listed in Table 1. There are 18 SNP, and 3 of them (rs72224084, rs58201766, rs59046770) are located in intron. Other 15 SNP are all located in exon. Most of them are located in exon 3 (27 events) and exon 11 (32 events). Only SNP rs3733609 is located in exon 9, and this is synonymous mutation. There are 9 SNP located in exon are not reported in reference yet. Among these, 4 SNP is synonymous mutation. All SNPs are heterozygous, except 4 SNP are homozygous, which are all SNP rs2454206 (I1762V). The clinical characteristics between patients with or without TET2 SNP, including sex, age, white count while diagnosis, chromosome abnormalities, death and relapse are not different between this 2 groups. Kaplan–Meier survival analysis is used to test the correlation between TET2 gene polymorphism to prognosis, including overall survival and event free survival. There was no difference.Table 1TET2 gene alterations in childhood AML. (n=56)RegiondbSNP rs# cluster idcDNA position & SNP alleleAmino acid position & protein residuePatient numberintronrs72224084-/AGATAGAT2rs58201766-/ATGATAGA25rs59046770-/TAGA12Exon 3rs12498609149 C→GP29R2rs6843141715 G→AV218M8983 T→CL307P11485 G→AP474P11889 C→GS609C12667 T→GF868L42503 C→TR814C1rs37969273180 G→AS1039S8rs1116786783179 C→TS1039L1Exon 9rs37336094193 T->CH1380H3Exon 114601 A→GE1513G2rs24542065347 A→GI1762V275502 A→GQ1813Q15387 G→AS1765N15657 C→GA1865G1 Conclusion:As we know, we are the first group to publish TET2 gene alterations in childhood AML in Asian. We conclude the prevalence of TET2 mutations in pediatric AML patients is far lower than in adults and the TET2 polymorphisms are not associated with prognosis. Disclosures:No relevant conflicts of interest to declare.

A unique case of a sarcoma arising in a testicular non-seminomatous mixed germ cell tumour with a predominant yolk sac component

We present a unique case of a sarcoma arising in a testicular non-seminomatous mixed germ cell tumour with a predominant yolk sac tumour (YST) component. This is the first case reported in which a sarcoma is linked to YST of the testis in a patient not having undergone prior chemotherapy. This finding confirms the ability of YST to contain sarcoma; it underlies its importance for urologists, oncologists and pathologists to be aware of this phenomenon and to modify treatment strategies appropriately.

Usefulness of 18-F FDG PET/CT in the pre-treatment evaluation of thymic epithelial neoplasms

Background To assess the usefulness of 18fluorine-fluorodeoxyglucose positron emission tomography/computed tomography ( 18F-FDG PET/CT) for differentiating the grade of malignancy of thymic epithelial neoplasm, and to determine whether 18F-FDG PET/CT can have a role in pretreatment evaluation and possibly modify treatment strategy. Materials and methods The data of 26 consecutive patients (14 males and 12 females) diagnosed with a thymic epithelial neoplasm were prospectively collected and analyzed retrospectively. All patients underwent standard clinical assessment and 18F-FDG PET/CT. The patients were divided into two subgroups according to a simplified histologic classification: low-risk thymoma (types A, AB and B1) and high-risk thymoma (types B2, B3 and C). The maximum standardized uptake value (SUV max) of the tumor, the mean SUV of mediastinum, and the tumor/mediastinum (T/M) ratio (ratio of peak SUV of the tumor to mean SUV of mediastinum) were compared to determine whether the two subgroups (low-risk versus high-risk tumors) could be distinguished by 18F-FDG PET/CT, and to test for possible correlations between 18F-FDG uptake and disease stage. Results There was a strong statistical correlation between SUV max and patient subgroup and between SUV max and disease stage, and an even stronger correlation between SUV max and patient subgroup and the T/M ratio; a T/M ratio of 2.75 emerged as the cut-off value for differentiating between low-risk and high-risk thymomas. Conclusions 18F-FDG PET/CT can be used a “metabolic biopsy” to divide thymic epithelial neoplasm into two subgroups of high and low risk and is useful in pretreatment staging.

Five Chinese Pediatric Patients with Leukemias Possibly Arising from Immature Natural Killer Cells: Clinical Features and Courses

Leukemias arising from immature nature killer (NK) cells have been proposed as distinct entities and are rare. Treatment and prognosis of these diseases are controversial, and data on children are limited. According to the literature, one of these distinct leukemias may be myeloid/NK cell precursor acute leukemia (MNKPL), with the blasts being cytochemically myeloperoxidase negative (MPO−) and phenotypically CD56+CD3−CD7+CD34+ and myeloid antigens+. The other may be myeloid/NK cell acute leukemia (MNKL), in which the blasts were cytochemically MPOdim and phenotypically CD56+CD16−CD3−CD33+HLA-DR−. Between 2005 and 2008, 4 MNKPL and 1 MNKL children aged 1.3 to 12.5 years were encountered in the First Affiliated Hospital of Sun Yat-Sen University. In those with MNKPL, remarkable extramedullary involvement usually occurring in adults was not observed; however, myelofibrosis was found in 2 children. The child with MNKL abandoned treatment. Those with MNKPL were treated with a protocol designed for childhood high-risk acute lymphoblastic leukemia (ALL) containing cytarabine, mitoxantrone, etoposide, l-asparaginase, and methotrexate according to the myeloid and lymphoid characteristics of MNKPL. They responded slowly to chemotherapy and were in complete remission (CR) for 26 to 63 months, except 1 who died in CR from pneumonia. They had longer survival and seemed to have a better outcome than those reported previously. In conclusion, childhood leukemias with immature NK cell markers may have different characteristics from their adult counterparts. A protocol including agents used for acute myeloid leukemia combined with those for ALL is seemingly effective for treatment of MNKPL. However, a modified treatment strategy designed more specifically for MNKPL and longer observations are needed.

Screening Tests for Renal Impairment in Patients with Type 2 Diabetes: The what, when, and how

The global course of obesity and diabetes presents an alarming forecast for the near future. As the prevalence rates continue to increase and the afflicted population grows younger in age, the associated complications of diabetes will come to pose a greater strain on patients, society, and national health care systems. In recent years, a number of studies have demonstrated the clinical benefits of strict diabetes control in the prevention of debilitating complications, including retinal, renal, and cardiovascular disease. These data highlight the need to maximize our efforts in diabetes prevention and early disease management. Renal dysfunction is a surrogate marker of diabetic microvascular disease, and thus early recognition of renal impairment in patients with diabetes provides an opportunity to modify treatment strategy and improve long-term disease outcomes. This review will summarize methods of assessing renal function and the most recent guidelines for the early screening and diagnosis of diabetic kidney disease.

Gene expression profiles as an additional tool to conventional predictive factors to assist in management of early endocrine responsive breast cancer

Cancer treatment has revolutionized from a “one size fits all” approach to a more individualized approach with the advancement of medicine and molecular biology. Several predictive and prognostic factors have been studied and applied to clinical practice to assist clinicians in cancer management. In breast cancer therapeutics, the appearance of biomarkers such as expressions of hormone receptor and human epidermal growth factor (HER) receptors has modified treatment strategies from chemotherapy to molecular-targeted therapy including endocrine therapy and anti-HER therapy. With better understanding of the molecular level of tumorigenesis, cancer pathogenesis and metastases, several novel biomarkers such as cyclo-oxygennase-2 enzyme and tyrosine kinases have been discovered and new anti-cancer agents have been introduced into the currently available treatments. The change has also modified pre-operative treatment for locally advanced and early breast cancers. The neo-adjuvant treatment indeed provides an excellent platform for translational research which is a widely used research method in clinical research. The study of gene and protein expressions from tissue and blood samples collected before, during and after neo-adjuvant treatment provides a lot of keys to decipher the signaling pathways and discover novel biomarkers which are essential for development of new drugs and prediction of the clinical outcome of therapy. The addition of gene expression profiling to conventional predictive factors will give more prognostic information to clinicians for better management of the disease.

Selective retina therapy (SRT) in patients with geographic atrophy due to age-related macular degeneration

For geographic atrophy (GA) due to age-related macular degeneration (AMD) there is so far no approved treatment option. Usually, increased autofluorescence (AF) levels of different patterns adjacent to the atrophic area indicate lipofuscin-laden retinal pigment epithelium (RPE) cells at a high risk for apoptosis. Herein, SRT was used to selectively treat these cells to stimulate RPE proliferation, in order to reduce or ideally stop further growth of the atrophic area. Six eyes of six patients with bilateral equally pronounced GA were treated by SRT, while the fellow eye served as control. Irradiation was performed using a prototype SRT laser (Medical Laser Center Lübeck, Nd:YLF laser; 527 nm; 200 ns/1.7 micros pulse duration; 30 repetitive pulses at 100 Hz). Test lesions with increasing energies were applied at the lower vessel arcade to determine the individual angiographic and ophthalmoscopic threshold radiant exposures. Treatment was then performed in the area of increased AF adjacent to the GA using energies between both thresholds. The GA progression rates of treated and fellow eyes were evaluated. After a 1-year follow-up, a progression of the atrophic area was observed in the treated eyes (0.7-8.0 mm(2)/yr, mean 3.0 mm(2)/yr; 46%/yr) whereas the progression rates of the fellow eyes were insignificantly lower (0.46-4.04 mm(2)/yr, mean 1.9 mm(2)/yr; 30%/yr; p = 0.134). The progression rate in the treated eyes of two patients increased significantly, while in the other four patients, the progression rates were nearly the same between both eyes. Moreover, one of these two eyes showed an unexpected RPE reaction after treatment, since all laser lesions led to RPE atrophy and thus an accelerated enlargement of the GA occurred. SRT in the hyperautofluorescent areas of GA was not able to stop or slow down the progression of GA. However, modified treatment strategies might be more promising, e.g. placing the spots outside the hyperautofluorescent areas where RPE apoptosis is postulated. Moreover, SRT studies on GA might be more successfully performed on specific subgroups of GA, based on autofluorescence and other findings.

Risk Factors for Regrowth of Intracranial Meningiomas after Gamma Knife Radiosurgery: Importance of the Histopathological Grade and MIB-1 Index

The influence of histopathological grade and MIB-1 index of intracranial meningioma on the results of its radiosurgical management is not clear. The objective of the present retrospective study was to make an evaluation of these factors along with an analysis of other variables associated with progression-free survival after gamma knife radiosurgery (GKR). Thirty-four intracranial meningiomas with known detailed histopathological diagnosis were analyzed. Tumors of WHO histopathological grades I, II, and III were diagnosed in 24, 3, and 7 cases, respectively. The median MIB-1 index was 1.3% (range: 0-31.9%). In 14 cases the MIB-1 index was 3.0% and more. In 26 cases the treatment was done at the time of tumor recurrence. Median volume of the neoplasm at the time of GKR was 4.1 mL (range: 0.4-43.1 mL). Median marginal dose was 12 Gy (range: 8-19 Gy). Median length of follow-up constituted 63 months (range: 19-132 months). Actuarial progression-free survival at 1, 3, 5, and 10 years constituted 100, 94, 83, and 58%, respectively. Histopathological grade II or III (p<0.0001), MIB-1 index 3% and more (p=0.0004), and non-skull base location (p=0.0026) of the tumor showed negative associations with progression-free survival in multivariate analyses. Actuarial progression-free survival at 5 years after GKR for benign and non-benign meningiomas constituted 100 and 45%, respectively (p<0.0001). Radiosurgery is a highly effective management option for benign intracranial meningiomas, but growth control of non-benign ones is significantly worse. It requires close neuroradiological follow-up and necessitates the search for modified treatment strategies.

P03-127 Factors involved in treatment adherence in psychosis: Importance of treatment effectiveness for the patients

Aims:Treatment adherence is crucial to the therapeutic success in psychiatric disorders. Evaluating factors involved in treatment adherence will allow to modify treatment strategies for greater compliance. the aim of the study was to evaluate factors involved in treatment adherence, including subjective patients’ satisfaction.Method:The study included in- and outpatients who met the criteria according to DSM-IV TR of schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, psychosis not otherwise specified, brief psychotic disorder and bipolar disorder. the following questionnaires were applied:1.Demographic and clinical questionnaire;2.Treatment Satisfaction Questionnaire for Medication Version II (TSQM vII);3.Medication Adherence Rating Scale (MARS);4.Schedule for Assessment of Insight (SAI);5.World Health Organization Quality of Life-BREF Scale (WHOQoL-BREF).TSQM vII is a self-reporting questionnaire to assess the major dimensions of patients’ satisfaction with their medication, includes 11 items that make up three specific scales (effectiveness, side-effects and convenience).Results:Twenty patients, between 18 and 65 years of age, were included. an interview was made and the 5 questionnaires were applied. the statistical analysis, using Regression Analysis Stepwise, showed a significant positive correlation between medication adherence, evaluated by MARS, and treatment effectiveness to the patients, evaluated by TSQMvII effectiveness scale (p=0.028). the correlations between the others parameters were not statistically significant.Conclusion:In this study the authors found that the self-experience of treatment effectiveness, which is a major dimension for treatment satisfaction, had a positive correlation with treatment adherence. Strategies to enhance subjective treatment effectiveness are needed to improve medication adherence.

Übertragungsfokussierte Psychotherapie für Jugendliche: Der vorläufige Stand

This article describes transference focused psychotherapy and its treatment strategies for the psychoanalytic treatment of severe personality disorders. The specific modifications proposed for the treatment of adolescent patients with this disorder are discussed. Elaborately, we dwell on the assessment phase for evaluating adolescents with the specific modifications regarding contract setting and inclusion of parents and caregivers in the beginning of und during psychotherapy. Besides the modified treatment strategies the interventions or "treatment tactics" and specific "treatment techniques" are recommended which are essential during the treatment of adolescents with severe personality disorders.

Review article: current antiviral therapy of chronic hepatitis B

The long-term goals of therapy for chronic hepatitis B are to reduce serum HBV DNA to low or undetectable levels and ultimately reduce or prevent the development of cirrhosis and hepatocellular carcinoma. To review the current treatment of chronic hepatitis B, with a focus on diagnosis and management of resistance and active management of suboptimal responses. A systematic review of the literature, with a focus on recent guidelines, was undertaken. Among the six drugs licensed for the treatment of chronic hepatitis B in the US, the preferred agents in 2008 will include entecavir, peginterferon alfa-2a, possibly telbivudine, and tenofovir following licensure. When using an oral agent, a major focus of management is on the selection of a drug with high potency and low rate of resistance, and active on-treatment management to optimize therapy. Preventing the sequelae of antiviral drug resistance and appropriate management when resistance is initially detected are also the major focus of current management. The addition of an antiviral agent that is not cross-resistant is critical to restore suppression of viral replication. Newer agents and modified treatment strategies, especially using combination therapy, hold promise to optimize the management of patients with chronic hepatitis B by achieving the high potency and the lowest rate of resistance.

L’hyperthermie est un facteur pronostique des coups de chaleur climatiques

Classic heatstroke that is, due to very hot weather, rare in Europe. Its clinical characteristics and course in temperate zones are not well known. The objective of this study was to assess the influence of initial fever on prognosis in heatstroke. All patients admitted through the emergency department from 8-13 August 2003 for heatstroke (defined by fever > or = 40 degrees C, with neurologic symptoms in the absence of sepsis) were included in the study. Patients' clinical and laboratory indicators were recorded at admission. Follow-up took place at D28 and 1 year. The influence of fever on survival was assessed with the Kaplan-Meier method. During the study period, 63 patients, aged 78+/-9 years, were admitted for heatstroke, with a SAPS II (Simplified Acute Physiology Score) of 61+/-24. Core body temperature was 41.4+/-1.2 degrees C. Mortality was 59% at D28 and 67% at 1 year. Prognosis was influenced from admission by temperature, with a higher probability of survival for patients with temperature < 41 degrees C, compared with those whose temperature > or = 41 degrees C (log-rank test: p<0.001). Prognosis is poor for classic heatstroke. Rapid temperature reduction, especially when it exceeds > 41 degrees C, must be considered a priority. Fever > or = 41 degrees C at admission for heatstroke is a poor prognostic factor that is simple to identify and may modify treatment strategies in the future.

Gender Medizin in der Onkologie

The whole field of Oncology benefits from the huge amount of basic science "invested" and from the experience accumulated during several decades that enables more patients with malignant diseases to be cured or to survive for longer periods. Incidence and mortality rates from cancer have been decreasing by around 1 % per year since the mid-nineties of the past century in the European Union. However, the spectrum of malignant diseases and the outcome is not equally distributed between the two sexes. Startlingly, in advanced cancers, women receiving the same treatment schemes as men fare better. Until recently, however, the pharmacological knowledge of the pharmacokinetic and pharmacodynamic action of cytotoxic drugs was scarce for women, as like in other fields of medicine, studies recruited far more men than women and because results were often not reported separately for both sexes. These practices are slowly changing and gender specific outcome data are progressively accumulating. Such data on gender-specific differences or similarities are essential for building newer, more adequate tools for dosing drugs than the current form based on a "falsely accurate and individualzed" estimation of the body surface area. Nevertheless, the socioeconomical and sociocultural context of living remains genderspecifically different, influencing the coping of individuals with a life-threatening disease. On the other hand, as recently shown for chronic lymphocytic leukaemia, gender-specific analysis might open new insights in the biology of the disease and modify treatment strategies.

Dropouts versus completers among chronically depressed outpatients

Background Premature termination is common among patients treated for depression with either pharmacotherapy or psychotherapy. Yet little is known about factors associated with premature treatment termination among depressed patients. Methods This study examines predictors of, time to, and reasons for dropout from the 12-week acute phase treatment of nonpsychotic adult outpatients, age 18–75, with chronic major depression who were randomly assigned to nefazadone alone (MED), cognitive behavioral analysis system of psychotherapy alone (CBASP) or both treatments (COMB). Results Of 681 randomized study participants, 156 were defined as dropouts. Dropout rates were equivalent across the three treatments. Among dropouts, those in COMB remained in treatment (Mean = 40 days) significantly longer than those in either MED (Mean = 27 days) or CBASP (Mean = 28 days). Dropouts attributed to medication side-effects were significantly lower in COMB than in MED, suggesting that the relationship with the psychotherapist may increase patient willingness to tolerate side-effects associated with antidepressant medications. Ethnic or racial minority status, younger age, lower income, and co-morbid anxiety disorders significantly predicted dropout in the full sample. Within treatments, differences between completers and dropouts in minority status and the prevalence of anxiety disorders were most pronounced in MED. Among those receiving CBASP, dropouts had significantly lower therapeutic alliance scores than completers. Limitations The sample included only individuals with chronic depression. Conclusions Predictors of dropout included baseline patient characteristics, but not early response to treatment. Ethnic and racial minorities and those with comorbid anxiety are at higher risk of premature termination, particularly in pharmacotherapy, and may require modified treatment strategies.

Syndrome d’hypersensibilité médicamenteuse associé à une primo-infection HHV6

Drug hypersensitivity syndrome is a severe life-threatening drug reaction. An association between this syndrome and HHV6 reactivation has been hypothesized.A 45 year-old women was treated with sulfasalazine for polyarthralgia. One month after beginning the treatment, she developed a drug hypersensitivity syndrome with severe acute hepatic failure. HHV6 serology and serum PCR revealed a primary HHV6 infection.We report the second case of drug hypersensitivity syndrome associated with a primary HHV6 infection. An immunological disorder may explain such an association by increasing viral replication. Detection and titration of anti-HHV6 antibodies in each case of drug hypersensitivity syndrome should help to confirm this association and possibly modify treatment strategy.