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.

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.

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.

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.

HCV transmission through blood transfusion: are HCV-RNA titer in donor serum and genotype major determinants of infection outcome?

In this paper we report the results of a retrospective investigation on anti-HCV supplemental test positive blood donors from 1993 and 1994. 22 living recipients of blood/blood components from 15 donors were localized and enrolled in the study. Serum from these individuals were tested by serological assays and RT/PCR. HCV-RNA titer was determined for all positive donors. Genotyping was performed for all HCV-RNA positive individuals (donors and recipients). We observed that less than 50% of the recipients of previous donations from those positive donors did develop serological markers of HCV infection. HCV-RNA titers in donor's serum varied from 2 x 10(3) to 5 x 10(5) copies/ml but a direct correlation between viral RNA titer and the outcome of infection could not be established. Genotype investigation revealed 100% identity of genotypes within the pairs of donors/recipients. Genotype 1 b reached a prevalence of 75% within this group.

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.

Predictable exodontia in general practice.

Exodontia that is carefully and skillfully done by general dentists is a valuable service to patients. The majority of patients would rather have their family dentist perform necessary extractions or other minor surgery procedures than be referred outside the office. Most teeth that need to be extracted could be removed by a generalist if that person has developed the expertise to do not only relatively easy extractions, but also that percentage that is inevitably more difficult--requiring "surgical" removal. To be successful with exodontia, the dentist must have the ability to select cases within his or her level of comfort and ability, have a working knowledge of sound surgical principles, be able to apply a variety of patient management techniques, and then be prepared to handle whatever complications may arise. This article has presented ideas that should be integrated into the operator's own systematic approach to extractions. It is one of many resources to help the general dentist provide a higher level of surgical treatment.

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.