[Shortened Treatment Concepts in Forensic Commitment According to Section 64 of the German Penal Code: A Tailored Treatment Pathway?] / Verkürzte Therapiekonzepte im Maßregelvollzug gemäß §64 StGB: Ein maßgeschneiderter Behandlungspfad?

Die forensische Therapie gemäß §64 StGB zeichnet sich aktuell durch hohe Abbruch- bzw. Erledigungsquoten aus. Das hier vorgestellte verkürzte Therapiekonzept der Klinik für Forensische Psychiatrie des Pfalzklinikums für Patienten mit günstigen Prognosemerkmalen soll durch Förderung von Eigeninitiative, Verantwortung und Motivation sowie eine möglichst individualisierte, störungsorientierte, strafzeit- und tatangemessene Behandlung mit intensiver Erprobung unter Alltagsbedingungen zu einer Verkürzung der stationären Unterbringung führen. Empirische Belege hierfür fehlen jedoch bislang. Erstmals werden hier Pilotdaten aus dem Zeitraum April 2016 bis Mai 2021 vorgestellt. Zusammenfassend hat sich das o.g. Konzept als umsetzbar erwiesen. Die erhobenen Daten weisen darauf hin, dass die im verkürzten Therapieprogramm behandelten Patienten eine geringere Erledigungsquote als der Durchschnitt aller gemäß §64 StGB untergebrachter Patienten aufweist. Eine deutliche Verkürzung der durchschnittlichen Behandlungsdauer ließ sich demgegenüber jedoch nicht belegen. Die vorliegende Arbeit will einen ersten Beitrag zur Diskussion und Weiterentwicklung derartiger Behandlungsoptionen leisten. Mögliche Nachteile derartiger Therapieangebote bei für ungeeignet befundenen Patienten, z. B. eine Abnahme der Therapiemotivation, werden diskutiert.Forensic therapy according to section 64 of the German penal code is currently characterized by high drop-out rates. The shortened therapy concept of the Department of Forensic Psychiatry of the Pfalzklinikum focusing on patients with favorable prognostic characteristics presented here is intended to lead to a shortening of hospital stay by promoting initiative, responsibility and motivation. It is supposed to provide a treatment as individualized and disorder-oriented as possible and appropriate to the individual time of detention as well as the specific kind of offense with intensified testing under everyday conditions. However, so far empirical evidence for this concept is lacking. For the first time, pilot data for the period from April 2016 to May 2021 are presented here. The concept described herein has proven to be feasible. The collected data hint at a lower drop-out rate of patients treated according the shortened therapy concept compared to the average of all patients assigned to forensic treatment according to section 64 of the German penal code. Yet, there was no evidence for a significant shortening of hospital stay. The present work aims at making a first contribution to the discussion and further development of such treatment options. Possible disadvantages for patients who are found to be unsuitable, e. g. those with a decrease in therapeutic motivation, are discussed.

Oxidation of cofilin mediates T cell hyporesponsiveness under oxidative stress conditions.

Oxidative stress leads to impaired T cell activation. A central integrator of T cell activation is the actin-remodelling protein cofilin. Cofilin is activated through dephosphorylation at Ser3. Activated cofilin enables actin dynamics through severing and depolymerization of F-actin. Binding of cofilin to actin is required for formation of the immune synapse and T cell activation. Here, we showed that oxidatively stressed human T cells were impaired in chemotaxis- and costimulation-induced F-actin modulation. Although cofilin was dephosphorylated, steady-state F-actin levels increased under oxidative stress conditions. Mass spectrometry revealed that cofilin itself was a target for oxidation. Cofilin oxidation induced formation of an intramolecular disulfide bridge and loss of its Ser3 phosphorylation. Importantly, dephosphorylated oxidized cofilin, although still able to bind to F-actin, did not mediate F-actin depolymerization. Impairing actin dynamics through oxidation of cofilin provides a molecular explanation for the T cell hyporesponsiveness caused by oxidative stress.

Costimulation induced phosphorylation of L-plastin facilitates surface transport of the T cell activation molecules CD69 and CD25.

Rearrangements in the actin cytoskeleton play a pivotal role for costimulation-induced formation of the immunological synapse and T cell activation. Yet, little is known about the actin-binding proteins that link costimulation to rearrangements in the actin cytoskeleton. Here we demonstrate that phosphorylation of the actin bundling protein L-plastin in response to costimulation through TCR/CD3 plus CD2 or CD28, respectively, is important for the activation of human peripheral blood T lymphocytes (PBT). Mass spectrometry and site-directed mutagenesis revealed that Ser5 represents the only phospho-acceptor site of L-plastin in PBT. Wild-type L-plastin (wt-LPL) and a non-phosphorylatable 5A-L-plastin (5A-LPL) equally relocalized to the immunological synapse between PBT and APC. Yet importantly, cells expressing 5A-LPL showed a significantly lower expression of the T cell activation molecules CD25 and CD69 on the cell surface than cells expressing wt-LPL. This effect is due to a failure in the transport of CD25 and CD69 to the cell surface since the total amount of these proteins within the cells remained unchanged. In conclusion, phosphorylation of the actin bundling protein L-plastin represents a so-far-unknown mechanism by which costimulation controls the transport of activation receptors to the T cell surface.

Diagnosis-related frequency of compulsory measures in 10 German psychiatric hospitals and correlates with hospital characteristics.

OBJECTIVE: To investigate the incidence of coercive measures in standard psychiatric care in different psychiatric hospitals. METHODS: We developed a common documentation of mechanical restraint, seclusion, and medication by coercion, and introduced it in 10 participating hospitals. We developed software able to process the data and to calculate four key indicators for routine clinical use. RESULTS: 9.5% of 36,690 cases treated in 2004 were exposed to coercive measures with the highest percentage among patients with organic psychiatric disorders (ICD-10 F0) (28.0%). Coercive measures were applied a mean 5.4 times per case and lasted a mean 9.7 h each. The incidence and duration of coercive measures varied highly between different diagnostic groups and different hospitals. Use of detailed guidelines for seclusion and restraint was associated with a lower incidence of coercive measures. DISCUSSION: Data interpretation should consider numerous confounding factors such as case mix and hospital characteristics. Suggestions on how to cope with ethical and technical problems in the processing of large multi-site data sets in routine clinical use are made.

[Incidence of coercive measures as an indicator of quality in psychiatric hospitals. Problems of data recording and processing, preliminary results of a benchmarking study]. / Die Inzidenz von Zwangsmassnahmen als Qualitätsindikator in psychiatrischen Kliniken. Probleme der Datenerfassung und -verarbeitung und erste Ergebnisse.

OBJECTIVE: The clinical practice concerning the use of coercive measures in psychiatry should be compared. METHOD: A common documentation of physical restraint, seclusion, and medication by coercion was introduced among 10 hospitals. RESULTS: 8.4 % of cases treated within the first 6 months of 2004 were exposed to coercive measures with the highest percentage among patients with psychoorganic disorders (32.1 %). The incidence of coercive measures varied highly between different diagnostic groups and hospitals. DISCUSSION: The processing of the large multi-site data sets yields considerable technical problems. Data interpretation should consider confounding factors such as case mix and hospital structure characteristics.