Existential behavioural therapy for informal caregivers of palliative patients: a randomised controlled trial.

BACKGROUND: Existential behavioural therapy (EBT) was developed to support informal caregivers of palliative patients in the last stage of life and during bereavement as a manualised group psychotherapy comprising six sessions. We tested the effectiveness of EBT on mental stress and quality of life (QOL). METHODS: Informal caregivers were randomly assigned (1:1) to EBT or a treatment-as-usual control group using computer-generated numbers in blocks of 10. Primary outcomes were assessed with the Brief Symptom Inventory (subscales somatisation, anxiety and depression), the Satisfaction with Life Scale (SWLS), the WHOQOL-BREF and a numeric rating scale for QOL (QOL-NRS, range 0-10). Data were collected at baseline, pre-treatment, post-treatment and follow-ups after 3 and 12 months. Treatment effects were assessed with a multivariate analysis of covariance. RESULTS: Out of 160 relatives, 81 were assigned to EBT and 79 to the control group. Participants were 54.5 ± 13.2 years old; 69.9% were female. The multivariate model was significant for the pre-/post-comparison (p=0.005) and the pre-/12-month comparison (p=0.05) but not for the pre-/3-month comparison. Medium to large effects on anxiety and QOL (SWLS, WHOQOL-BREF, QOL-NRS) were found at post-treatment; medium effects on depression and QOL (QOL-NRS) emerged in the 12-month follow-up. No adverse effects of the intervention were observed. CONCLUSION: Existential behavioural therapy appears to exert beneficial effects on distress and QOL of informal caregivers of palliative patients. Further longitudinal evidence is needed to confirm these findings.

Liquid compressibility effects during the collapse of a single cavitating bubble.

The effect of liquid compressibility on the dynamics of a single, spherical cavitating bubble is studied. While it is known that compressibility damps the amplitude of bubble rebounds, the extent to which this effect is accurately captured by weakly compressible versions of the Rayleigh-Plesset equation is unclear. To clarify this issue, partial differential equations governing conservation of mass, momentum, and energy are numerically solved both inside the bubble and in the surrounding compressible liquid. Radiated pressure waves originating at the unsteady bubble interface are directly captured. Results obtained with Rayleigh-Plesset type equations accounting for compressibility effects, proposed by Keller and Miksis [J. Acoust. Soc. Am. 68, 628-633 (1980)], Gilmore, and Tomita and Shima [Bull. JSME 20, 1453-1460 (1977)], are compared with those resulting from the full model. For strong collapses, the solution of the latter reveals that an important part of the energy concentrated during the collapse is used to generate an outgoing pressure wave. For the examples considered in this research, peak pressures are larger than those predicted by Rayleigh-Plesset type equations, whereas the amplitudes of the rebounds are smaller.

Long-Term Impact of Toxoplasma gondii Infection on Human Monocytes.

Toxoplasma gondii is a prevalent parasite of mammals and birds including up to 30% of humans world-wide. Primary infection of immunocompetent hosts leads to a robust cell-mediated immune response, which controls but does not clear the infection, thus enabling long-term parasite persistence in brain and muscle tissues. Chronic toxoplasmosis in mice is associated with resistance to heterologous pathogens and this has been related to increased numbers of inflammatory monocytes. Here we have analyzed whether chronic T. gondii infection impacts the subset distribution and the phenotype of peripheral human monocytes in vivo and their responses to parasite infection in vitro. CD14+ monocytes from T. gondii-seropositive blood donors expressed significantly less FcγRIII (CD16) than those from seronegative controls, but they did not show a shift in the distribution of classical, intermediate and non-classical monocyte subpopulations. Percentages of CD62L+ and CD64+ monocytes were however decreased and increased, respectively, in chronically infected individuals as compared to naïve controls. Infection of monocyte-enriched PBMCs from both seropositive and seronegative individuals with T. gondii led to an increase of CD14+CD16- classical monocytes and a decrease of CD14+CD16+ double positive monocytes. Remarkably, after in vitro parasite infection, expression of the chemokine receptor CCR2 was severely impaired in monocytes from both, individuals with chronic toxoplasmosis and seronegative controls. In contrast, only monocytes from chronically infected humans but not those from controls dose-dependently up-regulated HLA-DR, DP, DQ expression following in vitro infection. Furthermore, monocyte-enriched PBMCs from seropositive individuals up-regulated IL-12 mRNA more vigorously after in vitro infection than cells from naïve controls. Collectively, our results establish that infection of humans with T. gondii exerts long-term effects on the phenotype and responsiveness of blood monocytes. This may have important implications for innate immune responses to T. gondii and unrelated pathogens.

Predominant immunoglobulin gene rearrangements in two patients with immunodeficiency: restricted use of V gene segments and DNA hypermethylation.

The majority of common variable immunodeficiencies (CVID) is caused by intrinsic B cell defects which impede distinct stages of B cell differentiation. B cell differentiation is accompanied by the rearrangement of immunoglobulin (Ig) genes. The first step in the rearrangement process is the assembly of IgH genes, and subsequently, IgL genes are rearranged. During B cell maturation, Ig genes are demethylated in a stepwise, locus-specific manner. Here, we examined the Ig gene rearrangements of four patients with classical CVID and of one child suffering from an unusual immunodeficiency associated with CD5+ B cell lymphocytosis. In one of the four adult patients with CVID, we observed a predominant type of VHDJH-gene rearrangement. In the child, different polyclonal VHDJH-gene rearrangements were found together with a predominant type of kappa light chain gene rearrangement. The rearranged kappa chain genes were methylated (as in the pre-B cell stage). These findings together with the cell phenotype analysis and the clinical course of the disease in the child suggests that in some patients with primary immunodeficiency a maturation arrest may occur in B cells leading to a predominant Ig V gene rearrangement.

Quantitative analysis of CCR5 chemokine receptor and cytochrome P450 aromatase transcripts in swim-up spermatozoa isolated from fertile and infertile men.

We determined the CCR5 chemokine receptor and cytochrome P450 aromatase (P450arom) transcript copies number in swim-up sperm isolated from fertile and infertile men. The ejaculates were purified by centrifugation through discontinuous Percoll density gradient and swim-up techniques. RNA was isolated from sperm, treated with DNase I and reverse-transcribed into cDNA. Quantitative analysis of CCR5 and P450arom cDNA were performed by real-time quantitative (RQ-PCR) SYBR Green I analysis. There was a higher content of CCR5 and P450arom transcripts copy number in swim-up sperm of fertile than from infertile donors. The decrease in CCR5 and P450arom transcripts in swim-up sperm may be associated with male infertility.

Effect of sperm subpopulation's kinetics on human fertilization in vitro.

The present study was carried out to investigate the relationship between sperm subpopulation kinetics on in vitro fertilization rate. The ability of human sperm to achieve fertilization oocytes was investigated in relation to particular motility parameters obtained on a computer aided sperm analysis system base. Analysis covers velocity straight linear (VSL), cross beat frequency (CBF), lateral head displacement (LHD) and homogeneity of progressive motility velocity (HPMV) of fresh semen and semen after density gradient selection. Investigation was based on sperm samples from 82 infertile couples undergoing IVF. Two subpopulations were extracted from each sample using the clustering method with respect to VSL parameter: a slow and rapid one. Comparison of obtained results before and after selection shows no significant change of subpopulations percentage. However, this method of selection strongly influences motility parameters of both subpopulations. There was found a positive correlation for VSL, LHD and HPMV and a negative correlation for CBF parameters found in slow fraction of fresh semen and percentage of fertilized oocytes. On the other hand, rapid subpopulation parameters for fresh semen and parameters found for both subpopulations in semen after selection did not correlate with one. This means that information of slow sperm subpopulation kinetics carries important prognostic value of IVF success. Since the current prognosis factors ignore motility parameters of slow sperms, our results show the importance of such an analysis.

Predictive value of selected sperm parameters for classical in vitro fertilization procedure of oocyte fertilization.

A proportion of fertilized oocytes during classical in vitro fertilization (IVF) procedure was analysed depending on the following factors: number of mature oocytes, seminological criteria such as sperm morphology in raw semen and after its selection in a density gradient (six structural defects of a male gamete were taken into consideration), sperm concentration, motility parameters according to World Health Organization criteria and the functional tests: hypo-osmotic swelling assay and acrosomal reaction induced by calcium ionophore. Evaluation of DNA content in sperm by image cytometry and determination of malonyldialdehydes in seminal plasma were also performed. Seventy-nine semen samples from patients undergoing IVF were assessed. Apart from significant correlations obtained for selected semen parameters and proportion of fertilized eggs, logistic regression analysis showed that the best predictive factors for oocyte fertilization were normal morphology of sperm before and after gradient selection, grade B and C of sperm movement in raw semen, and DNA content after density gradient centrifugation, which all accounted for 76.7% of fertilization predictive value.

[Detection of antibodies to extractable nuclear antigens with counterimmunoelectrophoresis and the Western blot technic]. / Nachweis von Antikörpern gegen extrahierbare nukleäre Antigene (ENA) mit Uberwanderungselektrophorese (CIE) und Western-Blot.

Detection of antibodies against extractable nuclear antigens (ENA) by counter immunoelectrophoresis (CIE) is currently used to screen sera from patients with collagen vascular disease. Although fast and reliable, the method has its limitations with regard to the differentiation of various antigen-antibody systems. In this study, results of the anti-ENA analysis by CIE and by Western-Blot technique are compared. Except for a higher frequency of Sm antibodies by Western-blot, the results of CIE were confirmed. The source of antigen and the higher sensitivity of the Western-Blot technique are responsible for the different results obtained. With respect to the relationship of antibody profile and illness, both methods demonstrated a high frequency of antibodies against U1-sn-RNP in mixed connective tissue disease and of anti-SS-B antibodies in Sjögren's syndrome.

Plasmablastic immunoglobulin-secreting lymphoma. Report of a case and a glimpse at the prognosis.

The case of a 57-year-old patient with a plasmablastic lymphoma is described. The primary diagnosis was an ordinary plasmacytoma, type IgG kappa. The final course of the disease involved almost all of the organs. The clinical aspect was determined by multiple skin infiltrations. The present report has in common with other published cases the fact that multiple secondary skin involvement of immunoglobulin-secreting tumors, regardless of their origin, have a very poor prognosis. In comparison, primary multiple cutaneous immunoglobulin-secreting tumors have a better prognosis.

Reticulocytopenia in severe autoimmune hemolytic anemia (AIHA) of the warm antibody type.

A patient with severe AIHA of the warm antibody type, absence of reticulocytes and red cell hyperplasia of the bone marrow is described. In order to maintain a reasonable hemoglobin level 38 units of washed packed red cells were required within 24 days. The treatment with high doses of steroids showed no permanent beneficial effect. After splenectomy the red cell destruction was immediately reduced and the patient went into a remission. Bone marrow culture studies during the acute phase of the disease and at the time of complete hemato- and immunological remission, i.e. 4 months after splenectomy suggested a circulating autoantibody directed to early erythroid progenitors (BFU-E). The inhibitory activity in the patient's plasma did not influence granulocytic or mixed colony formation (CFU-GEMM). In addition to autoantibodies directed to erythroblasts and erythropoietin involved in the pathogenic mechanisms leading to red cell aplasia type I and II the culture studies suggest an unusual autoantibody that might cause the observed reticulocytopenia and erythropoietic hyperplasia of the bone marrow in AIHA. After the splenectomy the patient recovered, he required no further blood transfusions and his disease has not recurred.

[Gamma-1 heavy chain disease with the demonstration of Bence-Jones proteins]. / Gamma-1-Schwerkettenkrankheit mit Nachweis von Bence-Jones-Proteinen.

We describe a 61-year-old patient suffering from gamma-1-heavy-chain disease (gamma 1-HCD) associated with Bence-Jones-lambda proteinemia and proteinuria. The analysis of the patients gamma 1-HCD protein (WIN) shows a deletion of the complete Fd fragment. The N-terminal seven amino-acid residue does not resemble any of the known immunoglobulin-heavy-chain variable regions. Unexpectedly, in PBL-DNA and in DNA from EBV-immortalized cells we found in addition to the expected predominantly rearranged Ig-lambda-light-chain gene a predominant rearrangement of an Ig-kappa gene. These findings show that the gamma-1-heavy-chain disease of the patient involves a defective regulation of Ig-light-chain-gene activation as well.

[Unusual rearrangements of immunoglobulin genes in a patient with IgD/lambda plasmacytoma]. / Ungewöhnliche Immunglobulin-Gen-Rearrangements bei einem Patienten mit IgD/lambda-Plasmozytom.

The mechanisms of Ig gene expression in B-lymphocytes are not yet fully understood. A hierarchy of Ig gene rearrangements has been suggested starting with Ig heavy chain genes followed by kappa and lambda light chain genes. According to this principle, B-cells with productive lambda light chain expression have their kappa genes either unproductively rearranged or deleted. By examining B-cells from patients with various lymphoproliferative diseases the developmental hierarchy of the Ig gene rearrangements could be confirmed with one notable exception: in a patient with IgD/lambda-plasmocytoma we found the kappa genes in germ line configuration. This finding points to an aberrant light chain gene expression in IgD-producing plasma cells.

IgD/lambda plasmocytoma with immunoglobulin kappa light-chain genes in the germ-line configuration.

Human immunoglobulin (Ig) genes are rearranged in an ordered sequence of events during B-cell differentiation: starting at the IgH locus, a productive VHDJH rearrangement leads to the expression of mu chains. Light-chain gene rearrangements have been found in pre-B cells which express mu chains. In these cells rearrangements of Ig kappa light-chain genes precede that of lambda genes. In an IgD/lambda-producing plasmocytoma, however, we found an apparent exception to this rule: the kappa genes were not rearranged. Together with the observation that roughly 90% of human IgD plasmocytomas produce lambda light-chain proteins, the finding reported here leads us to suggest that lambda light-chain genes are rearranged preferentially in IgD-producing plasma cells. Ig gene rearrangement, isotype switch, and the phenomenon of isotypic and allelic exclusion are discussed with special reference to our findings.

Unusual sequence of immunoglobulin L-chain rearrangements in a gamma heavy chain disease patient.

Patients with gamma heavy chain disease (gamma-HCD) generally produce incomplete immunoglobulin (Ig) gamma-heavy chains (gamma-HCD protein) which cannot associate with light chains (IgL). In most patients Bence Jones proteins (BJP) are not observed. However, in the 61-year-old patient WIN we found gamma l-HCD proteins and lambda BJP in serum and urine. WIN gamma l-HCD protein does not carry the Ig Fd region, has a molecular weight of 33.5 kDa, and the seven N-terminal amino acid residues are not translated from any of the known immunoglobulin heavy chain (IgH) gene sequences. These residues are followed by the C gamma l-hinge region. In DNA from peripheral blood lymphocytes of patient WIN we found bands representing dominant rearrangements in one of the two alleles of the IgH, Ig kappa and Ig lambda locus. Taken together, the data from protein and DNA analysis strongly suggest, albeit do not formally prove, that one dominant B-cell clone which carries a rearranged and a non-rearranged allele of each Ig locus produces gamma-HCD protein and lambda BJP. The productive lambda-gene rearrangement in this clone thus has not been preceded by abortive rearrangements in both kappa-locus alleles. Lymphocytes with an unusual sequence of IgL-chain gene activation seem to be involved in the case of gamma-HCD described here.

[Immunoglobulin and T-cell receptor gene rearrangements in patients with autoimmune diseases]. / Immunglobulin- und T-Zellrezeptor-Genrearrangements bei Patienten mit Autoimmunkrankheiten.

Immunoglobulin-(Ig-) and T-cell-receptor-(TcR-)gene rearrangements were investigated in peripheral blood lymphocytes (PBL) of patients with various autoimmune disorders. In patients with SLE there was no predominant Ig- or TcR-gene rearrangement. This was also true in patients with a long disease duration and with excessive hypergammaglobulinemia. These results lead us to suggest that B cells are activated polyclonally in these patients. In those cases, where predominantly rearranged Ig- or TcR-genes were found, the autoimmune disorder was associated with a low-grade non-Hodgkin lymphoma (NHL). This coherence of B-cell malignancy and autoimmunity was only found in patients with cryoglobulinemia (KG), cold agglutinin disease (KA), and hemolytic anemia (AIHA).

[Unusual immunoglobulin gene rearrangements in patients with immunodeficiency]. / Ungewöhnliche Immunglobulin-Gen-Rearrangements bei Patienten mit Immundefekt.

In a 64-year-old patient with typical common variable immunodeficiency (CVID) DNA prepared from peripheral blood lymphocytes (PBL) showed a prominent immunoglobulin heavy chain (IgH) gene rearrangement; the immunoglobulin light chain (IgL) genes were found to be in the germline configuration. In contrast, a 13-year-old girl with a hitherto unidentified immunodeficiency showed polyclonal IgH gene rearrangements and a dominant IgL gene rearrangement. In both cases neither monoclonal B-lymphocytes nor monoclonal immunoglobulins were detectable. Our explanation for this unusual observation is that V-gene use in a given B-cell is not entirely random. This may be the consequence of a maturation arrest of B-cells.

[In vitro and in vivo studies with interleukin 2 (IL-2) and various immunostimulants in a patient with AIDS]. / In-vitro- und In-vivo-Studien mit Interleukin-2 (IL-2) und verschiedenen Immunstimulanzien bei einer Patientin mit AIDS.

We report on a lethal course of an acquired immunodeficiency syndrome (AIDS) in a young female patient. She had spent her vacancies six years before diagnosis in Haiti, where a sexual intercourse with a Haitian man had occurred. Leading clinical symptoms consisted of recurrent Herpes simplex infections of the genital and perianal region as well as unexplained high temperatures. There were some typical laboratory and immunologic features of this disease with leukopenia, hypergammaglobulinemia, cutaneous anergy, a reduction of peripheral T-lymphocytes (OKT 3) and an almost complete loss of OKT 4 (helper cells) positive lymphocytes. The mitogenic response upon stimulation with allogeneic cells (MLC) or with the mitogens PHA, Con A and PWM was significantly reduced. There was no measurable interleukin-2 (IL-2) secretion of peripheral blood lymphocytes. Several immunostimulators (thymopentin, inosiplex, bestatin) were tested in lymphocyte proliferation assays in vitro. The mitogenic response could not be enhanced by neither of these substances. A clinical trial with Delimmun (inosiplex) for 14 days did not show any clinical or immunologic improvement in this patient. The intravenous application of high dose immunoglobulin G was without any observable effect. The proliferation inducing capacity of a highly purified IL-2 preparation on the AIDS cells in vitro led us to a clinical trial with this substance. We applied 100 Bödeker units of IL-2 per kg body weight and day subcutaneously for 16 days. A therapeutical effect, however, could not be observed. Cell marker analyses did not show significant changes in lymphocyte subpopulation composition under IL-2 therapy. There was an increase in the spontaneous cell proliferation 14 days after start of IL-2 therapy. The PHA- and IL-2 response of the AIDS cells, however, was unchanged. It cannot be excluded that an administration of IL-2 in earlier stages of AIDS may have beneficial effects.