Ontogeny of the Therapeutic Alliance in Borderline Patients

The development of the therapeutic alliance is explored in a prospective study of 33 borderline personality disorder patients. Assessments of the alliance were made by both the patients and their therapists using the Penn Helping Alliance Questionnaire at six weeks, six months, and then annually for up to five years.The major findings were: (1) The alliance was rated highly by both patients and therapists throughout treatment; (2) the alliance showed steady and significant improvement over time (and no significant deterioration at any point); (3) patients and therapists corresponded closely in their assessments; (4) therapists rated the alliance higher than did patients at three and four years; (5) therapist ratings of the alliance at six weeks was predictive of subsequent dropping out; but (6) early alliance scores were not strongly related to subsequent level of change. These results frame issues for future research in this area.Die Entwicklung der therapeutischen Allianz wurde in einer prospektiven Studie bei 33 Patienten mit Borderline-Persönlichkeitsstörungen überprüft. Die Einschätzungen der Allianz wurden sowohl von den Patienten als auch von ihren Therapeuten mit Hilfe des Penn Helping Alliance Fragbogens nach sechs Wochen, sechs Monaten und dann jährlich über den Zeitraum von fünf Jahren vorgenommen.Die Ergebnisse der Studie sind: 1) Die Allianz wurde sowohl von den Patienten als auch von den Therapeuten über die gesamte Behandlung hinweg hoch eingeschätzt; 2) Die Allianz verbesserte sich stetig und signifikant innerhalb des Behandlung-szeitrwams und wies keine signifkante Verschlechterung an irgendeiner Stelle des Prozesses auf; 3) Patienten und Therapeuten stimmten in ihren Einschätzungen weitgehend überein; 4) Therapeuten schätzten die Allianz im dritten und vierten Jahr höher ein als die Patienten; 5) Die Einschätzung der therapeutischen Allianz nach sechs Wochen durch den Therapeuten kann spétere Therapieabbrüche vorhersagen, aber 6) die frühen Allianzwerte waren nicht sehr ausgeprägt bezogen auf spätere Veränderungswerte. Die Ergebnisse stecken den Rahmen für zukünftige Studien in diesem Bereich ab.Le développement de l'alliance thérapeutique est exploré dans une étude prospective sur 33 patients avec trouble de la personnalité borderline. Des évaluations de l'alliance ont été faites par les patients et leur thérapeute à l'aide du Questionnaire Penn Helping Alliance, à six semaines, six mois et ensuite annuellement pendant cinq ans.Les découvertes majeures ont été: 1) L'alliance a été à évaluée ‘forte’ à la fois par les patients et les thérapeutes pendant le traitement; 2) L'alliance a montré une amélioration stable et significative à travers le temps (et à aucun moment il n'y a eu de détérioration significative); 3) Les évaluations des patients et des thérapeutes correspondaient fortement; 4) Les thérapeutes ont évalués l'alliance plus forte que l'ont fait les patients aprés trois et quat ans; 5) Les évaluations de l'alliance par les thérapeutes étaient prédictives d'un subséquent désistement; mais 6) Les scores de l'alliance précoce n'étaient pas fortement liés à un subséquent niveau de changement. Ces résultats formulent des points intéressants de discussion pour de futures recherches dans ce domaine.     

Disinfection of contaminated metal implants with an Er:YAG laser

Infections related to orthopedic procedures are considered particularly severe when implantation materials are used, because effective treatments for biofilm removal are lacking. In this study, the relatively new approach for infection control by using an erbium:yttrium-aluminum-garnet (Er:YAG) laser was tested. This laser vaporizes all water containing cells in a very effective, precise, and predictable manner and results in only minimal thermal damage. For preliminary testing, 42 steel plates and 42 pins were seeded with mixed cultures. First, the minimally necessary laser energy for biofilm removal was determined. Subsequently, the effectiveness of biofilm removal with the Er:YAG laser and the cleansing of the metal implants with octenidine-soaked gauze was compared. Then, we compared the effectiveness of biofilm removal on 207 steel pins from 41 patients directly after explantation. Sonication and scanning electron microscopy were used for analysis. Laser fluences exceeding 2.8 J/cm² caused a complete extinction of all living cells by a single-laser impulse. Cleansing with octenidine-soaked gauze and irradiation with the Er:YAG laser are both thoroughly effective when applied to seeded pins. In contrast, when explanted pins with fully developed biofilms were analyzed, we found a significant advantage of the laser procedure. The Er:YAG laser offers a secure, complete, and nontoxic eradication of all kinds of pathogens from metal implants without damaging the implant and without the possible development of resistance. The precise noncontact removal of adjacent tissue is a decisive advantage over conventional disinfectants. Therefore, laser irradiation could become a valuable method in every debridement, antibiotics, and implant retention procedure.     

Masked polycythemia Vera (mPV): Results of an international study

We examined the baseline features and clinical outcomes of 140 patients presenting with JAK2V617F positivity and a bone marrow morphology conforming with WHO criteria of polycythemia vera (PV), but a hemoglobin level of <18.5 g/dL in males (range 16.0–18.4) and <16.5 g/dL in females (range 15.0–16.4). This cohort operationally referred to as masked PV (mPV) was compared with 257 patients with overt PV and displayed male predominance, a more frequent history of arterial thrombosis and thrombocytosis. Incidence of thrombosis was similar between the two groups but mPV displayed significantly higher rates of progression to myelofibrosis and acute leukemia and inferior survival. In multivariable analysis mPV diagnosis was an independent predictor of poor survival along with age >65 years and leukocyte count >10 × 10⁹/L. Our data suggest that mPV is a heterogeneous myeloproliferative neoplasia and not necessarily an early/ pre‐polycythemic form of classical PV that at onset in a small fraction of patients clinically may mimic essential thrombocythemia. On the other hand, the majority mPV may have a longer prodrome of undiagnosed PV or a disease biology akin to primary myelofibrosis‐post PV myelofibrosis that could explain the worsening of outcome in comparison to overt/classical manifestations. Am. J. Hematol. 89:52–54, 2014. © 2013 Wiley Periodicals, Inc.     

Effect of Aspiration Thrombectomy on Microvascular Obstruction in NSTEMI Patients : The TATORT-NSTEMI Trial

Background

Aspiration thrombectomy in ST-segment elevation myocardial infarction is recommended by current guidelines based on several randomized trials. There are no trials assessing thrombectomy in non–ST-segment elevation myocardial infarction (NSTEMI) patients.

Objectives

The TATORT-NSTEMI (Thrombus Aspiration in Thrombus Containing Culprit Lesions in Non–ST-Elevation Myocardial Infarction) trial sought to assess the effect of aspiration thrombectomy on microvascular injury in patients with NSTEMI compared with standard percutaneous coronary intervention (PCI).

Methods

This prospective, controlled, multicenter study randomized 440 patients to adjunctive thrombectomy (n = 221) compared with conventional PCI (n = 219) in NSTEMI patients with thrombus-containing lesions. The primary endpoint of the extent of microvascular obstruction (MO) in the percentage of left ventricular mass (%LV) was assessed by cardiac magnetic resonance imaging within 4 days. Secondary endpoints included infarct size, myocardial salvage index, and angiographic parameters including myocardial blush grade and Thrombolysis In Myocardial Infarction flow grade. The combined clinical endpoint consisted of death, reinfarction, target vessel revascularization, and new congestive heart failure within 6 months.

Results

The primary endpoint of MO was not different between the thrombectomy and the standard PCI group with 2.0%LV (interquartile range [IQR]: 0.8 to 4.1) versus 1.4%LV (IQR: 0.7 to 2.6) (p = 0.17). Similarly, no significant differences were observed for infarct size (8.6%LV; IQR: 4.0 to 14.7 vs. 7.4%LV; IQR: 4.1 to 13.1; p = 0.46), myocardial salvage index (63.3; IQR: 35.4 to 87.2 vs. 65.6; IQR: 46.9 to 82.6; p = 0.45), or angiographic parameters such as blush grade (p = 0.63) and Thrombolysis In Myocardial Infarction flow grade (p = 0.66). Clinical follow-up at 6 months revealed no differences in the combined clinical endpoints (p = 0.22).

Conclusions

Aspiration thrombectomy in conjunction with PCI in NSTEMI with a thrombus-containing lesion does not lead to a reduction in MO. (Thrombus Aspiration in Thrombus Containing Culprit Lesions in Non-ST-Elevation Myocardial Infarction [TATORT-NSTEMI]; NCT01612312).     

From the Cover: Functional changes of the reward system underlie blunted response to social gaze in cocaine users

Social interaction deficits in drug users likely impede treatment, increase the burden of the affected families, and consequently contribute to the high costs for society associated with addiction. Despite its significance, the neural basis of altered social interaction in drug users is currently unknown. Therefore, we investigated basal social gaze behavior in cocaine users by applying behavioral, psychophysiological, and functional brain-imaging methods. In study I, 80 regular cocaine users and 63 healthy controls completed an interactive paradigm in which the participants’ gaze was recorded by an eye-tracking device that controlled the gaze of an anthropomorphic virtual character. Valence ratings of different eye-contact conditions revealed that cocaine users show diminished emotional engagement in social interaction, which was also supported by reduced pupil responses. Study II investigated the neural underpinnings of changes in social reward processing observed in study I. Sixteen cocaine users and 16 controls completed a similar interaction paradigm as used in study I while undergoing functional magnetic resonance imaging. In response to social interaction, cocaine users displayed decreased activation of the medial orbitofrontal cortex, a key region of reward processing. Moreover, blunted activation of the medial orbitofrontal cortex was significantly correlated with a decreased social network size, reflecting problems in real-life social behavior because of reduced social reward. In conclusion, basic social interaction deficits in cocaine users as observed here may arise from altered social reward processing. Consequently, these results point to the importance of reinstatement of social reward in the treatment of stimulant addiction.Cocaine dependence is a chronically relapsing disorder defined by uncontrolled and compulsive drug use (1). Despite severe negative consequences including disrupted social relationships, loss of employment, and somatic and psychiatric illnesses, an addicted person’s life is often centered around the drug of choice and activities related to it (2). Therefore, drug use is classified as a major social, legal, and public health problem (3). After cannabis, cocaine is the second most prevalent illegal drug in the United States and Europe (4, 5), with a lifetime prevalence among young adults of 6.3% in Europe (15- to 34-y-olds) (4) and 13.3% in the United States (18- to 25-y-olds) (5).Social cognition and social support for drug users are of great clinical relevance, as they have been reported to influence onset of drug use and development of substance use disorders, and treatment success in patients with substance use disorders (6, 7). Impairments in social cognition may augment the risk of social isolation, aggression, and depression, likely supporting the vicious circle of drug use (8). Additionally, impaired social cognition may contribute to the decay of social relationships in addicted patients (9) with negative consequences for treatment success given that higher social support predicted longer abstinence duration (10). Furthermore, no efficient pharmacological treatment for cocaine addiction is currently available (11), and treatment approaches such as cognitive behavioral therapy rely, at least in part, on the emotional responsiveness and social abilities of drug users (12). Previous results suggest that cocaine users (CUs) show impairments in different facets of social cognition, particularly in emotional empathy, mental perspective taking, and emotion recognition in prosody, which are related to deficits in real-life social behavior such as fewer social contacts and more criminal offenses (13, 14). Furthermore, in money distribution games, CUs act more self-servingly and less altruistically than stimulant-naïve controls (15). Volkow et al. (9) postulated that neuroadaptations in the reward systems of drug users (e.g., ventral striatum and orbitofrontal cortex) alter reward processing such that the value of the abused drug is enhanced and concurrently the value of nondrug rewards, including social interaction, is reduced. Consequently, general social competence might become impaired and promote antisocial and criminal behavior. This may explain why social consequences of drug use (e.g., imprisonment or familial problems) do not prompt drug-addicted people to quit using the drug as well as how they contribute to increased drug use and transition from recreational drug use to addiction (9). However, whereas altered processing of monetary rewards has been reported in CUs (16), social reward processing has not been studied yet, neither on the psychological nor the neural level. Therefore, it remains elusive whether CUs (i) show behavioral differences to reward stemming from social interactions and, if so, (ii) which neural adaptations within reward circuitry underlie these potential changes in social interaction behavior.An essential part of social interaction is the phenomenon of “social gaze,” which has two aspects: Gaze can be used by the gazing person as a deictic cue to manipulate the attention of others, and can be read out by observers as a hint toward attentional focus of the gazing person (17). Both aspects can converge in joint attention (JA), which is a central element of social interaction (18) and is established when a person follows the direction of another person’s gaze so that both attend to the same object (19). Engagement in JA is considered to reflect our understanding of another person’s point of view (20). The capacity of JA emerges at 8–12 mo of age (21) and is predictive for later language learning (22) and the development of more advanced social skills such as mental perspective taking (e.g., the attribution of intentions and goals to others, also known as theory of mind) (23). Impaired JA is a core symptom of autism spectrum disorders (24).To test for social gaze differences between CUs and healthy controls (HCs), we applied a paradigm designed to capture the reciprocal and interactive nature of JA (25) (Fig. S1), where participants engage in an online interaction with an anthropomorphic virtual character in real time. Compared with self-initiated nonjoint attention (NJA; i.e., if the counterpart does not follow one’s gaze but rather pays attention to another object), self-initiated JA (i.e., if the counterpart follows one’s own gaze) is perceived as more pleasurable and associated with stronger activation of reward-related brain areas in healthy controls (25). This rewarding nature of JA might underlie the human motivation to engage in the sharing of experiences that emerges in early childhood (22, 25).It has been suggested that changes in social reward processing might underlie alterations in social behavior and cognition in CUs (9). Here we conducted two studies assessing JA processing, which constitutes an elegant approach to investigate basic social interaction patterns related to social reward processing (25), in CUs and stimulant-naïve HCs by means of behavioral, psychophysiological, and functional brain-imaging methods. In study I, a large sample of relatively pure CUs with few psychiatric comorbidities (n = 80) and stimulant-naïve HCs (n = 63) completed an interactive JA task (25) while valence and arousal ratings, error scores, reaction time, and pupil size were obtained. Pupil dilation provides an objective index of affective processing (26, 27). Based on the observations obtained in study I, we further investigated the neural correlates of the blunted emotional response to social gaze in subsamples of 16 CUs and 16 HCs using functional magnetic resonance imaging (fMRI) during an abridged version of the paradigm (study II). We hypothesized that altered emotional responses to JA are accompanied by less pronounced activation in reward-related brain areas of CUs.     

Siegen,wenn die Chancen schlecht stehen!

Approximately, in every fourth family one member suffers from a psychic illness. It is shown, that the big need for help is answered by very poor offers of service structures (either preventive or therapeutic). Additionally, in Austria we need to promote the discussion about this matter to make it more present for doctors and therapists concerned. Subsequently, the service offers can be better used by the families. This article depicts our psychodrama group-work with children and young adults with special reference to children with at least one parent suffering from psychic problems.The parents of the children valued their development and progress predominantly positive (>50%), only 30% rated the difficulties and symptoms of the children as stable. Subsequently examples from our psychodrama groups for children and young adults are presented to show the effects of our actions and activities. The presented group work shall be a contribution to facilitate the situation of the children concerned in Salzburg.     

Can online benchmarking increase rates of thrombolysis? Data from the Austrian stroke unit registry

Despite its widespread availability and known safety and efficacy, a therapy with intravenous thrombolysis is still undergiven. We aimed to identify whether nationwide quality projects—like the stroke registry in Austria—as well as online benchmarking and predefined target values can increase rates of thrombolysis. Therefore, we assessed 6,394 out of 48,462 patients with ischemic stroke from the Austrian stroke registry (study period from March 2003 to December 2011) who had undergone thrombolysis treatment. We defined lower level and target values as quality parameters and evaluated whether or not these parameters could be achieved in the past years. We were able to show that rates of thrombolysis in Austria increased from 4.9 % in 2003 to 18.3 % in 2011. In a multivariate regression model, the main impact seen was the increase over the years [the OR ranges from 0.47 (95 % CI 0.32–0.68) in 2003 to 2.51 (95 % CI 2.20–2.87) in 2011). The predefined lower and target levels of thrombolysis were achieved at the majority of participating centers: in 2011 the lower value of 5 % was achieved at all stroke units, and the target value of 15 % was observed at 21 of 34 stroke units. We conclude that online benchmarking and the concept of defining target values as a tool for nationwide acute stroke care appeared to result in an increase in the rate of thrombolysis over the last few years while the variability between the stroke units has not yet been reduced.