Current state of psychiatric involvement on palliative care consult services: results of a national survey.

CONTEXT: Palliative care consult services have emerged as an excellent resource for physicians seeking help with patients' symptoms. Symptoms include those of a psychiatric nature (e.g., depression, anxiety, delirium); however, little information is known about whether palliative care services include psychiatric input as part of multidisciplinary teams. OBJECTIVES: To explore 1) the current level of collaboration between psychiatrists and palliative care consult services across the U.S. and 2) the factors that support or restrict such involvement. METHODS: A national survey was developed and distributed electronically to program directors identified in the National Palliative Care Registry maintained by the Center to Advance Palliative Care. Analyses examined trends in psychiatry involvement with hospital-based palliative care teams. RESULTS: The survey had a 59% response rate, with final analyses including surveys completed by 260 palliative care program directors (67% inclusion rate from total respondents). Seventy-two percent of respondents reported some form of involvement with a psychiatrist on their palliative care service, with only 10% of those identifying a psychiatrist as a full- or part-time member of the team. Most respondents reported that they would like psychiatrists to be more involved with the palliative care services (71%). Secondary analyses of qualitative responses identified common impediments to increased psychiatry involvement, which included financial constraints, provider interest, and perceived disciplinary disconnect. CONCLUSION: There are shared objectives between psychiatry and palliative care; however, currently, co-involvement on treatment teams is quite limited. Future research is needed to identify ways to facilitate the interface of palliative care and psychiatry.

Ex vivo priming of naïve T cells into EBV-specific Th1/Tc1 effector cells by mature autologous DC loaded with apoptotic/necrotic LCL.

Posttransplant lymphoproliferative disorders (PTLDs) represent life-threatening complications of bone marrow and solid organ transplantation (SOTx). These are B-cell malignancies triggered by Epstein-Barr Virus (EBV) infection in chronically immunosuppressed (IS) recipients. Immunosuppressed EBV seronegative (EBV(-)) organ recipients are at highest risk of developing PTLD owing to the lack of anti-EBV memory T cells to control subsequent EBV challenges. Our aim is to establish effective anti-EBV T-cell generation protocols for prevention or treatment of PTLD encountered in SOTx. We have used autologous dendritic cells (DCs) loaded with apoptotic/necrotic lymphoblastoid cell lines (LCLs) to evaluate the ability of such an approach to activate naïve T cells in vitro. In EBV(-) individuals, both CD8+ and CD4+ T-cell responses were amplified by this approach, as detected by IFN-gamma ELISPOT and cytotoxicity assays. The CD8+ T cells were poly-specific anti-EBNA3 A, -LMP2 and -BMLF1, with uniform reversion to a CD45RO+/RA-phenotype, decreased CD62L expression, and up-regulation of the activation markers CD28 and CD69. Addition of rhIL-12 improved anti-viral T-cell responses and reduced the functional differences observed between EBV(+) and EBV(-) responders. In conclusion, the DC/LCL method promotes cross-presentation of EBV-associated epitopes and may serve as an effective protocol for the adoptive immunotherapy of PTLD in EBV(-) SOTx patients.