[Mentalizing as Psychosocial Vaccination in Child and Adolescent Psychotherapy]. / Mentalisieren als psychosoziale Impfung in der Kinder- und Jugendlichenpsychotherapie.

Based on the psychological stress caused by theCovid 19 pandemic in families, this article explores the fundamental question of how the psychological process of mentalizing - metaphorically speaking - can act as a psychosocial vaccination in stressful times. To this end, we look at the developments in the psychosocial context under the conditions of the pandemic and consider the effects on child and adolescent psychotherapy on the basis of a vignette of a group therapy session.

Long-term trajectories of SARS-CoV-2 neutralizing antibodies and predictive value of first dose vaccination-induced IgG-antibodies in hemodialysis patients.

PURPOSE: The predictive value of antibody titers after the first SARS-CoV-2 vaccination and long-term trajectories of antibody titers in hemodialysis patients are unknown. METHODS: SARS-CoV-2 IgG antibodies and their neutralizing effect six weeks after the first and second vaccination were analysed in 30 hemodialysis patients. IgG titers served to classify participants as responders or non-responders and to calculate sensitivity, specificity, and accuracy. Associations between potential risk factors and post-vaccine non-response were analysed by Mann-Whitney-U test and Chi-Squared test. Long-term follow-up analysis (ANOVA) on the evolution of neutralizing IgG-titers was performed in 24 participants 94 and 135 days after the second immunization. RESULTS: IgG antibodies ≥ 1 AU/L (mean 9 ± 20 AU/L) after the first dose were found in 20 patients (66.7%). After the second dose only two participants (6.7%) remained sero-negative and 16.6% showed neutralizing levels below 30%, whereas 25 patients showed IgG antibodies with the high neutralizing activity of 86 ± 18%. Positive IgG antibodies 6 weeks after the first vaccination predicted vaccination effectiveness after two cycles with a specificity of 100%, sensitivity of 76%, and accuracy of 87%. Even low-dose immunosuppressive therapy increased the relative risk for non-response after the first and second dose 1.9 (95% CI 0.8-4.6) and 4.9 (95% CI 1.0-23.8) times, respectively. Over a period of about 4.5 months IgG titers slowly declined by 51% from baseline or by 0.45 AU/mL per day, respectively. CONCLUSION: Two cycles of SARS-CoV-2 vaccination-induced high seroconversion rates comparable to the general population. Immunosuppressive medication is a major risk factor for vaccination non-response. Mounted IgG antibodies showed a high neutralizing capacity as evidence of protective effectiveness. IgG antibodies after the first dose may serve to predict later vaccination outcome. Patients on dialysis display a more rapid decline in antibody titers on long-term follow-up compared to healthy controls.

The influence of chronic kidney disease on the duration of hospitalisation and transfusion rate after elective hip and knee arthroplasty.

PURPOSE: Elective hip or knee replacement is an optimal, standardised orthopaedic surgical procedure. The influence of chronic kidney disease, defined as an estimated glomerular filtration rate (eGFR) of 15-45 ml/min/1.73 m2 body surface area (BSA) (KDIGO stage G3a-G4), on the duration of hospitalisation, perioperative decrease in haemoglobin (Hb) levels, and transfusion rates after orthopaedic procedures has not been fully clarified. Our study, therefore, aimed to evaluate the impact of chronic kidney disease on the previously mentioned variables. METHODS: We conducted a retrospective multicentre analysis involving two orthopaedic centres. Patients who underwent elective total hip and knee replacement between 2010 and 2015 were included. We used descriptive methods and multivariate linear and binary regression analyses for our statistical evaluations. RESULTS: We evaluated 3301 datasets (1120 men [33.9%], 2181 women [66.1%], 2043 [61.9%], and 1258 [38.1%]) elective total hip and knee replacements, respectively. The following variables were identified as risk factors for a prolonged hospital stay: patient age, admission Hb and potassium levels, perioperative Hb level decrease, year of surgery, blood transfusion, and a preoperative eGFR of 15-45 ml/min/m2 BSA. Patients with an eGFR of > 45 ml/min/m2 BSA were discharged within 11.7 ± 3.0 days, while patients with an eGFR of 15-45 ml/min/1.73 m2 BSA remained inpatient for 13.5 ± 5.0 days (p < 0.001). Identified risk factors for postoperative blood transfusions included age, initial Hb level, perioperative Hb decrease, prosthetic hip replacement, and the presence of allergic diathesis. Blood transfusions were performed in 7.5% of patients with an eGFR of > 45 ml/min/m2 BSA compared to 24.1% of patients with an eGFR of 15-45 ml/min/1.73 m2 BSA (p < 0.001). An eGFR level of 15-45 ml/min/m2 BSA was identified as a risk factor for a postoperative decrease in Hb levels. CONCLUSION: Chronic kidney disease, defined as an eGFR level of 15-45 ml/min/1.73 m2 BSA, was a risk factor for a prolonged hospital stay after elective hip and knee arthroplasty. Further studies are necessary to better define the effect of reduced kidney function on relevant clinical and socioeconomic outcome parameters.

Impact of low-dose steroids on HbA1c levels and development of pre-diabetes and NODAT in non-diabetic renal transplant recipients on long-term follow-up.

BACKGROUND: This study aimed to evaluate the impact of 5 mg of prednisolone/day on HbA1c levels and its association with the development of pre-diabetes and new-onset diabetes mellitus (NODAT) in non-diabetic first renal transplant recipients on long-term follow-up. METHODS: Four hundred patients were analysed on an average of 4.1 ± 3.0 years after successful transplantation: 96 (24%) were steroid-free and 304 (76%) treated with 5 mg of prednisolone/day combined with cyclosporine A (CsA) or tacrolimus (Tac) as part of their immunosuppressive protocol. Pre-diabetes and NODAT were defined based on the HbA1c levels according to the current ADA guidelines. The Mann-Whitney U test and the Chi-square test were used to determine intergroup differences. Multivariate logistic regression analyses (adjusted for steroid-free versus 5 mg of prednisolone per day, body mass index (BMI), number of HLA mismatches, eGFR according to the CKD-EPI formula, sex, negative vs. positive PRA titre, CMV and HCV positivity of the recipient, CsA vs. Tac immunosuppressive medication, dialysis vintage (years), age at the last follow-up and time from transplantation to the last follow-up) were performed to identify an independent effect of low-dose steroids on the evolution of pre-diabetes and NODAT. RESULTS: A small but statistically significant difference in HbA1c levels was observed between the control and the steroid groups (5.56 ± 0.54 vs. 5.67 ± 0.0.45%, p = 0.045). The incidence rates of pre-diabetes and NODAT per 100 patients per year were 9.3 and 3.0, respectively. Regression analysis showed that low-dose steroids (p = 0.026, risk ratio (RR) 1.789, 95%; confidence interval (CI) 1.007-3.040) and age (p = 0.000, RR 1.037/year, 95% CI 1.018-1.057) were associated with pre-diabetes, whereas BMI (p = 0.000, RR 1.190, 95% CI 1.084-1.307), age (p = 0.000, RR 1.087/year, 95% CI 1.047-1.129) and Tac use (p = 0.010, RR 3.300, 95% CI 1.328-8.196) were associated with NODAT. CONCLUSION: Using 5 mg of prednisolone/day was associated with increased HbA1c levels and an increased risk in developing pre-diabetes, but not NODAT, whereas BMI, age and the use of tacrolimus were associated with an increased risk in developing NODAT.

Ibandronate in stable renal transplant recipients with low bone mineral density on long-term follow-up.

BACKGROUND: Bone mineral density (BMD) has been reported to increase without specific treatment in long-term renal transplant recipients. The aim of this study was to evaluate the effect of ibandronate on BMD and kidney function in long-term renal transplant recipients as compared to a control group. Furthermore, we searched for a gender-specific treatment effect of ibandronate on BMD. METHODS: In a retrospective, matched case-control study 60 stable renal transplant recipients were included on long-term follow-up. The patient cohort was divided into two groups. The control group (n = 30) comprised patients with close-to-normal bone mineral density who did not receive ibandronate treatment and the treatment group (n = 30) comprised patients with reduced bone mineral density who received ibandronate treatment. The groups were matched for sex, age at the time of renal transplantation, use of steroids, renal transplant function and time lag between the dual-energy X-ray absorptiometry (DEXA) measurements and renal transplantation. Patients of the treatment group were treated with 12.0 ± 6.7 g ibandronate. Treatment cycles lasted 19.3 ± 11.0 months. The first bone mineral density testing was performed 55.3 ± 60.2 months after renal transplantation followed by a second measurement 26.8 ± 12.1 months later. RESULTS: Both groups did not differ in absolute (g/cm(2)) or relative (%) changes in BMD at the lumbar spine (0.033 ± 0.079 vs. 0.055 ± 0.066 g/cm(2), p = 0.217 and 3.6 ± 7.8 vs. 6.4 ± 8.1 %, p = 0.124) or femoral neck (0.013 ± 0.106 vs. 0.025 ± 0.077 g/cm(2), p = 0.647 and 3.2 ± 13.6 vs. 5.0 ± 13.1 %, p = 0.544) over the study period. There was no correlation of ibandronate dosages with changes in BMD (LS: r = -0.089; p = 0.639 and FN: r =+0.288; p = 0.445). We could neither determine a negative effect of ibandronate on renal transplant function over the study period, estimated via the CKD-EPI formula (-2.9 ± 7.6 vs. -2.7 ± 10.6 mL/min/1.73 m(2), p = 0.900) nor a gender-specific action of ibandronate on bone mass changes. CONCLUSIONS: Ibandronate treatment was safe with respect to renal transplant function but did not result in a significant additive improvement in bone mineral density as compared to the untreated control group. A gender-specific action of ibandronate on BMD at the LS or FN could not be determined either.

Daily postdilutional hemodiafiltration with FX800 polysulfone dialyzers for removing kappa light chains in multiple myeloma-induced kidney injury.

Multiple myeloma is an increasing cause of renal failure in the elderly. Early diagnosis of myeloma-associated acute renal failure is paramount and rapid initiation of disease-specific treatments with a combination of chemotherapy and dialytic therapies for instant removal of free light chains have been proposed. For immediate light chain removal, high cut-off dialyzers have been reported to yield superior light chain clearance parameters, but these dialyzers are not widely used due to increased treatment costs. In addition, the clinical virtue of hemodiafiltration (HDF) has not yet been definitively determined. We hereby present the case of a 70-year-old female patient with kappa light chain myeloma and acute on chronic renal failure. Daily HDF for 1-week using standard polysulfone high-flux dialyzers was implemented and led to remarkable and effective light chain reduction ratios between 87% and 95%.

Intravenous iloprost: a new therapeutic option for patients with post-transplant distal limb syndrome (PTDLS).

The purpose of this study was to investigate the application of intravenous iloprost as a novel therapy for the treatment of post-transplant distal limb syndrome (PTDLS). PTDLS is a benign but disabling complication in the first year after renal transplantation. It is characterized by bilateral, often incapacitating pain in the feet and or knees on motion and a significant rise in alkaline phosphatase levels on laboratory evaluation. On MRI, bone marrow edema of the affected bone regions can be demonstrated. PTDLS differs from steroid induced osteonecrosis of the hip in terms of localization, an average cumulative steroid dosage within expected limits, and a benign outcome, as PTDLS does not progress to overt cell necrosis. From August 2003 to April 2005 we treated 10 patients with MRI-proven diagnosis of PTDLS following a standardized regimen of intravenous iloprost over 5 days. Iloprost led to prompt pain relief measured on a visual analogous scale (VAS) ranging from 1 to 10 (5.6 +/- 1.5 before vs. 2.1 +/- 1.3 after treatment, p = 0.0004). PTDLS represents a benign but disabling complication following renal transplantation. Intravenous iloprost might be a promising therapeutic concept leading to a quick relief of symptoms without relevant side effects.