Antipsychotic medications are highly effective in the treatment of patients experiencing first-episode psychosis. However, some patients do not respond to the first antipsychotic medication they are given, and may require trials of several drugs before an effective treatment is found. While antipsychotics may take months to achieve their full effect, recent evidence suggests that it is possible to predict whether a patient will respond to a particular drug by assessing early response after as little as 2 weeks of treatment. Assessing early antipsychotic response has the potential to improve treatment strategies for psychotic patients, but there is still a great deal of uncertainty about what early response can and cannot predict, and how the predictive value of early response differs among drugs and patient populations. The work presented in this thesis addresses some of the most pressing questions about early antipsychotic response in several samples of antipsychotic-naive patients with first-episode psychosis. This work demonstrates that: (1) the appropriate time point at which to assess early response differs between antipsychotic drugs; (2) early improvement in depressive and manic symptoms predicts treatment outcome, while early improvement in anxiety symptoms may not; (3) strong early response is associated with decreased rates of extrapyramidal side-effects; (4) early antipsychotic response can predict long-term treatment outcome at least 2 years after treatment initiation; (5) the appropriate time point at which to assess early response differs in patients who receive antidepressant treatment in addition to antipsychotic treatment; (6) patients with a poor early response may benefit from being switched to another antipsychotic, particularly one with a distinct receptor binding profile. These results highlight several weaknesses of the current literature, suggesting that early antipsychotic response should be assessed differently depending on the psychiatric symptom profile of each patient and the specific medications that are being used. However, the data presented here also emphasize the potential therapeutic value of assessing early response. The ability of early response to predict treatment outcome appears to be even greater than previously thought, and understanding how to appropriately use this important assessment to guide treatment strategies may improve the efficiency and efficacy of treatment for psychotic patients. / Thesis / Doctor of Philosophy (PhD)

BACKGROUND:In breast cancer endocrine therapy, post-therapy Ki-67 assay of biopsy material predicts recurrence-free survival but is invasive and prone to sampling error. 18F]Fluorodeoxyglucose (FDG) positron emission tomography (PET) has shown an early agonist or 'flare' response to tamoxifen and estradiol, but has not been tested in response to estrogen-lowering aromatase inhibitors (AIs). We hypothesized that decreased agonistic response to AIs would result in early FDG uptake decline. We also measured early response to trastuzumab (T), another targeted agent for breast cancer with differing mechanisms of action. Our study was designed to test for an early decline in FDG uptake in response to AI or T and to examine association with Ki-67 measures of early response.METHODS:Patients with any stage of newly diagnosed or recurrent breast cancer were eligible and enrolled prior to initiation (or resumption) of AI or T therapy. FDG PET and tissue biopsy were planned before and after 2 weeks of AI or T therapy, with pretreatment archival tissue permitted. Cutoffs of greater than or equal to]20% decline in standardized uptake value (SUV) as FDG PET early response and less than or equal to]5% post-treatment expression as Ki-67 early response were defined prior to analysis.RESULTS:Forty-two patients enrolled, and 40 (28 AI, 12 T) completed serial FDG-PET imaging. Twenty-two patients (17 AI, 5 T) had newly diagnosed disease, and 23 (14 AI, 9 T) had metastatic disease (5 newly diagnosed). Post-treatment biopsy was performed in 25 patients (63%) and was either refused or not feasible in 15. Post-treatment biopsy yielded tumor in only 17/25 cases (14 AI, 3 T). Eleven of 14 AI patients with post-therapy tissue showed FDG PET early response, and there was 100% concordance of PET and post-therapy Ki-67 early response. For the T group, 6/12 showed an FDG PET early response, including 2/3 patients with post-therapy biopsy, all with Ki-67 >5%.CONCLUSIONS:Substantial changes in FDG PET SUV occurred over 2 weeks of AI therapy and were associated with low post-therapy proliferation. SUV decline was seen in response to T, but few tissue samples were available to test association with Ki-67. Our results support further investigation of FDG PET as a biomarker for early response to AI therapy.

Malignant melanoma (MM) is the deadliest skin cancer with an ever-increasing incidence. New treatments have improved the prognosis for patients with advanced MM. Still, most patients do not respond, and the side effects can be severe, underlining the need for better therapies. The overall aim of this thesis was to evaluate new means to improve the treatment for patients with advanced MM. Immunostimulatory gene therapy (AdCD40L) was evaluated in a clinical study and BRAF-inhibitory treatment in rare cases of BRAF-mutated MM. Due to its immunogenicity, MM is an attractive target for immunostimulatory gene therapy. AdCD40L is an adenovirus carrying the human gene for CD40 ligand, which in different ways can stimulate the immune system to combat cancer. We conducted a Phase I/IIa study with AdCD40L in patients with metastatic MM having received established treatments. In cohort 1 (n=6), four weekly, intratumoural AdCD40L injections were given. In cohort 2 (n=9), low dose cyclophosphamide was added to increase the immune response. Since irradiation may act synergistically with immunotherapy, patients in cohort 3 (n=9) also received a single fraction of radiotherapy (8 Gy). This fraction was given towards the lesion selected for injections. The primary objectives were to assess the feasibility and safety of AdCD40L-treatment and secondarily its anti-tumour effects. Patients were thoroughly assessed for toxicity. The anti-tumour response was evaluated by imaging techniques (FDG-PET/CT, DW-MRI scans), tumour biopsies and blood tests. Plasma protein markers were measured with a multiplex platform. Another objective was to evaluate the potential of DW-MRI and FDG-PET/CT for prediction of AdCD40L treatment response, in terms of overall survival (OS). AdCD40L was well tolerated with mild transient reactions. Local and distant responses in PET/CT scans along with a significantly better 6-month survival in the cohorts that received cyclophosphamide conditioning were observed. Effector lymphocyte responses were elicited. All patients had an increased T effector/T regulatory-cell ratio and death receptors were significantly up-regulated post therapy. Inflammatory cytokines and other plasma proteins were altered in favourable ways by the AdCD40L treatment. The analyses support that the functional DWI parameters may be better early predictors of OS than the established metabolic and morphologic criteria of FDG-PET/CT and CT/MRI, respectively. In conclusion, the stimulation of the CD40 pathway to initiate anti-tumour immunity is a promising treatment alternative for MM patients. However, further studies with developed treatment schemes are warranted. In the first report ever on treatment of a pregnant patient with a BRAF-inhibitor, the therapy was initiated in the second trimester. The treatment with vemurafenib enabled prolonged gestation, hence reducing the risk of immaturity-related complications. Further, we report the first case worldwide of a patient with metastatic conjunctival melanoma who benefitted from treatment with vemurafenib. Additional studies are needed to assess the efficacy of BRAF -inhibitors in the different subtypes of ocular melanoma.

Background: It is well known that web-based interventions can be effective treatments for various conditions. Less is known about predictors, moderators, and mediators of outcome and especially interrelations between participant and interventions characteristics, process variables and outcomes in online interventions. Clinical trials often lack statistical power to detect variables that affect intervention effects and their interrelations. Within ICare, we can investigate the interrelation of potential predictor and process variables in a large sample. Method: The ICare consortium postulated a model of interrelations between participant and intervention characteristics, process variables and outcomes in online interventions. We will assess general and disorderspecific interrelations between characteristics of the intervention, characteristics of the participants, adherence, working alliance, early response, and intervention outcomes in a sample of over 7500 participants from seven clinical trials evaluating 15 online interventions addressing a range of mental health conditions and disorders, using an individual participant data meta-analyses approach. Discussion/conclusion: Existing research tends to support the efficacy of online mental health interventions, but the knowledge base regarding factors that affect intervention effects needs to be expanded. The overarching analyses using data from the ICare intervention trials will add considerably to the evidence.

Das Darmhormon Glucagon-like peptide-1 (GLP-1) ist ein vielversprechendes Therapeutikum in der Behandlung des Typ 2-Diabetes. Allerdings liegen nur wenige Daten über die molekulare Wirkung des Hormons vor. Daher wurden die intrazellulären Effekte, die GLP-1-induzierten Signaltransduktion und Genexpression am Beispiel der pankreatischen ß-Zellinie INS-1 untersucht. In den INS-1-Zellen zeigte sich nach einer GLP-1-Stimulation eine zeit-, dosis- und glukose-abhängige Phosphorylierung von ERK1/2 bzw. der Aktivierung der Transkriptionsfaktoren Elk-1 und CREB. Während GLP-1 die beiden Signalmoleküle bereits nach wenigen Minuten transient aktivierte, führte Glukose zu einer verzögerten, aber anhaltenden Aktivierung. Beide Stimulanzien gemeinsam bewirkten eine synergistische Aktivierung von ERK1/2 und CREB. Sowohl am Mechanismus der glukose- als auch GLP-1-induzierten Aktivierung sind Ca2[plus]-regulierte Signalprozesse in antagonistischer Weise involviert. So führte die Inhibition von CaM-Kinasen und der intrazellulären Ca2[plus]-Erhöhung zu einer Reduktion der GLP-1- und glukosestimulierten ERK1/2-Phosphorylierung, die induzierte Aktivierung von CREB wurde leicht verstärkt. Die Inhibition der PKA und MEK ließen die Rückschlüsse zu, daß die Aktivie-rung der MAPK-Kaskade teilweise durch die PKA vermittelt wird und eine Wechselwirkung zwischen den Kaskaden existiert. Insbesondere die Induktion der frühen Gene junB, c-fos, nur-77 und zif268, die mit der GLP-1-induzierten ERK1/2- und CREB-Phosphorylierung korrelierten, belegten, daß GLP-1 einen Teil seiner Wirkung über diese Signalwege vermittelt. Die Glukosewirkung hinsichtlich der IEG-Induktion war gering. Beide Stimuli gemeinsam führten analog zum synergistischen Effekt auf signaltransduktorischer Ebene zu einer gesteigerten und verlängerten IEG-Expression, die somit die physiologische Bedeutung von GLP-1 als Glukosekompetenzfaktor unterstrichen.