Antje Timmer

Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials

BACKGROUND Many patients with borderline personality disorder receive pharmacological treatment, but there is uncertainty about the usefulness of such therapies. AIMS To evaluate the evidence of effectiveness of pharmacotherapy in treating different facets of the psychopathology of borderline personality disorder. METHOD A Cochrane Collaboration systematic review and meta-analysis of randomised comparisons of drug v. placebo, drug v. drug, or single drug v. combined drug treatment in adult patients with borderline personality disorder was conducted. Primary outcomes were overall disorder severity as well as specific core symptoms. Secondary outcomes comprised associated psychiatric pathology and drug tolerability. RESULTS Twenty-seven trials were included in which first- and second-generation antipsychotics, mood stabilisers, antidepressants and omega-3 fatty acids were tested. Most beneficial effects were found for the mood stabilisers topiramate, lamotrigine and valproate semisodium, and the second-generation antipsychotics aripiprazole and olanzapine. However, the robustness of findings is low, since they are based mostly on single, small studies. Selective serotonin reuptake inhibitors so far lack high-level evidence of effectiveness. CONCLUSIONS The current evidence from randomised controlled trials suggests that drug treatment, especially with mood stabilisers and second-generation antipsychotics, may be effective for treating a number of core symptoms and associated psychopathology, but the evidence does not currently support effectiveness for overall severity of borderline personality disorder. Pharmacotherapy should therefore be targeted at specific symptoms.

Oral contraceptive use and smoking are risk factors for relapse in Crohn's disease ☆ ☆☆

Abstract Background & Aims: Lifestyle factors have been shown to influence prognosis in Crohns disease. The purpose of this study was to prospectively assess the effects of smoking and oral contraceptive use on clinical relapse rates. Methods: Placebo-treated patients formed a prospective cohort, followed up for 48 weeks or until relapse. The influence of smoking and the use of oral contraceptives on relapse risk was examined by life-table analysis (log rank tests) and Cox proportional hazards modeling, taking into account demographic and disease characteristics. Results: Of 152 patients, 61 (40%) had a relapse. Univariate analysis showed unfavorable outcomes for women ( P = 0.05), current smokers ( P = 0.005), and use of oral contraceptives ( P = 0.001). Recent surgery was associated with a decreased risk of relapse ( P = 0.02). The Cox model retained current smoking vs. never smoking (hazard ratio, 2.1; 95% confidence interval, 1.1–4.2), oral contraceptive use (hazard ratio, 3.0; 95% confidence interval, 1.5–5.9), and medical compared with surgical induction of remission (hazard ratio, 2.1; 95% confidence interval, 1.0–4.2) as predictors of relapse. Ex-smokers did not have an increased risk. Finally, sex, age, time in remission, disease location, and disease duration were not significant predictors. Conclusions: Oral contraceptive use and smoking are associated with an increased risk of relapse in patients with Crohns disease. GASTROENTEROLOGY 1998;114:1143-1150

The incidence of inflammatory bowel disease in a rural region of Southern Germany: a prospective population-based study.

Objective Although important advances in understanding the aetiology and pathogenesis of inflammatory bowel disease (IBD) have been made, many questions remain unanswered. As the most recent data available on the incidence of IBD in Germany were collected about 15 years ago, we set up a new population-based cohort to determine current incidence data for a defined region in Germany and to establish a basic cohort for prospective follow-up. Methods All patients living in the region of Oberpfalz newly diagnosed with IBD between 1 January 2004 and 31 December 2006 were included in this study by setting up a network of reporting clinicians and general practitioners in hospitals as well as in private practices. Demographic and clinical characteristics such as age at first diagnosis, localization of the disease, extraintestinal manifestations or family history on IBD were documented. Age-adjusted incidence rates are presented with 95% Poisson confidence intervals (CIs), based on the European standard population. Results In total, 286 newly diagnosed patients with IBD were reported in this region, 168 patients suffering from Crohns disease (CD), 105 patients with ulcerative colitis. Age-standardized incidence rates were 11.0/105 (95% CI: 9.1–11.6) for IBD, 6.6/105 (95% CI: 5.6–7.7) for CD and 3.9/105 (95% CI: 3.2–4.7) for ulcerative colitis. Peak incidences were found in the age interval of 16–24 years for both diseases, predominantly for CD. Age at first diagnosis was lower, extraintestinal manifestations and a positive family history on IBD were more common in patients with CD. Conclusion The incidence rate in IBD seems to be stable in Germany as compared with previously reported data, as is the remarkable predominance of CD. Prospective follow-up studies will be based on this incidence cohort.

Determinants of female sexual function in inflammatory bowel disease: a survey based cross-sectional analysis

BackgroundSexual function is impaired in women with inflammatory bowel disease (IBD) as compared to normal controls. We examined disease specific determinants of different aspects of low sexual function.MethodsWomen with IBD aged 18 to 65 presenting to the university departments of internal medicine and surgery were included. In addition, a random sample from the national patients organization was used (separate analyses). Sexual function was assessed by the Brief Index of Sexual Function in Women, comprising seven different domains of sexuality. Function was considered impaired if subscores were < -1 on a z-normalized scale. Results are presented as age adjusted odds ratios with 95% CI based on multiple logistic regression.Results336 questionnaires were included (219 Crohns disease, 117 ulcerative colitis). Most women reported low sexual activity (63%; 17% none at all, 20% moderate or high activity). Partnership satisfaction was high in spite of low sexual interest in this group. Depressed mood was the strongest predictor of low sexual function scores in all domains. Urban residency and higher socioecomic status had a protective effect. Disease activity was moderately associated with low desire (OR 1.8, 95% CI 1.0 to 3.2). Severity of the disease course impacted most on intercourse frequency (OR 2.3, 95% CI 1.4 to 4.7). Lubrication problems were more common in smokers (OR 2.5, 95% CI 1.3 to 5.1).ConclusionMood disturbances and social environment impacted more on sexual function in women with IBD than disease specific factors. Smoking is associated with lubrication problems.

Determinants of knowledge gain in evidence-based medicine short courses: an international assessment

Background Health care professionals worldwide attend courses and workshops to learn evidence-based medicine (EBM), but evidence regarding the impact of these educational interventions is conflicting and of low methodologic quality and lacks generalizability. Furthermore, little is known about determinants of success. We sought to measure the effect of EBM short courses and workshops on knowledge and to identify course and learner characteristics associated with knowledge acquisition. Methods Health care professionals with varying expertise in EBM participated in an international, multicentre before–after study. The intervention consisted of short courses and workshops on EBM offered in diverse settings, formats and intensities. The primary outcome measure was the score on the Berlin Questionnaire, a validated instrument measuring EBM knowledge that the participants completed before and after the course. Results A total of 15 centres participated in the study and 420 learners from North America and Europe completed the study. The baseline score across courses was 7.49 points (range 3.97–10.42 points) out of a possible 15 points. The average increase in score was 1.40 points (95% confidence interval 0.48–2.31 points), which corresponded with an effect size of 0.44 standard deviation units. Greater improvement in scores was associated (in order of greatest to least magnitude) with active participation required of the learners, a separate statistics session, fewer topics, less teaching time, fewer learners per tutor, larger overall course size and smaller group size. Clinicians and learners involved in medical publishing improved their score more than other types of learners; administrators and public health professionals improved their score less. Learners who perceived themselves to have an advanced knowledge of EBM and had prior experience as an EBM tutor also showed greater improvement than those who did not. Interpretation EBM course organizers who wish to optimize knowledge gain should require learners to actively participate in the course and should consider focusing on a small number of topics, giving particular attention to statistical concepts.

The role of domestic hygiene in inflammatory bowel diseases: hepatitis A and worm infestations.

Background Environmental factors are likely to be involved in the pathogenesis of inflammatory bowel disease (IBD), as the incidence of both Crohns disease (CD) and ulcerative colitis (UC) increased with improved living standards in Europe after World War II. On the basis of earlier reports suggesting that hygienic standards may also play a role in the pathogenesis of IBD, we investigated the influence of hepatitis A seroprevalence as an indicator for poorer hygienic conditions and worm infestations in IBD. Methods Hepatitis A seroprevalence was examined in patients with UC and CD. Patients with minor endocrinological disorders served as controls. All patients were questioned about immunizations, parasitic infections (worms), contact with animals, living on a farm, and ever traveling abroad. Patients were excluded for active hepatitis A immunization or recent passive immunization. Results are presented as Mantel–Haenszel odds ratios with 95% confidence interval, adjusted for age group. Results The sample included 307 patients (73 CD, 48 UC, and 186 controls). Hepatitis A seroprevalence was strongly associated with age older than 50 years. Age adjusted Mantel–Haenszel odds ratios were 0.25 (0.09–0.71) for UC and 0.75 (0.38–1.46) for CD versus controls. For parasitic infections, the odds ratios were 1.15 (0.52–2.53) for UC and 0.34 (0.13–0.89) for CD. Conclusion We were able to demonstrate a negative association of hepatitis A infection with UC only. In contrast, a novel finding was a strong protective effect of worm infestations for the occurrence of CD, but not UC.

Meta-Analyse randomisierter klinischer Studien, Publikationsbias und evidenzbasierte Medizin

Randomisierte klinische Studien sind ein wichtiges Mittel der Erkenntnisgewinnung in der medizinischen Forschung; ihre Ergebnisse bilden eine wesentliche Grundlage fur eine evidenzbasierte Medizin (Evidence-based Medicine; EbM). Dabei spielt die Zusammenfassung mehrerer Studien zur gleichen Fragestellung eine immer wichtigere Rolle. Werden die Daten bzw. Ergebnisse mehrerer unabhangig voneinander durchgefuhrter Studien in einer zusammenfassenden statistischen Analyse bewertet, spricht man von einer Meta-Analyse. Bezieht sich eine solche Meta-Analyse nur auf publizierte Studien, so kann ihr Ergebnis sehr stark davon abhangen, inwieweit alle zur Fragestellung durchgefuhrten Studien auch tatsachlich publiziert wurden. Dieses als Publikationsbias bezeichnete Phanomen muss bei der kritischen Bewertung der Ergebnisse von Meta-Analysen unbedingt beachtet werden. In diesem Kapitel wird diese Problematik in leicht verstandlicher Form und am Beispiel von konkreten Studien diskutiert. Gleichzeitig wird auf das Prinzip der evidenzbasierten Medizin und die Rolle der Cochrane Collaboration hingewiesen.

Measuring satisfaction with health care in young persons with inflammatory bowel disease -an instrument development and validation study

BackgroundPatient satisfaction is a relevant prognostic factor in young persons with chronic disease and may be both age and disease specific. To assess health care quality from the patient’s view in young persons with inflammatory bowel disease, an easy to use, valid, reliable and informative specific instrument was needed.MethodsAll parts of the study were directed at persons with inflammatory bowel disease aged 15 to 24 (“youth”). A qualitative internet patient survey was used to generate items, complemented by a physician survey and literature search. A 2nd internet survey served to reduce items based on perceived importance and representativeness. Following pilot testing to assess ease of use and face validity, 150 respondents to a postal survey in patients from a paediatric clinical registry were included for validation analyses. Construct validity was assessed by relating summary scores to results from global questions on satisfaction with care using ANOVA. To assess test-retest reliability using intraclass correlation coefficients (ICC), a subset of patients were assessed twice within 3 months.Results302 persons with IBD and 55 physicians participated in the item generating internet survey, resulting in 3,954 statements. After discarding redundancies 256 statements were presented in the 2nd internet survey. Of these, 32 items were retained. The resulting instrument assesses both the perceived relevance (importance) of an item as well as the performance of the care giver for each item for calculation of a summary satisfaction score (range 0 to 1). Sensibility testing showed good acceptance for most items. Construct validity was good, with mean scores of 0.63 (0.50 to 0.76), 0.71 (0.69 to 0.74) and 0.81 (0.79 to 0.83) for no, some and good global satisfaction (ANOVA, p < 0.001). Test-retest reliability was satisfactory (ICC 0.6 to 0.7).ConclusionsWe developed an easy to use, patient oriented, valid instrument to assess satisfaction with care in young persons with IBD for use in survey research.

Transition from pediatric to adult medical care – A survey in young persons with inflammatory bowel disease

Background Transition to adult health services is a vulnerable phase in young persons with chronic disease. We describe how young persons with inflammatory bowel disease in Germany and Austria experience care during the transitional age, focusing on differences by type of provider (pediatric vs. adult specialist, no specialist). Methods This was a follow up survey in patients previously registered with a pediatric IBD registry. Patients aged 15 to 25 received a postal questionnaire, including a measure of health care experience and satisfaction. Descriptive analyses were stratified by age. Sub-analyses in the 18–20 year age group compared health care experience by type of provider. Determinants of early or late transfer were examined using multinomial logistic regression. Results 619 patients responded to the survey; 605 questionnaires were available for analysis. Usual age of completing transition was 18. Earlier transfer was more common with low parental SES (OR 1.8, 95% CI 0.7 to 4.6), and less common with advanced schooling (OR 0.5, 95% CI 0.2 to 1.2). Structured transition was uncommon. 48% of the respondents had not received any preceding transition advice. Overall satisfaction with IBD care was high, especially with respect to interpersonal aspects, but less so in aspects of continuity of care. Conclusions Despite high overall patient satisfaction, relevant deficiencies in transitional care were documented. Some of these were associated with lower parental social status. Differences in health care satisfaction by type of provider (adult vs. pediatric) were small.

Reduced risk of ulcerative colitis after appendicectomy

Is related to the underlying appendicitis, not the operation