Self-help treatments for disorders of recurrent binge eating: a systematic review

OBJECTIVE

To evaluate self-help interventions for patients with binge eating disorder (BED) and bulimia nervosa (BN), tested in randomized controlled trials, and compared with waiting list or any other type of control group.

METHODS

A systematic review including quality appraisal was conducted of randomized controlled trials, using self-help techniques in patients with BED and/or BN. Six databases were searched during the period between January 1994 and June 2004.

RESULTS

A total of 2686 articles were identified, 1701 abstracts were evaluated in detail and, nine studies fulfilled the inclusion criteria for this review. All studies indicated that patients treated with active interventions had a reduced number of binge eating episodes at end of treatment.

CONCLUSION

The results support self-help interventions but shall be interpreted with caution. Because of the small number of studies using self-help techniques for BED and BN, further larger randomized, multi-center controlled studies that apply standardized inclusion criteria, evaluation instruments and self-help materials, are needed.

Antidepressants for anorexia nervosa

BACKGROUND

Anorexia Nervosa (AN) is an illness characterised by extreme concern about body weight and shape, severe self-imposed weight loss, and endocrine dysfunction. In spite of its high mortality, morbidity and chronicity, there are few intervention studies on the subject.

OBJECTIVES

The aim of this review was to evaluate the efficacy and acceptability of antidepressant drugs in the treatment of acute AN.

SEARCH STRATEGY

The strategy comprised of database searches of the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register, MEDLINE (1966 to April 28th, 2005), EMBASE (1980 to week 36, 2004), PsycINFO (1969 to August week 5, 2004), handsearching the International Journal of Eating Disorders and searching the reference lists of all papers selected. Personal letters were sent to researchers in the field requesting information on unpublished or in-progress trials.

SELECTION CRITERIA

All randomised controlled trials of antidepressant treatment for AN patients, as defined by the Diagnostic and Statistical Manual, fourth edition (DSM-IV) or similar international criteria, were selected.

DATA COLLECTION AND ANALYSIS

Quality ratings were made giving consideration to the strong relationship between allocation concealment and potential for bias in the results; studies meeting criteria A and B were included. Trials were excluded if non-completion rates were above 50%. The standardised mean difference and relative risk were used for continuous data and dichotomous data comparisons, respectively. Whenever possible, analyses were performed according to intention-to-treat principles. Heterogeneity was tested with the I-squared statistic. Weight change was the primary outcome. Secondary outcomes were severity of eating disorder, depression and anxiety symptoms, and global clinical state. Acceptability of treatment was evaluated by considering non-completion rates.

MAIN RESULTS

Only seven studies were included. Major methodological limitations such as small trial size and large confidence intervals decreased the power of the studies to detect differences between treatments, and meta-analysis of data was not possible for the majority of outcomes. Four placebo-controlled trials did not find evidence that antidepressants improved weight gain, eating disorder or associated psychopathology. Isolated findings, favouring amineptine and nortriptyline, emerged from the antidepressant versus antidepressant comparisons, but cannot be conceived as evidence of efficacy of a specific drug or class of antidepressant in light of the findings from the placebo comparisons. Non-completion rates were similar between the compared groups.

AUTHORS' CONCLUSIONS

A lack of quality information precludes us from drawing definite conclusions or recommendations on the use of antidepressants in acute AN. Future studies testing safer and more tolerable antidepressants in larger, well designed trials are needed to provide guidance for clinical practice.

Immunological and virological consequences of patient-directed antiretroviral therapy interruption during chronic HIV-1 infection

Increasing numbers of patients are choosing to interrupt highly active antiretroviral therapy (HAART). We describe the effect of patient-directed treatment interruption (PDTI) on plasma viral loads (pVL), proviral DNA (pDNA), lymphocyte subsets and immune responses in 24 chronically HIV-1 infected individuals. Patients were divided into group A with pVL > 50 copies/ml and group B with pVL < 50 copies/ml, prior to the PDTI. pVL rose significantly in group B during the first month off HAART and was associated with a significant decrease in CD4 T-cell count. At baseline there was a significant difference in HIV-1 pDNA levels between groups A and B, however, levels significantly increased in group B, but not in group A during PDTI becoming equivalent after 1 month PDTI. We have previously shown no increase in pDNA over the time of substitution in patients switching HAART regimens despite a small rebound in pVL. These observations indicate that to protect low pDNA levels PDTI should be discouraged and that changing regimen at the first sign of failure should be advised where possible. Only transient, no longer than 4 week, HIV-1-specific responses were observed during PDTI in 5/24 patients, 2 from group A and 3 from group B. The low numbers of responders and the transient nature of the anti-HIV-1 immune responses do not favour the auto-vaccination hypothesis.

Life in the littoral zone: lactobacilli losing the plot

Recurrent bacterial vaginosis is a challenge for those affected by it, and their physicians. Our inability to prevent relapse after treatment, may be because of the flawed approach of using antibiotics to treat a condition that is an imbalance rather than an infection. The maintenance of a healthy lactobacillus population offers an approach to preventing relapse: the problem is how best to do this. Physiological approaches such as the use of hydrogen peroxide, lactic acid, and exogenous lactobacilli need to be explored further. The role of bacterial vaginosis as a risk factor for acquisition of HIV and other STIs is a further impetus to attempting to prevent bacterial vaginosis from recurring.

A prospective multicentre study of discontinuing prophylaxis for opportunistic infections after effective antiretroviral therapy

OBJECTIVE

To assess the medium-term safety of discontinuing prophylaxis (primary or secondary) for opportunistic infections following an effective response to antiretroviral therapy.

METHODS

Participating clinical sites prospectively identified patients in whom the discontinuation of prophylaxis for any opportunistic infection was considered to be clinically indicated, although CD4 levels were not predefined. A follow-up report was subsequently sent every 6 months requesting information on changes in prophylaxis, antiretroviral drugs, new AIDS-defining events, and CD4 cell count results.

RESULTS

Prophylaxis for Pneumocystis carinii pneumonia (PCP) was withdrawn in 524 patients (426 primary and 98 secondary prophylaxis), prophylaxis for Mycobacterium avium complex (MAC) was withdrawn in 28 patients (13 primary and 15 secondary), and prophylaxis for cytomegalovirus (CMV) retinitis was withdrawn in 10 patients. CD4 counts were generally maintained above accepted prophylaxis threshold levels during the period of follow up (95-98% of the time). Total follow up to last report or re-continuation of prophylaxis was 680 and 144 person-years for patients discontinuing primary and secondary PCP prophylaxis, respectively. No cases of PCP were reported, giving incidence rates of 0.0 (upper 95% confidence limit 0.4) and 0.0 (2.1) per 100 person-years. No cases of MAC were reported, but one patient had a recurrence of CMV retinitis. PCP prophylaxis was restarted in 30 patients; no patients restarted MAC or CMV prophylaxis.

CONCLUSIONS

Previous studies have demonstrated a low risk of PCP in the short term following the withdrawal of prophylaxis in patients who have responded well to antiretroviral therapy. The present study suggests a continuing low level of risk with extended follow up, provided adequate CD4 count levels are maintained. The case of recurrent CMV retinitis in a patient with impressive immunological and virological response indicates the need for close monitoring of patients previously diagnosed with this condition.

Baseline survey of sexually transmitted infections in a cohort of female bar workers in Mbeya Region, Tanzania

OBJECTIVES

To determine baseline prevalence of sexually transmitted infections (STI) and other reproductive tract infections (RTI) and their association with HIV as well as sociodemographic and behavioural characteristics in a newly recruited cohort of female bar workers in Mbeya Region, Tanzania.

METHODS

600 female bar workers were recruited from 17 different communities during September to November 2000 and underwent gynaecological examination, laboratory testing for HIV/STI, and interviews using structured questionnaires.

RESULTS

HIV-1 seroprevalence was 68%. Prevalences of STI/RTI were high titre syphilis (TPPA/RPR >/=1/8), 9%; herpes simplex virus 2 antibodies, 87%; chlamydia, 12%; gonorrhoea, 22%; trichomoniasis, 24%; and bacterial vaginosis, 40%. HIV infection was associated with TPPA and HSV-2 seropositivity, bacterial vaginosis and clinically diagnosed genital ulcers, blisters, and warts. Reported high risk sexual behaviour during the past year (having multiple casual partners) was associated with prevalent STI.

CONCLUSION

Female bar workers in Mbeya are at high risk of STI and HIV infection. Targeted STI/HIV prevention interventions for these women and their sexual partners need to be reinforced. Methods should be sought to improve healthcare seeking and to provide easily accessible and affordable STI care services.

Associations between Mycoplasma genitalium, Chlamydia trachomatis and pelvic inflammatory disease

OBJECTIVE

To evaluate the association between Mycoplasma genitalium, Chlamydia trachomatis, and pelvic inflammatory disease (PID) METHODS: A case-control methodology was used. Swab eluates were processed using the QIAamp DNA mini kit. Polymerase chain reaction (PCR) for M genitalium was carried out using a real time in-house 16S based assay. An endocervical swab was taken and tested for the presence of C trachomatis (ligase chain reaction, Abbott Laboratories), and a high vaginal swab was taken and tested for the presence of Neisseria gonorrhoeae and bacterial vaginosis.

RESULTS

Of the PID cases 13% (6/45) had evidence of M genitalium infection compared to none of the controls (0/37); 27% (12/45) of the cases had C trachomatis infection compared to none of the controls; and 16% (7/45) of cases only had serological evidence of C trachomatis infection compared to 5% (2/37) of controls. Cases were more likely to present with M genitalium and/or C trachomatis than controls (p<0.001).

CONCLUSIONS

This study indicates that there may be an association between M genitalium and PID, and that this relation is largely independent of C trachomatis. Future studies need to investigate the pathological basis of the relation between M genitalium and PID using samples from women with PID diagnosed using laparoscopy and endometrial biopsy. Little is known about the epidemiology of M genitalium: large scale epidemiological investigations are needed to determine the prevalence, incidence, and factors associated with this emerging infection.

Urine based screening for asymptomatic/undiagnosed genital chlamydial infection in young people visiting the accident and emergency department is feasible, acceptable, and can be epidemiologically helpful

OBJECTIVE

To assess the acceptability and the feasibility of urine based Chlamydia trachomatis screening in asymptomatic young people aged 16-35 years attending an inner city accident and emergency (A&E) department.

DESIGN

Cross sectional study.

SETTING

A&E department in a teaching hospital, in south London, UK.

METHOD

From July to November 2001 a urine based chlamydia screening test was offered to 719 consecutive A&E attendees aged 16-35 years and their companions. Participants were given an information sheet and were asked to complete a demographic and sexual health questionnaire. Following informed consent, eligible participants provided first pass urine specimens. Specimens were tested for C. trachomatis using nucleic acid amplification.

RESULTS

Of the A&E attendees asked, 76.5% (550/719) agreed to participate. Prevalence of genital chlamydial infection was 4.2% (18/432; 95% confidence interval (CI) 2.5 to 6.6). 12 of the positive participants (66.7%; 95% CI 40.99 to 86.65) were women, of whom seven were Afro-Caribbean. Nine of the chlamydia positive participants (50%; 95% CI 26.0 to 73.9) were aged 25 years. Three of the positive urine specimens were from companions, of whom a total of 143 were screened. All the positive participants were contactable, and were offered treatment.

CONCLUSION

Urine based screening for undiagnosed genital chlamydial infection in the A&E department was acceptable and feasible. The department provides a unique site for screening young patients and companions, men and women.

Associations between Mycoplasma genitalium, Chlamydia trachomatis, and pelvic inflammatory disease

OBJECTIVE

To evaluate the association between Mycoplasma genitalium, Chlamydia trachomatis, and pelvic inflammatory disease (PID) METHODS: A case-control methodology was used. Swab eluates were processed using the QIAamp DNA mini kit. Polymerase chain reaction (PCR) for M. genitalium was carried out using a real time in-house 16S based assay. An endocervical swab was taken and tested for the presence of C. trachomatis (ligase chain reaction, Abbott Laboratories), and a high vaginal swab was taken and tested for the presence of Neisseria gonorrhoeae and bacterial vaginosis.

RESULTS

Of the PID cases 13% (6/45) had evidence of M. genitalium infection compared to none of the controls (0/37); 27% (12/45) of the cases had C. trachomatis infection compared to none of the controls; and 16% (7/45) of cases only had serological evidence of C. trachomatis infection compared to 5% (2/37) of controls. Cases were more likely to present with M. genitalium and/or C trachomatis than controls (p<0.001).

CONCLUSIONS

This study indicates that there may be an association between M. genitalium and PID, and that this relation is largely independent of C. trachomatis. Future studies need to investigate the pathological basis of the relation between M. genitalium and PID using samples from women with PID diagnosed using laparoscopy and endometrial biopsy. Little is known about the epidemiology of M. genitalium: large scale epidemiological investigations are needed to determine the prevalence, incidence, and factors associated with this emerging infection.

Evaluation of a novel diagnostic test for bacterial vaginosis: 'the electronic nose'

The objectives were, first, to determine the sensitivity and specificity of the Osmetech Microbial Analyser (OMA) for the diagnosis of bacterial vaginosis (BV) and, secondly, to determine the factors that interfere with the performance of the test. Women presenting to a genitourinary medicine clinic underwent routine screening for genital infections. Additional swabs were tested on the OMA, and by Nugent scoring. The optimum method for sampling was determined on the first 372 samples. BV was diagnosed in 182 (27%) of the remaining 665 subjects by Amsel criteria, and 188 (29%) of 642 women with evaluable Gram-stains. The sensitivity and specificity of the OMA were 81.45% and 76.1% compared to Amsel criteria and 82.9% and 77.3% compared to Gramstain. Further refinements to improve the sensitivity and specificity of the OMA are required to provide an accurate near patient testing method.

Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa

BACKGROUND

Anorexia nervosa is a disorder of high morbidity and significant mortality. It is commonest in young adult women, in whom the incidence may be increasing. The focus of treatment has moved to an outpatient setting and a number of differing psychotherapies are presently used in treatment.

OBJECTIVES

The aim of the present review was to evaluate the evidence from randomised controlled trials for the efficacy of outpatient psychotherapies used in the treatment of older adolescents and adults with anorexia nervosa

SEARCH STRATEGY

The strategy comprised database searches of MEDLINE, EXTRAMED, EMBASE,PSYCLIT, CURRENT CONTENTS, Cochrane Collaboration Controlled Trials Register and the Depression and Anxiety Neuroses Cochrane Group (CCDAN), a hand-search of The International Journal of Eating Disorders, and he reference lists of all papers selected. Personal letters were sent to identified notable researchers published in the area, requesting information on trials that are unpublished or in progress.

SELECTION CRITERIA

All randomised controlled trials of adult individual outpatient therapy for anorexia nervosa as defined by the DSM-IV or similar international criterion. Quality ratings were made according to the CCDAN criteria and in addition, whether the trial had examined treatment integrity.

DATA COLLECTION AND ANALYSIS

A range of outcome variables were selected, including physical state, severity of eating disorder attitudes and beliefs, interpersonal function, and general psychiatric symptom severity. Continuous outcome data comparisons were made with the standardized mean difference statistic, and binary outcome comparisons made with the relative risk statistic. Reliability of data extraction and quality ratings were made with the kappa statistic. Sensitivity analyses to evaluate the effects of trial quality and subgroup analyses to explore specific questions of treatment effects from different settings, frequency and duration of therapies were planned.

MAIN RESULTS

Six small trials only, two of which included children or adolescents, were identified from the search and aggregation of data was not possible. Bias was possible due particularly to lack of blinding of outcome assessments. The results in two trials suggested that 'treatment as usual' or similar may be less efficacious than a specific psychotherapy. No specific treatment was consistently superior to any other specific approach. Dietary advice as a control arm had a 100% non-completion rate in one trial.

REVIEWER'S CONCLUSIONS

No specific approach can be recommended from this review. It is unclear why 'treatment as usual' performed so poorly or why dietary advice alone appeared so unacceptable as the reasons for non-completion were not reported. There is an urgent need for large well-designed trials in his area.

An international study of the interobserver variation between interpretations of vaginal smear criteria of bacterial vaginosis

An international workshop on vaginal smear-based diagnosis of bacterial vaginosis was organized where 13 investigators scoring 258 slides with smears from vaginal fluid. Interobserver reproducibility of interpretations of Nugent scores, Hay/Ison scores and wet smear scores for the diagnosis of bacterial vaginosis was shown to be high. Detailed analysis of individual scoring results however indicated that basic standards of quality control to ensure robust individual readings of slides must be adhered to.

Long-term follow-up of antiretroviral-naive HIV-positive patients treated with nevirapine

This article reports on the extended follow-up of 125 antiretroviral (ARV)-naive patients treated with nevirapine (NVP) in the United Kingdom. The patients have been observed for a median of 1.8 years after starting NVP (range, 4 days-2.7 years). Baseline CD4 counts and HIV RNA levels were 210 (interquartile range, 130 - 335) cells/mm3 and 4.86 (range, 4.52-5.26) log10 copies/ml, respectively. Eleven patients (9.0%) developed a rash thought to be related to NVP, of whom 4 permanently discontinued NVP. Twenty-four months after starting NVP, RNA levels had dropped by a median of 2.32 log10 copies/ml and CD4 counts increased by a median of 143 cells/mm3. In all, 96 patients had at least one viral load measured <500 copies/ml, a median of 2.8 months after starting NVP. RNA levels rebounded >500 copies/ml in 37 of these patients, on average 2 years after initial response. In conclusion, in ARV-naive patients, NVP is generally well tolerated and long-term response rates are good.

Experience of nevirapine use in a London cohort of HIV-infected pregnant women

OBJECTIVE

To describe the experience of four London HIV centres prescribing nevirapine (NVP) to HIV-1 infected pregnant women with respect to immunological and virological response, tolerability and pregnancy outcome.

METHODS

We identified all HIV-1-infected women who received NVP as part of a triple antiretroviral regimen during pregnancy between January 1997 and September 1999. Laboratory results, clinical events, side-effects and pregnancy outcome were abstracted using a standardized proforma from the medical records.

RESULTS

Forty-six women were identified, 85% of whom were black African. At initiation of NVP, the median age was 29 years and the median baseline CD4 cell count and viral load were 242 cells/microL and 4.15 log10 copies/mL, respectively. Thirty-two out of 36 women who had a plasma sample obtained at, or just prior to, delivery had an undetectable viral load (< 50 to < 400 copies/mL). Adverse events that were definitely attributed to NVP included a generalized rash (n = 2) and hepatitis (n = 2). Obstetric complications occurred in nine women (19.5%), which was not statistically different (P = 0.36) from that found in a historical (1990-96) control group 7/51 (14%). The rate of preterm delivery (13%) was similar to that previously reported in HIV-1 infected pregnant women (18%).

CONCLUSIONS

NVP (as part of highly active antiretroviral therapy) reduced plasma viraemia to below the limit of detection in 89% of women. It was generally well tolerated and clinical and laboratory adverse events were infrequent. There was no evidence of an increase in obstetric complications including preterm delivery during the second and third trimesters of pregnancy.

Antidepressants versus placebo for people with bulimia nervosa

BACKGROUND

Bulimia Nervosa (BN) represents an important public health problem and is related to serious morbidity and even mortality. This review attempted to systematically evaluate the use of antidepressant medications compared with placebo for the treatment of bulimia nervosa.

OBJECTIVES

The primary objective of this review was to determine whether using antidepressant medications was clinically effective for the treatment of bulimia nervosa. The secondary objectives were: (i) to examine whether there was a differential effect for the various classes/types of antidepressants with regard to effectiveness and tolerability (ii) to test the hypothesis that the effect of antidepressants on bulimic symptoms was independent of its effect on depressive symptoms

SEARCH STRATEGY

(1) electronic searches of MEDLINE (1966 to December 2000), EMBASE (1980-December 2000), PsycLIT (to December 2000), LILACS & SCISEARCH (to 1997) (2) the Cochrane Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register - ongoing (3) inspection of the references of all identified trials (4) contact with the pharmaceutical companies and the principal investigator of each included trial (5) inspection of the International Journal of Eating Disorders - ongoing

SELECTION CRITERIA

INCLUSION CRITERIA

every randomized, placebo-controlled trial in which antidepressant medications were compared to placebo to reduce the symptoms of bulimia nervosa in patients of any age or gender. Quality criteria: reports were considered adequate if they were classified as A or B according to the Cochrane Manual. The Jadad scale, with a cut off of 2 points, was applied to check the validity of the above referred criterion but was not used as an inclusion criterion.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers for each included trial. Dichotomous data were evaluated by the relative risk with 95% confidence intervals (CI) around this measure, based on the random effects model; continuous data were evaluated by the standardised mean difference with the 95% CI. NNT was calculated using the inverse of the absolute risk reduction.

MAIN RESULTS

Currently the review includes 16 trials comparing antidepressants with placebo: 6 trials with TCAs (imipramine, desipramine and amitryptiline), 3 with SSRIs (fluoxetine), 4 with MAOIs (phenelzine, isocarboxazid and brofaromine) and 3 with other classes of drugs (mianserine, trazodone and bupropion). Similar results were obtained in terms of efficacy for these different groups of drugs. The pooled RR for remission of binge episodes was 0.88 (95% CI 0.83-0.93; p<0,001) favoring drugs. The NNT for a mean treatment duration of 8 weeks, taking the non-remission rate in the placebo controls of 92% as a measure of the baseline risk was 9 (95% CI 6 - 16). The RR for clinical improvement, defined as a reduction of 50% or more in binge episodes was 0.63 (95% CI 0.55-0.74) and the NNT for a mean treatment duration of 9 weeks was 4 (95% CI 3 - 6), with a non-improvement rate of 67% in the placebo group. Patients treated with antidepressants were more likely to interrupt prematurely the treatment due to adverse events. Patients treated with TCAs dropped-out due to any cause more frequently that patients treated with placebo. The opposite was found for those treated with fluoxetine, suggesting it may be a more acceptable treatment. Independence between antidepressant and antibulimic effects could not be evaluated due to incomplete published data.

REVIEWER'S CONCLUSIONS

The use of a single antidepressant agent was clinically effective for the treatment of bulimia nervosa when compared to placebo, with an overall greater remission rate but a higher rate of dropouts. No differential effect regarding efficacy and tolerability among the various classes of antidepressants could be demonstrated.

Antidepressants versus psychological treatments and their combination for bulimia nervosa

BACKGROUND

Psychotherapeutic approaches, mainly cognitive behavior therapy, and antidepressant medication are the two treatment modalities that have received most support in controlled outcome studies of bulimia nervosa.

OBJECTIVES

The primary objective was to conduct a systematic review of all RCTs comparing antidepressants with psychological approaches or comparing their combination with each single approach for the treatment of bulimia nervosa.

SEARCH STRATEGY

(1) electronic searches of MEDLINE (1966 to December 2000), EMBASE (1980-December 2000), PsycLIT (to December 2000), LILACS & SCISEARCH (to 1999) (2) the Cochrane Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register - ongoing (3) handsearches of the references of all identified trials (4) contact with the pharmaceutical companies and the principal investigator of each included trial (5) handsearch of the International Journal of Eating Disorders - ongoing

INCLUSION CRITERIA

every randomized controlled trial in which antidepressants were compared with psychological treatments or the combination of antidepressants with psychological approaches was compared to each treatment alone, to reduce the symptoms of bulimia nervosa in patients of any age or gender. Quality criteria: reports were considered adequate if they were classified as A or B according to the Cochrane Manual.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers for each included trial. The main outcome for efficacy was full remission of bulimic symptoms, defined as 100% reduction in binge or purge episodes from baseline to endpoint. Dichotomous data was evaluated by the relative risks and 95% confidence intervals around this measure, based on the random effects model; continuous data was evaluated by the average difference and the 95% confidence interval. Number needed to treat (NNT) and number needed to harm (NNH) were calculated using the inverse of the absolute risk reduction.

MAIN RESULTS

Five trials were included in comparison one (antidepressants versus psychological treatments), five in comparison two (antidepressants versus the combination) and seven in comparison three (psychological treatments versus the combination). Remission rates were 20% for single antidepressants compared to 39% for single psychotherapy (DerSimonian-Laird Relative Risk = 1.28; 95% Confidence Interval = 0.98;1.67). Dropout rates were higher for antidepressants than for psychotherapy (DerSimonian-Laird Relative Risk = 2.18; 95% Confidence Interval = 1.09;4.35). The NNH for a mean treatment duration of 17.5 weeks was 4 (95% confidence interval = 3;11). Comparison two found remission rates of 42% for the combination versus 23% for antidepressants (DerSimonian-Laird Relative Risk = 1.38; 95% Confidence Interval = 0.98;1.93). Comparison three showed a 36% pooled remission rate for psychological approaches compared to 49% for the combination (DerSimonian-Laird Relative Risk = 1.21; 95% Confidence Interval = 1.02;1.45). The NNT for a mean treatment duration of 15 weeks was 8 (95% Confidence Interval = 4;320). Dropout rates were higher for the combination compared to single psychological treatments (DerSimonian-Laird Relative Risk = 0.57; 95% Confidence Interval = 0.38;0.88). The NNH was 7 (95% Confidence Interval = 4;21).

REVIEWER'S CONCLUSIONS

Using a more conservative statistical approach, combination treatments were superior to single psychotherapy. This was the only statistically significant difference between treatments. The number of trials might be insufficient to show the statistical significance of a 19% absolute risk reduction in efficacy favouring psychotherapy or combination treatments over single antidepressants. Psychotherapy appeared to be more acceptable to subjects. When antidepressants were combined to psychological treatments, acceptability of the latter was significantly reduced.

Spinal malformations in the fetuses of HIV infected women receiving combination antiretroviral therapy and co-trimoxazole

HIV positive women of reproductive age are increasingly treated with a combination of antiretroviral agents, with effects on the developing human fetus that are largely unknown. We report two cases of severe spinal malformations in the fetuses of women treated with combination antiretroviral therapy and co-trimoxazole.

Recurrent Bacterial Vaginosis

Bacterial vaginosis (BV) is a common cause of vaginal discharge in women of childbearing age. In some individuals, it recurs frequently after treatment, frustrating both the patient and the physician. Standard BV treatment--metronidazole or clindamycin, administered either intravaginally or orally--is followed by relapse in approximately 30% of cases, within one month. Our inability to prevent relapse reflects our lack of understanding of how BV originates. BV has been associated with infectious morbidity in obstetrics and gynecology. Recent studies have found it to be a risk factor for HIV spread. These findings increase the need for us to be able to control recurrent BV and reduce its prevalence in the general population.

Is acute appendicitis another inflammatory condition associated with highly active antiretroviral therapy (HAART)?

OBJECTIVE

To report the occurrence of acute appendicitis as a possible manifestation of the immune restoration inflammatory syndrome (IRIS) following the commencement of highly active antiretroviral therapy (HAART) in HIV patients.

DESIGN

Case-note review of HIV patients on HAART with acute appendicitis.

METHODS

Review of HIV markers, antiretroviral therapy and abdominal ultrasound results of four HIV patients with acute appendicitis and the histopathology reports on the appendix in two of the patients.

RESULTS

From a population of approximately 350 HIV patients on HAART, we found four patients who developed acute appendicitis within 6 months of commencing or changing HAART.

CONCLUSION

Acute appendicitis occurring in HIV patients on HAART may represent a variant of IRIS. Further immunohistopathological and epidemiological evaluation will be needed to define this relationship fully.

Loss of CD4+ T cell proliferative ability but not loss of human immunodeficiency virus type 1 specificity equates with progression to disease

In this study, we compared human immunodeficiency virus (HIV) type 1-specific proliferative responses with HIV-1-induced intracellular cytokine production in a cohort of clinically nonprogressing patients and individuals with progressive HIV-1 infection. We found strong HIV-1-specific proliferative responses in the clinical nonprogressor cohort that correlated with significant numbers of circulating HIV-1-specific CD4(+) T cells. In contrast, HIV-1-specific proliferative responses were absent in most individuals with progressive HIV-1 infection, even though interferon-gamma-producing HIV-1-specific CD4(+) T cells were detectable by flow cytometry. The implication of these data is that the important dysfunction seen in most HIV-positive patients from very early in disease may be an inability of HIV-1-specific CD4(+) memory T cells to proliferate in response to HIV antigens rather than an absolute loss of circulating virus-specific CD4(+) T cells.

Thalidomide analogue CC-3052 reduces HIV+ neutrophil apoptosis in vitro

Thalidomide has significant immunomodulatory properties and has been used successfully in the treatment of oral ulcers and wasting in HIV patients. However, its use is limited by its poor bioavailability due to low solubility and short half life in solution, and teratogenic and neurotoxic side-effects. Recently, water-soluble analogues of thalidomide with significantly greater immunomodulatory activity and reduced side-effects have become available. We examined the effect of thalidomide and one analogue, CC-3052, on neutrophil apoptosis following culture for 20 h in vitro. Apoptosis was assessed by reduced CD16 expression and Annexin V binding using flow cytometry. Thalidomide or CC-3052 alone had no effect on neutrophil apoptosis when used at physiological levels. However, when used together with prostaglandin E2 (10-7 M), a potent adenylate cyclase activator, CC-3052 but not thalidomide (both 10-5 M) reduced apoptosis in neutrophils from normal and HIV+ donors. The reduced apoptosis could not be attributed to the ability of CC-3052 to reduce tumour necrosis factor-alpha (TNF-alpha) production, but may be due to its PDE4 inhibitor properties, as it increased [cAMP]i, and mimicked the effect of increasing [cAMP]i using dibutryl cAMP, a membrane-permeable analogue of cAMP. The results suggest a role for thalidomide analogue CC-3052 in reducing persistent activation of the TNF-alpha system in HIV without markedly impairing neutrophil viability.

Antidepressants versus placebo for the treatment of bulimia nervosa: a systematic review

OBJECTIVE

The objective of this study was to valuate the effectiveness, tolerability and acceptability of various classes of antidepressants compared with placebo in the treatment of bulimia nervosa.

METHOD

A meta-analysis including 16 randomised controlled trials and 1300 bulimic patients was performed. Dichotomous outcomes were analysed by calculating relative risks, and continuous outcomes by calculating effect sizes. Methodological quality, heterogeneity in the results and selective publication were assessed.

RESULTS

Short-term remission in bulimic symptoms was statistically more likely on antidepressants than placebo (Relative Risk=0.88, 95% CI=0.83-0.94, p<0.0001). Drop-out rates were high but no statistical difference was found between treatment groups (34.6% and 31.4% for drug and placebo; RR=1.03, 95% CI=0.80-1.32, p=0.8). No difference in efficacy could be demonstrated among different classes of antidepressants.

CONCLUSIONS

The use of a single antidepressant agent was clinically effective for the treatment of bulimia nervosa when compared with placebo, with an overall greater remission rate and a higher rate of drop-outs. No differential effect regarding efficacy and tolerability among the various classes of antidepressants could be demonstrated.

Combination of antidepressants and psychological treatments for bulimia nervosa: a systematic review

This review assessed the effect of a combination of antidepressants plus psychological approaches compared to each single treatment for bulimia nervosa.

METHOD

Trials were included in two meta-analyses: single antidepressants versus combination and single psychological approaches versus combination. Methodological quality and homogeneity of results were assessed. Dichotomous outcomes were analysed by calculating relative risks (RR).

RESULT

Five trials were included in meta-analysis 1 and 7 in meta-analysis 2. Remission rates were 42% for combination versus 23% for antidepressants (RR = 1.38; 95% CI=0.98-1.93; P=0.06) and 36% for psychological approaches compared to 49% for combination (RR= 1.21; P=0.03). Drop-out rates were 16% for psychological approaches and 30% for combination (RR =0.57; 95% CI = 0.38-0.088; P=0.11).

CONCLUSION

Efficacy of combined treatments was superior to single approaches. When antidepressants were combined to treatment, acceptability of psychological approaches was significantly reduced.

Condom promotion in women attending inner city general practices for cervical smears: a randomized controlled trial

BACKGROUND

Although condom promotion schemes have been widely piloted in UK general practices, there have been no rigorous evaluations of their effectiveness.

OBJECTIVES

To see if a practice-based sexual health education intervention increases the number of women having smears who are given condoms and advice on avoiding STDs. To see if this low cost intervention affects subsequent condom use.

METHOD

We conducted a cluster randomized trial of condom promotion in 1382 women aged <35 years attending 28 South London general practices for cervical smear tests.

RESULTS

More women in intervention than control practices reported receiving advice on avoiding sexually transmitted infections (27% versus 10%) and being given condoms (28% versus 1%, P < 0.05). However, there was no difference in subsequent condom use, even in the 22% of women reporting >/=2 sexual partners in the previous year.

CONCLUSIONS

To provide evidence of effectiveness, future interventions may need to be more intensive or focus on higher risk groups.

Hydroxyurea-induced nail pigmentation in HIV patients

Hydroxyurea (HU), a cytotoxic agent used in myeloproliferative disorders, has recently been introduced as an adjunct to combination anti-retroviral therapy. We describe abnormal nail pigmentation in four HIV-seropositive patients treated with HU and discuss the likely factors associated with its development.

Incidence of gonorrhoea diagnosed in GUM clinics in South Thames (west) region

OBJECTIVES

To describe the incidence of gonorrhoea diagnosed in genitourinary medicine (GUM) clinics in South Thames (West) between 1995 and 1996, and how it changed among population subgroups.

SETTINGS AND SUBJECTS

Cases of uncomplicated and complicated gonorrhoea diagnosed at 13 GUM clinics in the former South Thames West (STW) Regional Health Authority that reported disaggregate data to the South Thames GUM Clinic Collaborative STD Surveillance Scheme.

METHODS

Annual incidence rates (per 100,000) of gonorrhoea diagnoses by sex, age group, ethnic group, area of residence, and year were calculated. Poisson regression models were used to calculate risk ratios (RR) to describe the key differences in the variation of gonorrhoea cases by these variables. Relative differences in the incidence of diagnosed gonorrhoea between 1995 and 1996 were investigated by including an interaction between year and the other variables (age group, sex, ethnic group, region) and testing whether any were significant using a likelihood ratio test.

RESULTS

Area of residence, sex, age group, and ethnic group were key predictors of the rates of diagnosed gonorrhoea. The risk ratio for gonorrhoea (after adjustment for the other variables) was: 13 times higher among blacks than the white population; twice as high in inner London compared with outer London; and three times lower in the "shire" region compared with outer London. The rate of diagnosed gonorrhoea was significantly higher in the black population in the shire region than the inner London white population. The rate of gonorrhoea diagnosed by GUM clinics from 1995 to 1996 almost doubled in the white population aged 15-44 years, from 16 cases per 100,000 to 30 cases per 100,000 (adjusted RR 2.0, 95% CI 1.6 to 2.4), whereas increased rates in the black and Asian/other ethnic groups were not statistically significant (adjusted RR 1.1, 95% CI 0.9 to 1.4; and 1.4, 95% CI 0.7 to 2.7 respectively).

CONCLUSION

The observed increase in gonorrhoea between 1995 and 1996 occurred mostly among heterosexual white men and women. Overall, the rates of gonorrhoea among young people, especially in the black population and in inner London represent a significant public health problem that may merit further targeted interventions, the effectiveness of which could be monitored through further development of routine surveillance data.

Bacterial vaginosis: sequelae and management

The prevalence and complications of bacterial vaginosis are population dependent. In pregnancy, bacterial vaginosis is associated with late miscarriages and infection driven pre-term delivery. Regardless of the aetiology of pre-term delivery, surviving infants are at increased risk of subsequent neurodevelopmental handicap. Intervention studies in bacterial vaginosis positive pregnant women at high risk of pre-term delivery demonstrate the benefits of antibiotic treatment. Current evidence suggests that bacterial vaginosis may increase the efficiency of heterosexual HIV transmission. Metronidazole remains the mainstay of treatment of bacterial vaginosis. No treatment prevents relapse, which occurs in 20-30% of cases within 1 month. New approaches that are based on a better understanding of the pathophysiology of bacterial vaginosis are required to improve the clinical management of recurrent bacterial vaginosis.

The epidemiology of eating disorder behaviors: an Australian community-based survey

OBJECTIVE

The study aims were to evaluate the prevalence and distribution of respective eating disorder behaviors (DSM-IV criteria) in a representative community-based sample.

METHOD

Data were obtained from 3,001 interviews of a randomly selected sample of 4,200 individuals' (age > 15 years) households in South Australia.

RESULTS

Ninety-six (3.2%) of respondents had regular current episodes of binge eating, 48 (1.6%) regularly fasted or used strict dieting, 24 (0.8%) purged. An estimated 8 (0.3%) had bulimia nervosa and 30 (1%) had binge eating disorder. Binge eating and dieting were most common in people who were in their early to mid thirties. Dieting and purging, but not regular binge eating, were more common in women than in men. Purging was most common in the 35-44 year age range. The only behavior significantly associated with (increased) weight was binge eating. Unmarried subjects were less likely to diet than married subjects. No significant differences in rates of these behaviors were found for household income.

DISCUSSION

Problematic eating disorder behaviors in older women and in men were more common than expected and merit further clinical and research attention.

Abnormal intracellular IL-2 and interferon-gamma (IFN-gamma) production as HIV-1-assocated markers of immune dysfunction

We used three-colour cytometry to analyse intracellular cytokine production in activated whole blood cultures derived from patients with HIV-1 infection. We assessed mitogen-induced IL-2, IL-4 and IFN-gamma production from T cells as possible markers of immune dysfunction. The percentages of T cells staining for IL-2 were significantly reduced in stimulated cultures from HIV+ individuals relative to normal controls (P<0.0001); this reduction was observed in both the CD4+ and the CD8+ subsets. IL-2 production was significantly reduced in CD4+ T cells from HIV+ individuals clinically classified as symptomatics compared with HIV+ asymptomatics (P<0.001); in addition, production of IL-2 inversely correlated with viral load (r2=0.832). On the other hand, HIV+ individuals showed significantly more T cells staining positive for IFN-gamma (P<0.0001); subset analysis identified these T cells as CD8+. Increased IFN-gamma production in the CD8+ T cell subset of HIV+ individuals correlated neither with clinical status nor with plasma viral load. IL-4 staining in activated T cells was low (<5%) and no differences were observed between HIV+ and control groups. Three-colour FACS analysis of whole blood provides a sensitive, rapid and relatively easy means to detect cytokine profiles within T cell subpopulations. Only small volumes of blood are required (0.5 ml), since there is no need for cell isolation, making it more practical than ELISA or reverse transcriptase-polymerase chain reaction (RT-PCR) for the analysis of immune function in HIV+ individuals. This technique could therefore play a role in mapping the dynamics and extent of immune recovery in AIDS patients undergoing triple combination therapy.

The validity of the DSM-IV scheme for classifying bulimic eating disorders

OBJECTIVE

This study was designed to assess the validity of the DSM-IV scheme for classifying recurrent binge eating.

METHOD

A general population sample of 250 young women with recurrent binge eating was recruited using a two-stage design. Information on their eating habits and associated psychopathology was obtained by personal interviews. Subjects were reassessed 1 year later.

RESULTS

The diagnosis of bulimia nervosa had good descriptive and predictive validity. On present state features it was not possible to distinguish binge-eating disorder from the nonpurging subtype of bulimia nervosa. However, these groups differed in their outcome at 1 year. Within eating disorder not otherwise specified (EDNOS), there was a subgroup of subjects with milder symptoms which were relatively unstable over time.

DISCUSSION

The findings suggest that bulimic eating disorders exist on a continuum of clinical severity, from bulimia nervosa purging type (most severe), through bulimia nervosa nonpurging type (intermediate severity), to binge-eating disorder (least severe). The data on outcome support retaining a distinction between nonpurging bulimia nervosa and binge-eating disorder.

Failure of trimethoprim in the treatment of donovanosis

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Optimisation of a peptide-based indirect ELISA for the detection of antibody in the serum of HIV-1 seropositive patients

A modified peptide-based indirect ELISA technique for the detection of HIV-1 specific antibodies in the sera of HIV-1 seropositive individuals is described. We found that the reduction of non-specific binding of HIV-1 seropositive sera to the ELISA plate was essential for the reliable detection of serum antibodies in the peptide based indirect ELISA. Optimal results were obtained using Immulon microtitre plates, different concentrations of denatured. purified grade of casein in the blocking (1%) and washing (0.25%) solutions and by diluting HIV-1 seropositive sera 1 in 1600. These conditions reduced non-specific binding and improved assay sensitivity. We show that the inclusion of a control peptide is essential to reducing the incidence of false positive and false negative results. Taken together, the modifications described in this report improve reliability of the peptide-based indirect ELISA without compromising its sensitivity and have particular relevance for those wishing to apply the peptide-based indirect ELISA technique to serum samples which exhibit high levels of non-specific binding. To illustrate this, levels of antibody in the sera of HIV-1 seropositive and seronegative donors that are specific for peptides derived from a conserved region of HIV-1 gp120 sharing homology with the FAS apoptosis antigen were analysed using this technique.

General practice update: chlamydia infection in women

The prevalence of cervical Chlamydia trachomatis infection in general practice populations ranges between 2% and 12%. Untreated infection can cause pelvic inflammatory disease, tubal infertility and ectopic pregnancy. These risks are increased by cervical invasive procedures, especially termination of pregnancy. However, most women with chlamydia infection have no symptoms. General practitioners and practice nurses carrying out pelvic examinations should have facilities for taking endocervical specimens for chlamydia. Routine chlamydia screening, should be considered if the local prevalence of infection is over 6%. Otherwise chlamydia testing should be offered to women requesting termination of pregnancy and to those who have risk factors: aged less than 25 years, absence of barrier contraception, recent change of sexual partner, vaginal discharge, friable cervix or sterile pyuria. Women found to have chlamydia infection need appropriate antibiotics, advice about contact tracing and referral to a genitourinary medicine clinic. Good communication between general practitioners and genitourinary physicians is essential. Both general practitioners and practice nurses have an important role to play in reducing the prevalence of cervical chlamydia infection and its potentially devastating consequences.

Does neurosurgery for obsessive-compulsive disorder produce personality change?

Seventeen patients suffering from intractable obsessive-compulsive disorder treated with neurosurgery were assessed before surgery and a mean 10 +/- 5.1 years after surgery. Change in personality was assessed using a special 34-item schedule on patients and informants. The majority of subjects had not noted any significant changes in personality. The subjects were rated by themselves and their informants to have improved overall in the following characteristics: they were less obsessional, cried less, demonstrated a greater depth of feelings, laughed more, were more sociable, and were less anxious or dependent. Six subjects were judged by informants to have improved in their degree of obsessionality, which was distinguishable from the impact on obsessive-compulsive symptoms. The traits that showed an overall negative change were initiative/drive and energy level. Four subjects (2/4 open and 2/13 stereotactic surgery) were judged to have a negative personality change. Ratings of neuroticism, anxiety, depression, and capacity for pleasure showed significant improvement. We conclude that while most obsessive-compulsive disorder patients treated with stereotactic surgery do not experience a personality change, a small proportion report a positive or negative impact. Of note is the improvement in obsessionality in some patients, and an adverse personality change of the "frontal lobe type" in a few patients.

Neuropsychological outcome from psychosurgery for obsessive-compulsive disorder

Seventeen obsessive-compulsive disorder patients treated with psychosurgery were administered a comprehensive neuropsychological test battery. Their performance on neuropsychological testing was compared with that of an age and severity matched sample of 17 OCD sufferers who had not received psychosurgery. The psychosurgery and control groups did not differ in intellectual or memory functioning, consistent with earlier findings that psychosurgery does not reduce global ability estimates. The psychosurgery group performed more poorly than the control group on an adaptation of the Wisconsin Card Sorting Test, demonstrating the possible impact of frontal lobe lesions on the abilities underpinning the formation and shifting of response sets.

Fluid handling properties of hydrogel dressings

The fluid handling properties of four hydrogel dressings were examined in a laboratory-based study to determine their ability to absorb liquid from or donate liquid to a range of standard test substrates simulating wound tissue in various states of hydration. The tests suggest that three of the dressings are likely to be effective fluid-donating agents, and one of the dressings has a dual ability to donate or absorb liquid depending upon moisture content and nature of the substrate to which it is applied. These observations are discussed in the context of the clinical use of hydrogel dressings.