Ambivalence and Pregnancy: The Effect of Adolescents' Attitudes on Contraception and Pregnancy

It has been argued that adolescents who get pregnant often do not sufficiently appreciate its unfavorable consequences, and that prevention programs should target participants' attitudes towards pregnancy. This study tests whether the nature and certainty of sexually active adolescent girls' attitudes towards pregnancy influence their contraceptive consistency and risk of pregnancy. It also tests whether attitudes towards contraception influence contraceptive consistency. Data are drawn from the National Longitudinal Study of Adolescent Health, a nationwide prospective study of adolescents in grades 7-12. Attitudes towards pregnancy, attitudes towards contraception, knowledge about fertility and other individual characteristics are included in a multivariate model of contraceptive consistency. Those variables, as well as contraceptive consistency itself, are then included in a multivariate model of pregnancy. Net of other factors, girls' attitudes towards getting pregnant did not affect whether they actually became pregnant. However, ambivalence about pregnancy made girls less likely to use contraception. Girls who were most opposed to pregnancy did not differ in contraceptive consistency from those least opposed. Implications for pregnancy prevention efforts are discussed

Metabolismus von Psychopharmaka durch das Cytochrom P450-Enzymsystem im Alter

Altern geht mit einer Reihe physiologischer Veränderungen einher. Da in höherem Lebensalter überdurchschnittlich viele Arzneistoffe eingenommen werden und häufig mehrere Erkrankungen gleichzeitig vorliegen, können Auffälligkeiten in den Arzneimittelkonzentrationen im Blut nicht nur altersbedingt, sondern auch krankheitsbedingt oder durch Arzneimittelwechselwirkungen verursacht sein.rnrnDie vorliegende Arbeit untersucht die Fragestellung, ob der Arzneimittelmetabolismus bei Alterspatenten generell, oder nur bei Patienten mit Multimorbidität und –medikation verändert ist, und in welchem Lebensalter diese Veränderungen einsetzen. Im Mittelpunkt stand dabei die Frage, ob die Aktivitäten distinkter Arzneimittel-abbauender Enzyme der Cytochrom P450-Enzym-Familie (CYP) verändert sind. Da viele Psychopharmaka nur bei Patienten im Alter zwischen 18 und 65 Jahren zugelassen sind, wurde die Hypothese geprüft, dass sich Patienten im Alter über und unter 65 Jahren in ihren Medikamentenspiegeln unterscheiden.rnrnFür die Untersuchungen wurde eine Datenbank aus Blutspiegelmessungen erstellt, die im Rahmen des pharmakotherapiebegleitenden TDM erhoben worden waren. Die Blutspiegel stammten von insgesamt 4197 Patienten, die mit Amisulprid, Aripiprazol, Citalopram, Clozapin, Donepezil, Escitalopram, Mirtazapin, Quetiapin, Risperidon, Sertralin, Venlafaxin oder Ziprasidon behandelt wurden. Die Messungen wurden ergänzt mit Angaben aus den TDM-Anforderungsscheinen bezüglich Tagesdosis, Begleitmedikamenten, Schweregrad der Erkrankung, Therapieerfolg und Verträglichkeit der Medikation. Zusätzlich wurden klinische Befunde der Leber- und Nierenfunktion einbezogen, sowie Angaben zur Berechnung des BMI. Die in vivo-CYP-Enzymaktivitäten wurden anhand von metabolischen Ratios (Serumkonzentrationen Metabolit/ Serumkonzentration Muttersubstanz) beurteilt.rnrnIm Mittel stieg der Schweregrad der Erkrankung mit dem Alter und der Therapieerfolg verschlechterte sich. Dies betraf im Einzelnen nur Patienten, die mit Amisulprid oder Clozapin behandelt worden waren. Ältere Patienten litten häufiger an Nebenwirkungen als jüngere.rnUnter Aripiprazol, Quetiapin, Sertralin und Venlafaxin erreichten Alterspatienten mit niedrigeren Tagesdosen gleiche Therapieerfolge wie jüngere Patienten.rnPatienten, die mit Clozapin oder Amisulprid behandelt wurden, zeigten im Alter schlechtere Behandlungserfolge bei gleicher (Clozapin) bzw. niedrigerer (Amisulprid) Tagesdosis.rnTherapieerfolg und mittlere Tagesdosis änderten sich bei Patienten, die Ziprasidon, Donepezil, Citalopram, Escitalopram und Mirtazapin einnahmen, nicht altersabhängig.rnrnAltersabhängige Unterschiede der Serumspiegel zeigten sich für Amisulprid, Aripiprazol, Donepezil, Mirtazapin, Desmethylmirtazapin, Quetiapin und DesmethylsertralinrnAllerdings lagen die Altersgrenzen außer bei Donepezil deutlich niedriger als die gängig angenommene, nämlich bei 35 Jahren (Aripiprazol), 70 Jahren (Donepezil), 55 Jahren (D-Sertralin), 41 Jahren (Amisulprid), 49 Jahren (Quetiapin) und 58 Jahren (Mirtazapin).rnEs bestand kein Zusammenhang zwischen dem Auftreten veränderter Serumspiegel im Alter und dem Verteilungsvolumen, der Plasmaproteinbindung oder der Eliminationshalbwertszeit der untersuchten Wirkstoffe. rnrnBei Patienten ohne Comedikation fand sich in keinem Fall eine altersabhängige Veränderung der Ratio. Es ergab sich daher kein Hinweis auf eine Veränderung der CYP-Aktivität im Alter. Die Einnahme von Comedikation nahm mit dem Alter zu, hierfür ließ sich eine Altersgrenze von 49 Jahren definieren. Unter Polytherapie wurden Veränderungen der CYP-Aktivität beobachtet.rnrnDer Einfluss veränderter Leber- oder Nierenfunktion auf die Biotransformation von Pharmaka wurde anhand von Serumspiegeln von Patienten, die mit Donepezil, Venlafaxin, Citalopram oder Escitalopram behandelt wurden, untersucht. rnBei keinem Wirkstoff wurden unter auffälligen Leber- oder Nierenparametern signifikant veränderte Serumspiegel gemessen.rnEine Abhängigkeit der Serumspiegel vom Körpergewicht wurde nur für Desmethylsertralin gefunden. Die Spiegel waren bei Patienten mit einem Body Mass Index unter 20 signifikant höher als bei Patienten mit einem Index über 20. Aufgrund der kleinen Fallgruppe und der Tatsache, dass der Serumspiegel der Muttersubstanz nicht stieg, konnte nicht zwingend von einem Alterseinfluss aufgrund der veränderten Körperzusammensetzung ausgegangen werden.rnInsgesamt ergaben sich aus den Untersuchungen Hinweise auf moderate altersabhängige Veränderungen der Pharmakokinetik. Es ließen sich allerdings keine allgemeinen Dosierempfehlungen für Alterspatienten ableiten. Es zeigte sich jedoch, dass mit altersabhängigen Veränderungen der Pharmakokinetik bereits nach dem 50. Lebensjahr zu rechnen ist. Weitere Untersuchungen sollten auch den Alterseffekt auf gastrointestinale Transporter einbeziehen, die die aktive Aufnahme von Arzneistoffen ins Blut bewerkstelligen. Unklar ist auch die Rolle des Alterns auf die Aktivität des P-Glykoproteins. rnAging is associated by a number of physiologic alterations. Moreover, comorbid diseases increase with age. Therefore, elderly patients take more medications than younger patients. Reported alterations of drug concentrations in blood of elderly patients may thus be a consequence of age, morbity and/or polypharmacy.rnrnThe aim of this study was to specify pharmacodynamic and pharmacokinetic differences in geriatric patients. It was analysed if changes in drug metabolism occur generally in advanced age, or only in patients with polypharmacy or multimorbidity, aiming to define age thresholds for these changes. The main focus was to identify age-related alterations in cytochrome P450 enzyme (CYP) activities. Since many psychotropic drugs are licensed for patients aged 18 to 65 years, it was hypothesized that drug concentrations are different in patients above 65 years of age.rnData were collected and analysed retrospectively from a therapeutic drug monitoring (TDM) survey for psychiatric patients. Data were raised from 4197 patients receiving amisulpride, aripirazole, citalopram, clozapine, donepezil, escitalopram, mirtazapine, quetiapine, risperidone, sertraline, venlafaxine or ziprasidone. Data collection included information on age, serum concentrations, gender, indication for pharmacologic treatment, reason for TDM, severity of illness, therapeutic effect, side effects and concomitant medication. These data were recorded from the TDM request forms and completed by information from patients’ records. Moreover, body weight and clinical chemistry data on liver- and kidney- parameters were recorded. Metabolic ratios calculated from concentrations of metabolite related to concentrations of parent compound were applied as measures for in vivo CYP–isoenzyme activities.rnGlobal analysis revealed that the severity of illness and therapeutic effects declined with age. In detail, this decline occurred in patients treated with amisulpride or clozapine, but not in patients taking any of the other drugs. Side effects were more common in elderly patients.rnrnUnder aripiprazole-, quetiapine-, sertraline- or venlafaxine- treatment elderly and younger patients showed comparable therapeutic effects related to daily dose.rnTherapeutic effects of clozapine or amisulpride decreased in patients of advanced age, while the mean daily dose was not different for clozapine and lower for amisulpride as in younger patients.rnrnDaily doses and therapeutic effects of citalopram, donepezil, escitalopram, mirtazapine and ziprasidone were comparable in all age groups.rnrnCluster analyses revealed that the age dependent threshold limits were lower than the commonly suggested of 65 years. They were at 35 years (for aripiprazole), 70 years (for donepezil), 55 years (for desmethylsertraline), 41 years (for amisulpride), 49 years (for quetiapine) and 58 years (for mirtazapine)rnAge-related differences in serum concentration were detected for amisulpride, aripiprazole, donepezil, mirtazapine and D- mirtazapine, quetiapine and desmethylsertraline.rnrnAge-dependent alterations in serum concentrations did not correlate with the drugs´ volumes of distribution, plasmaproteinbinding-properties, or elimination half-lives.rnrn rnIn patients under monotherapy, none of the analysed drugs showed an age-related alteration of metabolic ratios. This indicated that there was no age-related decline in CYP-activity.rnrnPolytherapy was more common in patients of 49 years or older.rnInfluence of liver- or kidney malfunction, indicated by laboratory parameters, on drug metabolism was analysed by samples of patients receiving citalopram, donepezil, escitalopram and venlafaxine. None of these serum concentrations were significantly different from these in patients with normal liver- or kidney function.rnrnWith one exception, body weight did not affect serum concentrations of citalopram, sertraline or venlafaxine. In patients with a body mass index below 20, desmethylsertraline serum concentrations were significantly higher than in patients with higher body mass indices. Whether this resulted from pharmacokinetic properties of sertraline interacting with the low percentage of body fat remained unclear.rnrnThe data taken together indicated that age has an effect on the pharmacokinetics of psychoactive drugs. Alterations, however, were moderate and could not be attributed to distinct CYP isoenzymes. Age-dependent alterations in plasma concentrations of psychoacitve drugs must already be considered in patients who are older than 50 years. Further investigations are necessary that examine the effect of age on transporters like P-glycoprotein that are involved in the absorption and distribution kinetics of psychoactive drugs. rn267 S

Ambivalence and Pregnancy: The Effect of Adolescents' Attitudes on Contraception and Pregnancy

It has been argued that adolescents who get pregnant often do not sufficiently appreciate its unfavorable consequences, and that prevention programs should target participants' attitudes towards pregnancy. This study tests whether the nature and certainty of sexually active adolescent girls' attitudes towards pregnancy influence their contraceptive consistency and risk of pregnancy. It also tests whether attitudes towards contraception influence contraceptive consistency. Data are drawn from the National Longitudinal Study of Adolescent Health, a nationwide prospective study of adolescents in grades 7-12. Attitudes towards pregnancy, attitudes towards contraception, knowledge about fertility and other individual characteristics are included in a multivariate model of contraceptive consistency. Those variables, as well as contraceptive consistency itself, are then included in a multivariate model of pregnancy. Net of other factors, girls' attitudes towards getting pregnant did not affect whether they actually became pregnant. However, ambivalence about pregnancy made girls less likely to use contraception. Girls who were most opposed to pregnancy did not differ in contraceptive consistency from those least opposed. Implications for pregnancy prevention efforts are discussed

Housing situation and healthcare for patients in a psychiatric centre in Berlin, Germany: a cross-sectional patient survey

OBJECTIVE: To determine the housing situation among people seeking psychiatric treatment in relation to morbidity and service utilisation. DESIGN: Cross-sectional patient survey. SETTING: Psychiatric centre with a defined catchment area in Berlin, Germany, March-September 2016. PARTICIPANTS: 540 psychiatric inpatients including day clinics (43.2% of all admitted patients in the study period (n=1251)). MAIN OUTCOME MEASURES: Housing status 30 days prior the interview as well as influencing variables including service use, psychiatric morbidity and sociodemographic variables. RESULTS: In our survey, 327 participants (68.7%) currently rented or owned an own apartment; 62 (13.0%) reported to be homeless (living on the street or in shelters for homeless or refugees); 87 (18.3%) were accommodated in sociotherapeutic facilities. Participants without an own apartment were more likely to be male and younger and to have a lower level of education. Homeless participants were diagnosed with a substance use disorder significantly more often (74.2%). Psychotic disorders were the highest among homeless participants (29.0%). Concerning service use, we did neither find a lower utilisation of ambulatory services nor a higher utilisation of hospital-based care among homeless participants. CONCLUSIONS: Our findings underline the need for effective housing for people with mental illness. Despite many sociotherapeutic facilities, a concerning number of people with mental illness is living in homelessness. Especially early interventions addressing substance use might prevent future homelessness

Users' Experiences with Psychosocial Counselling Services in a Community Mental Health Centre

OBJECTIVE: Analysis of users experiences with a low-threshold psychosocial counselling and case management service across separate sectors (e. g., outpatient, inpatient) and legal provisions (e. g., V and XII Books of Social Code). METHODS: Nine semi-structured interviews were conducted and analysed using content analysis. RESULTS: Several aspects of the users' experiences with counselling services have contributed towards their satisfaction with the service. The importance of short waiting times and the on-call telephone service as well as sufficient time taken for consultations, the availability of outreach counselling and the quality of the relationship with the counsellor were all highlighted. Potential for improvement was seen in the visibility of the service in the community. CONCLUSION: The investigated counselling and case management service can help to provide a low-threshold crisis intervention and could place users in more custom-fit community integration services.ZIEL: Analyse der Erfahrungen von Nutzern einer innovativen, rechtskreisübergreifenden psychosozialen Beratungsstelle. METHODE: Neun Einzelinterviews wurden qualitativ-inhaltsanalytisch ausgewertet. ERGEBNISSE: Das Angebot stärkte psychosoziale Ressourcen und die Autonomie der Nutzer. Positiv wurde die aufsuchende Beratung bewertet, kritisiert wurde die begrenzte Sichtbarkeit des Angebots. SCHLUSSFOLGERUNGEN: Eine rechtskreisübergreifende Beratungsstelle kann Hilfesuchende in Krisen auffangen und passgenau gemeindepsychiatrische oder psychosoziale Angebote vermitteln

Interagency Cooperation in a Community Mental Health Centre - A Qualitative Study about the Stakeholders' Experiences

OBJECTIVE This study explores the conditions for the stakeholders' cooperation in an integrative care model for people with psychosocial problems. METHODS Expert interviews on various community mental health care providers were led and content analyzed. RESULTS Joint objectives and conceptually comparable financing models were found to be essential for cooperation across mental health and social integration services. CONCLUSIONS Implementation of intersectoral financing for both clinical and social integration services can promote interagency cooperation.ZIEL Untersucht werden die Kooperationsbedingungen der beteiligten Akteure in einem Modellprojekt zur Koordination von SGB V- und XII-Leistungen. METHODE Interviews mit gemeindepsychiatrischen Akteuren aus der Modellregion und qualitativ-inhaltsanalytischer Auswertung. ERGEBNISSE Ähnliche Steuerungsziele und Vergütungsmodelle sind Voraussetzungen rechtskreisübergreifender Zusammenarbeit. Gemeindeferne Versorgung sowie (infra-)strukturelle Defizite wirken sich hinderlich aus. SCHLUSSFOLGERUNGEN Die Implementierung sektorenübergreifender Finanzierung für Behandlungs- als auch Eingliederungsleistungen sind ein erster Schritt in Richtung rechtskreisübergreifender Kooperation

Mapping education for sustainability in the Nordic countries

The project is concerned with sustainability in compulsory education in the Nordic countries and is part of the Iceland Presidency Project for the Nordic Council of Ministers initiated in 2018. The overall focus of the Presidency Project is on young people but this report looks at policy, curricula, teacher education and school practices. The analysis shows both similarities and differences across the Nordic Region. Compulsory education in the Nordic countries share some striking similarities, reflecting a strong emphasis on certain aspects of sustainability such as equality, democracy.Although sustainability education has a clear application in the fields of social and political life and economic activities in all of the Nordic countries, it is still the case that when sustainability education is discussed, an environmental perspective is most often taken

Magnetic Resonance Enterography Cannot Replace Upper Endoscopy in Pediatric Crohn Disease: An Imagekids Sub-study

Objectives: Although magnetic resonance enterography (MRE) can accurately reflect ileal inflammation in pediatric Crohn disease (CD), there are no pediatric data on the accuracy of MRE to detect upper gastrointestinal tract (UGI) lesions. We aimed to compare MRE and esophagogastroduodenoscopy (EGD) in detecting the spectrum and severity of UGI disease in children. Methods: This is an ancillary study of the prospective multi-center ImageKids study focusing on pediatric MRE. EGD was performed within 2 weeks of MRE (at disease onset or thereafter) and explicitly scored by SES-CD modified for the UGI and physician global assessment. Local and central radiologists scored the UGI region of the MRE blinded to the EGD. Accuracy of MRE compared with EGD was examined using correlational coefficients (r) and area under receiver operating characteristic curves (AUC). Results: One hundred and eighty-eight patients were reviewed (mean age 14 +/- 1 years, 103 [55%] boys);66 of 188 (35%) children had macroscopic ulcerations on EGD (esophagus, 13 [7%];stomach, 34 [18%];duodenum, 45 [24%]). Most children had aphthous ulcers, but 10 (5%) had larger ulcers (stomach, 2 [1%];duodenum, 8 [4%]). There was no agreement between local and central radiologists on the presence or absence of UGI inflammation on MRE (Kappa=0.02, P - 0.71). EGD findings were not accurately detected by MRE, read locally or centrally (r=-0.03 to 0.11, P = 0.18-0.88;AUC - 0.47-0.55, P = 0.53-1.00).No fistulae or narrowings were identified on either EGD or MRE. Conclusions: MRE cannot reliably assess the UGI in pediatric CD and cannot replace EGD for this purpose