Virological treatment outcome under HAART : does sex matter?

Background: In Germany, 17% of 59,000 persons living with HIV/AIDS are female. Accordingly, the research focus in clinical studies as well as in cohort analyses has been almost exclusively on HIV-positive men. As a consequence, there is an urgent need to characterize and evaluate the outcome of HAART in HIV-positive women and to identify special requirements of this particular patient population. Methods: Cross-sectional multicentre (n = 31 centres) evaluation to observe characteristics of 1,557 HIV-positive women receiving medical care in Germany between June 2007 and March 2008. Data acquisition was performed using standardized questionnaires. Summary of results: Of 1,557 HIV-positive women studied, 1,191 (77%) received HAART. Mean age was 40 years and average time of known HIV-infection was 9 years. Risk of HIV transmission was: 40% heterosexual intercourse in Germany, 36% heterosexual intercourse in a high prevalence country; 17% IDU; 7% other reasons for transmission. 46% of the women had a migration background. Mean time on antiretroviral treatment was 7 years. 53% of the female participants had been treated with >2 HAART-regimens. 47% of the study subjects received a PI-based regimen, 33% a NNRTI-based regimen; 20% were on other combinations. The most commonly used PI and NNRTI were lopinavir/r and nevirapine, respectively. Only 48% of all women under HAART achieved a viral load <40 copies/ml. There was a significant difference between the PI-treated group with 44% patients <40 copies/ml and the NNRTI-treated group with 56% <40 copies/ml (p = 0.003). Conclusion: We found that HIV-positive women depicted an inferior virological response to HAART compared to those previously published in German cohort analyses dominated by men (response rates >75%). Possible differences in adherence or drug resistance may have impacted these results and are currently being evaluated in ongoing sub-analyses. Of note, the lack of a study arm with male patients is a limitation of this investigation. However, this is partly off-set by the fact that there are good comparative data in the male population found in other cohorts. We conclude that our results are in discordance to the popular assumption that there are no gender specific differences in virological treatment outcome of HAART

Use of a goal setting intervention to increase adherence to low back pain rehabilitation: A randomized controlled trial

Objective: To examine the effects of a goal setting intervention on self efficacy, treatment efficacy, adherence and treatment outcome in patients undergoing low back pain rehabilitation. Design: A mixed-model 2 (Time) x 3 (Group) randomized controlled trial. Setting: A residential rehabilitation centre for military personnel. Subjects: UK military personnel volunteers (N=48); mean age was 32.9 (SD 7.9) with a diagnosis of non-specific low back pain. Interventions: Subjects were randomly assigned to either a goal setting experimental group (Exp, n=16), therapist-led exercise therapy group (C1, n=16), or non-therapist-led exercise therapy group (C2, n=16). Treatment duration for all groups was 3 weeks. Main measures: Self-efficacy, treatment efficacy and treatment outcome were recorded before and after the treatment period. Adherence was rated during regularly scheduled treatment sessions using the Sports Injury Rehabilitation Adherence Scale (SIRAS). The Biering-Sørensen test was used as the primary measure of treatment outcome. Results: ANCOVA results showed that adherence scores were significantly higher in the experimental group (13.70 ± 1.58) compared with C2 (11.74 ± 1.35), (P<0.025). There was no significant difference for adherence between the experimental group and C1 (P=0.13). Self-efficacy was significantly higher in the experimental group compared to both C1 and C2 (P<0.05), whereas no significant difference was found for treatment efficacy. Treatment outcome did not differ significantly between the experimental and two control groups. Conclusions: The findings provide partial support for the use of goal setting to enhance adherence in clinical rehabilitation

A meta-analysis of the relation between therapeutic alliance and treatment outcome in eating disorders.

The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, βs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments

Predicting alcoholism treatment outcome

The detrimental effects of alcoholism on society have stimulated the growth of addiction treatment centers. These programs are characterized by low completion rates. This fact has promoted a great deal of research aimed toward predicting treatment completion. If those "at risk" for dropping out of programs can be identified, they can be singled out for special consideration which could result in their success with treatment. Alternatively, if it can be determined that clients with certain characteristics have a high probability of completing treatment at specific centers, then patient characteristics can be "matched" with the program shown to offer such people the best opportunity for treatment completion. The majority of studies in this area have used MMPI scales and/or combinations of demographic variables for prediction. In general, these studies have not been very successful or have failed to replicate. Some reasons for this are small sample sizes, a limited number of variables used in prediction, and lack of cross validation. The present research addresses these problems by using large numbers of subjects and predictor variables. Cross validation was performed on an independent sample. Phase One subjects were drawn from archival records; a sample of three hundred and seventy subjects was obtained; two hundred were treatment completers and one hundred seventy non completers. Variables included in the analysis were; age, sex, race, education. marital status, nnuummbbeerr of dependents, employment status, previous treatments, weeks sober prior to treatment, place of residence, prescription medication, referring agent, self reported reasons for referral, and the three validity and ten standard clinical scales of the MMPI, Through discriminant analysis, an overall successful classification rate of 65.4% was obtained. Treatment completers were classified correctly 74.0% and non completers 55.3%. The cross validation sample was obtained and variables collected in the same manner as in phase one. Data from one hundred treatment completers and eighty non completers was collected. The discriminant function from phase one derived an overall successful classification rate of 56.1%. Treatment completers were classified correctly 69.0% and non completers 40.0%. Results highlight a dramatic failure to predict treatment dropouts. However, treatment completers could be predicted. The relevance of this finding for treatment matching was discussed. It was concluded that, due to the heterogeneity of alcoholic samples, personality measures such as the MMPI should only be used to describe population characteristics at specific treatment centers; generalization should not be expected. It was hypothesized that, by looking for specific predictors at each treatment center instead of searching for global predictors, treatment matching is feasible, and may be very helpful in reducing dropout rates

A genetic validation study reveals a role of vitamin D metabolism in the response to interferon-alfa-based therapy of chronic hepatitis C

Background: To perform a comprehensive study on the relationship between vitamin D metabolism and the response to interferon-α-based therapy of chronic hepatitis C. Methodology/Principal Findings: Associations between a functionally relevant polymorphism in the gene encoding the vitamin D 1α-hydroxylase (CYP27B1-1260 rs10877012) and the response to treatment with pegylated interferon-α (PEG-IFN-α) and ribavirin were determined in 701 patients with chronic hepatitis C. In addition, associations between serum concentrations of 25-hydroxyvitamin D3 (25[OH]D3) and treatment outcome were analysed. CYP27B1-1260 rs10877012 was found to be an independent predictor of sustained virologic response (SVR) in patients with poor-response IL28B genotypes (15% difference in SVR for rs10877012 genotype AA vs. CC, p = 0.02, OR = 1.52, 95% CI = 1.061–2.188), but not in patients with favourable IL28B genotype. Patients with chronic hepatitis C showed a high prevalence of vitamin D insufficiency (25[OH]D3<20 ng/mL) during all seasons, but 25(OH)D3 serum levels were not associated with treatment outcome. Conclusions/Significance: Our study suggests a role of bioactive vitamin D (1,25[OH]2D3, calcitriol) in the response to treatment of chronic hepatitis C. However, serum concentration of the calcitriol precursor 25(OH)D3 is not a suitable predictor of treatment outcome

Tyrol Prostate Cancer Demonstration Project : early detection, treatment, outcome, incidence and mortality

This study aimed to evaluate the effectiveness of a well-controlled programme of early detection and treatment of prostate cancer in the population of Tyrol, Austria, where such a programme of early detection and treatment was initiated in 1988 and where prostate-specific antigen (PSA) testing was offered for free to all men aged 45-75 years from 1993. Comparison of prostate cancer mortality rates in Tyrol and the rest of Austria was accomplished through a generalized additive model. A piecewise linear change-point Poisson regression model was used to compare mortality rates in Tyrol and the rest of Austria. Standardized mortality ratios were calculated with reference to the mortality rates in 1986-1990. In all, 86.6% of eligible men have been tested at least once since 1993. Cancer deaths in Tyrol in 2005 were 54% (95% confidence interval [CI] 34-69%) lower than expected compared with 29% (95% CI 22-35%) in the rest of Austria. The decreasing trend in prostate cancer mortality was significantly greater in Tyrol compared with the rest of Austria (P = 0.001). A significant migration to lower stage disease occurred and radical prostatectomy was associated with low morbidity. In the Tyrol region where treatment is freely available to all patients, where widespread PSA testing and treatment with curative intent occurs, there was a reduction in prostate cancer mortality rates which was significantly greater than the reduction in the rest of Austria. This reduction in prostate cancer mortality is most probably due to early detection, consequent down-staging and effective treatment of prostate cancer

The use of the "Once-Upon-A-Time…" Test in treatment outcome assessment

In an era in which the advent of managed health care is questioning the value of traditional psychological assessment, we discuss the role of the "Once-upon-a-time…" Test in treatment outcome assessment. The "Once upon a time..." Test (Fagulha, 1992, 1997) is a storytelling projective technique whose purpose is to describe the way children deal with the emotions of anxiety and pleasure. In psychodynamic theories, these emotions have an important adaptive function for psychological development (Freud, 1926/1978; Klein, 1932/1969). The “Once upon a time..." Test task is to complete seven stories which are presented as pictures in a cartoon format. Each story depicts common situations in the life of any child that evoke emotions of anxiety and of pleasure. Five cards refer to anxiety provoking situations and two refer to pleasurable experiences. For each card there are nine scenes that represent different possible ways of dealing with the emotional experience evoked by the card. These scenes are grouped into three categories of three scenes each – the Anxiety category (A), the Fantasy category (F) and the Reality category (R). The child is asked to complete the story drawn on the card by selecting and then placing three of these nine scenes in sequence. The categories of the scenes chosen by the child and the sequences organized with these scenes reflect the way children deal with their emotions, anxiety and pleasure, in a transitional space (Winnicott, 1971/1975) between fantasy and reality. After selecting and placing the scenes in sequence, the child tells the story that he/she has just invented. Although the majority of the studies done on the "Once upon a time..." Test have been centered on the analysis of the chosen scenes, according to their category (Anxiety, Fantasy and Reality) and their placement in sequence (in the first, second or third position), a complementary coding system was developed afterwards. This system involves the study of the arranged sequences based on the nine scenes available for each card, and not only the three categories (Pires & Fagulha, 2001). According to this system, the arranged sequences based on the nine scenes available for each card correspond to four different possible ways of facing anxiety and confronting with it. There is a strategy that represents the non-recognition of the painful emotion – Denial –, and three strategies that involve the recognition of this disturbing affect, corresponding to two distinct ways of coping with it – Operational Adaptive Strategy and Emotional Equilibration Strategy – and to one other that proves to be inefficient in dealing with it – Impossibility. The studies done with both coding systems have come to the same conclusion: the patterns of answers reflect differences in ages. As children mature they are able to master anxiety in a more active and efficient manner. In the coding system category of the scenes chosen and their position in the sequence, this developmental achievement is seen through a tendency to respond to anxious situations by choosing scenes that show either anxiety or reality in the first position of the sequence. There is also a progressive decrease in choice of anxiety scenes for story endings corresponding to an increase in the choice of reality or fantasy scenes. As children mature, fantasy scenes in first position of the sequence are less chosen because they reflect the denial of the distress reflected in the card (Fagulha, 1992, 1997, 2000) Regarding the complementary coding system sequences of scenes, the higher degree of emotional stability allows children to deal with anxious situations through adaptive strategies, such us Operational Adaptive Strategy and Emotional Equilibration Strategy. Denial of the anxiety and Impossibility to deal with it are strategies less used by mature children (Pires & Fagulha, 2001) In view of these empirical data is our aim to analyze and discuss a child pattern of answers to the "Once upon a time..." Test at two different moments of her psychotherapeutic process, at treatment initiation and then again to make a decision about treatment termination. We expect to give an account of the "Once upon a time..." Test potentialities to the objective evaluation of the results of child psychotherapy