The place of additional individual psychotherapy in the treatment of alcoholism: a randomized controlled study in nonresponders to anticraving medication-results of the PREDICT study.

BACKGROUND: Goal of the presented study is to evaluate whether alcohol-dependent patients given additional individual psychotherapy after a heavy relapse during pharmacotherapy remain abstinent for longer than those who continue with pharmacotherapy alone. METHODS: In a randomized, multicenter study, 109 alcohol-dependent patients who had suffered a heavy relapse either while receiving anticraving medication or placebo were randomized into 2 groups. One group received medication, medical management, and additional individual, disorder-specific, cognitive-behavioral psychotherapy, while the control group received medication and medical management only. Main outcome was defined as days until first heavy relapse. RESULTS: Fifty-four patients were randomized to the psychotherapy group, 55 to the control group. Intention-to-treat and completer analyses found no differences between groups, whereas as-treated analyses (patients who actually received psychotherapy compared with those who did not) found a significant effect of psychotherapy. CONCLUSIONS: Our data indicate that patients that are willing to attend psychotherapy benefit from receiving psychotherapy in addition to pharmacotherapy. We suggest that it may be beneficial to consider patients' preferences concerning psychotherapy at an earlier stage during treatment.

Efficacy of psychosocial interventions in men and women with sexual dysfunctions--a systematic review of controlled clinical trials: part 2--the efficacy of psychosocial interventions for female sexual dysfunction.

INTRODUCTION: As yet, a summary of the research evidence concerning the efficacy of psychological treatment in female sexual dysfunction is lacking. Previous reviews were often nonsystematic or explored one specific sexual dysfunction. AIM: Our systematic review provides an overview of the efficacy of psychosocial interventions in all female sexual dysfunction. MAIN OUTCOME MEASURES: Main outcome measures included for example psychometrically validated scales, diary notes, interviews, and vulvar algesiometer. The efficacy of psychosocial interventions was measured for example by the frequency of and satisfaction with sexual activity and sexual functioning. Safety and acceptance were evaluated on the basis of adverse events and dropout rates. METHODS: The systematic literature search included electronic database search, handsearch, contact with experts, and an ancestry approach. Studies were included if the woman was given a formal diagnosis of a sexual dysfunction (International Statistical Classification of Diseases and Related Health Problems-ICD10/-9; Diagnostic and Statistical Manual of Mental Disorders-IV/-III-R) and when the intervention was psychosocial or psychotherapeutic. The control group included either another treatment or a waiting-list control group. The report of relevant outcomes was necessary for inclusion as well as the design of the study (randomized, controlled trials [RCTs] and controlled clinical trials). The assessment of methodological quality comprised aspects of randomization, blinding, incomplete outcome data, selective reporting, and allegiance. RESULTS: We identified 15 RCTs that investigated efficacy in female sexual dysfunction and two further studies that examined male and female sexual dysfunction together. Most trials explored sexual pain disorders. About half of all studies in women used either a concept derived from Masters and Johnson or a cognitive-behavioral treatment program. Both approaches showed significant improvements compared with a control group. Benefit was not always maintained over the (variable) follow-up period. CONCLUSIONS: Traditional sexual therapeutic concepts proved to be efficacious in the treatment of female sexual dysfunction. A shortcoming was the rather low methodological quality of included studies.

Management of sexual dysfunction due to antipsychotic drug therapy.

BACKGROUND: Psychotropic drugs are associated with sexual dysfunction. Symptoms may concern penile erection, lubrication, orgasm, libido, retrograde ejaculation, sexual arousal, or overall sexual satisfaction. These are major aspects of tolerability and can highly affect patients' compliance. OBJECTIVES: To determine the effects of different strategies (e.g. dose reduction, drug holidays, adjunctive medication, switching to another drug) for treatment of sexual dysfunction due to antipsychotic therapy. SEARCH METHODS: An updated search was performed in the Cochrane Schizophrenia Group's Trials Register (3 May 2012) and the references of all identified studies for further trials. SELECTION CRITERIA: We included all relevant randomised controlled trials involving people with schizophrenia and sexual dysfunction. DATA COLLECTION AND ANALYSIS: We extracted data independently. For dichotomous data we calculated random effects risk ratios (RR) with 95% confidence intervals (CI), for crossover trials we calculated Odds Ratios (OR) with 95% CI. For continuous data, we calculated mean differences (MD) on the basis of a random-effects model. We analysed cross-over trials under consideration of correlation of paired measures. MAIN RESULTS: Currently this review includes four pioneering studies (total n = 138 , duration two weeks to four months), two of which are cross-over trials. One trial reported significantly more erections sufficient for penetration when receiving sildenafil compared with when receiving placebo (n = 32, MD 3.20 95% CI 1.83 to 4.57), a greater mean duration of erections (n = 32, MD 1.18 95% CI 0.52 to 1.84) and frequency of satisfactory intercourse (n = 32, MD 2.84 95% CI 1.61 to 4.07). The second trial found no evidence for selegiline as symptomatic treatment for antipsychotic-induced sexual dysfunction compared with placebo (n = 10, MD change on Aizenberg's sexual functioning scale -0.40 95% CI -3.95 to 3.15). No evidence was found for switching to quetiapine from risperidone to improve sexual functioning (n = 36, MD -2.02 95% CI -5.79 to 1.75). One trial reported significant improvement in sexual functioning when participants switched from risperidone or an typical antipsychotic to olanzapine (n = 54, MD -0.80 95% CI -1.55 to -0.05). AUTHORS' CONCLUSIONS: We are not confident that cross-over studies are appropriate for this participant group as they are best for conditions that are stable and for interventions with no physiological and psychological carry-over. Sildenafil may be a useful option in the treatment of antipsychotic-induced sexual dysfunction in men with schizophrenia, but this conclusion is based only on one small short trial. Switching to olanzapine may improve sexual functioning in men and women, but the trial assessing this was a small, open label trial. Further well designed randomised control trials that are blinded and well conducted and reported, which investigate the effects of dose reduction, drug holidays, symptomatic therapy and switching antipsychotic on sexual function in people with antipsychotic-induced sexual dysfunction are urgently needed.

Is one question enough to detect female sexual dysfunctions? A diagnostic accuracy study in 6,194 women.

INTRODUCTION: Literature shows that recognition of sexual dysfunctions in women is insufficient and existing instruments to aid detection are mostly too extensive to be used in routine practice. AIM: To develop a brief and accurate screening instrument to detect female sexual dysfunctions in routine care. METHODS: The initial item pool for the index test consisted of 15 items. In a 4-year period, a total of 12,957 persons filled out the test on a specifically designed web-site. Six thousand one hundred ninety-four complete data sets could be used for statistical analysis. The validated German version of the Female Sexual Function Index (FSFI-d) served as reference standard to estimate the accuracy of the screening test. In order to test several possible ways of combining items a multi-step procedure employing univariate analyses, multiple logistic regression, and classification and regression tree analysis was applied to a learning sample and cross-validated in a test sample. MAIN OUTCOME MEASURES: Diagnostic performance (sensitivity, specificity, positive and negative predictive value, accuracy, diagnostic odds ratio as well as adjusted odds ratio) of the items and resulting models to discriminate women with sexual dysfunction from those without were calculated. RESULTS: One dichotomous question for overall satisfaction proved to show high accuracy as a stand-alone instrument and played also a central role in multivariate models. It may be recommended as a one-question screening test (76.4% sensitivity and 76.5% specificity in the test sample). A hierarchical two-question test yielded higher sensitivity (93.5%) and lower specificity (60.1%). A slightly more extensive version consists of five questions (83.1% sensitivity and 81.2% specificity). CONCLUSIONS: Despite some methodological limitations of our study all developed tests showed acceptable to good diagnostic performance, all are very short and could therefore be easily implemented into routine care. Further tests of psychometric properties in other settings are needed.

Effect of sexual function on health-related quality of life mediated by depressive symptoms in cardiac rehabilitation. findings of the SPARK project in 493 patients.

INTRODUCTION: Empirical evidence suggests associations between cardiovascular diseases, sexual functioning, depressive symptoms, and quality of life. However, to date, the interrelation of these constructs has not been examined simultaneously in a structural analysis. AIM: To estimate the prevalence of sexual disorders and depressive symptoms and to examine the association between sexual disorders, depressive symptoms, and quality of life in patients in the rehabilitation of cardiovascular disorders. AIM: A postal survey in five German inpatient rehabilitation centers for cardiovascular diseases was conducted. Prevalence of sexual disorders and depressive symptoms were assessed using psychometrically sound instruments. To analyze complex associations, structural equation modeling was used. MAIN OUTCOME MEASURES: For epidemiological questions, proportions with 95% confidence intervals were calculated. The strength of association in structural equation models was expressed as a standardized regression coefficient. RESULTS: Data from 493 patients were analyzed (response rate 22.7%). At least moderate erectile dysfunction proved to be present in 20.3% of men. The prevalence of female sexual dysfunction lay at 43.1%. At least moderate depressive symptoms were present in 14.4% of men and 16.5% of women. A considerable association between sexual functioning and quality of life was found in both sexes, which was largely mediated by depressive symptoms. Major drawbacks of the study are imprecision of the estimates due to limited sample size and questionable generalizability of the findings due to possible self-selection bias. CONCLUSIONS: Considering the high prevalence of depressive symptoms and their role as a mediating factor between sexual functioning and quality of life, it is recommended to routinely screen for depression in men and women with cardiac disease.

Interrelationship of sildenafil treatment effects on the physiological and psychosocial aspects of erectile dysfunction of mixed or organic etiology.

INTRODUCTION: In a previous paper using mediation modeling, the direct and indirect effects of sildenafil on erection maintenance were demonstrated. OBJECTIVE: In an extension of this previous work, the historical psychosocial paradigm of ED, which focuses on performance anxiety, is tested by using mediation modeling to define the relationship of the physiological aspects (hardness and maintenance) and the associated psychosocial aspects (confidence, sexual relationship satisfaction, and performance anxiety) of ED. METHODS: Statistical mediation analysis using the following outcomes from a double-blind placebo-controlled trial of fixed-dose sildenafil 100 mg or 50 mg: Erection Hardness Score; the 15-item International Index of Erectile Function (IIEF), including item 4 (frequency of erection maintenance after penetration) and item 5 (difficulty of erection maintenance to intercourse completion); the Self-Esteem And Relationship questionnaire; and the question, "Do you feel anxious about your next attempt at sexual intercourse?" MAIN OUTCOME MEASURES: Estimated percentages of direct and indirect effects of sildenafil on psychosocial aspects of ED (95% confidence intervals). RESULTS: The model estimated that erection hardness mediated 43.7% (29.3%, 62.4%) of the effect of treatment onto confidence and 45.9% (32.2%, 61.8%) of the effect of treatment onto sexual relationship satisfaction, and that erection maintenance (using IIEF item 4 as a proxy) mediated 23.0% (10.1%, 39.1%) and 22.4% (10.1%, 36.5%), respectively. Similar results were obtained when IIEF item 5 was used as the proxy for measurement of maintenance. Of all possible paths to performance anxiety, only that from treatment via confidence was statistically significant, mediating an estimated 88.6% (55.5%, 146.2%; item 4 model) or 74.9% (47.0%, 121.0%; item 5 model) of the effect of treatment onto anxiety. The direct path to anxiety from treatment was not statistically significant. CONCLUSIONS: In men treated with sildenafil for ED, performance anxiety might be ameliorated by improved confidence. Improved confidence might be mainly mediated via increased erection hardness.

Understanding the effects of sildenafil treatment on erection maintenance and erection hardness.

INTRODUCTION: Erectile dysfunction (ED) is defined as the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance. Although intuitively related, the link between erection hardness and erection maintenance has not been formally established and quantified. AIM: To understand the components of erection maintenance through statistical modeling. METHODS: Data from a double-blind placebo-controlled trial of fixed-dose sildenafil (100 or 50 mg, 8 weeks) with open-label extension of flexible-dose sildenafil (100 and 50 mg, 4 weeks) were analyzed. Erection maintenance was assessed with item 4 (how often erection was maintained) or item 5 (difficulty in maintaining erection) of the International Index of Erectile Function (IIEF). Erection hardness was assessed with the Erection Hardness Score. MAIN OUTCOME MEASURES: Longitudinal modeling estimated mean treatment differences averaged over the double-blind phase for sildenafil 100 mg vs. placebo and 50 mg vs. placebo. Statistical mediation analysis was applied to partition the effect of sildenafil (pooled into one treatment group) on erection maintenance directly and indirectly through erection hardness. RESULTS: Longitudinal mean differences for sildenafil 100 and 50 mg vs. placebo were high (P < 0.0001 for each), with large standardized effect sizes (>0.8). Mediation modeling showed that sildenafil treatment affected maintenance directly as well as indirectly via erection hardness, when measured by IIEF item 4 (direct effect, 44.6%; indirect effect, 55.4%) or IIEF item 5 (direct effect, 56.9%; indirect effect, 43.1%). CONCLUSIONS: Sildenafil treatment significantly improved erection maintenance, a physiologic requirement for satisfactory sexual performance. According to our model, only approximately half of the effect of sildenafil on erection maintenance was estimated to be driven through direct effects. Rather, the effect of sildenafil on erection maintenance seems to be substantially driven by erection hardness. Therefore, achievement of optimal initial erection hardness appears to be an important treatment goal for enhancing erection maintenance and achieving successful ED treatment.

Association of sexual functioning and quality of partnership in patients in cardiovascular rehabilitation--a gender perspective.

INTRODUCTION: In the general population, studies indicate a strong association between sexual dysfunction and partnership quality. Despite a high prevalence of sexual problems in patients with cardiovascular diseases, this association has not yet been examined in this sample. AIM: The central task of this paper is to determine the association between sexual dysfunction and quality of partnership under a gender-specific view. METHODS: A written survey was handed out to all newly admitted patients in five participating inpatient rehabilitation centers for cardiovascular diseases in Germany. The survey included a gender-specific questionnaire to assess sexual functioning (International Index of Erectile Function for men, and Female Sexual Function Index for women), and a Partnership Questionnaire. MAIN OUTCOME MEASURES: Correlations were calculated between sexual function and relationship satisfaction, and differences between groups (cardiovascular diseased men and women with and without sexual problems) were tested using covariance analyses. RESULTS: Overall, 44.3% of 98 female participants and 52.7% of 395 male participants stated to have at least one sexual problem. Patients with sexual problems showed significantly more quarrelling (P = 0.001), significantly less tenderness (P < 0.001), communication (P < 0.001), as well as significantly lower overall quality of partnership (P < 0.001), compared with cardiac men and women without sexual problems. Suffering from a sexual problem impaired partnership quality for women to a significantly greater extent than for men. CONCLUSIONS: Possible shortcomings of our study are selection bias, i.e., it is unknown whether all newly admitted patients received the questionnaire by their physician, as well as an overall low response rate, probably because of the private character of questions. This study suggests for the first time that men and women who suffer from cardiovascular diseases and sexual problems show a significantly decreased partnership satisfaction compared with those without sexual dysfunction. Further longitudinal studies might confirm the causal nature of found correlations.

Meta-analysis: are 3 questions enough to detect unhealthy alcohol use?

BACKGROUND: Both the 10-item Alcohol Use Disorders Identification Test (AUDIT) and its abbreviated 3-item version (Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]) are considered to detect unhealthy alcohol use accurately. PURPOSE: To examine whether the AUDIT-C is as accurate as the full AUDIT for detecting unhealthy alcohol use in adults. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, and BIOSIS Previews from 1998 to July 2008. STUDY SELECTION: Three independent reviewers selected studies that administered both the AUDIT and the AUDIT-C, applied a valid reference standard, avoided verification and incorporation bias, and reported relevant data. No language restrictions were applied. DATA EXTRACTION: Two reviewers extracted study characteristics and outcome data, which were cross-checked by a third reviewer. One reviewer assessed methodological quality with a standardized checklist. DATA SYNTHESIS: Fourteen studies were found. Most involved primary care patients in Europe and the United States. Sample sizes ranged between 112 and 13 438 patients, and sex and age distributions varied considerably. No statistically significant differences were found between the overall accuracy of the AUDIT and the AUDIT-C for detecting risky drinking, alcohol use disorders, or unhealthy alcohol use in primary care. Hierarchical summary receiver-operating characteristic curve analysis yielded pooled positive likelihood ratios of 6.62 for the AUDIT and 2.99 for the AUDIT-C, respectively, for detecting risky drinking; 4.03 and 3.82, respectively, for detecting any alcohol use disorder; and 4.82 and 3.91, respectively, for detecting risky drinking or any alcohol use disorder. Findings from a few studies on general population samples and inpatients suggested but did not prove that the AUDIT might be better than the AUDIT-C for identifying severe conditions, such as alcohol dependence. LIMITATION: Studies used different reference standards and had heterogeneous findings. CONCLUSION: Available evidence is inconclusive but suggests that the full AUDIT may be superior to the AUDIT-C for identifying unhealthy alcohol use in adults in some settings.

[Alcohol use and consumption advice of medical students]. / Alkoholgebrauch und Konsumpermission bei Medizinstudenten.

BACKGROUND: An increased incidence of hazardous alcohol consumption in medical practitioners is widely discussed. We conducted a survey of 80 medical students with a standardized questionnaire in order to assess the impact of harmful drinking patterns on the ideas of recommendations about alcohol consumption intended for patients. The statistical analyses were descriptive and inferential. RESULTS: Only one of 80 medical students rated his own consumption as hazardous. The weekly alcohol median consumption was 30 g for women and 60 g for men. 24% of students answering the AUDIT-questionnaire were found to be in the at-risk consumption category. Every 10th student had more than 6 drinks once per week. The weekly estimated non-risk allowance for patients was 80 g of alcohol in women and 100 g for men. DISCUSSION: In contrast to the self rating we found a high percentage of hazardous drinking behaviour patterns when using standardized instruments. Compared to the WHO recommendations the students rated weekly alcohol consumption more strictly. This points both towards the need of preventive measures in this target group as well as the need to improve educative competency.

Effects of written information material on help-seeking behavior in patients with erectile dysfunction: a longitudinal study.

INTRODUCTION: Neither men with erectile dysfunction (ED) nor their physicians are willing to discuss sexual problem sufficiently. Written information material could facilitate a dialogue and encourage men to seek treatment. AIM: The central task of this article was to determine the effectiveness and acceptance of patient information material for sexual dysfunction. METHODS: Through an information campaign, men received informational material. Eight thousand men also received a first survey, which asked about the intention to seek treatment and to discuss the sexual problem with a physician or partner. A second follow-up questionnaire, 3-6 months after the first one, asked for the implementation of these intentions. Descriptive and regression-based analyses were applied. MAIN OUTCOME MEASURES: Help-seeking behavior, subjective assessment of change in disease severity and partnership quality, satisfaction. RESULTS: Four hundred forty-three men participated in both surveys. Nearly 90% of them became active after reading the information material. More than half talked with their partner (57.8%) and a physician (65%), and one-third sought treatment (31.8%). Especially discussing the problem with the partner and receiving treatment improved erectile functioning and led to an increase in the quality of partnership (P

St John's wort for major depression.

BACKGROUND: In some countries extracts of the plant Hypericum perforatum L. (popularly called St. John's wort) are widely used for treating patients with depressive symptoms. OBJECTIVES: To investigate whether extracts of hypericum are more effective than placebo and as effective as standard antidepressants in the treatment of major depression; and whether they have fewer adverse effects than standard antidepressant drugs. SEARCH STRATEGY: Trials were searched in computerised databases, by checking bibliographies of relevant articles, and by contacting manufacturers and researchers. SELECTION CRITERIA: Trials were included if they: (1) were randomised and double-blind; (2) included patients with major depression; (3) compared extracts of St. John's wort with placebo or standard antidepressants; (4) included clinical outcomes assessing depressive symptoms. DATA COLLECTION AND ANALYSIS: At least two independent reviewers extracted information from study reports. The main outcome measure for assessing effectiveness was the responder rate ratio (the relative risk of having a response to treatment). The main outcome measure for adverse effects was the number of patients dropping out due to adverse effects. MAIN RESULTS: A total of 29 trials (5489 patients) including 18 comparisons with placebo and 17 comparisons with synthetic standard antidepressants met the inclusion criteria. Results of placebo-controlled trials showed marked heterogeneity. In nine larger trials the combined response rate ratio (RR) for hypericum extracts compared with placebo was 1.28 (95% confidence interval (CI), 1.10 to 1.49) and from nine smaller trials was 1.87 (95% CI, 1.22 to 2.87). Results of trials comparing hypericum extracts and standard antidepressants were statistically homogeneous. Compared with tri- or tetracyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), respectively, RRs were 1.02 (95% CI, 0.90 to 1.15; 5 trials) and 1.00 (95% CI, 0.90 to 1.11; 12 trials). Both in placebo-controlled trials and in comparisons with standard antidepressants, trials from German-speaking countries reported findings more favourable to hypericum. Patients given hypericum extracts dropped out of trials due to adverse effects less frequently than those given older antidepressants (odds ratio (OR) 0.24; 95% CI, 0.13 to 0.46) or SSRIs (OR 0.53, 95% CI, 0.34-0.83). AUTHORS' CONCLUSIONS: The available evidence suggests that the hypericum extracts tested in the included trials a) are superior to placebo in patients with major depression; b) are similarly effective as standard antidepressants; c) and have fewer side effects than standard antidepressants. The association of country of origin and precision with effects sizes complicates the interpretation.

Characteristics of predrinking and associated risks: a survey in a sample of German high school students.

OBJECTIVES: Finding predictors for predrinking and placing the new phenomenon of predrinking on a greater database. Predrinking is defined as alcohol consumption, alone or with friends, at home or at public places, before going out in the evening to a party or in bars or discotheques. METHODS: Data were collected from a representative sample of 757 ninth- and tenth-grade students from 31 high schools located in a south German rural region and a city. RESULTS: Predrinkers, especially those who show this behaviour frequently, were notably more likely to engage in hazardous drinking, and experienced significantly more frequent involvements in fights and alcohol-induced blackouts. They also stated more often that they had the intention of getting drunk when consuming alcohol. CONCLUSIONS: Predrinking proves to be a high-risk behaviour, particularly when it occurs at a high frequency. This behaviour has to be seen as part of a new youth culture, which does not seem to be limited to a certain subgroup-with all of the associated risks.

What works for patients in outpatient treatment for alcohol addiction? An explorative study into clients' evaluation of subjective factors and therapy satisfaction.

This explorative survey investigated clients' evaluation of therapy elements and other supportive factors within a randomized controlled trial. The treatment of patients with alcohol dependence consisted of pharmacotherapy (acamprosate/naltrexone/placebo) and biweekly medical management (MM). Forty-nine study participants were surveyed with a questionnaire to measure both the patients' satisfaction with the therapy and the subjective assessment of treatment elements and supportive factors.Study participants were highly satisfied with the treatment. The supportive factors previously identified by Orford et al1 were confirmed. 'Pharmacotherapy' was rated significantly less effective than 'MM' and 'global study attendance' (P < 0.001). The significant differences in the evaluation of treatment elements point to a preference for regular low-key contacts rather than for medication. Such contacts based on MM could be a useful intervention in clinical care, and its effectivity should be examined more closely in further research.

Treatment of depressive symptoms and attitudes towards treatment options in a representative German general population sample.

Objective. To estimate treatment rates, self-medication, and preferences for treatment options of depressive symptoms. Methods. A German nationwide representative sample (n=2224) was interviewed. Subjects were asked to fill in a depressive symptom checklist, as well as to answer questions about current treatments and treatment preferences. Results. A total of 16.7% was mildly, 7.5% moderately and 6.5% strongly affected by depressive symptoms; 22.7% of the total affected group were currently or previously being treated by a physician. Self-initiated treatments had been stated as effective in 54.2% of cases. The preference for phytotherapeutic treatment approaches was about 3-6-fold higher than for standard antidepressants and psychotherapies. Treatment preference and wish for treatment increased with increasing severity of symptoms with regard to treatments that had to be professionally initiated. Conclusion. Despite considerable educational efforts, the prevalence of untreated and undiagnosed depressive symptoms seems to be high. There is still little acceptance for the most efficacious therapies for depression. More efforts should be made to increase knowledge about self-administered phytotherapeutic drugs, which might play an important role in a stepped-care approach of future depression management.

[General practitioners online: the conditions are good, but use of the Internet for continuing medical education found to be poor]. / Hausärzte online: Gute Voraussetzungen, aber geringe Nutzung des Internets zur Fortbildung.

BACKGROUND AND OBJECTIVE: In recent years, there has been an increasing trend towards the development of e-learning-modules for general medical training and continuing medical education (CME). The majority of these offerings make use of the Internet. The aim of this study was to examine general practitioners' attitude towards and their use of the Internet and online CME, their demand for such offerings and the problems associated with it on the basis of a representative survey. METHODS: In June 2006, a standardized 6-page questionnaire with 27 questions about "The Internet and online CME" was sent out to all general practitioners in six districts (n = 1304) of South-Baden and South-Württemberg in Germany. Data were subjected to descriptive statistical analysis. RESULTS: 351 physicians (27%) returned the questionnaire. The majority (94.5%) reported to have Internet access, but mostly at home, and not in the office. 45.9% of the respondents rated their Internet skills as "moderate", and 31.9% as "good" or "very good". The physicians' rating of the effectiveness of online CME was similar: 39% rated it as "moderate", and 31.1% as "high" or "very high". Usage of online CME was low: only 19.9% reported "frequent" or "very frequent" use. CONCLUSION: The technical conditions for using the Internet are quite favourable. The effectiveness of online CME was rated between "moderate" and "high". However, the use of such offerings is poor. Further analyses of the data will provide possible starting points for implementing online CME services or for increasing its use.

The alcohol use disorders identification test for detecting at-risk drinking: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this study was to perform a systematic review of the diagnostic accuracy of the Alcohol Use Disorders Identification Test (AUDIT) for detecting at-risk drinking. METHOD: The MEDLINE, PsycINFO, Science Citation Index Expanded, BIOSIS Previews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDION, and Cochrane Library databases were searched for relevant studies. The criteria for inclusion were a valid reference standard, AUDIT consisting of 10 items, avoiding bias that may result from how the reference standard was obtained, and when and how many participants were tested. Data were extracted independently by two reviewers. Data synthesis was performed by applying direct pooling of proportions and random effects model for likelihood ratios and diagnostic odds ratio. RESULTS: Twenty-three studies were included in the systematic review, 19 of which were included in the meta-analysis. With a cutoff of 8 points, sensitivity ranged from .31 to .89 and specificity ranged from .83 to .96 across the eight studies conducted in primary care. A single trial in general hospital inpatients found a sensitivity of .93 and a specificity of .94; another trial in emergency-department patients found a sensitivity of .72 and a specificity of .88. A study in university students found a sensitivity of .82 and a specificity of .78. Three studies in elderly patients found sensitivities between .55 and .83 at a pooled specificity of .96. There was large heterogeneity between study results, which could only partly be explained by setting diversity. The analysis of results with population-specific cutoff points led to similar findings. CONCLUSIONS: Findings on the diagnostic performance of the AUDIT proved to be largely heterogeneous. Its use should be restricted to primary care populations, inpatients, and elderly patients.

[Management of sexual dysfunctions in the rehabilitation of cardiovascular diseases. Results of a staff survey]. / Umgang mit sexuellen Funktionsstörungen in der Rehabilitation kardiovaskulärer Erkrankungen : Ergebnisse einer Mitarbeiterbefragung.

BACKGROUND AND PURPOSE: Many studies demonstrate a high prevalence of erectile dysfunction (ED) in cardiovascular patients. Findings show that patients often do not talk about their sexual problems. Many patients believe that their physician would not take their problem seriously. However, they wish to be asked by their physician and want to get information. The medical staff also avoids to broach the issue of sexual problems even when they assume an ED. Reasons for an insufficient inquiry are often lack of time or knowledge as well as emotional inhibitions. METHODS: 51 members of the medical staff of five hospitals for rehabilitation of cardiovascular diseases filled in a standardized, anonymous five-page questionnaire. It consisted of questions regarding sociodemography, estimated prevalence of sexual dysfunction, knowledge, responsibility, impediments for adequate diagnosis and therapy, as well as need for continuing medical education. Likely predictors (age, sex, profession, knowledge, and responsibility) for an active attitude were examined using relative risks. RESULTS: Of the 51 employees, 54% were men, more than half were physicians. The mean age was 44.3 years. The estimated prevalence of sexual dysfunction was 45.4 +/- 20.3%. Less than half of the medical professionals rated their knowledge concerning therapy motivation (47.9%) and general consultation of cardiovascular patients (38.8%) as at least good (see Figure 1). While more than two thirds felt responsible for motivation to subsequent treatment of sexual dysfunction, less than one quarter motivated the patients actively. Over 50% felt responsible for consultation and information, but only 27% did it actively (see Figure 2). The main impediment for an adequate management of sexual problems was the lack of time (38.3%). However, every fourth also believed that the patient would not accept the diagnosis (29.2%) or a therapy (22.9%). One third of the employees agreed that the own lack of knowledge makes care of sexual problems difficult. On the question what would be helpful to improve the management with sexual concerns, most employees said that education and training (85.7%) would be the most effective method (see Figure 3). The highest need for training can be seen in diagnostics (64.4%; see Figure 4). Almost all professionals believed that a screener would be reasonable. A higher knowledge state was the only significant predictor for an active management of sexual problems (see Table 1). CONCLUSION: The reported prevalence of sexual dysfunction in cardiac rehabilitation is very high. This requires skills concerning diagnosis and treatment of sexual dysfunction, which are only scarcely present. Furthermore, there are many impediments that are mainly positioned in the health-care system. The skills should be improved by an effort in continuing medical education. Patients with ED often have depression and a reduced quality of life. To improve the quality of life of patients in the cardiovascular rehabilitation, the treatment of ED is a necessary condition. Trials show that a widespread rehabilitation program which includes a sexual education leads to a better sexual activity. The patients' quality of life can only be improved, if the medical staff includes relevant concomitant disorders to cardiovascular disease, like ED, in the treatment program of patients.

The validity of the laboratory marker combinations DOVER and QUVER to detect physician's diagnosis of at-risk drinking.

Especially in situations where it might be favorable for the patient to dissimulate the existing alcohol problem, 'objective' laboratory tests can be helpful. In this study we report validation of the two combinations DOVER (DOctor VERified) and QUVER (QUestionnarie VERified) of the biological markers percent carbohydrate-deficient transferrin (%CDT) and gamma-glutamyl-transferase (gamma-GT) to detect patients that have been identified by their physicians with at-risk drinking behavior. Fifty-eight general practitioners (GPs) participated at two study sites in South-West Germany. Patients filled in a questionnaire that included the alcohol use disorders identification test (AUDIT) and gave a blood sample. The GP recorded his/her assessment about the presence of an alcohol-related disorder in the patient. Receiver operating characteristics (ROC) analyses of the marker combinations DOVER and QUVER were performed. A total of 2940 patients participated in the study, of which 2496 completed data sets that could be used for further analysis. The area under the curve (AUC) of 79.5% for DOVER and 77.2% (QUVER) are in a higher range than the values for gamma%CDT (75.7%) or gamma-GT (72.5%) and %CDT (64.5%) and suggest superiority of the proposed marker combinations. Cross-validation results were almost identical with 76.6% and 73.3% for DOVER and QUVER, respectively. Our analysis demonstrated that the combination of the markers gamma-GT and %CDT with the physician's judgement of the condition as reference was superior to the use of single markers.

Detection and management of alcohol use disorders in German primary care influenced by non-clinical factors.

AIMS: The primary objective was to assess the proportion of detected and correctly referred patients in German primary care. The secondary objective was to identify patient and practitioner characteristics that predict detection and correct referral. METHODS: In this clustered cross-sectional survey in German primary care, 3003 patients were consecutively invited to participate, and were asked to fill in a standardized health questionnaire. They were then screened for problematic alcohol consumption using the Alcohol Use Disorders Identification Test. The physicians recorded their assessment of the presence of any alcohol use disorder and documented the treatment course of all identified patients for 3 months. RESULTS: Correctly identified problem drinkers were 38.6% in a per-protocol analysis and 33.6% using a worst-case scenario. Referral behaviour of physicians was in conformity with current practice guidelines in 64.6% of the documented cases and 27.0% in a worst-case scenario. Several patient (e.g. sex, age) and practitioner characteristics (e.g. age), which influence the diagnosis and referral of patients, could be identified. CONCLUSIONS: There is a clear need to increase the special diagnostic and therapeutic skills of general practitioners so that they may be able to indicate and perform secondary prevention. Further research should focus on the likely effects of the implementation of these diagnostic and management tools.