The Alternative Model of Personality Disorders: Assessment, Convergent and Discriminant Validity, and a Look to the Future

The Alternative Model of Personality Disorders (AMPD) is a dimensional, empirically based diagnostic system developed to overcome the serious limitations of traditional categories. We review the mounting evidence on its convergent and discriminant validity, with an incursion into the less-studied ICD-11 system. In the literature, the AMPD's Pathological Trait Model (Criterion B) shows excellent convergence with normal personality traits, and it could be useful as an organizing framework for mental disorders. In contrast, Personality Functioning (Criterion A) cannot be distinguished from personality traits, lacks both discriminant and incremental validity, and has a shaky theoretical background. We offer some suggestions with a view to the future. These include removing Criterion A, using the real-life consequences of traits as indicators of severity, delving into the dynamic mechanisms underlying traits, and furthering the integration of currently disengaged psychological paradigms that can shape a sounder clinical science. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 20 is May 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Intermediate risk of choledocholithiasis: are we on the right path?

The risk of choledocholithiasis should be assessed in every patient undergoing cholecystectomy to define the next step. The American Society for Gastrointestinal Endoscopy proposed a stratified predictor scale of choledocholithiasis. Therefore, we aimed to describe our experience managing patients with an intermediate risk of choledocholithiasis according to the American Society for Gastrointestinal Endoscopy guidelines and the actual presence of bile duct stones in magnetic resonance cholangiopancreatography.

Methods

A retrospective observational study with a prospective database was conducted. The analysis included sociodemographic data, laboratory values, and imaging. Bivariate, multivariate, and receiver operating characteristic analysis were performed.

Results

Three hundred twenty-seven patients had an intermediate risk for choledocholithiasis. Half the patients were at least 65 years old. 24.77% were diagnosed with choledocholithiasis. Bile duct dilation was documented in only 3.06% of cases. Diagnosis of choledocholithiasis is associated with an age odds ratio (OR): 1.87 (P 0.02), alkaline phosphatase OR: 2.44 (P 0.02), and bile duct dilation greater than 6 mm OR: 14.65 (P 0.00).

Conclusions

High variability in the accuracy of imaging techniques results in a large number of patients classified as intermediate risk without choledocholithiasis in cholangioresonance. Therefore, enhancing the criteria to define intermediate risk for patients in order to optimize resources is of paramount importance.

Differentiating Abnormal, Normal, and Ideal Personality Profiles in Multidimensional Spaces

Abstract: Current dimensional taxonomies of personality disorder (PD) establish that intense traits do not suffice to diagnose a disorder, and additional constructs reflecting dysfunction are required. However, traits appear able to predict maladaptation by themselves, which might avoid duplications and simplify diagnosis. On the other hand, if trait-based diagnoses are feasible, it is the whole personality profile that should be considered, rather than individual traits. This takes us into multidimensional spaces, which have their own particular – but poorly understood – logic. The present study examines how profile-level differences between normal and disordered subjects can be used for diagnosis. The Dimensional Assessment of Personality Pathology – Basic Questionnaire (DAPP-BQ) and the Personality Inventory for DSM-5 (PID-5) were administered to a community and a clinical sample each (total n = 1,925 and 3,543 respectively). Intense traits proved to be common in the general population, so empirically-based thresholds are indispensable not to take as abnormal what is at most unideal. Profile-level parameters such as Euclidean and Mahalanobis distances outperformed individual traits in predicting mental problems and equaled the performance of published measures of dysfunction or severity. Personality profiles can play a more central role in identifying disorders than is currently acknowledged, provided that adequate metrics are used.

Asparaginase activity monitoring in pediatric acute lymphoblastic leukemia: A cross-sectional nationwide study in Spain

BACKGROUND

A cross-sectional nationwide study was designed to assess national compliance with international consensus/guidelines of monitoring asparaginase levels in children with acute lymphoblastic leukemia (ALL) treated with asparaginase in routine clinical practice.

METHODS

An ad hoc questionnaire was designed and completed by staff physicians from Hemato-Oncology Units throughout Spain.

RESULTS

A total of 39 physicians (64% pediatricians) with a mean (SD) age 43.5 (7.9) years and 15.3 (17.6) years of professional activity participated in the study. They accounted for 90% of hospitals in which children with ALL are treated in Spain. A total of 19 participants (48.7%) reported that asparaginase levels were routinely monitored (own center in 2 cases [10.5%], another hospital in 17 cases [89.5%]). Asparaginase was not monitored in 51.3% of the cases, mostly (80%) because unavailability of testing. When asparaginase was monitored, 68% of participants reported that this was done in all asparaginase-treated patients and 84% in all phases of the disease (induction, consolidation, re-induction, maintenance) with a time interval of 7 days for the pegylated form, 48 h for Erwinia asparaginase and 14 days for maintenance with the pegylated form. All participants reported that they modified treatment according to results of testing, with a limit of total depletion of ≥100 IU/L. Levels <100 or 20 IU/L were considered indicative of hypersensitivity by 46% of physicians.

CONCLUSION

There is still a gap between what is recommended and what is done in clinical practice, with more than 50% of centers not monitoring the level of asparaginase activity in pediatric ALL. Protocols for asparaginase testing in daily practice should be implemented.

The evolution of personality disorders: A review of proposals

Personality disorders (PDs) are currently considered dysfunctions. However, personality differences are older than humanity and are ubiquitous in nature, from insects to higher primates. This suggests that a number of evolutionary mechanisms-other than dysfunctions-may be able to maintain stable behavioral variation in the gene pool. First of all, apparently maladaptive traits may actually improve fitness by enabling better survival or successful mating or reproduction, as exemplified by neuroticism, psychopathy, and narcissism. Furthermore, some PDs may harm important biological goals while facilitating others, or may be globally beneficial or detrimental depending on environmental circumstances or body condition. Alternatively, certain traits may form part of life history strategies: Coordinated suites of morphological, physiological and behavioral characters that optimize fitness through alternative routes and respond to selection as a whole. Still others may be vestigial adaptations that are no longer beneficial in present times. Finally, variation may be adaptative in and by itself, as it reduces competition for finite resources. These and other evolutionary mechanisms are reviewed and illustrated through human and non-human examples. Evolutionary theory is the best-substantiated explanatory framework across the life sciences, and may shed light on the question of why harmful personalities exist at all.

A Double-Track Pathway to Fast Strategy in Humans and Its Personality Correlates

The fast-slow paradigm of life history (LH) focuses on how individuals grow, mate, and reproduce at different paces. This paradigm can contribute substantially to the field of personality and individual differences provided that it is more strictly based on evolutionary biology than it has been so far. Our study tested the existence of a fast-slow continuum underlying indicators of reproductive effort-offspring output, age at first reproduction, number and stability of sexual partners-in 1,043 outpatients with healthy to severely disordered personalities. Two axes emerged reflecting a double-track pathway to fast strategy, based on restricted and unrestricted sociosexual strategies. When rotated, the fast-slow and sociosexuality axes turned out to be independent. Contrary to expectations, neither somatic effort-investment in status, material resources, social capital, and maintenance/survival-was aligned with reproductive effort, nor a clear tradeoff between current and future reproduction was evident. Finally, we examined the association of LH axes with seven high-order personality pathology traits: negative emotionality, impulsivity, antagonism, persistence-compulsivity, subordination, and psychoticism. Persistent and disinhibited subjects appeared as fast-restricted and fast-unrestricted strategists, respectively, whereas asocial subjects were slow strategists. Associations of LH traits with each other and with personality are far more complex than usually assumed in evolutionary psychology.

Borderline, where are you? A psychometric approach to the personality domains in the International Classification of Diseases, 11th Revision (ICD-11)

The inclusion of the borderline pattern in the International Classification of Diseases, 11th Revision (ICD-11) dimensional classification of personality disorders (PDs) has caused controversy. Unease about leaving out these clinically challenging patients seems to conflict with the need of an evidence-based and credible diagnostic system. However, the accommodation of borderline within the new diagnostic system has not yet been studied in depth. To this end, we examine in a sample of 1799 general population and clinical subjects the joint structure of the five initial ICD-11 domains and the borderline pattern. Regression and item-level factor analyses reveal that borderline criteria do not form a separate construct and are indissociable from negative affectivity. Furthermore, borderline adds nothing to the remaining domains when it comes to predict PD severity. The borderline pattern appears as largely superfluous and even misguiding, unless their criteria are properly integrated within the structure of personality pathology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Severity in the ICD-11 personality disorder model: Evaluation in a Spanish mixed sample

Severity is the main component of the ICD-11 personality disorder (PD) classification, but pertinent instruments have only recently been developed. We analyzed the psychometric properties of the ICD-11 Personality Disorder Severity scale (PDS-ICD-11) in a mixed sample of 726 community and clinical subjects. We also examined how the different components of the ICD-11 PD system -five trait domains, the borderline pattern specifier, and severity, all of them measured through self-reports- are interconnected and operate together. PDS-ICD-11 properties were adequate and similar to those of the original instrument. However, regressions and factor analyses showed a considerable overlap of severity with the five personality domains and the borderline specifier (72.6%). Bifactor modeling resulted in a general factor of PD (g-PD) that was not equivalent to severity nor improved criterion validity. The whole ICD-11 PD system, i.e., five personality domains, borderline, and severity, explained an average of 43.6% of variance of external measures of well-being, disability, and clinical problems, with severity contributing 4.8%. Suggestions to further improve the ICD-11 PD taxonomy include remodeling the present definition of severity to give more weight to the real-life consequences of traits.

Psychometric properties of the Five-Factor Personality Inventory for ICD-11 (FFiCD) in Spanish community samples

At present, there are two models of pathological personality represented in two measurement instruments, the Personality Inventory for DSM-5 (PID-5) and the Personality Inventory for ICD-11 (PiCD). Although both instruments have shown high convergence, the PID-5 has the advantage of including facets that might offer greater predictive capacity. An alternative to the PiCD has recently been proposed to overcome this drawback, namely the Five-Factor Personality Inventory for ICD-11 (FFiCD). The present study aims to explore its internal structure and to offer additional validity evidence. Data were collected for a total of 1,409 community individuals from two populations in Spain. They responded to the FFiCD, PiCD, the PID-5/SF, and measures of personality functioning and personality disorder screening (Level of Personality Functioning Scale Self-Report [LPFS-SR] and International Personality Disorder Examination [IPDE]). The internal structure of the FFiCD was analyzed through exploratory factor analysis with oblique and bifactor rotations. The predictive capacity of the domains and facets was examined. The structure reported in the original study was replicated, as were the convergent validity data with respect to the PID-5/SF and the PiCD. Facets were grouped into four factors corresponding to the theoretical domains, including a bipolar Anankastia/Disinhibition factor. High correlations were found with the LPFS-SR, and the patterns of relationships with the IPDE shed light on which aspects of pathological personality contribute most to the 10 traditional personality disorders. In general, validity evidence is provided to support the use of the FFiCD, though four of the 20 facets merit revision so that a simpler factor structure can be obtained. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Impact of an enhanced screening program on the detection of non-AIDS neoplasias in patients with human immunodeficiency virus infection

BACKGROUND

The incidence of non-AIDS defining cancer (NADC) is higher in people living with HIV (PLWH) than in the general population, and it is already one of the leading causes of death in the HIV-infected population. It is estimated that the situation will be aggravated by the progressive aging of PLWH. Early diagnosis through intensive cancer screening may improve the ability for therapeutic interventions and could be critical in reducing mortality, but it might also increase expenditure and harms associated with adverse events. The aim of this study is to evaluate an enhanced screening program for early diagnosis of cancer in PLWH compared to standard practice. The specific objectives are (1) to compare the frequency of cancer diagnosed at an early stage, (2) to analyze safety of the enhanced program: adverse events and unnecessary interventions, (3) to analyze the cost-utility of the program, and (4) to estimate the overall and site-specific incidence of NADC in PLWH.

METHODS

We will conduct a multicenter, non-blinded, randomized, controlled trial, comparing two parallel arms: conventional vs enhanced screening. Data will be recorded in an electronic data collection notebook. Conventional intervention group will follow the standard of care screening in the participating centers, according to the European AIDS Clinical Society recommendations, and the enhanced intervention group will follow an expanded screening aimed to early detection of lung, liver, anal, cervical, breast, prostate, colorectal, and skin cancer. The trial will be conducted within the framework of the Spanish AIDS Research Network Cohort (CoRIS).

DISCUSSION

The trial will evaluate the efficacy, safety, and efficiency of an enhanced screening program for the early diagnosis of cancer in HIV patients compared to standard of care practice. The information provided will be relevant since there are currently no studies on expanded cancer screening strategies in patients with HIV, and available data estimating cost effectiveness or cost-utility of such as programs are scarce. An enhanced program for NADC screening in patients with HIV could lead to early diagnosis and improve the prognosis of these patients, with an acceptable rate of unnecessary interventions, but it is critical to demonstrate that the benefits clearly outweigh the harms, before the strategy could be implemented.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04735445. Registered on 25 June 2019.

A third hierarchical level of narrower traits for the Dimensional Assessment of Personality Pathology-Basic Questionnaire

Current dimensional taxonomies of personality disorder show a stronger empirical grounding than categories, but may lack the necessary level of detail to make accurate predictions and case formulations. We need to further develop the lower levels of the hierarchy until reaching the building blocks of personality pathology. The Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ) is well-suited to this purpose due to its multilayered structure and its agreement with the official dimensional classifications. We disaggregated the 18 DAPP-BQ mid-level facets through exploratory and confirmatory factor analysis in a sample of 3233 community subjects and outpatients. We obtained a set of 72 clinically relevant, narrower subfacets, which were reliable, well-fitted to the data, and invariant between clinical and community subjects and between the sexes. This third level of abstraction increases by 4.7% the capacity to predict DSM categorical personality disorders, gives a particular advantage in capturing dependent, histrionic, paranoid, obsessive, and schizoid features and can provide the detailed information that clinical decisions demand.

Alternative DSM-5 Model for Personality Disorders Through the Lens of an Empirical Network Model

The Alternative Model for Personality Disorders defined in Diagnostic and Statistical Manual of Mental Disorders-Fifth edition (DSM-5) has recently attracted considerable interest in empirical research, with different hypotheses being proposed to explain the discordant results shown in previous research. Empirical network analysis has begun to be applied for complementing the study of psychopathological phenomena according to a new perspective. This article applies this analysis to personality facets measured in a sample of 626 patients with mental disorders and a 1,034 normative sample, using the Personality Inventory for DSM-5. The results reveal five substructures partially equivalent to domains defined in the DSM-5. Discordant facets (suspiciousness, hostility, rigid perfectionism, attention seeking, and restricted affectivity) play the role of connectors between substructures. Invariance between clinical and community networks was found except for the connection between unusual beliefs and perceptual dysregulation (stronger in the clinical sample). Considering the strength centrality index, anxiousness, emotional lability, and depressivity can be highlighted for their relative importance within both clinical and normative networks.

Clinical profile of patients admitted in an acute psychiatric ward before and during the COVID-19 lockdown

Introduction

The COVID-19 pandemic entailed several changes in health and medical assistance, economy, and lifestyle. In the Acute Psychiatric Ward of the Hospital Clínic of Barcelona, the implementation of restrictive measures was necessary in order to ensure patients’ safety.

Objectives

To compare clinical profiles and course of hospitalization of patients admitted before and during the COVID-19 lockdown in our Acute Psychiatric Ward.

Methods

All patients admitted from January 7^th to February 25^th and from March 19^th to May 7^th of 2020 in the Acute Psychiatric Hospitalization Unit of Hospital Clínic of Barcelona, Spain, were retrospectively included for analysis and divided into two groups according to the period when they were admitted. Statistical analyses were performed using SPSS, 23.0 version.

Results

A total of 117 inpatients were included (73 admitted before lockdown and 44 during lockdown), being 50.4% male, with a mean age of 42.4 (SD 15.73). Patients from the first group presented a significantly higher proportion of antidepressants prescription at discharge (p<0.05) and more substance use disorders (p<0.05). Regarding the lockdown group, 51% of patients manifested COVID-19-related stress. Time of hospitalization was significantly lower in the lockdown group (p<0.05), even though a significantly higher proportion of patients were discharged at home (p<0.05) compared with the first group.

Conclusions

The situation of lockdown led to a series of changes in our unit and also in the profile of patients admitted, having shorter admissions, lower prescription of antidepressants, and often COVID-related stress. These differences should be considered in future situations in which restrictive measures may be necessary.

Disclosure

No significant relationships.

Incubation period of COVID-19: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

The incubation period of COVID-19 helps to determine the optimal duration of the quarantine and inform predictive models of incidence curves. Several emerging studies have produced varying results; this systematic review aims to provide a more accurate estimate of the incubation period of COVID-19.

METHODS

For this systematic review, a literature search was conducted using Pubmed, Scopus/EMBASE, and the Cochrane Library databases, covering all observational and experimental studies reporting the incubation period and published from 1 January 2020 to 21 March 2020.We estimated the mean and 95th percentile of the incubation period using meta-analysis, taking into account between-study heterogeneity, and the analysis with moderator variables.

RESULTS

We included seven studies (n = 792) in the meta-analysis. The heterogeneity (I2 83.0%, p < 0.001) was significantly decreased when we included the study quality and the statistical model used as moderator variables (I2 15%). The mean incubation period ranged from 5.6 (95% CI: 5.2 to 6.0) to 6.7 days (95% CI: 6.0 to 7.4) according to the statistical model. The 95th percentile was 12.5 days when the mean age of patients was 60 years, increasing 1 day for every 10 years.

CONCLUSION

Based on the published data reporting the incubation period of COVID-19, the mean time between exposure and onset of clinical symptoms depended on the statistical model used, and the 95th percentile depended on the mean age of the patients. It is advisable to record sex and age when collecting data in order to analyze possible differential patterns.

Integration of the ICD-11 and DSM-5 Dimensional Systems for Personality Disorders Into a Unified Taxonomy With Non-overlapping Traits

The promise of replacing the diagnostic categories of personality disorder with a better-grounded system has been only partially met. We still need to understand whether our main dimensional taxonomies, those of the International Classification of Diseases, 11th Revision (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), are the same or different, and elucidate whether a unified structure is possible. We also need truly independent pathological domains, as they have shown unacceptable overlap so far. To inquire into these points, the Personality Inventory for DSM-5 (PID-5) and the Personality Inventory for ICD-11 (PiCD) were administered to 677 outpatients. Disattenuated correlation coefficients between 0.84 and 0.93 revealed that both systems share four analogous traits: negative affectivity, detachment, dissociality/antagonism, and disinhibition. These traits proved scalar equivalence too, such that scores in the two questionnaires are roughly interchangeable. These four domains plus psychoticism formed a theoretically consistent and well-fitted five-factor structure, but they overlapped considerably, thereby reducing discriminant validity. Only after the extraction of a general personality disorder factor (g-PD) through bifactor analysis, we could attain a comprehensive model bearing mutually independent traits.

Cardiac MRI in Patients with Acute Chest Pain

Acute chest pain is a common reason for visits to the emergency department. It is important to distinguish among the various causes of acute chest pain, because treatment and prognosis are substantially different among the various conditions. It is critical to exclude acute coronary syndrome (ACS), which is a major cause of hospitalization, death, and health care costs worldwide. Myocardial ischemia is defined as potential myocyte death secondary to an imbalance between oxygen supply and demand due to obstruction of an epicardial coronary artery. Unobstructed coronary artery disease can have cardiac causes (eg, myocarditis, myocardial infarction with nonobstructed coronary arteries, and Takotsubo cardiomyopathy), and noncardiac diseases can manifest with acute chest pain and increased serum cardiac biomarker levels. In the emergency department, cardiac MRI may aid in the identification of patients with non-ST-segment elevation myocardial infarction or unstable angina or ACS with unobstructed coronary artery disease, if the patient's clinical history is known to be atypical. Also, cardiac MRI is excellent for risk stratification of patients for adverse left ventricular remodeling or major adverse cardiac events. Cardiac MRI should be performed early in the course of the disease (<2 weeks after onset of symptoms). Steady-state free-precession T2-weighted MRI with late gadolinium enhancement is the mainstay of the cardiac MRI protocol. Further sequences can be used to analyze the different pathophysiologic subjacent mechanisms of the disease, such as microvascular obstruction or intramyocardial hemorrhage. Finally, cardiac MRI may provide several prognostic biomarkers that help in follow-up of these patients. Online supplemental material is available for this article. ^©RSNA, 2020.

Toward an Integrated Model of Pathological Personality Traits: Common Hierarchical Structure of the PID-5 and the DAPP-BQ

A dimensional classification seems to be the next move in the personality disorders field. However, it is not clear whether there is one dimensional model or many, or whether the currently available dimensional instruments measure the same traits. To help clarify these issues, the authors administered the Personality Inventory for DSM-5 (PID-5) and the Dimensional Assessment of Personality Pathology (DAPP-BQ) to 414 psychiatric outpatients. Factor analyses showed that a common hierarchical structure underlies both instruments, even if each one measures slightly different aspects of it. Disattenuated correlations indicated that, at the lower order level, two thirds of the PID-5 and DAPP-BQ facets measure essentially the same traits, although the pairings were not exactly as predicted. Among higher order domains, only PID Negative Affectivity and Detachment converged unambiguously with DAPP Emotional Dysregulation and Inhibition. Overall, the PID-5 and the DAPP-BQ reflect, with small divergences, one and the same structure of pathological personality traits.

Incubation period of COVID-19: A systematic review and meta-analysis

Background and objective

The incubation period of COVID-19 helps to determine the optimal duration of the quarantine and inform predictive models of incidence curves. Several emerging studies have produced varying results; this systematic review aims to provide a more accurate estimate of the incubation period of COVID-19.

Methods

For this systematic review, a literature search was conducted using Pubmed, Scopus/EMBASE, and the Cochrane Library databases, covering all observational and experimental studies reporting the incubation period and published from 1 January 2020 to 21 March 2020.We estimated the mean and 95th percentile of the incubation period using meta-analysis, taking into account between-study heterogeneity, and the analysis with moderator variables.

Results

We included seven studies (n = 792) in the meta-analysis. The heterogeneity (I² 83.0%, p < 0.001) was significantly decreased when we included the study quality and the statistical model used as moderator variables (I² 15%). The mean incubation period ranged from 5.6 (95% CI: 5.2–6.0) to 6.7 days (95% CI: 6.0–7.4) according to the statistical model. The 95th percentile was 12.5 days when the mean age of patients was 60 years, increasing 1 day for every 10 years.

Conclusion

Based on the published data reporting the incubation period of COVID-19, the mean time between exposure and onset of clinical symptoms depended on the statistical model used, and the 95th percentile depended on the mean age of the patients. It is advisable to record sex and age when collecting data in order to analyze possible differential patterns.

Personality Disorders in the ICD-11: Spanish Validation of the PiCD and the SASPD in a Mixed Community and Clinical Sample

The International Classification of Diseases–11th revision (ICD-11) classification of personality disorders is the official diagnostic system that is used all over the world, and it has recently been renewed. However, as yet very few data are available on its performance. This study examines the Personality Inventory for ICD-11 (PiCD), which assesses the personality domains of the system, and the Standardized Assessment of Severity of Personality Disorder (SASPD), which determines severity. The Spanish versions of the questionnaires were administered to a community (n = 2,522) and a clinical sample (n = 797). Internal consistency was adequate in the PiCD (α = .75 to .84) but less so in the SASPD (α = .64 and .73). Factor analyses suggested a unidimensional or bidimensional structure for severity, while revealing that the personality trait qualifiers are organized into four factors: negative affectivity, detachment, dissociality, and a bipolar domain of disinhibition–anankastia. The mutual relationships between traits and severity were analyzed, as well as the ability of the whole system to identify clinical subjects. Although further improvements are required, the results generally support the use of the PiCD and the SASPD and help substantiate the new ICD-11 taxonomy that underlies them.

Mean-level change in pathological personality dimensions over 4 decades in clinical and community samples: A cross-sectional study

Although normal personality traits change gradually with age, personality disorders have been reported to remit rapidly and completely in little more than 10 years. Such a benign prognosis is surprising and may be due in part to the combined use of categorical diagnoses, seriously ill patients, and longitudinal designs in the existing literature. This study examines, for the first time, the development of personality pathology across a life span by means of dimensional models, represented by the Dimensional Assessment of Personality Pathology-Basic Questionnaire and the Personality Inventory for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. We draw upon a cross-sectional design and four large clinical and community samples to avoid previous biases. We found that personality pathology declined by around 0.5 SD overall from age 20 to 60, though with noticeable differences between domains: Dissocial behavior and antagonism decreased by between two thirds and 1 SD; compulsivity increased at the same rate; disinhibition, negative affect, and psychoticism dropped by 0.5 SD; and detachment remained stable or rose slightly. In short, the changes in many clinically important traits are modest, occur at a slow pace, and roughly parallel the maturation effect found for normal personality traits. The resulting picture of personality disorder development is not as optimistic as previous studies would have us believe. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Risk of cardiovascular disease in patients with HIV infection undergoing antiretroviral therapy

BACKGROUND

The increased survival of patients with HIV infection thanks to antiretroviral therapy (ART) is accompanied by a higher rate of cardiovascular disease (CVD). We analysed the prevalence of the cardiovascular risk factors (CRFs) and estimated the risk of CVD in a cohort of patients with HIV in Spain.

METHODS

We conducted a cross-sectional, observational study of CRFs in the Spanish VACH cohort of patients with HIV who undergo ART.

RESULTS

The study assessed 15,559 patients with HIV (76% men; mean age, 46 years). Some 3.7% had experienced at least 1 CVD event. The prevalence of CRFs was high (hyperlipidaemia, 64%; tobacco use, 47%; arterial hypertension, 22%; and diabetes, 16%). According to the Framingham scale, 10.9% of the patients presented a high CVD risk, and 28.8% presented a moderate risk. Of the patients with a high CVD risk, 49% took protease inhibitors and 43% took abacavir. Fifty-three percent of the patients diagnosed with arterial hypertension took antihypertensive drugs, and 2.6% of the patients with diabetes took antidiabetic agents.

CONCLUSIONS

Classical CRFs are common in patients with HIV undergoing ART in Spain, and a large proportion of them have a moderate-high risk of CVD. Therefore, controlling the modifiable CRFs in patients with HIV should be improved, and the use of drugs with a better cardiovascular risk profile should be assessed.

The General Criteria for Personality Disorders Assessed by Interview: Do They Still Have a Role to Play?

On the path to developing dimensional models of personality disorder (PD), we are at risk of leaving key diagnostic aspects behind. The general criteria for PD may be important ones because they reflect the defining aspects of personality pathology: long duration, independence from psychopathological states, and harmfulness. We assessed these criteria by interview in a sample of 362 psychiatric outpatients after administering the Personality Diagnostic Questionnaire-4+. The result was a 42.5% fall in self-reported endorsements, due to misinterpretations (11.5%), short duration of traits or contamination by state psychopathology (9.8%), and traits being non-harmful (21.2%). However, not all personality traits and disorders underwent correction to the same extent, and ultimately, the interview did not improve the prediction of clinical variables. These findings raise doubts about the practical relevance of the general criteria for PD and support the role of self-report questionnaires for diagnostic purposes.

Dimensional Personality Assessment among a Chronic Fatigue Syndrome (CFS) sample with Personality Inventory for DSM-5 (PID-5)

INTRODUCTION

Personality Disorders (PD) are highly prevalent among Chronic Fatigue Syndrome (CFS) patients, but studies based on the DSM-5 are still scarce. Validated instruments have not yet been specifically used in CFS patients. Therefore, our aim was to analyze the differences in personality facets and domains profiles among CFS patients with and without a PD using the Personality Inventory for DSM-5 (PID-5). Additionally, we analyzed the ability of this instrument to predict PD in a sample of CFS patients. This instrument is validated for PDs, but not for CFS.

METHODS

All of the 84 CFS patients were evaluated through a clinical interview and underwent psychopathological evaluation with the SCID I and SCID II. Dimensional personality facets and domains were evaluated with the PID-5, according to DSM-5.

RESULTS

In our sample, 54 (64%) of the patients fulfilled the criteria of a PD. The most significant facets in CFS with PD in comparison to those patients without a PD were Separation Insecurity, Perseveration, Withdrawal, Depressivity, Rigid Perfectionism, Unusual Beliefs and Experiences. Negative Affectivity and Detachment were the two significant domains in CFS-PD patients. In the regression analyses, only Detachment and Rigid Perfectionism constituted a prognostic factor leading to high probability of an endorsed PD. Conclussion. According to these results, the PID-5 domains and facets could be adequate and useful to differentiate between PD and non-PD patients in clinical samples and suggest a more frequent dimensional personality profile in CFS patients.

Decreasing rates of acute myocardial infarction in people living with HIV: a nationwide cohort study in Spain, 2004-2015

OBJECTIVES

Contemporary data from country-wide cohorts are needed to reveal trends in the occurrence of acute myocardial infarction (AMI) in people living with HIV (PLWH). We analysed time trends in the standardized incidence rate (sIR) of AMI in PLWH in Spain from 2004 to 2015, and compared them with trends in the general population.

METHODS

A longitudinal study in a nationwide contemporary multicentre HIV-infected cohort was carried out. Data on all incident AMI events were collected, and age- and sex-standardized IRs calculated. To analyse the IR of AMI in the general population, the national rates of hospital discharges for AMI per 100 000 inhabitants stratified for age and sex from 2004 to 2015 were obtained using the morbidity report data from the National Statistics Institute. A Poisson regression model was fitted to assess the effect of covariates of interest on AMI occurrence.

RESULTS

The sIRs of AMI in 2004-2015 were 237.92 [95% confidence interval (CI) 225.95-249.90] and 66.75 (95% CI: 23.49-110.01) per 100 000 patient-years in male and female PLWH, respectively. There was a decrease in the sIR of AMI in male PLWH from 279.02 (95% CI: 265.46-292.59) per 100 000 person-years in 2004-2009 to 222.13 (95% CI: 210.83-233.42) per 100 000 person-years in 2010-2015. Compared with the general population, the sIR ratio was 1.41 (95% CI: 1.26-1.55) in 2004-2009, and 1.28 (95% CI: 1.15-1.43) in 2010-2014. AMI occurrence was associated with older age (P < 0.066 for each 10-year age stratum ≥ 35-years compared with the 25-34 year stratum), higher plasma HIV RNA (P < 0.001), lower CD4 count (P < 0.04 for CD4 strata > 350 cells/μL compared with the 0-100 cells/μL stratum), and the period 2004-2009 (P < 0.001).

CONCLUSIONS

There has been a decreasing incidence of AMI in PLWH in Spain, associated with improving immune and virological status, but the incidence of AMI has remained higher than in the general population.

Genotypic tropism testing of proviral DNA to guide maraviroc initiation in aviraemic subjects: 48-week analysis of results from the PROTEST study

OBJECTIVES

Maraviroc (MVC) is a suitable drug for aviraemic subjects on antiretroviral treatment (ART) developing toxicity. Its prescription requires prior tropism testing. It is unknown if proviral DNA genotypic tropism testing is reliable for guiding MVC initiation in aviraemic subjects, so this study was carried out to address this issue.

METHODS

PROTEST was a phase 4, prospective, single-arm clinical trial carried out in 24 HIV care centres in Spain. MVC-naïve HIV-1-infected patients with HIV-1 RNA < 50 copies/mL on stable ART during the previous 6 months who required an ART change because of toxicity and who had R5 HIV, as determined by proviral DNA genotypic tropism testing, initiated MVC with two nucleoside reverse transcriptase inhibitors (NRTIs) and were followed for 48 weeks. Virological failure was defined as two consecutive viral load measurements > 50 copies/mL.

RESULTS

Tropism results were available for 141 of 175 (80.6%) subjects screened: 60% had R5 and 85% of these (n = 74) were finally included in the study. Previous ART included protease inhibitors (PIs) in 62% of subjects, nonnucleoside reverse transcriptase inhibitors (NNRTIs) in 36%, and integrase inhibitors (INIs) in 2%. Main reasons for treatment change were dyslipidaemia (42%), gastrointestinal symptoms (22%) and liver toxicity (15%). MVC was given alongside tenofovir (TDF)/emtricitabine (FTC) (54%) and abacavir (ABC)/lamivudine (3TC) (40%) in most patients. Eighty-four per cent of patients maintained a viral load < 50 copies/mL to week 48, whereas 16% discontinued treatment: two withdrew informed consent, one had an R5 to X4 shift between screening and baseline, one was lost to follow-up, one developed an adverse event (rash), two died from non-study-related causes, and five developed protocol-defined virological failure.

CONCLUSIONS

Initiation of MVC plus two NRTIs in aviraemic subjects based on genotypic tropism testing of proviral HIV-1 DNA is associated with low rates of virological failure for up to 1 year.

Assessment of bevacizumab quality and stability in repackaged syringes for clinical use

Objectives

Among measures taken to optimise financial resources, the off-label use of bevacizumab (Avastin) in the treatment of age-related macular degeneration (AMD) involves its repackaging from higher volume dosage forms. This use requires studies to analyse the viability of the repackaged preparations to ensure their quality, safety and efficacy. Our aim was to assess the structural stability and particle size of bevacizumab after it was repackaged from the original glass vials and stored in plastic syringes.

Methods

High performance liquid chromatography by size exclusion (HPLC-SE) was used to quantify the bevacizumab and determine its degradation products after stress stability testing, with a particle size counter employed after repackaging and subsequent storage.

Results

The syringes stored for 3 days at 4°C maintained the area of the main chromatographic peak above 100±10% of its initial value, and the observed particle size is the same as at baseline (20 nm) but with a double distribution towards larger sizes.

Conclusions

This study shows how the repackaging of Avastin in plastic syringes permits their use for 3 days if stored under normal refrigeration. In this way, hospital pharmacy services can help optimise health resources without compromising the pharmaceutical standards of the drug.

Borderline Personality Disorder and Personality Inventory for DSM-5 (PID-5): Dimensional personality assessment with DSM-5

INTRODUCTION

Borderline personality disorder (BPD) diagnosis has been considered highly controversial. The Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) proposes an alternative hybrid diagnostic model for personality disorders (PD), and the Personality Inventory for DSM-5 (PID-5) has adequate psychometric properties and has been widely used for the assessment of the dimensional component.

METHODS

Our aim was to analyze the utility of the personality traits presented in Section III of the DSM-5 for BPD diagnosis in an outpatient clinical sample, using the Spanish version of the PID-5. Two clinical samples were studied: BPD sample (n=84) and non-BPD sample (n=45). Between-sample differences in PID-5 scores were analyzed.

RESULTS

The BPD sample obtained significantly higher scores in most PID-5 trait facets and domains. Specifically and after regression logistic analyses, in BPD patients, the domains of Negative Affectivity and Disinhibition, and the trait facets of emotional lability, [lack of] restricted affectivity, and impulsivity were more significantly associated with BPD.

CONCLUSIONS

Although our findings are only partially consistent with the algorithm proposed by DSM-5, we consider that the combination of the PID-5 trait domains and facets could be useful for BPD dimensional diagnosis, and could further our understanding of BPD diagnosis complexity.

2016 Expert consensus document on prevention, diagnosis and treatment of short-term peripheral venous catheter-related infections in adult

The use of endovascular catheters is a routine practice in secondary and tertiary care level hospitals. Short peripheral catheters have been found to be associated with the risk of nosocomial bacteremia resulting in morbidity and mortality. Staphyloccus aureus is mostly associated with peripheral catheter insertion. This Consensus Document has been elaborated by a panel of experts of the Spanish Society of Cardiovascular Infections in cooperation with experts from the Spanish Society of Internal Medicine, Spanish Society of Chemotherapy and Spanish Society of Thoracic-Cardiovascular Surgery and aims at define and establish the norm for management of short duration peripheral vascular catheters. The document addresses the indications for insertion, catheter maintenance and registry, diagnosis and treatment of infection, indications for removal and stresses on continuous education as a driver for quality. Implementation of this norm will allow uniformity in usage thus minimizing the risk of infection and its complications.

Psychometric Properties of the Spanish PID-5 in a Clinical and a Community Sample

The Personality Inventory for DSM-5 (PID-5) measures the trait part (Criterion B) of the alternative model for personality disorders proposed in Section III of DSM-5. Although its psychometric properties have proven adequate thus far, evidence is limited in other languages and in clinical samples. The Spanish PID-5 was examined in two samples comprising 446 clinical and 1,036 community subjects. Facet scales showed good internal consistency in both samples (median α = .86 and .79) and were unidimensional under exploratory and confirmatory approaches. They were also able to distinguish between clinical and community subjects with a mean standardized difference of z = 0.81. All facets except for Risk Taking were unipolar, such that the upper poles indicated pathology and the lower poles reflected normality, rather than the opposite pole of abnormality. The entire PID-5 hierarchical structure, from one to five factors, was confirmed in both samples with Tucker's congruence coefficients over .95.

Cerebellar Degeneration in Cattle Grazing Solanum Bonariense (“Naranjillo”) in Western Uruguay

Cattle in western Uruguay that were eating Solanum bonariense developed periodic episodes of ataxia, hypermetria, hyperesthesia, head and thoracic limb extension, opisthotonus, nystagmus, and falling to the side or backward. Similar clinical signs were experimentally reproduced in cattle by administration of S. bonariense via rumen cannula at a dose of 1,024 g/kg body mass. No significant gross lesions were observed in field cases or experimentally induced cases. Spontaneous and induced histologic lesions were similar and included vacuolation, degeneration, and loss of Purkinje cells. Axonal spheroids, microcavitations, and other changes of wallerian-type degeneration in cerebellar white matter were also observed. Ultrastructural changes included increased number of electron-dense residual storage bodies in membrane-bound vesicles in affected Purkinje cells, and similar vesicles and mitochondria in axonal spheroids. No histologic lesions were detected in the other examined tissues. The Purkinje-cell swelling and vacuolation with subsequent cerebellar degeneration are suggestive of Purkinje-cell specific toxin that produces abnormal lysosome function and cell specific axonal transport. This is the first report of S. bonariense toxicity.

Toward a comprehensive care of HIV patients: finding a strategy to detect depression in a Spanish HIV cohort

Depression is a common but frequently undiagnosed feature in individuals with HIV infection. To find a strategy to detect depression in a non-specialized clinical setting, the overall performance of the Hospital Anxiety and Depression Scale (HADS) and the depression identification questions proposed by the European AIDS Clinical Society (EACS) guidelines were assessed in a descriptive cross-sectional study of 113 patients with HIV infection. The clinician asked the two screening questions that were proposed under the EACS guidelines and requested patients to complete the HADS. A psychiatrist or psychologist administered semi-structured clinical interviews to yield psychiatric diagnoses of depression (gold standard). A receiver operating characteristic (ROC) analysis for the HADS-Depression (HADS-D) subscale indicated that the best sensitivity and specificity were obtained between the cut-off points of 5 and 8, and the ROC curve for the HADS-Total (HADS-T) indicated that the best cut-off points were between 12 and 14. There were no statistically significant differences in the correlations of the EACS (considering positive responses to one [A] or both questions [B]), the HADS-D ≥ 8 or the HADS-T ≥ 12 with the gold standard. The study concludes that both approaches (the two EACS questions and the HADS-D subscale) are appropriate depression-screening methods in HIV population. We believe that using the EACS-B and the HADS-D subscale in a two-step approach allows for rapid, assumable and accurate clinical diagnosis in non-psychiatric hospital settings.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Increased risk of non-AIDS-related events in HIV subjects with persistent low CD4 counts despite cART in the CoRIS cohort

The aim was to analyze clinical complications in HIV-infected subjects who persistently maintain low CD4 levels despite virological response to cART in the Spanish CoRIS cohort. The main inclusion criteria were CD4 counts <200cells/mm(3) at cART-initiation and at least 2years under cART achieving a viral load <500copies/mL. Those patients with CD4 counts <250cells/mm(3) 2years after cART were classified as the Low-CD4 group, and clinical events were collected from this time-point. Poisson regression models were used to calculate incidence rate ratios of death, AIDS-defining events, serious non-AIDS-defining events (NAE) and of each specific NAE category (non-AIDS-defining malignancies (non-ADM), cardiovascular, kidney- and liver-related events). Of 9667 patients in the cohort, a total of 1128 met the criteria and 287 (25.4%) were classified in the Low-CD4 group. A higher risk of death (aIRR: 4.71; 95% CI: 1.88-11.82; p-value=0.001) and of non-ADM were observed in this group (aIRR: 2.23; 95% CI: 1.07-4.63; p=0.03). Our results stress the need to control accelerated aging in this population to counter their increased risk of non-AIDS-defining diseases, particularly cancer, and are consistent with the concept that clinical complications are potentially affected by genetics and lifestyle.

Diagnostic agreement between the Personality Diagnostic Questionnaire-4+ (PDQ-4+) and its Clinical Significance Scale

BACKGROUND

The Personality Diagnostic Questionnaire-4+ (PDQ-4+) is composed of a self-report and an interview, the Clinical Significance Scale, but no studies have reported joint findings. This study is the first to examine the diagnostic agreement between the Spanish version of the PDQ-4+ self-report and its corresponding interview.

METHOD

The sample comprised 235 psychiatric outpatients who were assessed with both instruments.

RESULTS

The interview reduced to one half the number of diagnoses provided by self-report (83.4% to 38.3%; mean number of diagnoses 3.29 to .62). Diagnostic agreement was between fair and moderate (mean kappa .45 for PDQ-4+ total score).

CONCLUSIONS

Findings suggest the utility of jointly administering the PDQ-4+ and its Clinical Significance Scale to screen for the presence or absence of personality disorders (PDs). Modifications in the diagnostic cut-offs for individual PDs and the PDQ-4+ total score may improve the efficacy of the instrument.

Interpreting the reasons for the choice and changing of two drug regimens in an observational cohort: comparison of a ritonavir-boosted protease inhibitor-based versus a nonnucleoside reverse transcriptase inhibitor-based first-line regimen

OBJECTIVES

We compared reasons for the choice of regimen, time to and reasons for third drug modification, virological response and change in CD4 T-cell counts in patients started on atazanavir/ritonavir (ATV/r)- vs. efavirenz (EFV)-based first-line regimens.

METHODS

We included patients from the Cohort of the Spanish HIV Research Network (CoRIS), a multicentre cohort of HIV-positive treatment-naïve subjects, in the study. We used logistic regression to assess factors associated with choosing ATV/r vs. EFV, proportional hazards models on the subdistribution hazard to estimate subdistribution hazard ratios (sHRs) for third drug modification, logistic regression to estimate odds ratios (ORs) for virological response and linear regression to assess mean differences in CD4 T-cell count increase from baseline.

RESULTS

Of 2167 patients, 10.7% started on ATV/r. ATV/r was more likely than EFV to be prescribed in injecting drug users [adjusted OR 1.85; 95% confidence interval (CI) 1.03-3.33], in 2009-2010 (adjusted OR 1.63; 95% CI 1.08-2.47) and combined with abacavir plus lamivudine (adjusted OR 1.53; 95% CI 0.98-2.43). Multivariate analyses showed no differences, comparing ATV/r vs. EFV, in the risk of third drug modification (sHR 1.04; 95% CI 0.74-1.46) or in virological response (OR 0.81; 95% CI 0.46-1.41); differences in mean CD4 T-cell count increase from baseline were at the limit of statistical significance (mean difference 29.8 cells/μL; 95% CI -4.1 to 63.6 cells/μL). In patients changing from EFV, 48% of changes were attributable to toxicity/adverse events, 16% to treatment failure/resistance, 3% to simplification, and 8 and 12%, respectively, to patients' and physicians' decisions; these percentages were 24, 6, 12, 14 and 24%, respectively, in those changing from ATV/r.

CONCLUSIONS

ATV/r- and EFV-based regimens meet the requirements of both efficacy and safety for initial combination antiretroviral regimen, which relate to better durability.

Spanish version of the Dimensional Obsessive-Compulsive Scale (DOCS): psychometric properties and relation to obsessive beliefs

OBJECTIVES

Our main goal was to provide the psychometric properties of the Spanish version of the Dimensional Obsessive-Compulsive Scale (DOCS) in a non-clinical sample (n = 237) and in adult patients with Obsessive-Compulsive Disorder (OCD) (n = 110). We also examined the association between OC symptom dimensions and obsessive beliefs.

METHODS

The psychometric properties involved four steps: reliability, structural validity, convergent and discriminant validity and diagnostic sensitivity. Linear regression analyses were used to assess the associations between OC symptoms and obsessive beliefs.

RESULTS

Exploratory and confirmatory factor analyses replicated the original four-factor structure in both samples. The DOCS showed good performance in terms of internal consistency, test-retest reliability and convergent validity in both samples. The DOCS showed better diagnostic sensitivity than another self-report instrument of OC symptoms, the Obsessive-Compulsive Inventory Revised. Findings of the relationship between obsessive beliefs and OC symptoms revealed that certain obsessive beliefs predicted specific OC symptom dimensions.

CONCLUSIONS

The Spanish version of the DOCS has similar psychometric properties than the original English instrument, although its performance is somewhat better in OCD patients than in students. It will be important to ascertain its ability to discriminate OCD from other associated disorders.

Temperament and character in transsexuals

The aim of this study was to evaluate personality in transsexuals. The Temperament and Character Inventory (TCI) profiles of 166 male-to-female (MF) and 88 female-to-male (FM) transsexuals were compared with those of a control group of males and females. MF and FM transsexuals scored significantly lower than males and females in RD4 (more independent) and C3 (more self-centeredness). MF transsexuals scored higher than males and females in HA4 (more fatigable), ST and ST3 (more spiritual acceptance), and lower in C5 (more opportunistic); moreover, they showed higher scores than males in RD1 (more sentimental) and lower than females in C (less cooperativeness). FM transsexuals scored lower than females in HA2 (more daring and confident), RD (less sentimental), and C5 (more opportunistic). Compared with FM, MF transsexuals scored higher on HA2 (more fearful), RD, RD1 (more sentimental), ST, ST2 and ST3 (more spiritual). All these differences were less than half a standard deviation except for C3. Data show that transsexuals and controls display a similar personality profile, even though there are some differential personality traits. Moreover, the personality profile of transsexuals was closer to the profile of subjects who shared their gender identity than those who shared their anatomical sex.

Risk of clinically significant depression in HIV-infected patients: effect of antiretroviral drugs

OBJECTIVES

We aimed to characterize depression in newly diagnosed HIV-infected patients, to determine the effect of antiretroviral therapy (ART) on its incidence, and to investigate whether efavirenz use was associated with a higher risk, compared with non-efavirenz-containing regimens, in the Spanish CoRIS cohort.

METHODS

CoRIS is a contemporary, multicentre cohort of HIV-infected patients, antiretroviral-naïve at entry, launched in 2004. Poisson regression models were used to investigate demographic, clinical and treatment-related factors associated with a higher incidence of clinically significant depression to October 2010.

RESULTS

In total, 5185 patients (13 089 person-years) participated in the study, of whom 3379 (65.2%) started ART during follow-up. The incidence rates of depression before and after starting ART were 11.68 [95% confidence interval (CI) 9.01-15.15] and 7.06 (95% CI 5.45-9.13) cases per 1000 person-years, respectively. After adjustment, there was an inverse association between the occurrence of depression and the initiation of ART [incidence rate ratio (IRR) 0.53; 95% CI 0.28-0.99], while the likelihood of depression increased in patients of age > 50 years (IRR 1.94; 95% CI 1.21-3.12). Longer exposure to ART was associated with a decreased IRR of depression in unadjusted and adjusted analyses. The IRR for patients receiving < 2, 2-4 and > 4 years of ART was 0.72 (95% CI 0.36-1.44), 0.10 (95% CI 0.04-0.25) and 0.05 (95% CI 0.01-0.17), respectively, compared with ART-naïve patients. This protective effect was also observed when durations of exposure to nonnucleoside reverse transcriptase inhibitor-based regimens and efavirenz-containing regimens were analysed separately.

CONCLUSIONS

The incidence of clinically significant depression was lower among HIV-infected patients on ART. The protective effect of ART was also observed with efavirenz-containing regimens.

[Hypolipidemic agents drug interactions: approach to establish and assess its clinical significance. Structured review]

OBJECTIVE

To carry out a structures review of drug interactions of hypolipidemic drugs and to assess their clinical relevance.

METHOD

Structured review of drug interactions of hypolipidemic drugs in humans through PubMed/Medline of published articles, without language restrictions and with full text access until June 30th of 2012. The following Mesh terms were used: Drug Interactions, Lipid Regulating Agents, Herb-Drug Interactions, Food-Drug Interactions y Hypolipidemic Agents (Pharmacological Action). The information was completed with those articles considered to be relevant. Finally, a method was used to assess the clinical relevance of the interaction, based on the likelihood of occurrence and the severity of the effect of the interaction.

RESULTS

849 publications were gathered, of which 243 references were selected, among which 189 interactions were identified. Thirty-three of them were considered of very high risk (level 1) and 42 of high risk (level 2), basically associated to increased risk for rhabdomyolisis. Enzymatic inhibition of CYP450 was the most common mechanism for these interactions.

CONCLUSIONS

Of the interactions identified in patients on hypolipidemic drugs, 60.3% (128/189) are clinically relevant (very high or high risk), mainly associated to the occurrence of rhabdomyolisis. Most of these interactions are attributed to simultaneous use of CYP3A4 inhibitors. Therefore, statins metabolized through CYP3A4 (simvastatin, lovastatin and atorvastatin) are the ones with the highest number of clinically relevant interactions.