Personality disorders in bipolar and depressive disorders.

The association of mood disorders with personality disorders (PDs) is relevant from a clinical, therapeutic and prognostic point of view. To examine this issue, we compared the prevalence of DSM-III-R personality disorders assessed with SCID-II in patients with depressive (n = 117) and bipolar (n = 71) disorders both recovered from a major depressive index episode that needed hospital admission. PDs prevalence and comorbidity with axis I were calculated. Avoidant PD (31.6%) (O.R. = 1.7, C.I. = 1.06-2.9. P < 0.01), borderline PD (30.8%) and obsessive-compulsive PD (30.8%) were the most prevalent axis II diagnoses among patients with depressive disorder. In bipolar disorder group, patients showed more frequently obsessive-compulsive PD (32.4%), followed by borderline PD (29.6%) and avoidant PD (19.7%). Avoidant PD showed a trend toward being significantly more prevalent among depressives (P < 0.07). A different pattern of PDs emerges between depressive and bipolar patients.

[Personality disorders prevalence study among inpatients with mood disorders, psychoactive use disorders and anxiety disorders]. / Valutazione della prevalenza di disturbi di personalità in una popolazione di pazienti psichiatrici ospedalizzati per disturbi dell'umore, disturbi da uso di sostanze psicoattive e disturbi d'ansia.

OBJECTIVE: The aim of this study was to asses type and prevalence of Personality Disorders (PDs) and their patterns of comorbidity with Axis I disorders in a sample of psychiatric inpatients. SETTING: The sample consisted of 300 subjects admitted to a psychiatric unit on a voluntary bases for an index episode. The study was conducted over a period of 12 months, from 1.11.1997 to 31.10.1998. MAIN OUTCOME MEASURES: The Italian version of SCID-II-PQ (Structured Clinical Interview for DSM-III-R personality disorders, with Personality Questionnaire--PQ--a self report questionnaire). RESULTS: More than half the patients had at least one personality disorder. The mean of disorders per patient was 2.83 +/- 1.93 (+/- SD). The most prevalent Axis II disorders were Borderline PD (30.7%), Obsessive-compulsive PD (30.7%) and Avoidant PD (25.3%). Women were significantly more likely than men to meet criteria for Dependent PD and Avoidant PD. Man showed significantly more frequently than women Antisocial PD. Significant associations (p < 0.05) were found for comorbidity of Mood Disorders and Avoidant PD, and for Psicoactive Use Disorders and Antisocial PD. CONCLUSIONS: Our study confirms the high prevalence of PDs in psychiatric inpatients and showe some interesting associations between Axis I and Axis II disorders. These results can't be generalized to outpatients because our clinical sample involved mainly severely ill inpatients, but they raise questions about the exact nature of PDs and of the relationship with Axis I disorders. Further research involving outpatients and general population is needed to examine factors that could affect development and course of Personality Disorders.

Patterns of comorbidity among DSM-III-R personality disorders.

The aim of this study was to examine patterns of comorbidity among personality disorders (PDs) in a sample of 156 psychiatric inpatients. PDs were assessed with Semistructured Clinical Interview for DSM-III-R Personality Disorders. To determine significant co-occurrence among axis II diagnoses, odds ratio and the percent of co-occurrence of pairs of disorders were calculated. Both statistical methods revealed high rates of comorbidity: significance association was found for 36 pairs of disorders using the percent of co-occurrence, and for 22 pairs of disorders using the odds ratio. These results support the concept of 'apparent comorbidity' for most PDs, deriving from conceptual and definitional artifacts or from a 'state-biasing effect'. In light of these observations, a categorical approach to PDs, resulting in a list of diagnoses, appears useless in psychiatric practice. A dimensional classification is probably better suited for PDs, improving the understanding of personality psychopathology and its clinical implications.

Ifosfamide, cisplatin and etoposide combination in locally advanced inoperable non-small-cell lung cancer: a phase II study.

From March 1993 to February 1997, 43 eligible patients with inoperable stage IIIA (ten patients) and stage IIIB (33 patients), histologically confirmed NSCLC received 3 courses of the ICE combination (ifosfamide 1.5 g m(-2) and mesna 750 mg m(-2) two times a day, cisplatin 25 mg m(-2) and etoposide 100 mg m(-2), all administered intravenously (i.v.) on days 1-3 every 3 weeks) with G-CSF support. After three cycles, patients were submitted to radical surgery or received two additional courses of the ICE regimen and/or curative radiotherapy. Grade 3-4 neutropenia occurred in 21% of 114 evaluable courses, but was of short duration, leading to neutropenic fever in 5% of the courses. Severe thrombocytopenia and anaemia were observed in 13% and 3% of the courses respectively. Non-haematological toxicity was generally mild with only two episodes of reversible renal impairment. The overall response rate after three chemotherapy courses was 69% (28 partial responses, one complete response). Ten patients (8/10 patients in stage IIIA, 2/33 patients in stage IIIB) underwent radical surgery. Median TTP for patients not undergoing surgery (n = 33) was 8 months (range 3-34+); median DFS for patients rendered NED by surgery (n = 10) was 26 months (range 1-54+). Median OS for the entire group was 12.5 months (range 2-57+). The ICE regimen is active in locally advanced NSCLC with acceptable toxicity and warrants further exploration as induction chemotherapy in larger series.

[The use of the Italian version of the Parental Bonding Instrument (PBI) in a clinical sample and in a student group: an exploratory and confirmatory factor analysis study]. / Utilizzazione della versione italiana del Parental Bonding Instrument (PBI) in un campione clinico ed in un campione di studenti: uno studio di analisi fattoriale esplorativa e confermatoria.

OBJECTIVE: The aim of this study was to verify the construct validity of the Italian version of Parental Bonding Instrument (PBI) a questionnaire which estimates the parental style as reported by the son or daughter. METHOD: The questionnaire was administered to a group of 102 students (62 males and 40 females) attending University of L'Aquila and to a sample of 128 patients (76 males and 52 females) consecutively admitted to a psychiatric unit for an index episode. We compared the means of the two factors (care, protection) separately for each parent in the two groups using a t-test for independent samples. After having estimated the internal consistency of items of each scale by calculating Cronbach's coefficient alpha, a factor analysis was performed for students and patients to find the structural factors of the questionnaire; then, we conducted a confirmatory factor analysis of the PBI items, for the students only, to evaluate the fit of the real items to models proposed in the literature. RESULTS: The Italian version of the Parental Bonding Instrument, demonstrated the ability to discriminate between patients and controls; it showed an high internal consistency. The factor analysis identified a two factors solution which accounted for 44.6% and 44.3% of the variance of the mother's and father's PBI scores respectively for the group of students and it identified two factors which accounted for 49.3% and 46.6% of the variance in the group of patients. CONCLUSIONS: The psychiatric patients showed a low "care"-high "protection" confirming an association between the "affectionless control" pattern and psychiatric disorders.

Mitomycin C plus vindesine plus etoposide (MEV) versus mitomycin C plus vindesine plus cisplatin (MVP) in stage IV non-small-cell lung cancer: A phase III multicentre randomised trial. The "Gruppo Oncologico Centro-Sud-Isole' (G.O.C.S.I.).

PURPOSE: To compare mitomycin C plus vindesine plus etoposide (MEV) vs. mitomycin C plus vindesine plus cisplatin (MVP) in the treatment of stage IV non-small-cell lung cancer. PATIENTS AND METHODS: 204 patients were entered in a phase III multicentre randomised trial from June 1990 to December 1994 and stratified according to the ECOG performance status (0-1 vs. 2). MVP was given in the following dosages: mitomycin C 8 mg/m2+vindesine 3 mg/m2+cisplatin 100 mg/m2 i.v. day 1 and vindesine 3 mg/m2 i.v. day 8 with cycles repeated every 4 weeks. MEV was given in the following dosages: mitomycin C 8 mg/m2+vindesine 3 mg/ m2 i.v. day 1 and etoposide 100 mg/m2 i.v. days 1 to 3 with cycles repeated every 3 weeks. For both treatments a maximum of 6 cycles was planned. Response and toxicity were evaluated according to WHO. Subjective responses were assessed by numerical scales. Analyses were made on the basis of intent to treat. RESULTS: The objective response rate was 21.4% (1 CR + 21 PR among 103 patients) in the MEV and 28.7% (1 CR + 28 PR among 101 patients) in the MVP arm (P = 0.48). Symptoms were similar in the two arms. 196 patients progressed and 182 died. The median times to progression were 10 weeks (95% CI 9-12) and 12 weeks (95% CI 10-15) and median survivals were 29 weeks (95% CI 25-36) and 28 weeks (95% CI 25-35) in the MEV and MVP arms, respectively. The relative risks of progressing and of dying were 0.89 (95% CL 0.66-1.20) and 0.96 (95% CL 0.71-1.30), respectively, for patients receiving MVP as compared with those receiving MEV at multivariate analysis adjusted by sex, age, histologic type, number of metastatic sites, performance status at entry, and centre. CONCLUSIONS: In the present study, no significant differences were observed in response rate, survival or palliation of symptoms between the MEV and MVP regimens, while toxicity was significantly more frequent and severe with MVP. Thus, MEV should be considered a reasonable alternative to the MVP regimen in the treatment of stage IV NSCLC.

Prognostic value of lymph node metastases after neoadjuvant chemotherapy for large-sized operable carcinoma of the breast.

BACKGROUND: Neoadjuvant chemotherapy followed by surgery or radiation therapy, or both, has become the treatment of choice for patients with large-sized resectable carcinoma of the breast in whom mastectomy is the conventional option. Since tumor regression before surgery is considered a favorable prognostic factor, there is still controversy regarding the need to perform an axillary dissection after a good response to systemic induction treatment. STUDY DESIGN: Between February 1990 and December 1993, we conducted a prospective study of 56 consecutive patients receiving high-dose anthracycline-based preoperative chemotherapy for large but potentially resectable carcinoma of the breast. Patients who had a good clinical response to induction systemic treatment received the same chemotherapy in the adjuvant phase, while those whose response was less than optimal received alternative adjuvant chemotherapy regimens. A multivariate analysis was made to evaluate the relative influence on disease-free survival rates of 11 clinicopathologic and treatment-related variables, including clinical response to primary chemotherapy, primary pathological (p-T) staging, and the number of metastatic lymph nodes. RESULTS: At a median follow-up period of 36 months, only the number of metastatic lymph nodes was found to be an independent predictor of relapse. Clinical response to systemic induction treatment and p-T staging did not correlate with prognosis. In the group of patients with axillary lymph node involvement, those who did not respond to preoperative chemotherapy showed a lower relapse rate compared with those who achieved an objective response. CONCLUSIONS: These findings suggest that axillary lymphadenectomy should be considered an important component of the combined modality therapy for patients with large-sized resectable carcinoma of the breast in order to identify subgroups of patients that may benefit from alternative treatments in the adjuvant setting.

Accelerated chemotherapy with high-dose epirubicin and cyclophosphamide plus r-met-HUG-CSF in locally advanced and metastatic breast cancer.

BACKGROUND: This study evaluated the toxicity of high-dose epirubicin and cyclophosphamide plus r-met-HUG-CSF (G-CSF) given every 2 weeks and compared the dose-intensity achieved with this schedule with that obtained in a previous study we conducted in which the same regimen was given every 3 weeks without G-SCF (EC 21). The secondary objective was to explore the activity of this regimen. PATIENTS AND METHODS: Between December 1991 and March 1994, 41 patients (pts), 19 with locally advanced breast cancer (LABC) and 22 with metastatic breast cancer (MBC), were given high-dose epirubicin (Hd-Epi) (120 mg/m2) and cyclophosphamide (CTX) (600 mg/m2) on day 1 every 14 days (EC 14) plus granulocyte colony-stimulating factor (G-CSF) (5 mcg/kg/d s.c. on days 2-12). A total of 8 cycles in LABC pts (4 pre- and post-surgery), and 6-8 cycles in MCB pts were administered. The results were compared with those obtained in the previous study. RESULTS: The incidence of WHO grade 3-4 neutropenia was significantly reduced in the EC 14 + G-CSF regimen (25.2% vs. 46.8% in 214 and 250 evaluable cycles, respectively, p<0.0001), as well as the incidence of neutropenic fever (7% vs. 3%, p=0.05). Grade 3-4 anemia (36.6% vs. 8% pts, p=0.001) and grade 3-4 thrombocytopenia (17.1% vs. 0 pts, p=0.002), were significantly more frequent in EC 14 + G-CSF. No significant differences in the other side effects were found. A total of 17 of 207 of the cycles (8.2%) were delayed in the EC 14 + G-CSF vs. 58/271 (21.4%) in the EC 21 (p<0.0001). The main reasons for these treatment delays were neutropenia (1% vs. 15%), anemia (3% vs. 0) and thrombocytopenia (1% vs. 0). As a result of treatment acceleration and differences in dose delays, the patients on EC 14 + G-CSF received a higher dose-intensity (Epi 58.51 mg/m2/wk vs. 36.8 mg/m2/wk; CTX 292.52 mg/m2/wk vs. 182.9 mg/m2/wk). A complete response at surgery was obtained in 9/19 (47.4%) LABC pts. An objective CR was obtained in 11/22 MBC pts (50%) and a partial response in 8/22 (36.4%), yielding an overall response rate of 86.4%. CONCLUSIONS: Hd-Epi + CTX is very active against both LABC and MBC. The administration of G-CSF allows dose intensification of both drugs (a 59.5% increase of the actual dose intensity) with acceptable clinical tolerance (a lower incidence of neutropenia but a higher incidence of anemia and thrombocytopenia). Only a specifically designed phase III trial will lead to definitive conclusions regarding the greater antitumor activity of accelerated CSF-including regimens as compared to standard chemotherapy for advanced breast cancer.

Phase II trial of high-dose epirubicin and cyclophosphamide in advanced breast cancer.

Between February 1990 and December 1991 high-dose epirubicin (Epi)(120 mg/m2) plus cyclophosphamide (CTX)(600 mg/m2) were given every 3 weeks to 52 patients with locally advanced and metastatic breast cancer. 26 patients with locally advanced disease received four courses of this regimen before and after local treatments. 26 patients had metastatic disease: they received eight courses unless progression or unacceptable toxicity occurred. Responses were seen in 37/48 (77%) evaluable patients including 14 complete responses (CR), 23 partial responses (PR), nine stable disease, two progressive disease. Among the 25 evaluable patients with locally advanced disease, 9 had a CR and 11 a > 80% decrease in tumour volume. 6 patients (24%) had a pathologically confirmed complete response. 18 patients (72%) had a tumour reduction to 0-2 cm. The 3-year disease-free survival was 60%. Of the 23 evaluable patients with metastatic disease, 5 obtained a CR and 10 a PR, yielding an overall response rate of 65%. Myelosuppression was substantial with a grade 3-4 leucopenia in 76% of the patients even if neutropenic fever occurred in only 7% of the courses. A clinical congestive heart failure occurred in 1 patient following a total Epi dose of 960 mg/m2 and a bilateral quadrantectomy and radiotherapy. We conclude that (1) high-dose Epi + CTX is a very active regimen, in particular for the patients with locally advanced breast cancer; (2) breast conservation after this regimen in some of these patients may be considered; (3) neutropenia is the dose-limiting toxicity. Currently, a phase II study using the same combination given every 2 weeks together with r-methuG-CSF is ongoing.