Beneficios de la dieta cetogénica en la enfermedad de McArdle: empoderando a un paciente / Benefits of ketogenic diet on McArdle disease: empowering a patient

La enfermedad de almacenamiento de glucógeno tipo V o enfermedad de McArdle, con una prevalencia de 1 entre 167 mil personas, se caracteriza por una incapacidad para la degradación del glucógeno muscular. El síntoma cardinal es la intolerancia al ejercicio, manifestado por fatiga, debilidad muscular, mialgias, disnea y taquicardia, con posible rabdomiolisis. Los pacientes afectos por esta enfermedad presentan un fenómeno patognomónico denominado "segundo aliento". Existe poca evidencia respecto al tratamiento de la enfermedad. Algunos estudios apuntan el posible beneficio de la dieta cetogénica (DC). Se presenta un caso clínico de un varón de 38 años diagnosticado de enfermedad de McArdle que decide, por cuenta propia, llevar a cabo una DC durante un mes. Se realizó la valoración enfermera según las 14 Necesidades de Virginia Henderson y se identificaron los diagnósticos enfermeros: disposición para mejorar la gestión de la propia salud y fatiga, así como las complicaciones potenciales: rabdomiolisis y alteración perfil hepático Se objetivaron una disminución sustancial en los valores enzimas musculares y la desaparición por completo del fenómeno del "segundo aliento", lo que apoya el efecto beneficioso de la DC en estos sujetos. En este caso, el paciente tuvo que tomar una decisión al margen de las recomendaciones terapéuticas. El empoderamiento del paciente lo capacita para escoger de manera adecuada entre las distintas opciones terapéuticas a su alcance

Glycogen storage disease type V or McArdle disease has a prevalence of 1 per 167 thousand persons; it is characterized by the inability to break down muscle glycogen. The main symptom is exercise intolerance, shown by fatigue, muscle weakness, myalgia, dyspnea and tachycardia, with potential rhabdomyolisis. Patients affected by this disease present a pathognomonic phenomenon called "second wind". There is little evidence regarding the treatment of this disease. Some studies point at the potential benefit of ketogenic diet (KD). We present a case report of a 38-year-old male patient diagnosed with McArdle disease who decided on his own to follow a KD during one month. Nursing assessment was conducted according to the 14 Needs by Virginia Henderson, and the nursing diagnoses Willingness to improve the management of his own health and Fatigue were identified, as well as potential complications: rhabdomyolisis and hepatic profile alteration. It was objectively observed that there was a significant reduction in the values of muscle enzymes, and the "second wind" phenomenon disappeared completely; this supports the beneficial effect of KD in these subjects. In this case, the patient had to make a decision outside treatment recommendations. Patient empowerment enables them to choose adequately among the different treatment options available

Remediation therapy in patients with alcohol use disorders and neurocognitive disorders: A Pilot Study. / Terapia de rehabilitación cognitiva en pacientes con trastorno por consumo de alcohol y trastorno neurocognitivo. Estudio piloto.

Many alcohol-dependent patients suffer from cognitive impairment of variable severity, manifested by alterations in retrograde and anterograde memory, visuospatial processing, cognitive abilities and attention, some of which are reversible. In this context, cognitive remediation therapies could significantly improve patients' performance; therefore, these are considered a valuable alternative. The aim of this study was to implement cognitive remediation therapy in patients with alcohol dependence and cognitive impairment and evaluate its viability and effectiveness. The participants were sixteen abstinent, alcohol-dependent patients (mean age of 59 years, 63% males) from the Addictive Behaviours Unit of a tertiary hospital. Over 6 months, a nurse led 1-hour weekly sessions (24 sessions in total) during which exercises for improving functional, social and cognitive performance were completed. Patients were assessed at baseline, at the end of the study and 6 months later, using the Mini-Mental State Examination (MMSE) and the Memory Alteration Test (M@T). Their respective scores were 26.4 (SD 3.16), 29 (SD 1.67) and 27 (SD 3.1) for the MMSE and 38.7 (SD 6.81), 45.7 (SD 5.6) and 41.1 (SD 7.86) for the M@T. Changes were assessed with both Friedman and Wilcoxon signed-rank tests, with mostly statistically significant differences (p < 0.05). Assistance and satisfaction were high. Therefore, the therapy was viable, widely accepted and effective.

El deterioro cognitivo es común en los pacientes alcohólicos. Éste se manifiesta por alteraciones en la memoria anterógrada y retrógrada, el procesamiento visual-espacial, y en las habilidades cognitivas y la atención, siendo algunas reversibles. Las terapias de rehabilitación cognitiva podrían mejorar el rendimiento de los pacientes, siendo una alternativa terapéutica de interés. El objetivo de este estudio piloto fue evaluar la implementación, viabilidad y efectividad de la terapia de rehabilitación cognitiva en pacientes con dependencia al alcohol y deterioro cognitivo asociado. Se trata de un estudio piloto con 16 pacientes (63% hombres, edad media de 59 años) seguidos en la Unidad de Conductas Adictivas de un hospital de tercer nivel. Siendo la abstinencia un requisito para la inclusión, durante 6 meses una enfermera realizó sesiones semanales de una hora (24 sesiones), realizándose ejercicios de psico-estimulación para la mejora del rendimiento cognitivo, funcional y social. Se evaluó a los pacientes al inicio, al final y pasados 6 meses, mediante las escalas MMSE (test Mini-mental de Lobo) y T@M (test de Alteración de Memoria). Sus puntuaciones medias respectivas fueron 26.4 (DE 3,16), 29 (DE 1,67) y 27 (DE 3,1) para MMSE y 38,7 (DE 6,81), 45,7 (DE 5,6) y 41,1 (DE 7,86) para T@M. Los datos se analizaron mediante la prueba de Friedman y se comparon los distintos periodos temporales mediante la prueba de rangos con signo de Wilcoxon, siendo la mayoría de comparaciones significativas (p < 0,05). La asistencia y la satisfacción fueron elevadas. Así pues, la terapia fue viable, ampliamente aceptada y mostró ser efectiva.

Terapia de rehabilitación cognitiva en pacientes con trastorno por consumo de alcohol y trastorno neurocognitivo. Estudio piloto / Remediation therapy in patients with alcohol use disorders and neurocognitive disorders: A Pilot Study

El deterioro cognitivo es común en los pacientes alcohólicos. Éste se manifiesta por alteraciones en la memoria anterógrada y retrógrada, el procesamiento visual-espacial, y en las habilidades cognitivas y la atención, siendo algunas reversibles. Las terapias de rehabilitación cognitiva podrían mejorar el rendimiento de los pacientes, siendo una alternativa terapéutica de interés. El objetivo de este estudio piloto fue evaluar la implementación, viabilidad y efectividad de la terapia de rehabilitación cognitiva en pacientes con dependencia al alcohol y deterioro cognitivo asociado. Se trata de un estudio piloto con 16 pacientes (63% hombres, edad media de 59 años) seguidos en la Unidad de Conductas Adictivas de un hospital de tercer nivel. Siendo la abstinencia un requisito para la inclusión, durante 6 meses una enfermera realizó sesiones semanales de una hora (24 sesiones), realizándose ejercicios de psico-estimulación para la mejora del rendimiento cognitivo, funcional y social. Se evaluó a los pacientes al inicio, al final y pasados 6 meses, mediante las escalas MMSE (test Mini-mental de Lobo) y T@M (test de Alteración de Memoria). Sus puntuaciones medias respectivas fueron 26.4 (DE 3,16), 29 (DE 1,67) y 27 (DE 3,1) para MMSE y 38,7 (DE 6,81), 45,7 (DE 5,6) y 41,1 (DE 7,86) para T@M. Los datos se analizaron mediante la prueba de Friedman y se comparon los distintos periodos temporales mediante la prueba de rangos con signo de Wilcoxon, siendo la mayoría de comparaciones significativas (p < 0,05). La asistencia y la satisfacción fueron elevadas. Así pues, la terapia fue viable, ampliamente aceptada y mostró ser efectiva

Many alcohol-dependent patients suffer from cognitive impairment of variable severity, manifested by alterations in retrograde and anterograde memory, visuospatial processing, cognitive abilities and attention, some of which are reversible. In this context, cognitive remediation therapies could significantly improve patients' performance; therefore, these are considered a valuable alternative. The aim of this study was to implement cognitive remediation therapy in patients with alcohol dependence and cognitive impairment and evaluate its viability and effectiveness. The participants were sixteen abstinent, alcohol-dependent patients (mean age of 59 years, 63% males) from the Addictive Behaviours Unit of a tertiary hospital. Over 6 months, a nurse led 1-hour weekly sessions (24 sessions in total) during which exercises for improving functional, social and cognitive performance were completed. Patients were assessed at baseline, at the end of the study and 6 months later, using the Mini-Mental State Examination (MMSE) and the Memory Alteration Test (M@T). Their respective scores were 26.4 (SD 3.16), 29 (SD 1.67) and 27 (SD 3.1) for the MMSE and 38.7 (SD 6.81), 45.7 (SD 5.6) and 41.1 (SD 7.86) for the M@T. Changes were assessed with both Friedman and Wilcoxon signed-rank tests, with mostly statistically significant differences (p < 0.05). Assistance and satisfaction were high. Therefore, the therapy was viable, widely accepted and effective

Alcohol in Primary Care. Differential characteristics between alcohol-dependent patients who are receiving or not receiving treatment. / El Alcohol en Atención Primaria. Características diferenciales entre los pacientes dependientes del alcohol que han solicitado o no tratamiento.

primary health care services for other reasons. The aim of the present study is to describe the differential characteristics of AD patients in primary care, distinguishing between those who receive treatment and those who do not, and their reasons for not seeking it. In a cross-sectional study patients were evaluated by their general practitioner (GP) and interviewed by a member of the research team. Sociodemographic, diagnostic and clinical data were collected. From 1,372 patients interviewed in Catalonia, 118 (8.6%) were diagnosed as AD. These patients showed a lower socioeconomic status (48.3% vs 33.3%, odds ratio 2.02), higher unemployment rates (32.2% vs 19.2 %, odds ratio 2.11), and greater psychological distress and disability. Patients with AD receiving treatment (16.9%), were older (44 vs 36 years of age), reported higher unemployment rates (66% vs 25.5%, odds ratio 6.32) and higher daily alcohol consumption (61.5 vs 23.7 grams), suggesting a more advanced disease. Patients with AD in general showed a higher degree of comorbidity compared to other patients, with patients in treatment showing the most elevated level. The main reasons given for not seeking treatment were shame, fear of giving up drinking and barriers to treatment. Taken together, the data suggest the need to implement earlier strategies for the detection and treatment of AD.

A pesar de la elevada morbi-mortalidad de la dependencia del alcohol (DA), pocos pacientes afectos reciben tratamiento. Sin embargo, muchos de ellos son visitados en atención primaria por otras razones. El objetivo del presente estudio es describir las características diferenciales de los pacientes dependientes del alcohol atendidos en Atención Primaria, distinguiendo también entre aquellos que realizan tratamiento o no, y los motivos por los que no lo solicitan.Se trata de un estudio transversal en el que los pacientes fueron entrevistados tanto por sus médicos de atención primaria (MAP) como por un investigador del estudio. Se recabaron datos sociodemográficos, diagnósticos y clínicos.De 1372 entrevistados, 118 (8,6%) fueron diagnosticados de DA. Éstos presentaron un nivel socioeconómico más bajo (48.3% vs 33.3%, odds ratio 2.02), más desempleo (32.2% vs 19.2 %, odds ratio 2.11), y mayores niveles de malestar psicológico y de incapacidad. Los que recibían tratamiento (16,9%), tenían más edad (44 vs 36 años), mayores tasas de desempleo (66% vs 25.5%, odds ratio 6.18) y mayor consumo diario de alcohol (61.5 vs 23.7 gramos), sugiriendo una mayor evolución de la enfermedad. La mayoría de variables clínicas analizadas mostraron una mayor comorbilidad en los pacientes afectos de dependencia del alcohol, y dentro de éstos, una mayor gravedad en los que recibían tratamiento respecto a los que no lo hacían. Las principales razones esgrimidas para no acudir a tratamiento fueron la vergüenza, el miedo a dejar de beber y las barreras para acceder al tratamiento. Estos datos sugieren pues la necesidad de implementar estrategias de detección y tratamiento precoces de la DA.

Detección y prevalencia del trastorno por uso de alcohol en los centros de atención primaria de Cataluña / Detection and prevalence of alcohol use disorders in primary health care in Catalonia

OBJETIVO: Describir el grado de reconocimiento del trastorno por uso de alcohol (TUA) y dependencia de alcohol por los médicos de atención primaria (MAP) y determinar su prevalencia. DISEÑO: Estudio transversal. EMPLAZAMIENTO: Veinte centros de atención primaria de Cataluña. PARTICIPANTES Y MEDICIONES: Se encuestó a 23 MAP seleccionados al azar acerca del consumo de alcohol y otras enfermedades de sus pacientes. Se entrevistó y evaluó a 1.372 pacientes con la Composite International Diagnostic Interview (CIDI) para determinar el diagnóstico de TUA en el último año, y otros cuestionarios (el K10, de cribado, y el World Health Organization Disability Assessment Schedule 2.0) para evaluar la discapacidad y la salud mental. RESULTADOS: La CIDI diagnosticó TUA en un 9,6% del total de la muestra. Los MAP detectaron un 4,8% de TUA. La CIDI detectó mayor proporción de casos entre las edades más jóvenes, y el MAP detectó mayor porcentaje de TUA y dependencia de alcohol en personas de mayor edad y con enfermedades concomitantes. Los MAP identificaron el 28,8% de los casos diagnosticados de TUA por la CIDI. El 42,4% de los pacientes diagnosticados por el MAP no fueron identificados por la CIDI. Al utilizar como criterio diagnóstico indistintamente la CIDI o la impresión clínica del MAP, la prevalencia de TUA en atención primaria se situó en el 11,7%, y la de dependencia de alcohol, en el 8,6%. CONCLUSIONES: Los MAP reconocen poco el TUA en gente joven, mientras que detectan más la enfermedad en pacientes de mayor edad y con comorbilidades asociadas. La prevalencia de TUA es elevada en atención primaria

AIM: To describe the detection by general practitioners (GP) of alcohol use disorders (AUD) and alcohol dependence, and their prevalence in primary health settings. DESIGN: Cross-sectional study. Settings: Twenty Catalan primary health care centres (Spain). PARTICIPANTS AND MEASUREMENTS: Twenty three randomly selected GP were surveyed about alcohol and other diseases of their patients. A total of 1,372 patient interviews were collected. Patients and GPs were asked about AUD and other mental and health conditions. The Composite International Diagnostic Interview (CIDI) as the gold standard was used, as well as other structured interviews (K10 screening and World Health Organization Disability Assessment Schedule 2.0). RESULTS: The CIDI diagnosed 9.6% of the total sample with an AUD, and 4.8% diagnosed by GPs. CIDI could detect more AUD in young adults, while GPs diagnosed more AUD and alcohol dependence in elderly people, who also had more health conditions. GPs recognised AUD in 28.8% of patients diagnosed with CIDI, but 42.4% of patients diagnosed by GPs were not detected with CIDI. Taking both into consideration, the gold standard and the GP clinical impression, 11.7% of patients had an AUD and 8.6% an AD. CONCLUSIONS: GP recognise AUD better in the elderly with worst health conditions than CIDI. AUD and alcohol dependence prevalence is high in primary health care centre

[Detection and prevalence of alcohol use disorders in primary health care in Catalonia]. / Detección y prevalencia del trastorno por uso de alcohol en los centros de atención primaria de Cataluña.

AIM: To describe the detection by general practitioners (GP) of alcohol use disorders (AUD) and alcohol dependence, and their prevalence in primary health settings. DESIGN: Cross-sectional study. SETTINGS: Twenty Catalan primary health care centres (Spain). PARTICIPANTS AND MEASUREMENTS: Twenty three randomly selected GP were surveyed about alcohol and other diseases of their patients. A total of 1,372 patient interviews were collected. Patients and GPs were asked about AUD and other mental and health conditions. The Composite International Diagnostic Interview (CIDI) as the gold standard was used, as well as other structured interviews (K10 screening and World Health Organization Disability Assessment Schedule 2.0). RESULTS: The CIDI diagnosed 9.6% of the total sample with an AUD, and 4.8% diagnosed by GPs. CIDI could detect more AUD in young adults, while GPs diagnosed more AUD and alcohol dependence in elderly people, who also had more health conditions. GPs recognised AUD in 28.8% of patients diagnosed with CIDI, but 42.4% of patients diagnosed by GPs were not detected with CIDI. Taking both into consideration, the gold standard and the GP clinical impression, 11.7% of patients had an AUD and 8.6% an AD. CONCLUSIONS: GP recognise AUD better in the elderly with worst health conditions than CIDI. AUD and alcohol dependence prevalence is high in primary health care centres.

El Alcohol en Atención Primaria. Características diferenciales entre los pacientes dependientes del alcohol que han solicitado o no tratamiento / Alcohol in Primary Care. Differential characteristics between alcohol dependent patients receiving or not treatment

A pesar de la elevada morbi-mortalidad de la dependencia del alcohol (DA), pocos pacientes afectos reciben tratamiento. Sin embargo, muchos de ellos son visitados en atención primaria por otras razones. El objetivo del presente estudio es describir las características diferenciales de los pacientes dependientes del alcohol atendidos en Atención Primaria, distinguiendo también entre aquellos que realizan tratamiento o no, y los motivos por los que no lo solicitan. Se trata de un estudio transversal en el que los pacientes fueron entrevistados tanto por sus médicos de atención primaria (MAP) como por un investigador del estudio. Se recabaron datos sociodemográficos, diagnósticos y clínicos. De 1372 entrevistados, 118 (8,6%) fueron diagnosticados de DA. Éstos presentaron un nivel socioeconómico más bajo (48.3% vs 33.3%, odds ratio 2.02), más desempleo (32.2% vs 19.2 %, odds ratio 2.11), y mayores niveles de malestar psicológico y de incapacidad. Los que recibían tratamiento (16,9%), tenían más edad (44 vs 36 años), mayores tasas de desempleo (66% vs 25.5%, odds ratio 6.18) y mayor consumo diario de alcohol (61.5 vs 23.7 gramos), sugiriendo una mayor evolución de la enfermedad. La mayoría de variables clínicas analizadas mostraron una mayor comorbilidad en los pacientes afectos de dependencia del alcohol, y dentro de éstos, una mayor gravedad en los que recibían tratamiento respecto a los que no lo hacían. Las principales razones esgrimidas para no acudir a tratamiento fueron la vergüenza, el miedo a dejar de beber y las barreras para acceder al tratamiento. Estos datos sugieren pues la necesidad de implementar estrategias de detección y tratamiento precoces de la DA

Despite its high associated morbidity and mortality, few alcoholdependent (AD) patients receive treatment. However, many use primary health care services for other reasons. The aim of the present study is to describe the differential characteristics of AD patients in primary care, distinguishing between those who receive treatment and those who do not, and their reasons for not seeking it. In a cross-sectional study patients were evaluated by their general practitioner (GP) and interviewed by a member of the research team. Sociodemographic, diagnostic and clinical data were collected. From 1,372 patients interviewed in Catalonia, 118 (8.6%) were diagnosed as AD. These patients showed a lower socioeconomic status (48.3% vs 33.3%, odds ratio 2.02), higher unemployment rates (32.2% vs 19.2 %, odds ratio 2.11), and greater psychological distress and disability. Patients with AD receiving treatment (16.9%), were older (44 vs 36 years of age), reported higher unemployment rates (66% vs 25.5%, odds ratio 6.32) and higher daily alcohol consumption (61.5 vs 23.7 grams), suggesting a more advanced disease. Patients with AD in general showed a higher degree of comorbidity compared to other patients, with patients in treatment showing the most elevated level. The main reasons given for not seeking treatment were shame, fear of giving up drinking and barriers to treatment. Taken together, the data suggest the need to implement earlier strategies for the detection and treatment of AD

General practitioners recognizing alcohol dependence: a large cross-sectional study in 6 European countries.

PURPOSE: Although alcohol dependence causes marked mortality and disease burden in Europe, the treatment rate is low. Primary care could play a key role in reducing alcohol-attributable harm by screening, brief interventions, and initiating or referral to treatment. This study investigates identification of alcohol dependence in European primary care settings. METHODS: Assessments from 13,003 general practitioners, and 9,098 interviews (8,476 joint number of interviewed patients with a physician's assessment) were collected in 6 European countries. Alcohol dependence, comorbidities, and health service utilization were assessed by the general practitioner and independently using the Composite International Diagnostic Interview (CIDI) and other structured interviews. Weighted regression analyses were used to compare the impact of influencing variables on both types of diagnoses. RESULTS: The rate of patients being identified as alcohol dependent by the CIDI or a general practitioner was about equally high, but there was not a lot of overlap between cases identified. Alcohol-dependent patients identified by a physician were older, had higher rates of physicial comorbidity (liver disease, hypertension), and were socially more marginalized, whereas average consumption of alcohol and mental comorbidity were equally high in both groups. CONCLUSION: General practitioners were able to identify alcohol dependence, but the cases they identified differed from cases identified using the CIDI. The role of the CIDI as the reference standard should be reexamined, as older alcohol-dependent patients with severe comorbidities seemed to be missed in this assessment.

Cytokine-induced depression: current status and novel targets for depression therapy.

Current treatments of depression include psychological, pharmacological and physical approaches. Pharmacological interventions to treat depression have previously focused on modifying dysfunctional neurotransmitter systems. Overall, these treatments have demonstrated an ability to manage major depression but otucomes continue to be poor in many patients, especially those with long term illness or with previous multiple relapses. This may be due to the fact that depression is a systemic and neuroprogressive illness involving multiple biological pathways such as immunological factors. There is substantial evidence that cytokine therapies induce depressive symptoms in clinical populations. The model of cytokine-induced depression has provided important information relative to the risk factors and biological pathways involved in the etiology of depressive symptoms and, most importantly, the identification and knowledge of these factors has allowed new treatment targets to be explored. When an exogenous cytokine such as interferon-alpha is administered, proinflammatory cytokines are activated, leading to alterations in neurotransmission and endocrine pathways and producing neurotoxicity. Several new treatments for depression acting through pathways other than amine neurotransmission have emerged in recent years. The regulation of the inflammatory response, the decrease in the activity of the hypothalamic-pituitary-adrenal axis and the prevention of neurotoxicity are potential targets for new drugs. Though these drugs are mostly at the proof-of-concept stage, some of them have already shown promising results for the treatment of depression.

Serotonin and interleukin-6: the role of genetic polymorphisms in IFN-induced neuropsychiatric symptoms.

BACKGROUND: Cytokines and serotonin neurotransmission may play an important role on the development of psychopathological symptoms during interferon (IFN) treatment. The aim of the present study was to investigate the association between IFN-induced depression, anxiety and fatigue and functional genetic variants at the interleukin-6 gene (IL-6) and serotonin transporter gene (SERT). METHODS: 385 consecutive Caucasian outpatients with chronic hepatitis C initiating treatment with IFN-alpha and ribavirin were included. All patients were interviewed at baseline using the Structured Clinical Interview for DSM-IV (SCID-I) and those with a current major depressive disorder or anxiety disorder before starting treatment were excluded. Depression and anxiety were assessed at baseline during the treatment (at 4, 12, 24 and 48 weeks) using the Hospital Anxiety and Depression Scale and fatigue was evaluated using a visual analogue scale. The 5-HTTLPR region of SERT gene and the functional polymorphism located at the promoter region of IL-6 gene (rs1800795) were genotyped. RESULTS: Genotypic distribution was in the Hardy-Weinberg equilibrium for SERT (p=0.41) and for IL-6 (p=0.72) polymorphisms. At baseline we found only a significant effect of IL-6 polymorphism on fatigue symptoms. During antiviral treatment we reported that subjects with CC genotype (IL-6) presented significantly lower changes from baseline in IFN-induced depression (p=0.005) and IFN-induced anxiety (p=0.004). We did not find statistically significant differences on depression (p=0.21) or anxiety (p=0.15) between SS/SL and LL genotypes of SERT. CONCLUSIONS: Genetic variations in the IL-6 gene increase the risk of IFN-induced depression and anxiety. The IL-6 polymorphism was associated with fatigue rates in patients with chronic hepatitis C before treatment. Our study confirms the role of inflammatory mechanisms in IFN-induced psychopathological symptoms.

Long-term and bizarre self-injurious behavior: an approach to underlying psychological mechanisms and management.

Repeated self-harm usually presents with associated psychopathology, mostly in the form of obsessive-compulsive disorder, malingering, or personality disorders, and may persist for many years. This case presentation focuses on self-harm involving the deliberate ingestion of foreign bodies. This behavior remains poorly understood, and the relevant literature focuses almost entirely on gastroenterological and surgical management, with little or no discussion of underlying psychological mechanisms, psychopathology, or psychotherapeutic intervention. The goal of this article is to begin to fill that gap by presenting the case of a young woman who was diagnosed with borderline personality disorder and followed for 20 years, who repeatedly swallowed objects as a form of self-harming behavior. The nosological status and possible functions of this behavior are discussed, as are the difficulties of caring for patients with such long-standing, repeated selfinjury. This case illustrates how the boundaries between different self-injurious behaviors are blurred and also how different self-injurious behaviors are likely to share common patterns, functional integrity, and meanings. It should also serve to remind us how far we have to go in terms of understanding, classifying, and successfully treating certain patients who present with longterm and bizarre self-injurious behavior.

Interferon-induced depression in chronic hepatitis C: a systematic review and meta-analysis.

OBJECTIVE: To carry out a systematic review of the risk factors for, and incidence of, major depressive episode (MDE) related to antiviral therapy for chronic hepatitis C. DATA SOURCES: The MEDLINE, PsycINFO, and Cochrane databases were searched to locate articles published from the earliest available online year until June 2011 using the keywords hepatitis C, interferon-alpha, peginterferon, pegylated interferon, depression, and mood and Boolean operators. Articles written in English, Spanish, and French were included. STUDY SELECTION: Prospective studies reporting incidence of interferon-alpha-induced MDE were included. At baseline, patients did not present a DSM-IV/ICD depressive episode, and evaluation was performed by a trained clinician. Twenty-six observational studies met the inclusion criteria. DATA EXTRACTION: Extracted data included authors, year of publication, design, characteristics of the population, viral coinfection, adjunctive psychopharmacology, instruments to assess depression, dose and type of interferon-alpha, adjunctive ribavirin treatment, and follow-up time. Outcome of incidence of MDE (primary outcome measure) was abstracted, as were potential predictive variables. DATA SYNTHESIS: A full review was performed. Meta-analysis of the cumulative incidence of induced MDE as a function of time was carried out. Odds ratios (ORs) and mean differences were used to estimate the strength of association of variables. RESULTS: Overall cumulative incidence of depression was 0.25 (95% CI, 0.16 to 0.35) and 0.28 (95% CI, 0.17 to 0.42) at 24 and 48 weeks of treatment, respectively. According to our analysis, high baseline levels of interleukin 6 (mean difference = 1.81; 95% CI, 1.09 to 2.52), female gender (OR = 1.40; 95% CI, 1.02 to 1.91), history of MDE (OR = 3.96; 95% CI, 2.52 to 6.21), history of psychiatric disorder (OR = 3.18; 95% CI, 1.60 to 6.32), subthreshold depressive symptoms (mean difference = 0.96; 95% CI, 0.31 to 1.61), and low educational level (mean difference = -0.99; 95% CI, -1.59 to -0.39) were predictive variables of MDE during antiviral treatment. CONCLUSIONS: One in 4 chronic hepatitis C patients who start interferon and ribavirin treatment will develop an induced major depressive episode. Clinicians should attempt a full evaluation of patients before starting antiviral treatment in order to identify those at risk of developing interferon-induced depression.