Reconsidering the Use of Population Health Surveys for Monitoring of Mental Health.

Monitoring of the mental health status of the population and assessment of its determinants are 2 of the most relevant pillars of public mental health, and data from population health surveys could be instrumental to support them. Although these surveys could be an important and suitable resource for these purposes, due to different limitations and challenges, they are often relegated to the background behind other data sources, such as electronic health records. These limitations and challenges include those related to measurement properties and cross-cultural validity of the tools used for the assessment of mental disorders, their degree of representativeness, and possible difficulties in the linkage with other data sources. Successfully addressing these limitations could significantly increase the potential of health surveys in the monitoring of mental disorders and ultimately maximize the impact of the relevant policies to reduce their burden at the population level. The widespread use of data from population health surveys, ideally linked to electronic health records data, would enhance the quality of the information available for research, public mental health decision-making, and ultimately addressing the growing burden of mental disorders.

Reliability and cross-country equivalence of the 8-item version of the Patient Health Questionnaire (PHQ-8) for the assessment of depression: results from 27 countries in Europe.

Background: The 8-item version of the Patient Health Questionnaire (PHQ-8) is one of the self-reported questionnaires most frequently used worldwide for the screening and severity assessment of depression. However, in some European countries its reliability is unknown, and it is unclear whether its psychometric properties vary between European countries. Therefore, the aim of this study was to assess the internal structure, reliability and cross-country equivalence of the PHQ-8 in Europe. Methods: All participants from the 27 countries included in the second wave of the European Health Interview Survey (EHIS-2) between 2014 and 2015 with complete information on the PHQ-8 were included (n = 258,888). The internal structure of the PHQ-8 was assessed using confirmatory factor analyses (CFA) for categorical items. Additionally, the reliability of the questionnaire was assessed based on the internal consistency, Item Response Theory information functions, and item-discrimination (using Graded Response Models), and the cross-country equivalence based on multi-group CFA. Findings: The PHQ-8 shows high internal consistency for all countries. The countries in which the PHQ-8 was more reliable were Romania, Bulgaria and Cyprus and less reliable were Iceland, Norway and Austria. The PHQ-8 item with highest discrimination was item 2 (feeling down, depressed, or hopeless) in 24 of the 27 countries. Measurement invariance between countries in Europe was observed from multigroup CFA at the configural, metric and scalar levels. Interpretation: The results from our study, likely the largest study to the date assessing the internal structure, reliability and cross-country comparability of a self-reported mental health assessment measure, shows that the PHQ-8 has an adequate reliability and cross-country equivalence across the 27 European countries included. These results highlight the suitability of the comparisons of the PHQ-8 scores in Europe. They could be helpful to improve the screening and severity assessment of depressive symptoms at the European level. Funding: This work was partially funded by CIBER Epidemiology and Public Health (CIBERESP) as part of the Intramural call of 2021 (ESP21PI05).

Association between the Prime Diet Quality Score and depressive symptoms in a Mediterranean population with metabolic syndrome. Cross-sectional and 2-year follow-up assessment from PREDIMED-PLUS study.

The burden of depression is increasing worldwide, specifically in older adults. Unhealthy dietary patterns may partly explain this phenomenon. In the Spanish PREDIMED-Plus study, we explored (1) the cross-sectional association between the adherence to the Prime Diet Quality Score (PDQS), an a priori-defined high-quality food pattern, and the prevalence of depressive symptoms at baseline (cross-sectional analysis) and (2) the prospective association of baseline PDQS with changes in depressive symptomatology after 2 years of follow-up. After exclusions, we assessed 6612 participants in the cross-sectional analysis and 5523 participants in the prospective analysis. An energy-adjusted high-quality dietary score (PDQS) was assessed using a validated FFQ. The cross-sectional association between PDQS and the prevalence of depression or presence of depressive symptoms and the prospective changes in depressive symptoms were evaluated through multivariable regression models (logistic and linear models and mixed linear-effects models). PDQS was inversely associated with depressive status in the cross-sectional analysis. Participants in the highest quintile of PDQS (Q5) showed a significantly reduced odds of depression prevalence as compared to participants in the lowest quartile of PDQS (Q1) (OR (95 %) CI = 0·82 (0·68, 0·98))). The baseline prevalence of depression decreased across PDQS quintiles (Pfor trend = 0·015). A statistically significant association between PDQS and changes in depressive symptoms after 2-years follow-up was found (ß (95 %) CI = -0·67 z-score (-1·17, -0·18). A higher PDQS was cross-sectionally related to a lower depressive status. Nevertheless, the null finding in our prospective analysis raises the possibility of reverse causality. Further prospective investigation is required to ascertain the association between PDQS and changes in depressive symptoms along time.

Prevalence and variability of current depressive disorder in 27 European countries: a population-based study.

BACKGROUND: We aimed to estimate the prevalence of current depressive disorder in 27 European countries, and to explore differences in prevalence between European countries and by gender. METHODS: In this population-based study, we analysed data from respondents living in 27 European countries who were included in the second wave of the European Health Interview Survey, collected between 2013 and 2015. We assessed the prevalence of current depressive disorder using the eight-item Patient Health Questionnaire (PHQ-8), with depressive disorder defined as a PHQ-8 score of 10 or higher. Prevalence estimates and 95% CIs were calculated for all 27 countries overall and for each country individually. We assessed variation in prevalence (country vs the rest of Europe) using crude and adjusted prevalence ratios obtained from negative binomial regression models. We did all analyses for the total sample and stratified by gender. FINDINGS: Our analysis sample comprised 258 888 individuals, of whom 117 310 (weighted proportion 47·8%) were men and 141 578 (52·2%) were women. The overall prevalence of current depressive disorder was 6·38% (95% CI 6·24-6·52) with important variation across countries, ranging from 2·58% (2·14-3·02) in the Czech Republic to 10·33% (9·33-11·32) in Iceland. Prevalence was higher in women (7·74% [7·53-7·95]) than in men (4·89% [4·71-5·08]), with clear gender differences for all countries except Finland and Croatia. Compared with the other European countries in our sample, those with the highest adjusted prevalence ratios were Germany (1·80 [1·71-1·89]) and Luxembourg (1·50 [1·35-1·66]), and those with the lowest adjusted prevalence ratios were Slovakia (0·28 [0·24-0·33]) and the Czech Republic (0·32 [0·27-0·38]). INTERPRETATION: Depressive disorders, although common across Europe, vary substantially in prevalence between countries. These results could be a baseline for monitoring the prevalence of current depressive disorder both at a country level in Europe and for planning health-care resources and services. FUNDING: UK Medical Research Council and CIBER Epidemiology and Public Health (CIBERESP).

Accuracy of Self-Reported Items for the Screening of Depression in the General Population.

INTRODUCTION: Though self-reported items (SRD, self-reported depression) are commonly used in health surveys and cohort studies, their metric properties as a depression indicator remain unclear. The aims were to evaluate the measurement properties of SRD using the Patient Health Questionnaire-8 (PHQ-8) as reference and to identify factors related to the agreement between both indicators. METHODS: Data from the European Health Interview Survey in Spain in 2014/2015 (n = 22,065) were analyzed. Two indicators of depression were considered: SRD based on two items yes/no (positive: both yes), and the PHQ-8 (positive ≥ 10). Socioeconomic factors and use of health services were considered as independent variables. The prevalence of depression, sensitivity, specificity, global agreement, and positive and negative predictive values (PPV and NPV) of SRDs were evaluated using the PHQ-8 as a reference. Logistic regression models were fitted to determine factors associated with the agreement between indicators. RESULTS: The prevalence of depression was lower when assessed with PHQ-8 (5.9%) than with SRD (7.7%). SRD sensitivity and PPV were moderate-low (52.9% and 40.4%, respectively) whereas global agreement, specificity, and NPV were high (92.7%, 95.1%, and 97.0%, respectively). Positive agreement was associated with marital status, country of birth, employment status, and social class. Negative agreement was related to all independent variables except country of birth. CONCLUSIONS: SRD items tend to overestimate the current prevalence of depression. While its use in health surveys and cohorts may be appropriate as a quick assessment of possible depression, due to their low sensitivity, its use in clinical contexts is questionable.

Diet quality and nutrient density in subjects with metabolic syndrome: Influence of socioeconomic status and lifestyle factors. A cross-sectional assessment in the PREDIMED-Plus study.

BACKGROUND: Socioeconomic disparities and lifestyle factors are likely to determine the overall quality of the diet. In addition, overeating is compatible with inadequate micronutrient intake and it can lead to adverse health outcomes. OBJECTIVE: To assess adequacy of dietary nutrient intake and to investigate the influence of socioeconomic and lifestyle factors on nutrient density in a large primary cardiovascular prevention trial conducted in healthy participants with metabolic syndrome (MetS) to assess the cardiovascular effects of an energy-restricted Mediterranean diet (PREDIMED-Plus). METHODS: Baseline cross-sectional analysis of the PREDIMED-Plus trial with 6646 Spanish participants (aged 55-75 years in men and 60-75 years in women) with overweight/obesity and MetS. Energy and nutrient intake (for 10 nutrients) were calculated using a validated 143-item Food Frequency Questionnaire (FFQ) and nutrient density was estimated dividing the absolute nutrient intake by total energy intake. The prevalence of inadequate intake was estimated according to dietary reference intakes. Multivariable linear regression models were fitted to examine associations between socioeconomic status or lifestyle factors and nutrient density. RESULTS: A considerable proportion of the screened participants showed a deficient intake of vitamins A, D, E, B9, calcium, magnesium and dietary fibre. Inadequate intake of four or more of the ten nutrients considered was present in 17% of participants. A higher nutrient density was directly and significantly associated with female sex, higher educational level and a better adherence to the Mediterranean diet. Lifestyle factors such as non-smoking and avoidance of sedentary lifestyles were also independently associated with better nutrient density. CONCLUSIONS: Patients with MetS, despite being overweight, exhibited suboptimal nutrient intake, especially among men. Low nutrient density diet can be largely explained by differences in socioeconomic and lifestyle factors. These results highlight the importance of focussing on nutritional education in vulnerable populations, taking into account nutrient requirements.

Real-world Comparison of Afirma GEC and GSC for the Assessment of Cytologically Indeterminate Thyroid Nodules.

CONTEXT: Molecular tests have improved the accuracy of preoperative diagnosis of indeterminate thyroid nodules. The Afirma Gene Sequencing Classifier (GSC) was developed to improve the specificity of the Gene Expression Classifier (GEC). Independent studies are needed to assess the performance of GSC. OBJECTIVE: The aim was to compare the performance of GEC and GSC in the assessment of indeterminate nodules. DESIGN, SETTINGS, AND PARTICIPANTS: Retrospective analysis of Bethesda III and IV nodules tested with GEC or GSC in an academic center between December 2011 and September 2018. Benign call rates (BCRs) and surgical outcomes were compared. Histopathologic data were collected on nodules that were surgically resected to calculate measures of test performance. RESULTS: The BCR was 41% (73/178) for GEC and 67.8% (82/121) for GSC (P < .001). Among specimens with dominant Hürthle cell cytology, the BCR was 22% (6/27) for GEC and 63.2% (12/19) for GSC (P = .005). The overall surgery rate decreased from 47.8% in the GEC group to 34.7% in the GSC group (P = .025). One GEC-benign and 3 GSC-benign nodules proved to be malignant on surgical excision. GSC had a statistically significant higher specificity (94% vs 60%, P < .001) and positive predictive value (PPV) (85.3% vs 40%, P < .001) than GEC. While sensitivity and negative predictive value (NPV) dropped with GSC (97.0% vs 90.6% and 98.6% vs 96.3%, respectively), these differences were not significant. CONCLUSIONS: GSC reclassified more indeterminate nodules as benign and improved the specificity and PPV of the test. These enhancements appear to be resulting in fewer diagnostic surgeries.

Availability of specific tools to assess patient reported outcomes in hip arthroplasty in Spain. Identifying the best candidates to incorporate in an arthroplasty register. A systematic review and standardized assessment.

PURPOSE: 1) To systematically review the available scientific literature regarding specific instruments developed and/or tested in a Spanish population, to assess these PROMs in hip arthroplasty; 2) to carry out a standardized assessment of their measurement properties; and 3) to identify the best tools for use in Spain in an arthroplasty registry context. METHODS: A systematic review of PubMed/MEDLINE and EMBASE and CINHAL was done. Furthermore, a standardized assessment of the questionnaires identified using the Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) tool was performed. All developments, validation and studies aiming to assess the measurement properties of PROMs in hip arthroplasty in the Spanish population were included. Data from the questionnaires on metric properties was taken into account to identify the best candidates for inclusion in a register. RESULTS: A total of 853 documents were found. After screening title and abstract, 13 full text documents were reviewed and 8 questionnaires adapted and validated to assess some of the aspects of hip arthroplasty in the Spanish population were identified. After the EMPRO assessment, 4 questionnaires showed suitable properties (WOMAC, OAKHQOL, mini-OAKHQOL and PFH). CONCLUSIONS: In Spain, there are a few suitable hip-specific questionnaires currently available to assess PROMs in hip arthroplasty surgery. Some of the more widely used questionnaires, like the OHS and HOOS, have not been validated in the Spanish population until now. Identified tools are suitable for use in a clinical context, however their use in an arthroplasty register is more questionable due to the lack of validation studies of the widely used tools in other registers.

Helicobacter pylori seroprevalence in Spain: influence of adult and childhood sociodemographic factors.

Helicobacter pylori (H. pylori) chronic infection causes severe digestive diseases, including gastric cancer, and certain strains entail a higher risk. Risk factors for this infection are still not fully understood. The aim of this study was to describe the association of adult and childhood sociodemographic factors with the seroprevalence of H. pylori, and with CagA and VacA antigen-specific seropositivity among H. pylori-seropositive individuals in the Spanish adult population. Serum antibody reactivity to H. pylori proteins was evaluated using multiplex serology in 2555 population-based controls enrolled in the MCC-Spain study, a multicase-control study recruiting participants from 2008 to 2013 in different areas of Spain. H. pylori seroprevalence was defined as seropositivity against at least four bacterial proteins. Information on sociodemographics, lifestyles, and environmental exposures was collected through personal interviews. Prevalence ratios and 95% confidence intervals were estimated using Poisson regression models to assess the association of lifetime sociodemographic factors with H. pylori seroprevalence and with seropositivity for CagA and VacA. H. pylori seroprevalence was 87.2%. Seropositivity was statistically significantly higher in men, increased with age, BMI, and number of siblings, and decreased with education and socioeconomic family level at birth. Among H. pylori-seropositive individuals, seropositivity was 53.3% for CagA, 61.4% for VacA, and 38.8% for both CagA and VacA. Ever smokers had lower seroprevalence for CagA and VacA than never smokers. H. pylori seroprevalence among this Spanish adult population was high and one third of the population was seropositive for two well-known markers of gastric cancer risk: CagA and VacA. Sex, age, education, and BMI were associated with H. pylori seroprevalence.

Prevalence of major depressive disorder and association with personal and socio-economic factors. Results for Spain of the European Health Interview Survey 2014-2015.

BACKGROUND: Depression is a prevalent and most burdensome mental disorder. The objectives of this study are: to assess the prevalence of major depressive disorder in the adult population of Spain; and to analyse its association with personal and socio-economic factors. METHODS: Data from the European Health Interview Survey in Spain (2014-2015) were analysed (n = 21,546). DSM-IV Major Depressive Disorder (MDD) was assessed with the PHQ-8. Personal (age, marital status, and country of birth) and socio-economic (educational level, residence area, employment status and occupational social class) factors were also measured. Prevalence by gender and by personal and socio-economic factors was estimated. Crude (OR) and adjusted (aOR) Odds Ratio and their 95% Confidence Intervals (95%CI) were calculated using logistic regression models. All analyses were stratified by gender. RESULTS: Prevalence of MDD was 8.0% (95%CI: 7.3-8.6) among women and 4.1% (95%CI: 3.7-4.6) among men. For both genders, MDD was more prevalent among unemployed and among those in more disadvantaged social classes. Among women only, MDD was more prevalent for those widowed or separated, those with lower educational level, those retired, pre-retired or homemakers and in older ages. Among men only, MDD was more prevalent among those that were born in Spain. LIMITATIONS: Data are cross-sectional and the sensitivity and specificity of PHQ-8 are not perfect. CONCLUSIONS: Prevalence of MDD in Spain is high, especially among women, and is strongly associated with personal variables and socio-economic disadvantage. Intersectoral interventions aimed at diminishing the impact of socio-economic disadvantage may help decreasing the societal burden of depression.

Economic Evaluation of Health Services Costs During Pandemic Influenza A (H1N1) Pdm09 Infection in Pregnant and Non-Pregnant Women in Spain.

BACKGROUND: The healthcare and socio-economic burden resulting from influenza A (H1N1) pdm09 in Spain was considerable. Our aim was to estimate and compare the management (resource utilization) and economic healthcare impact in an at-risk group of unvaccinated pregnant women with an unvaccinated group of non-pregnant woman of childbearing age (15-44 yr old). METHODS: We addressed this question with a longitudinal, observational, multicentre study. Inputs were the requirements in managing both groups of women. Outcome measures were healthcare costs. Direct healthcare (including medical utilisation, prescriptions of antivirals, medication, diagnostic tests, and hospitalisation) costs and indirect (productivity loss) costs were considered. Unit of cost was attributed to the frequency of health service resources utilisation. The mean cost per patient was calculated in this group of women. RESULTS: We found that the influenza clinical pattern was worse in non-pregnant women as they had a high medical risk of 20.4% versus 6.1% of pregnant women. Non-pregnant required more antipyretics and antibiotics, and needed more health service resource utilisation (338 medical visits in non-pregnant women vs. 42 in pregnant women). The total cost of non-pregnant women was higher (€4,689.4/non-pregnant and €2,945.07/pregnant). CONCLUSIONS: Cost per (H1N1) pdm09 was lower for pregnant women, probably due to more preventive measures adopted for their protection in Spain. The highest costs were incurred by hospitalisations/day and work absenteeism for non-pregnant than for pregnant women. These data will allow better future pandemic influenza planning.

Inequalities in mental health in the working population of Spain: a National Health Survey-based study.

OBJECTIVE: In the working population, poor mental health is a significant problem whose prevalence rates and associated factors could differ by gender, especially in a period of socioeconomic changes. The aims of this study were: a) to determine the prevalence of poor mental health in the working population of Spain in 2011; b) to identify the association of this prevalence with socioeconomic and work-related variables for men and women separately; c) to determine if the patterns differ by gender. METHODS: A cross-sectional study was conducted with data from the National Health Survey of Spain (2011). Of the 21,007 participants in the survey, we selected 7396 whose employment status was described as "working" The General Health Questionnaire (GHQ-12) was used as a screening tool to detect poor mental health. Prevalences were calculated and bivariate and multivariate logistic regression models were fitted to verify the association between variables. RESULTS: The prevalence of poor mental health was higher among women (19.9%) than men (13.9%), the overall prevalence being 16.8%. The variables associated with a higher prevalence were type of contract and work-related variables in men, and age and socioeconomic variables in women. CONCLUSIONS: This study shows that, in the working population of Spain, the prevalence of poor mental health and its related factors differ by gender. Poor mental health is mainly related to socioeconomic variables in women but is mostly associated with work-related variables in men.

Effectiveness of vaccination with 23-valent pneumococcal polysaccharide vaccine in preventing hospitalization with laboratory confirmed influenza during the 2009-2010 and 2010-2011 seasons.

BACKGROUND: Since influenza predisposes to bacterial pneumonia caused by Streptococcus pneumoniae, studies have suggested that pneumococcal vaccination might reduce its occurrence during pandemics. We assessed the effectiveness of pneumococcal polysaccharide vaccination alone and in combination with influenza vaccination in preventing influenza hospitalization during the 2009-2010 pandemic wave and 2010-2011 influenza epidemic. RESULTS: 1187 cases and 2328 controls were included. The adjusted estimate of effectiveness of pneumococcal vaccination in preventing influenza hospitalization was 41% (95% CI 8-62) in all patients and 43% (95% CI 2-78) in patients aged ≥ 65 y. The adjusted effectiveness of dual PPV23 and influenza vaccination was 81% (95% CI 65-90) in all patients and 76% (95% CI 46-90) in patients aged ≥ 65 y. The adjusted effectiveness of influenza vaccination alone was 58% (95% CI 38-72). METHODS: We conducted a multicenter case-control study in 36 Spanish hospitals. We selected patients aged ≥ 18 y hospitalized with confirmed influenza and two hospitalized controls per case, matched according to age, date of hospitalization and province of residence. Multivariate analysis was performed using conditional logistic regression. Subjects were considered vaccinated if they had received the pneumococcal or seasonal influenza vaccine>14 d (or>7 d for pandemic influenza vaccine) before the onset of symptoms (cases) or the onset of symptoms in matched cases (controls). CONCLUSIONS: In elderly people and adults with chronic illness, pneumococcal vaccination may reduce hospitalizations during the influenza season. In people vaccinated with both the influenza and pneumococcal vaccines, the benefit in hospitalizations avoided was greater than in those vaccinated only against influenza.

Social factors related to the clinical severity of influenza cases in Spain during the A (H1N1) 2009 virus pandemic.

BACKGROUND: During the 2009 influenza pandemic, a change in the type of patients most often affected by influenza was observed. The objective of this study was to assess the role of individual and social determinants in hospitalizations due to influenza A (H1N1) 2009 infection. METHODS: We studied hospitalized patients (cases) and outpatients (controls) with confirmed influenza A (H1N1) 2009 infection. A standardized questionnaire was used to collect data. Variables that might be related to the hospitalization of influenza cases were compared by estimation of the odds ratio (OR) and 95% confidence intervals (CI) and the variables entered into binomial logistic regression models. RESULTS: Hospitalization due to pandemic A (H1N1) 2009 influenza virus infections was associated with non-Caucasian ethnicity (OR: 2.18, 95% CI 1.17 - 4.08), overcrowding (OR: 2.84, 95% CI 1.20 - 6.72), comorbidity and the lack of previous preventive information (OR: 2.69, 95% CI: 1.50 - 4.83). Secondary or higher education was associated with a lower risk of hospitalization (OR 0.56, 95% CI: 0.36 - 0.87) CONCLUSIONS: In addition to individual factors such as comorbidity, other factors such as educational level, ethnicity or overcrowding were associated with hospitalization due to A (H1N1) 2009 influenza virus infections.

Concentrations and correlations of disinfection by-products in municipal drinking water from an exposure assessment perspective.

Although disinfection by-products (DBPs) occur in complex mixtures, studies evaluating health risks have been focused in few chemicals. In the framework of an epidemiological study on cancer in 11 Spanish provinces, we describe the concentration of four trihalomethanes (THMs), nine haloacetic acids (HAA), 3-chloro-4-(dichloromethyl)-5-hydroxy-2(5H)-furanone (MX), four haloacetonitries, two haloketones, chloropicrin and chloral hydrate and estimate correlations. A total of 233 tap water samples were collected in 2010. Principal component analyses were conducted to reduce dimensionality of DBPs. Overall median (range) level of THMs and HAAs was 26.4 (0.8-98.1) and 26.4 (0.9-86.9) µg/l, respectively (N=217). MX analysed in a subset (N=36) showed a median (range) concentration of 16.7 (0.8-54.1)ng/l. Haloacetonitries, haloketones, chloropicrin and chloral hydrate were analysed in a subset (N=16), showing levels from unquantifiable (<1 µg/l) to 5.5 µg/l (dibromoacetonitrile). Spearman rank correlation coefficients between DBPs varied between species and across areas, being highest between dibromochloromethane and dibromochloroacetic acid (r(s)=0.87). Principal component analyses of 13 DBPs (4 THMs, 9 HAAs) led 3 components explaining more than 80% of variance. In conclusion, THMs and HAAs have limited value as predictors of other DBPs on a generalised basis. Principal component analysis provides a complementary tool to address the complex nature of the mixture.

[Smoking prevalence evaluation by three different methods among first-year health sciences students at the University of Leon, Spain, 2006]. / Valoración con tres métodos diferentes de la prevalencia de consumo de tabaco en estudiantes de primer curso de ciencias de la salud de la Universidad de León en 2006.

BACKGROUND: Intervention in the prevention and control of the smoking habit among health sciences students in order to improve the beliefs and attitudes of future professionals concerning this serious public health problem. The objective of this study is to compare the validity of three different methods for calculating the prevalence of smokers. METHODS: First-year students at a Health Sciences School. Smoking was evaluated by means of a self-administered questionnaire, the carbon monoxide (CO) in expiratory air and saliva cotinine. The prevalence found using each method, the agreement with the Kappa index and the internal validity of the questionnaire and the cooximetry were evaluated using the cotinine test as the gold standard. RESULTS: A total of 29.3% of the 181 students studied were classified as smokers by some measurement; 26.5% (cotinine), 22.1% (self-stated) and 9.4% (cooximetry). Two thirds of the smokers had low nicotine dependence. Good agreement was found only between the questionnaire and the cotinine test (Kappa Index=73.1%). Compared to the cotinine test, the questionnaire and the cooximetry respectively showed 72.9% and 35.4% sensitivity, and a 96.2% and 100% specificity. According to the questionnaire, 81.5% of the low-dependence smokers tested positive for the cotinine test, 14.5% having tested positive in the cooximetry. CONCLUSIONS: Cooximetry does not seem to be a good method for detecting smokers in this population. The cotinine test and the questionnaire are found to agree well, but the internal validity of the questionnaire in comparison to the cotinine test shows a lesser degree of sensitivity than expected. The gold standard criterion used must be revised for a low-dependence population with possible exposure to second-hand smoke.

Assessment of adherence to triple antiretroviral treatment including indinavir: role of the determination of plasma levels of indinavir.

OBJECTIVE: To assess the contribution of the determination of concentrations of indinavir (IND) in plasma to the assessment of self-reported adherence and keeping of appointments to withdraw drugs from the hospital pharmacy. PATIENTS AND METHODS: Adherence was assessed using three criteria: questionnaires, punctuality at appointments to withdraw drugs, and plasma concentrations of IND. Blood samples were obtained from 106 HIV-infected patients who had been receiving IND in combination with two nucleoside reverse transcriptase inhibitors for longer than 6 months. Logistic regression analysis was carried out, and receiver operating characteristic curves were drawn. RESULTS: The kappa index showed a low concordance for the three measures. When pharmacy appointments and self-report are used together, the nondetection of drug levels is more reliably predicted (AUC = 0.75). With the viral load as the gold standard, plasma levels contribute nothing to the information given by the other two measures combined (AUC = 0.63, AUC = 0.64). CONCLUSION: Measurement of adherence to highly active antiretroviral therapy is complex. Because there is no gold standard for it, we demonstrated that each of three common adherence measures has shortcomings that can be minimized in a combined measurement system. Indinavir plasma levels appear to provide no additional information, so further studies are undoubtedly necessary.

[Assessment of adherence to antiretroviral: role of determination of plasma levels of non nucleosides anologues]. / Valoración de la adhesión al tratamiento antirretroviral: papel de la determinación de la concentración plasmática de los fármacos no análogos de nucleósidos.

BACKGROUND AND OBJECTIVE: Our purpose was to assess the contribution of efavirenz and nevirapine plasma concentrations in the assessment of self-reported adherence and punctuality of appointments to take the drugs. PATIENTS AND METHOD: Adherence was assessed using questionnaires and plasma concentrations of efavirenz and nevirapine were determined. Patients received efavirenz or nevirapine in combination with two nucleotides reverse transcriptase inhibitors. RESULTS: Among the 45 enrolled patients, 7 were considered non-adherent according to the questionnaires, 17 regarding pharmacy appointments and 5 according to the plasma levels of efavirenz and nevirapine. 3.3% participants had detectable viral loads. CONCLUSION: Cross-validation between patients'self-reports and pharmacy appointments can improve the measurement of adherence to antiretroviral therapy.