Societal costs of personality disorders among treatment-seeking patients in Norway: the relative contribution of specific DSM-5 categories.

Personality disorders (PDs) are associated with high levels of societal costs, regardless of whether a single PD or a broad range of PDs have been studied. However, research on the relative contribution of specific PD-types on societal costs is limited. The aim of this study was to explore the possible contributions of the individual DSM-5 categories of PDs on the level of societal costs and its components (health service costs and productivity loss), while controlling for the impact of comorbid mental health and substance use disorders on these outcomes. Participants (n = 798) were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD-treatment units within specialist mental health services. The patients were referred to treatment in the time-period 2017-2020. Costs were assessed using a structured interview covering the 6-month period prior to assessment. Diagnoses were determined by semi-structured diagnostic interviews (SCID-5-PD and M.I.N.I.). Statistics included multiple regression analyses. The main result was that no specific PD had a unique contribution to the high level of societal costs generally found among treatment-seeking patients with PDs. Borderline PD (BPD) was the only PD with significantly higher health service costs than the other PDs, while BPD, avoidant PD, and unspecified PD were independently associated with enhanced productivity loss. The differential cost-effects of specific PDs on the cost components were small. Several comorbid mental health and substance use disorders were significant contributors to costs, irrespective of PD status. The results underscore the importance of developing and implementing effective treatments for a broader range of PDs, to reduce the high levels of societal costs associated with all PDs.

Societal costs of personality disorders: A cross-sectional multicenter study of treatment-seeking patients in mental health services in Norway.

OBJECTIVE: There is a relatively small body of research on the cost-of-illness of personality disorders (PDs). Most studies only include borderline PD. The aim of this study was to investigate mean societal costs, including its components, (direct) health service costs and (indirect) productivity loss, among treatment-seeking patients with the broad range of all PDs according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). METHODS: Cross-sectional data from 911 patients diagnosed with at least 1 PD were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD treatment units within specialist mental health services. The patients were referred in the time period 2017-2020. Estimation of costs was based on a bottom-up approach, using information from a structured interview covering the 6-month period before assessment, whereas unit costs were retrieved from public reports, public records, or public agencies. The human capital approach was used to calculate productivity loss. Diagnoses were determined by semi-structured diagnostic interviews (Structured Clinical Interview for DSM-5-PD [SCID-5-PD]). RESULTS: The mean societal costs were €20.260 during the 6-month period before specialized treatment. The largest cost component was productivity loss (65%), whereas health service costs constituted 35%. The main contributors to societal costs from the underlying health service cost components were inpatient treatment (20.5%) and individual outpatient treatment (10.5%). CONCLUSION: Societal costs were substantial among treatment-seeking patients with the broad range of DSM-5 PDs, comparable to the societal costs of schizophrenia, and significantly higher than the societal costs of both depression and anxiety disorders. The cost estimates converged with recent, register-based cost-of-illness studies of different PDs but exceeded previous findings from other bottom-up studies. Furthermore, the results underscore the importance of implementing effective and specialized treatment for patients with a broad range of PDs, not only to alleviate individual suffering but also to reduce the level of societal costs. The emphasis on productivity loss as a main contributor to the overall societal costs is substantiated, hence underlining the relevance of interventions focusing on improving occupational functioning.

Countertransference in the treatment of patients with personality disorders: A longitudinal study.

OBJECTIVE: This study examines how therapist emotional response/countertransference (CT) develops during treatment for patients with personality disorders (PDs) and how pre-treatment patient factors (severity of personality pathology, PD category, level of symptom distress) predict CT responses. Secondly, we explored associations between patient clinical outcome and CT. METHOD: A longitudinal, observational study including 1956 patients with personality pathology treated at psychotherapy units within specialist mental health services. Therapists' emotional response was repeatedly assessed by the Feeling Word Checklist-Brief Version (FWC-BV) with three subscales-Inadequate, Confident, and Idealized. RESULTS: Levels of Inadequate CT were lowest and stable over time while Confident and Idealized increased over time. Greater severity of personality pathology and borderline PD predicted higher initial Inadequate, lower initial Confident and decreasing Inadequate over time. Antisocial PD predicted decreasing Confident. Number of PD criteria had higher impact on therapist CT than level of symptom distress. Clinical improvement was associated with decreasing Inadequate. CONCLUSION: Therapists reported predominantly Confident CT when working with PD patients. More severe personality pathology, and borderline PD, specifically, predicted more negative CT initially, but the negative CT decreased over time. Patients who did not improve were associated with increasing Inadequate.

Injection of freshly collected autologous adipose tissue in complicated pilonidal disease: a prospective pilot study.

BACKGROUND: Pilonidal sinus disease (PSD) is a frequent disorder. Treatment failure and recurrence are common, leading to significant morbidity. The aim of this study was to investigate the impact and need for repeated treatment of injected autologous adipose tissue into non-healing PSD wounds and primary anal-near PSD or anal-near recurrence. METHODS: At the Department of Surgery, Randers Regional Hospital, Denmark, a prospective pilot study was conducted on consecutive PSD patients with lack of healing 3 months after surgery (Bascom's cleft lift) or with primary or recurrent anal-near pilonidal sinus disease from December 2018 to March 2020. The primary endpoint was time to healing. Autologous adipose tissue was harvested from the patients and injected into the lesions after surgical revision. Patients were examined 2 and 12 weeks after surgery. Patients with lack of healing after 12 weeks (undermining or no skin coverage) were offered re-injection. RESULTS: We included 30 patients [26 men and 4 women, median age 24 years (range 18-59 years)]. Complete healing was achieved in 25 patients [83.3%; 95% CI (69.9-96.7)]. Two patients had recurrence (6.7%). The median time to complete healing was 159 (189) days. The mean operation time was 70.6 ± 23.7 min and the mean amount of injected autologous adipose tissue was 19 ± 10 ml. There were no major complications. CONCLUSION: Freshly collected autologous adipose tissue injected into chronic non-healing or primary and recurrent PSD lesions near the anal verge is safe and efficient.

Development of therapeutic alliance in mentalization-based treatment-Goals, Bonds, and Tasks in a specialized treatment for borderline personality disorder.

Objective: Mentalization-based treatment (MBT) is an evidence-based long-term treatment for borderline personality disorder (BPD). Alliance is central for effective psychotherapies. Few studies have addressed aspects of working alliance in BPD evidence-based treatments. This study aimed to investigate alliance development in MBT therapies with different clinical outcomes. Method: The sample included 155 patients in an MBT programme. Clinical outcomes were based on Global Assessment of Functioning (GAF). The sample was divided in two subgroups according to GAF levels at the end of treatment (cut-off = 60). Working alliance was assessed by patient report (Working Alliance Inventory, subscales, Goals, Bonds and Tasks) and assessed repeatedly over 36 months. The method for statistical analyses was linear mixed models. Results: Initial levels of Goals, Bonds, and Tasks did not differ by subgroup, but change over time differed significantly by subgroup. In the good outcome subgroup, ratings of Goals, Bonds, and especially Tasks increased significantly over time. In the poor outcome subgroup, paranoid PD was associated with poorer alliance development over time. Conclusions: Good outcome therapies were characterized by a process where the working alliance grew over time. Results encourage an explicit focus on tasks in therapy particularly for patients with high levels of mistrust.

Risk factors during pregnancy and birth-related complications in HIV-positive versus HIV-negative women in Denmark, 2002-2014.

OBJECTIVES: We aimed to compare risk factors for adverse pregnancy outcomes in women living with HIV (WLWH) with those in women of the general population (WGP) in Denmark. Further, we estimated risk of pregnancy- or birth-related complications. METHODS: A retrospective cohort study including all WLWH who delivered a live-born child from 2002 to 2014 and WGP, matched by origin, age, year and parity, was carried out. We compared risk factors during pregnancy and estimated risk of pregnancy- and birth-related complications using multivariate logistic regression. RESULTS: A total of 2334 pregnancies in 304 WLWH and 1945 WGP were included in the study. WLWH had more risk factors present than WGP during pregnancy: previous caesarean section (CS) (24.7% versus 16.3%, respectively; P = 0.0001), smoking (14.2% versus 7.5%, respectively; P = 0.0001) and previous perinatal/neonatal death (2.3% versus 0.9%, respectively; P = 0.03). We found no difference between groups regarding gestational diabetes, hypertensive disorders, low birth weights or premature delivery. More children of WLWH had intrauterine growth retardation (IUGR) [adjusted odds ratio (aOR) 1.9; 95% confidence interval (CI) 1.1-3.2; P = 0.02]. Median gestational age and birth weight were lower in children born to WLWH. WLWH had a higher risk of emergency CS (EmCS) (aOR 1.6; 95% CI 1.2-2.1; P = 0.0005) and postpartum haemorrhage (aOR 1.4; 95% CI 1.0-1.9; P = 0.02) but not infection, amniotomy, failure to progress, low activity-pulse-grimace-appearance-respiration (APGAR) score or signs of asphyxia. CONCLUSIONS: WLWH had more risk factors present during pregnancy, similar risks of most pregnancy- and birth-related complications but a higher risk of postpartum haemorrhage and EmCS compared with WGP. Children born to WLWH had lower median birth weights and gestational ages and were at higher risk of IUGR.

Countertransference feelings and personality disorders: a psychometric evaluation of a brief version of the Feeling Word Checklist (FWC-BV).

BACKGROUND: The Feeling Word Checklist (FWC) is a self-report questionnaire designed to assess therapists' countertransference (CT) feelings. The primary aim of the study was to evaluate the psychometric properties of a brief, 12-item version of the Feeling Word Checklist (FWC-BV). The second aim was to validate the factor structure by examining the associations between the FWC-BV factors, patients' personality pathology and therapeutic alliance (TA). METHODS: Therapists at 13 different outpatient units within the Norwegian Network of Personality Disorders participated, and the study includes therapies for a large sample of patients (N = 2425) with personality pathology. Over a period of 2.5 years, therapists completed the FWC-BV for each patient in therapy every 6 months. Statistical methods included exploratory (EFA) and confirmatory (CFA) factor analysis. Internal consistency was estimated using Mc Donald's coefficient Omega (ωt). The Structured Clinical Interview for DSM-IV - Axis II (SCID II) and Mini International Neuropsychiatric Interview (MINI) were used as diagnostic instruments, and patient-rated TA was assessed using the Working Alliance Inventory (WAI-SR). RESULTS: Factor analyses revealed three clinically meaningful factors: Inadequate, Idealised and Confident. These factors had acceptable psychometric properties. Most notably, a number of borderline PD criteria correlated positively with the factors Inadequate and Idealised, and negatively with the factor Confident. All the factors correlated significantly with at least one of the WAI-SR subscales. CONCLUSIONS: The FWC-BV measures three clinically meaningful aspects of therapists' CT feelings. This brief version of the FWC seems satisfactory for use in further research and in clinical contexts.

Assessment of mode of delivery and predictors of emergency caesarean section among women living with HIV in a matched-pair setting with women from the general population in Denmark, 2002-2014.

OBJECTIVES: We aimed to assess mode of delivery and predictors of emergency caesarean section (EmCS) in women living with HIV (WLWH) in a matched-pair setting with women from the general population (WGP) in Denmark. Further, we analysed birth plan in WLWH. METHODS: All WLWH giving birth to live-born children from 2002 to 2014 were included in the study. Data were retrieved from medical records and national registries. WLWH were matched 1:5 by age, birth year, parity and ethnicity to WGP. Multivariate logistic regression was used to estimate predictors. RESULTS: We included 389 WLWH and 1945 WGP in the study. At delivery, all WLWH were on antiretroviral therapy and 85.6% had HIV RNA <40 HIV-1 RNA copies/mL. Mean age was 32.7 years [95% confidence interval (CI) 32.1-33.2 years]. Mode of delivery differed significantly between WLWH and WGP [vaginal delivery, 33.4% versus 73.3%, respectively; elective caesarean section (ECS), 40.6% versus 9.7%, respectively; EmCS, 26% versus 17%, respectively; P < 0.0001]. Age > 40 years [adjusted odds ratio (aOR) 2.3; 95% CI 1.5-3.5], asphyxia (aOR 3.2; 95% CI 2.4-4.1), delivery during the evening and at night [aOR 2.3 (95% CI 1.7-3.0) and aOR 2.0 (95% CI 1.5-2.7), respectively], preterm delivery (aOR 3.8; 95% CI 2.6-5.6) and premature rupture of membranes (aOR 3.0; 95% CI 2.1-4.4) predicted EmCS. WLWH had a higher risk of EmCS compared with WGP [2002-2006, aOR 2.0 (95% CI 1.2-3.3); 2007-2008, aOR 2.9 (95% CI 1.4-5.9); 2009-2014, aOR 2.6 (95% CI 1.7-3.9)]. After 2007, more than half of WLWH planned to deliver vaginally. Prior caesarean section was associated with ECS (aOR 11.0; 95% CI 4.5-26.8). No mother-to-child transmission occurred. CONCLUSIONS: Increasing numbers of WLWH deliver vaginally. Despite virological suppression, more WLWH plan and deliver by ECS than WGP. WLWH had a twofold higher risk of EmCS compared with WGP.

Incidence of cervical dysplasia and cervical cancer in women living with HIV in Denmark: comparison with the general population.

OBJECTIVES: Women living with HIV (WLWH) are reportedly at increased risk of invasive cervical cancer (ICC). A recent publication found that WLWH in Denmark attend the national ICC screening programme less often than women in the general population. We aimed to estimate the incidence of cervical dysplasia and ICC in WLWH in Denmark compared with that in women in the general population. METHODS: We studied a nationwide cohort of WLWH and a cohort of 15 age-matched women per WLWH from the general population for the period 1999-2010. Pathology samples were obtained from The Danish Pathology Data Bank, which contains nationwide records of all pathology specimens. The cumulative incidence and hazard ratios (HRs) for time from inclusion to first cervical intraepithelial neoplasia (CIN)/ICC and time from first normal cervical cytology result to first CIN/ICC were estimated. Sensitivity analyses were performed to include prior screening outcome, screening intensity and treatment of CIN/ICC in the interpretation of results. RESULTS: We followed 1140 WLWH and 17 046 controls with no prior history of ICC or hysterectomy for 9491 and 156 865 person-years, respectively. Compared with controls, the overall incidences of CIN1 or worse (CIN1+), CIN2+ and CIN3+, but not ICC, were higher in WLWH and predicted by young age and a CD4 count < 200 cells/µL. In women with normal baseline cytology, incidences of CIN1+ and CIN2+ were higher in WLWH. However, when we compared subgroups of WLWH and controls where women in both groups were adherent to the national ICC screening programme and had a normal baseline cytology, incidences of CIN and ICC were comparable. CONCLUSIONS: Overall, WLWH developed more cervical disease than controls. Yet, in WLWH and controls adherent to the national ICC screening programme and with normal baseline cytology, incidences of CIN and ICC were comparable.

Five-year outcomes following a randomized trial of femorofemoral and femoropopliteal bypass grafting with heparin-bonded or standard polytetrafluoroethylene grafts.

BACKGROUND: Cohort studies suggest superior long-term patency of luminal heparin-bonded polytetrafluoroethylene (Hb-PTFE) bypass grafts compared with standard PTFE grafts. The aim of this study was to compare the outcomes of Hb-PTFE grafts with those of standard PTFE grafts 5 years after a randomized trial. METHODS: Patients with intermittent claudication or critical limb ischaemia requiring femorofemoral or femoropopliteal bypass grafting were randomized in a clinical trial of Hb-PTFE versus standard PTFE in 11 Scandinavian centres between 2005 and 2009. Patients were followed up for 5 years with clinical assessment and surveillance Duplex ultrasound imaging. The primary endpoint of this study was primary patency. Secondary endpoints included major amputation and mortality. RESULTS: Overall, 569 patients were enrolled in the randomized trial. Some 552 had follow-up data available for analysis of the primary outcome. Use of Hb-PTFE significantly improved patency by 37 per cent at 2 years, but 5 years after randomization there was no difference in primary patency (adjusted hazard ratio (HR) 0·95, 95 per cent c.i. 0·71 to 1·28; P = 0·748). In patients with critical limb ischaemia the use of Hb-PTFE reduced the 5-year risk of loss of primary patency by 37 per cent (HR 0·63, 0·40 to 0·99; P = 0·049). CONCLUSION: In this study there was no difference in primary graft patency between Hb-PTFE and standard PTFE grafts. Patients receiving Hb-PTFE grafts for critical limb ischaemia were more likely to have a patent graft at 5 years than those with standard PTFE grafts.

Induction of Local Secretory IgA and Multifunctional CD4⁺ T-helper Cells Following Intranasal Immunization with a H5N1 Whole Inactivated Influenza Virus Vaccine in BALB/c Mice.

Avian influenza subunit vaccines have been shown to be poorly immunogenic, leading to the re-evaluation of the immunogenic and dose-sparing potential of whole virus vaccines. In this study, we investigated the immune responses after one or two doses of intramuscular or intranasal whole inactivated influenza H5N1 virus vaccine in BALB/c mice. Serum samples and nasal washings were collected weekly post-vaccination and analysed using enzyme-linked immunosorbent assay (ELISA). Sera were also analysed by the haemagglutination inhibition (HI) assay. Antibody-secreting cells were measured in lymphocytes from spleen and bone marrow via enzyme-linked immunospot (ELISPOT). Splenocytes were stimulated in vitro, and T-helper profiles were measured through multiplex bead assay in the supernatants, or intracellularly by multiparametric flow cytometry. Both vaccine routes induced high HI titres following the second immunization (intramuscular = 370, intranasal = 230). Moreover, the intramuscular group showed significantly higher levels of serum IgG (P < 0.01), IgG1 (P < 0.01) and IgG2a (P < 0.01) following the second vaccine dose, while the intranasal group exhibited significantly higher levels of serum IgA (P < 0.05) and local IgA (P < 0.01) in the nasal washings. Also, IgA antibody-secreting cells were found in significantly higher numbers in the intranasal group in both the spleen (P < 0.01) and the bone marrow (P < 0.01). Moreover, Th1 (TNF-α, IL-2, IFN-γ) and Th2 (IL-4, IL-5, IL-10) cytokines were expressed by both groups, yet only the intranasal group expressed the Th17 marker IL-17. As the intranasal vaccines induce local IgA and are easily administered, we suggest the intranasally administered whole virus vaccine as a promising candidate for a pandemic H5N1 vaccine.

On the characteristics of landslide tsunamis.

This review presents modelling techniques and processes that govern landslide tsunami generation, with emphasis on tsunamis induced by fully submerged landslides. The analysis focuses on a set of representative examples in simplified geometries demonstrating the main kinematic landslide parameters influencing initial tsunami amplitudes and wavelengths. Scaling relations from laboratory experiments for subaerial landslide tsunamis are also briefly reviewed. It is found that the landslide acceleration determines the initial tsunami elevation for translational landslides, while the landslide velocity is more important for impulsive events such as rapid slumps and subaerial landslides. Retrogressive effects stretch the tsunami, and in certain cases produce enlarged amplitudes due to positive interference. In an example involving a deformable landslide, it is found that the landslide deformation has only a weak influence on tsunamigenesis. However, more research is needed to determine how landslide flow processes that involve strong deformation and long run-out determine tsunami generation.

No change in viral set point or CD4 cell decline among antiretroviral treatment-naïve, HIV-1-infected individuals enrolled in the Danish HIV Cohort Study in 1995-2010.

OBJECTIVES: Recent studies have reported faster progression of HIV infection than anticipated based on results from earlier studies. The aim of the present study was to examine if the virulence of HIV-1 infection changed in the period 1995-2010 among chronically HIV-infected individuals in Denmark. METHODS: We included all patients registered in the Danish HIV Cohort Study, who were diagnosed in 1995-2009, had a CD4 count > 100 cells/µL at diagnosis and had at least two CD4 measurements prior to initiation of antiretroviral therapy (ART). Changes in viral set point and rate of CD4 cell decline from enrolment until the initiation of ART by calendar year of HIV diagnosis were analysed. Time to first CD4 count < 350 cells/µL was compared among patients diagnosed in 1995-2000, 2001-2005 and 2006-2010. RESULTS: We followed 1469 HIV-infected patients for a total of 5783 person-years. The median viral set point was 4.27 log10 HIV-1 RNA copies/mL [interquartile range (IQR) 3.58-4.73 log10 copies/mL]. The median CD4 cell decline per year was 57 cells/µL (IQR 10-139 cells/µL). In analyses adjusted for age, gender, origin, route of transmission and CD4 count at diagnosis, there were no associations between year of diagnosis and viral set point or CD4 cell decline. Time to first CD4 count < 350 cells/µL did not change in the study period [incidence rate ratio (IRR) 0.90 (95% confidence interval (CI) 0.76-1.06) for 2001-2005 and 1.09 (95% CI 0.79-1.34) for 2006-2010 compared with 1995-2000]. CONCLUSIONS: We found no evidence of changing trends in viral set point, CD4 cell decline or time to CD4 count < 350 cells/µL during the period 1995-2010 in a cohort of chronically HIV-infected individuals.

The effect of depth on the target strength of a humpback whale (Megaptera novaeangliae).

Marine mammals are very seldom detected and tracked acoustically at different depths. The air contained in body cavities, such as lungs or swimbladders, has a significant effect on the acoustic energy backscattered from whale and fish species. Target strength data were obtained while a humpback whale (Megaptera novaeangliae) swam at the surface and dove underneath a research vessel, providing valuable multi-frequency echosounder recordings of its scattering characteristics from near surface to a depth of about 240 m. Increasing depth dramatically influenced the backscattered energy coming from the large cetacean. This study is tightly linked to the ultimate goal of developing an automated whale detection system for mitigation purposes.

Causes of death among Danish HIV patients compared with population controls in the period 1995-2008.

PURPOSE: To compare the mortality and causes of death in human immunodeficiency syndrome (HIV) patients with the background population. METHODS: All adult HIV patients treated in Danish HIV centers from 1995 to 2008 and 14 controls for each HIV patient were included. Age-adjusted mortality rates (MR) and mortality rate ratios (MRR) were estimated using direct standardization and Poisson regression analyses. Up to four contributory causes of death for each person were included in analyses of cause-specific MR. RESULTS: A total of 5,137 HIV patients and 71,918 controls were followed for 37,838 and 671,339 person-years (PY), respectively. Among non-injection drug use (IDU) HIV patients, the acquired immune deficiency syndrome (AIDS)-related MR/1,000 PY declined dramatically from 122.9 [95 % confidence interval (CI) 106.8-141.4] in 1995 to 5.0 (95 % CI 3.1-8.1) in 2008. The non-AIDS-related MR did not change substantially from 6.9 (95 % CI 3.8-12.5) to 5.6 (95 % CI 3.6-8.8). The MR of unnatural causes declined from 6.9 (95 % CI 3.8-12.5) to 2.7 (95 % CI 1.4-5.1). The MRR of infections declined from 46.6 (95 % CI 19.6-110.9) to 3.3 (95 % CI 1.6-6.6). The MRR of other natural causes of death remained constant. CONCLUSIONS: After the introduction of highly active antiretroviral therapy (HAART), the AIDS-related mortality has decreased substantially, but the long-term exposure to HIV and HAART has not translated into increasing mortality from malignancy, cardiovascular, and hepatic diseases.

Temporal patterns in the soundscape of a Norwegian gateway to the Arctic.

As an Arctic gateway, the Norwegian Sea sustains a rich diversity of seasonal and resident species of soniferous animals, vulnerable to the effects of climate change and anthropogenic activities. We show the occurrence of seasonal patterns of acoustic signals in a small canyon off Northern Norway, and investigate cetacean vocal behavior, human-made noise, and climatic contributions to underwater sound between January and May 2018. Mostly median sound levels ranged between 68.3 and 96.31 dB re 1 µPa2 across 1/3 octave bands (13 Hz-16 kHz), with peaks in February and March. Frequencies under 2 kHz were dominated by sounds from baleen whales with highest rates of occurrence during winter and early spring. During late-spring non-biological sounds were predominant at higher frequencies that were linked mainly to ship traffic. Seismic pulses were also recorded during spring. We observed a significant effect of wind speed and ship sailing time on received sound levels across multiple distance ranges. Our results provide a new assessment of high-latitude continental soundscapes in the East Atlantic Ocean, useful for management strategies in areas where anthropogenic pressure is increasing. Based on the current status of the local soundscape, we propose considerations for acoustic monitoring to be included in future management plans.

Evaluation of competency-driven training for facilitators delivering a psychological intervention for children in Lebanon: a proof-of-concept study.

AIMS: The mounting evidence for effective delivery of psychological interventions by non-specialists in low- and middle-income settings has led to a rapid expansion of mental health and psychosocial support trainings globally. As such, there is a demand for strategies on how to train and implement these services to attain adequate quality. This study aims to evaluate the added value of a competency-driven approach to training of facilitators for a group intervention for children with severe emotional distress in Lebanon. METHODS: In a controlled before and after study, 24 trainees were randomly allocated to participate in either a competency-driven training (CDT) or training-as-usual (TAU) (1 : 1) for a psychological intervention for children with severe emotional distress. We assessed the change in demonstrated competencies, using standardised role-plays, before and after the training. Measures included the 13-item Working with children-Assessment of Competencies Tool (WeACT), the 15-item ENhancing Assessment of Common Therapeutic factors (ENACT) and the 6-item Group facilitation: Assessment of Competencies Tool (GroupACT). The trainer in the experimental arm used pre-training and during training competency assessment scores to make real-time adjustment to training delivery. Due to COVID-19 pandemic restrictions, all activities were done remotely. RESULTS: CDT resulted in significantly better outcomes on increasing competencies on the WeACT (repeated measures analysis of variance; F(1, 22) = 6.49, p < 0.018) and on the GroupACT (Mann-Whitney U = 22, p < 0.003), though not statistically significant on the ENACT. There is no significant between-group difference on the reduction of harmful behaviours, mainly because both forms of training appear equally successful in eliminating such behaviours. CONCLUSIONS: This proof-of-concept study demonstrates the potential of CDT, using standardised assessment of trainee competencies, to contribute to better training outcomes without extending the duration of training. CDT can result in up to 18% greater increase in adequate competency, when compared to TAU. The study also yields recommendations for further enhancing the benefits of competency-driven strategies. A fully powered trial is needed to confirm these findings.

HIV and risk of venous thromboembolism: a Danish nationwide population-based cohort study.

OBJECTIVE: The association between HIV infection and the risk of venous thromboembolism (VTE) is controversial. We examined the risk of VTE in HIV-infected individuals compared with the general population and estimated the impact of low CD4 cell count, highly active antiretroviral therapy (HAART) and injecting drug use (IDU). METHODS: We identified 4333 Danish HIV-infected patients from the Danish HIV Cohort Study and a population-based age- and gender-matched comparison cohort of 43,330 individuals. VTE diagnoses were extracted from the Danish National Hospital Registry. Cumulative incidence curves were constructed for time to first VTE. Incidence rate ratios (IRRs) and impact of low CD4 cell count and HAART were estimated by Cox regression analyses. Analyses were stratified by IDU, adjusted for comorbidity and disaggregated by overall, provoked and unprovoked VTE. RESULTS: The 5-year risk of VTE was 8.0% [95% confidence interval (CI) 5.78-10.74%] in IDU HIV-infected patients, 1.5% (95% CI 1.14-1.95%) in non-IDU HIV-infected patients and 0.3% (95% CI 0.29-0.41%) in the population comparison cohort. In non-IDU HIV-infected patients, adjusted IRRs for unprovoked and provoked VTE were 3.42 (95% CI 2.58-4.54) and 5.51 (95% CI 3.29-9.23), respectively, compared with the population comparison cohort. In IDU HIV-infected patients, the adjusted IRRs were 12.66 (95% CI 6.03-26.59) for unprovoked VTE and 9.38 (95% CI 1.61-54.50) for provoked VTE. Low CD4 cell count had a minor impact on these risk estimates, while HAART increased the overall risk (IRR 1.93; 95% CI 1.00-3.72). CONCLUSION: HIV-infected patients are at increased risk of VTE, especially in the IDU population. HAART and possibly low CD4 cell count further increase the risk.

Pandemic influenza vaccination elicits influenza-specific CD4+ Th1-cell responses in hypogammaglobulinaemic patients: four case reports.

In these case reports, we investigated pandemic influenza 2009 vaccination of primary hypogammaglobulinaemic patients. Three combined variable immunodeficiency (CVID) patients and one X-linked agammaglobulinaemia (XLA) patient were vaccinated with the pandemic vaccine A/California/7/2009 (H1N1)-like split virus (X179a) adjuvanted with the oil-in-water emulsion AS03. Subsequently, serum and peripheral blood mononuclear cells were sampled and used to measure the haemagglutination inhibition (HI) and antibody-secreting cell (ASC) responses. In addition, the IFN-γ, IL-2 and TNF-α producing CD4(+) Th1-cell response was determined as these cytokines are important indicators of cell-mediated immunity. Two of the CVID patients responded to vaccination as determined by a >4-fold rise in HI antibodies. These subjects also had influenza-specific ASC numbers, which, albeit low, were higher than prevaccination levels. In addition, vaccination induced CD4(+) Th1-cell responses in both the XLA patient and the CVID patients, although the frequency of influenza-responsive cells varied amongst the patients. These results suggest that hypogammaglobulinaemia patients can mount a CD4(+) Th1 cell-mediated response to influenza vaccination and, additionally, that influenza vaccination of some hypogammaglobulinaemia patients can produce an influenza-specific humoral immune response. The findings should be confirmed in larger clinical studies.

The Scandinavian Propaten(®) trial - 1-year patency of PTFE vascular prostheses with heparin-bonded luminal surfaces compared to ordinary pure PTFE vascular prostheses - a randomised clinical controlled multi-centre trial.

OBJECTIVE: To compare 1-year potencies' of heparin-bonded PTFE [(Hb-PTFE) (Propaten(®))] grafts with those of ordinary polytetraflouroethylene (PTFE) grafts in a blinded, randomised, clinically controlled, multi-centre study. MATERIALS AND METHODS: Eleven Scandinavian centres enrolled 569 patients with chronic functional or critical lower limb ischaemia who were scheduled to undergo femoro-femoral bypass or femoro-poplitaeal bypass. The patients were randomised 1:1 stratified by centre. Patency was assessed by duplex ultrasound scanning. A total of 546 patients (96%) completed the study with adequate follow-up. RESULTS: Perioperative bleeding was, on average, 370 ml with PTFE grafts and 399 ml with Heparin-bonded PTFE grafts (p = 0.32). Overall, primary patency after 1 year was 86.4% for Hb-PTFE grafts and 79.9% for PTFE grafts (OR = 0.627, 95% CI: 0.398; 0.989, p = 0.043). Secondary patency was 88% in Hb-PTFE grafts and 81% in PTFE grafts (OR = 0.569 (0.353; 0.917, p = 0.020)). Subgroup analyses revealed that significant reduction in risk (50%) was observed when Hb-PTFE was used for femoro-poplitaeal bypass (OR = 0.515 (0.281; 0.944, p = 0.030)), and a significant reduction in risk (50%) was observed with Hb-PTFE in cases with critical ischaemia (OR = 0.490 (0.249; 0.962, p = 0.036)). CONCLUSION: The Hb-PTFE graft significantly reduced the overall risk of primary graft failure by 37%. Risk reduction was 50% in femoro-poplitaeal bypass cases and in cases with critical ischaemia.