Identifying potential cases of eating disorders in an acute medical hospital

OBJECTIVE

To identify patients presenting to an acute medical hospital with common signs and symptoms that occur in people with eating disorders (EDs), and determine by retrospective file audit if these are diagnosed cases of an ED.

METHOD

The investigators screened electronic medical records of people 16 years and older for common signs and symptoms of an ED such as hypokalemia, in patients presenting to an acute hospital in Sydney, Australia from 2018 to 2020. Cases where the clinical finding was unexplained had their file audited. Cases with a known ED diagnosis or coded with an ED were also retrieved to audit.

RESULTS

Investigators identified 192 definite ED cases with a total of 598 episodes of care from 2018 to 2020 presenting to the hospital. Eighty-three cases were identified as possible EDs due to unexplained clinical signs consistent with an ED, but were not confirmed cases due to lack of clinical history in the file. Only 19.1% of presentations were diagnostically coded with an ED in the electronic medical record.

DISCUSSION

Our study revealed a large number of definite ED cases presenting to an acute medical hospital via the emergency department, who were not recognized as having an ED. Greater awareness of clinical signs and symptoms of an ED, such as unexplained low body mass index and hypokalemia, is necessary among acute care clinicians. Correctly identifying EDs in those seeking somatic care should be a public health priority, to facilitate timely and equitable access to diagnostic assessment and evidence based treatment.

PUBLIC SIGNIFICANCE

People with eating disorders (EDs) present to acute care settings and have a relatively high utilization of generalist health services with nonspecific problems such as abdominal pain. An enhanced understanding of healthcare utilization by people with EDs, who may not disclose their symptoms, is crucial for improving access to treatment.

Psychometric properties of the Marschak Interaction Method of Psychometrics and the Assessment of Parent-Child Interaction within residential care and non-referred settings

Introduction

Assessment and identification of children with developmental needs and their interaction with primary caregivers are critical for emotional and social development. However, to the best of our knowledge, there is a scarcity of valid observation-based tools that guide the work with family communication, which is essential for the child's healthy development.

Method

The Marschak Interaction Method of Psychometrics (MIM-P) and Assessment of Parent-Child Interaction (APCI) are both interaction and observation-based assessment tool, and they were explored for their validity and reliability in assessing caregiver-child interaction. The study included 30 trained and certified professionals who recruited referred and non-referred caregiver-child dyads over 11 months. Assessment data was collected from 139 caregiver-child dyads for the MIM-P with 278 individuals (100 referred and 178 non-referred) and 129 caregiver-child dyads for the APCI with 257 individuals (95 referred and 162 non-referred).

Results

The psychometric analyses show that both the MIM-P and APCI presents relevant sources of reliability and validity for assessing caregiver-child interaction including interrater reliability, internal consistency, test re-test reliability as well as concurrent and construct validity.

Discussion and conclusion

The study highlights the need for observation-based assessment tools within social work and contributes to the understanding of the importance of relationships and interaction in children's emotional and social development. However, further research is needed to explore norms and further strengthen implementation and quality of the tools.

Challenges and priorities for researching the gut microbiota in individuals living with anorexia nervosa

OBJECTIVE

The gut microbiota is implicated in several symptoms and biological pathways relevant to anorexia nervosa (AN). Investigations into the role of the gut microbiota in AN are growing, with a specific interest in the changes that occur in response to treatment. Findings suggest that microbial species may be associated with some of the symptoms common in AN, such as depression and gastrointestinal disturbances (GID). Therefore, researchers believe the gut microbiota may have therapeutic relevance. Whilst research in this field is rapidly expanding, the unique considerations relevant to conducting gut microbiota research in individuals with AN must be addressed.

METHOD

We provide an overview of the published literature investigating the relationship between the gut microbiota and symptoms and behaviors present in AN, discuss important challenges in gut microbiota research, and offer recommendations for addressing these. We conclude by summarizing research design priorities for the field to move forward.

RESULTS

Several ways exist to reduce participant burden and accommodate challenges when researching the gut microbiota in individuals with AN.

DISCUSSION

Recommendations from this article are foreseen to encourage scientific rigor and thoughtful protocol planning for microbiota research in AN, including ways to reduce participant burden. Employing such methods will contribute to a better understanding of the role of the gut microbiota in AN pathophysiology and treatment.

PUBLIC SIGNIFICANCE

The field of gut microbiota research is rapidly expanding, including the role of the gut microbiota in anorexia nervosa. Thoughtful planning of future research will ensure appropriate data collection for meaningful interpretation while providing a positive experience for the participant. We present current challenges, recommendations for research design and priorities to facilitate the advancement of research in this field.

Screening, assessment and diagnosis in the eating disorders: findings from a rapid review

BACKGROUND

Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.

METHODS

This paper forms part of a Rapid Review series scoping the evidence base for the field of eating disorders, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for studies published between 2009 and mid 2021 in English. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised through purposive sampling. Data from selected studies relating to Screening, Assessment and Diagnosis of eating disorders were synthesised and are disseminated in the current review.

RESULTS

Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.

CONCLUSIONS

A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many. Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia's National Eating Disorders Research and Translation Strategy 2021-2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.

Impact of patient characteristics on clinicians' decisions to involve dietitians in eating disorder treatment

BACKGROUND & AIMS

Dietetic involvement in eating disorder (ED) treatment is often initiated by other members of a patient's treating team. This study aimed to examine the impact of patient characteristics on clinicians' decisions to involve a dietitian in a patient's ED treatment, as well as the influence of clinician characteristics on their decision-making.

METHODS

ED clinicians were recruited to complete an online survey, which used case vignettes to assess their likelihood of referring patients to a dietitian or consulting with a dietitian for guidance. Questions were also included measuring clinician anxiety, beliefs about the therapy they deliver, beliefs about dietitians and views on evidence-based practice, to determine if these were related to their responses to case vignettes.

RESULTS

Fifty-seven clinicians completed the survey, with the largest group being clinical psychologists (n=22, 39%). ED diagnosis, weight status, medical co-morbidities and progress in treatment were all shown to be influential on whether clinicians involved dietitians in ED treatment. Clinician characteristics and their beliefs about dietitians were generally not correlated with the likelihood of seeking dietetic input.

CONCLUSIONS

This study indicates that clinicians' decisions to involve dietitians in ED treatment are systematic rather than random decisions influenced by individual clinician characteristics. Clinicians require further education on the potential for malnutrition regardless of patients'ED diagnosis or weight status, and the dietitian's role in addressing this. This article is protected by copyright. All rights reserved.

Discrepancies between Australian eating disorder clinicians and consumers regarding essential components of dietetic treatment

BACKGROUND

A recent Delphi study indicated that compared to eating disorder (ED) consumers and carers, ED specialists were less likely to endorse involvement of a dietitian as a standard component of treatment. Additionally, there was disagreement between these groups regarding the inclusion of a number of components of dietetic treatment.

OBJECTIVE

This study aimed to further investigate this data to identify areas of disagreement between ED specialist dietitians, ED specialist non-dietetic clinicians, consumers and carers with regards to outpatient dietetic treatment.

DESIGN AND PARTICIPANTS/SETTING

The ED specialists panel from a previous Delphi study was re-coded into two panels: ED specialist dietitians (n=31) and ED specialist non-dietetic clinicians (n=48) to compare responses of these panels to responses from consumers (n=32) and carers (n=23).

MAIN OUTCOME MEASURES

Statements under seven categories relating to referral to dietitian, essential components of outpatient dietetic treatment regarding four ED patient populations, strategies to promote multi-disciplinary collaboration and skills dietitians should possess if treating patients with an ED were rated on a five point Likert scale.

STATISTICAL ANALYSIS PERFORMED

One-way ANOVA were conducted with post-hoc multiple comparisons to compare mean statement ratings.

RESULTS

Thirty-seven statements (30%) showed statistically significant differences (p<0.05) in responses between panels. Discrepancies were primarily observed for statements regarding how and when dietetics is included in treatment and essential components of dietetic treatment, particularly the use of behavioural tasks such meal plans and self-monitoring. Results also highlighted deficits in participants' understanding of core responsibilities of dietitians in ED treatment and dietitians 'drifting' from delivering evidence-based components of dietetic treatment.

CONCLUSIONS

Results of this study show discrepancies amongst ED dietitians, clinicians, consumers and carers regarding what dietetic treatment for people with EDs should encompass. It also indicates the need for further research into optimising dietetic treatment for EDs which is conducted in collaboration with individuals with lived experience.

Overcoming Barriers to PhD Education in Nursing

BACKGROUND

Doctoral programs continue to have high attrition rates. This article discusses barriers and success strategies for developing a new PhD program in nursing.

METHOD

A university in the southeastern United States surveyed current Master of Science in Nursing students and graduates regarding barriers to enrolling in a doctoral program. The faculty and administrators developed strategies to guide students to success in a new PhD program.

RESULTS

Significant barriers to entering nursing doctoral education included financial constraints, job and family responsibilities, lack of program flexibility and faculty mentoring, and fear of research and the dissertation process. Strategies instituted were accelerated learning, convenient scheduling, and early guided dissertation work.

CONCLUSION

Recommendations for strengthening doctoral education are aimed at three significant components to guide the dissertation process: commitment, connectedness, and continuous improvement. [J Nurs Educ. 2021;60(7):400-403.].

Gastrointestinal symptoms following treatment for anorexia nervosa: A systematic literature review

OBJECTIVE

Gastrointestinal (GI) disturbances are a frequent and burdensome experience for patients with anorexia nervosa (AN). How GI symptoms respond to current interventions is not well characterized, yet is critical to facilitate treatment success, and to inform the development of new treatments for AN. Therefore, the aim of this systematic review was to identify which treatments are effective in improving GI symptoms in patients with AN.

METHOD

A systematic search for studies of AN treatments measuring GI symptoms pre- and post-treatment was conducted in May 2020 (PROSPERO ID: CRD42020181328). After removal of duplicates, title and abstracts of 3,370 studies were screened. Methodological quality was assessed using National Institute of Health Quality Assessment Tool.

RESULTS

Following full-text screening, 13 studies (12 observational studies and 1 randomized double-blind placebo-controlled trial) with 401 participants met eligibility criteria and were included. All observational studies included a component of nutritional rehabilitation, with half (n = 6) involving concurrent psychological treatment. The randomized controlled trial reported a drug therapy. Eleven studies reported an improvement in all (n = 6) or at least one (n = 5) patient-reported GI symptom following treatment. Two studies reported no change. Methodological quality was fair or poor across all studies.

DISCUSSION

This is the first systematic review to synthesize available evidence on the trajectory of patient-reported GI symptoms from commencement to end of treatment for AN. The results suggest that most studies showed improvement in one or more GI symptom in response to current treatments. Future therapeutic approaches should consider GI symptoms within their design for optimal treatment adherence and outcomes.

Dietetic intervention for adult outpatients with an eating disorder: a systematic review and assessment of evidence quality

CONTEXT

Eating disorders (EDs) are complex mental illnesses that require medical, psychological, and dietetic intervention to assist patients achieve recovery.

OBJECTIVE

Available evidence was reviewed regarding dietetic intervention for adult outpatients with an ED and the quality of this evidence was assessed.

DATA SOURCES

Systematic literature searches were conducted using 5 databases (MEDLINE, PreMEDLINE, EMBASE, CINAHL, PsycINFO) for studies comparing adults with an ED receiving a dietetic intervention with those receiving a psychological intervention alone, those receiving a combined dietetic and psychological intervention, or a control group.

DATA EXTRACTION

Literature searches returned 3078 results, with 10 articles reporting on 9 randomized controlled trials meeting the inclusion criteria. The quality of evidence was assessed using the Cochrane Risk-of-Bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

DATA ANALYSIS

GRADE assessments for studies involving individuals with anorexia nervosa indicated very low quality of evidence for outcomes including weight, ED psychopathology and ED behaviors , and no studies measured nutritional changes. For studies conducted with participants with bulimia nervosa or binge eating disorder, only 1 study included a group receiving combined evidence-based psychological and dietetic intervention. A combined intervention produced moderate-quality evidence for lower attrition, greater abstinence from ED behaviors, and more meals eaten per week in comparison with a stand-alone psychological or dietetic intervention.

CONCLUSIONS

There is currently limited evidence to sufficiently assess the impact of incorporating dietetic interventions into outpatient treatment for adults with an ED; however, available evidence supports clinical practice guidelines that dietetic intervention should not be delivered as a stand-alone treatment. Additional methodologically sound studies in larger samples are required to fully inform dietetic treatment in EDs and incorporation of such interventions as part of a multidisciplinary treatment approach.

A review of treatment manuals for adults with an eating disorder: nutrition content and consistency with current dietetic evidence

PURPOSE

This study aimed to summarise the nutrition and food-related content of treatment manuals for adults with eating disorders (EDs) and assess the degree to which this information conforms with current guidelines and literature.

METHODS

Treatment manuals for adults with an ED were identified by conducting an online search of Internet book dealer Amazon and University of Sydney library catalogue as per methods used in previous reviews of self-help patient resources. The nutrition and food-related content of these manuals was extracted and reviewed independently by two reviewers using a criteria based on current best evidence to date regarding dietetic treatment for EDs.

RESULTS

Twenty-two manuals met inclusion criteria, 20 (91%) of which contained some degree of nutrition and food-related content. Two manuals (9%) included content written by a dietitian, six (27%) included citation of dietetic literature to support the recommendations made and eight (36%) recommended a dietitian be consulted as part of a multidisciplinary approach to treatment. Thirteen manuals (60%) contained nutrition and food-related information not substantiated by current evidence.

CONCLUSION

It is common for treatment manuals for EDs to contain nutrition and food-related content. However, most of the authors of the 22 manuals identified did not appear to collaborate with a dietitian in writing this content or cite peer-reviewed literature to substantiate dietary advice given. Consistent with current clinical practice guidelines, greater collaboration between dietitians and clinicians is required to develop, evaluate and disseminate evidence-based approaches to dietetic management.

LEVEL OF EVIDENCE

Level V, narrative review.

ANZAED practice and training standards for dietitians providing eating disorder treatment

INTRODUCTION

Dietitians involved in eating disorder treatment are viewed as important members of the multidisciplinary team. However, the skills and knowledge that they require are not well characterised. Therefore, as part of a broader project to identify the key principles and clinical practice and training standards for mental health professionals and dietitians providing eating disorder treatment, the Australia & New Zealand Academy for Eating Disorders (ANZAED) sought to identify the key practice and training standards specific to dietitians. An expert working group of dietitians was convened to draft the initial dietetic standards. After expert review, feedback on the revised standards was then provided by 100 health professionals working within the eating disorder sector. This was collated into a revised version made available online for public consultation, with input received from treatment professionals, professional bodies and consumer/carer organisations.

RECOMMENDATIONS

Dietitians providing treatment to individuals with an eating disorder should follow ANZAED's general principles and clinical practice standards for mental health professionals and dietitians. In addition, they should also be competent in the present eating disorder-specific standards based around the core dietetic skills of screening, professional responsibility, assessment, nutrition diagnosis, intervention, monitoring and evaluation.

CONCLUSIONS

These standards provide guidance on the expectations of dietetic management to ensure the safe and effective treatment of individuals with an eating disorder. Implications for professional development content and training providers are discussed, as well as the importance of clinical supervision to support professional self-care and evidence-informed and safe practice for individuals with an eating disorder.

ANZAED eating disorder treatment principles and general clinical practice and training standards

INTRODUCTION

Eating disorders are complex to manage, and there is limited guidance around the depth and breadth of knowledge, skills and experience required by treatment providers. The Australia & New Zealand Academy for Eating Disorders (ANZAED) convened an expert group of eating disorder researchers and clinicians to define the clinical practice and training standards recommended for mental health professionals and dietitians providing treatment for individuals with an eating disorder. General principles and clinical practice standards were first developed, after which separate mental health professional and dietitian standards were drafted and collated by the appropriate members of the expert group. The subsequent review process included four stages of consultation and document revision: (1) expert reviewers; (2) a face-to-face consultation workshop attended by approximately 100 health professionals working within the sector; (3) an extensive open access online consultation process; and (4) consultation with key professional and consumer/carer stakeholder organisations.

RECOMMENDATIONS

The resulting paper outlines and describes the following eight eating disorder treatment principles: (1) early intervention is essential; (2) co-ordination of services is fundamental to all service models; (3) services must be evidence-based; (4) involvement of significant others in service provision is highly desirable; (5) a personalised treatment approach is required for all patients; (6) education and/or psychoeducation is included in all interventions; (7) multidisciplinary care is required and (8) a skilled workforce is necessary. Seven general clinical practice standards are also discussed, including: (1) diagnosis and assessment; (2) the multidisciplinary care team; (3) a positive therapeutic alliance; (4) knowledge of evidence-based treatment; (5) knowledge of levels of care; (6) relapse prevention; and (7) professional responsibility.

CONCLUSIONS

These principles and standards provide guidance to professional training programs and service providers on the development of knowledge required as a foundation on which to build competent practice in the eating disorder field. Implementing these standards aims to bring treatment closer to best practice, and consequently improve treatment outcomes, reduce financial cost to patients and services and improve patient quality of life.

Optimizing Hepatitis C Virus (HCV) Treatment in a US Colocated HCV/Opioid Agonist Therapy Program

Background

A minority of patients with opioid use disorder are treated for hepatitis C virus infection (HCV). While colocated HCV and opioid agonist therapy (OAT) along with harm reduction can facilitate prevention and cascade to cure, there are few real-world examples of such embedded care models in the United States in the direct-acting antiviral (DAA) era.

Methods

We conducted a retrospective chart review to determine sustained virologic response (SVR) and reinfection rates during the first 5-year period of DAA availability among individuals tested and treated on-site at Rhode Island’s only nonprofit methadone maintenance program.

Results

Of 275 who initiated DAAs, the mean age (range) was 43 (22–71) years, 34.5% were female, 57.5% had genotype 1a, 23.3% had cirrhosis, and 92% were Medicaid recipients. SVR was 85.0% (232/273), while modified intent-to-treat SVR was 93.2% (232/249); 17 patients did not achieve SVR, 2 awaited SVR 12 weeks post-end-of-treatment, and 24 were lost to follow-up. Thirty reinfections were identified over 375.5 person-years of follow-up (rate, 7.99/100 person-years). The median time to first reinfection (interquartile range) was 128 (85.25–202.5) days. Before July 1, 2018, 72 patients accessed DAAs over 3.7 years; after Medicaid DAA restrictions were lifted, 109 patients accessed DAAs over 1.3 years. The Prior Authorization (PA) process requires many steps, differing across 11 RI insurers, taking 45–120 minutes per patient.

Conclusions

DAA treatment was effective among a marginalized population in an urban colocated OAT/HCV program. Removing DAA restrictions facilitates treatment initiation. The PA process remains a modifiable barrier to expanding capacity in the United States.

Development of consensus-based guidelines for outpatient dietetic treatment of eating disorders: A Delphi study

OBJECTIVE

To generate consensus-based guidelines for outpatient dietetic treatment of patients with an eating disorder (ED) using Delphi methodology.

METHOD

A modified Delphi method was used to develop consensus-based guidelines in several categories: referral to a dietitian; essential components of outpatient dietetic treatment; strategies to promote collaboration between dietitians and other healthcare professionals; and skills dietitians should possess if treating patients with an ED. Participants (n = 162) were coded into three panels: ED specialists (n = 79), non-ED specialists (n = 28), and consumers and carers with lived experience of an ED (n = 55). A total of 122 statements were rated across three rounds.

RESULTS

Eighty-one statements reached consensus level (66.4%). A high proportion of endorsed statements were consistent with current guidelines for ED treatment, though some statements for which evidence exists were not endorsed as essential components of dietetic treatment. Compared to consumers and carers, ED specialists were less likely to endorse assessment or involvement by a dietitian as a standard component of treatment, and a number of discrepancies between ED specialists and consumers and carers were observed regarding essential components of dietetic treatment.

DISCUSSION

This study provides consensus-based guidelines in the current absence of clinical practice guidelines for dietetic treatment of EDs. It also highlights the importance of further research into: (a) the effectiveness of different components of dietetic intervention in this population and (b) how dietetic assessment and intervention is best incorporated into outpatient treatment.

Estimation of External Contamination and Exposure Rates Due to Fission Product Release

In the event of a radiological incident, the release of fission products into the surrounding environment and the ensuing external contamination present a challenge for triage assessment by emergency response personnel. Reference exposure rate and skin dose rate calibration data for emergency response personnel are currently lacking for cases where receptors are externally contaminated with fission products. Simulations were conducted to compute reference exposure rate coefficients and skin dose rate coefficients from photon-emitting fission products of radiological concern. To accomplish this task, simplified mathematical skin phantoms were created using surface area and height specifications from International Commission on Radiological Protection Publication 89. Simulations were conducted using Monte Carlo radiation transport code using newborn, 1-y-old, 5-y-old, 10-y-old, 15-y-old, and adult phantoms for 22 photon-emitting radionuclides. Exposure rate coefficient data were employed in a case study simulating the radionuclide inventory for a 17 × 17 Westinghouse pressurized water reactor, following three burn-up cycles at 14,600 MWd per metric ton of uranium. The decay times following the final cycle represent the relative activity fractions over a period of 0.5-30 d. The resulting data can be used as calibration standards for triage efforts in emergency response protocols.

Fracture prevention: a population-based intervention delivered in primary care

BACKGROUND

Osteoporosis is common, increasing as the population ages and has significant consequences including fracture. Effective treatments are available.

AIM

To support proactive fracture risk assessment (FRAX) and optimizing treatment for high-risk patients in primary care.

DESIGN

Clinical cohort.

SETTING

November 2017 to November 2018, support was provided to 71 practices comprising 69 of 90 practices within two National Health Service Clinical Commissioning Groups areas. Total population 579 508 (207 263 aged over 50 years).

PARTICIPANTS

FRAX (National Institute for Care and Clinical Excellence, NICE CG146) in (i) males aged 75 years and over, (ii) females aged 65 years and over, (iii) females aged under 65 years and males aged under 75 years with risk factors and (iv) under 50 years with major risk factors.

RESULTS

A total of 158 946 met NICE CG146, 11 961 were coded with an osteoporosis diagnosis (7.5%), of those, 42% were prescribed treatment with a bone sparing agent (BSA). In total, 6942 were assessed to initiate BSA. Thirty percent of untreated osteoporosis diagnosis patients had never been prescribed BSA. Even when prescribed, 1700 people (35%) were for less than minimum recommended duration. Of the total 9784 patients within the FRAX recommended to treat threshold, 3197 (33%) were currently treated with BSA and 3684 (37%) had no history of ever receiving BSA. From untreated patients, expected incidence of 875 fractures over a 3-year period (approximately £3.4 million). Treatment would prevent 274 fractures (cost reduction: £1 274 045, with prescribing costs: saving £805 145 after 3 years of treatment).

CONCLUSION

Underdiagnosis and suboptimal treatment of osteoporosis was identified. Results suggest that implementing NICE guidance and optimizing treatment options in practice is possible and could prevent significant fractures.

Sheep tick Ixodes ricinus management on Welsh hill farms of designated conservation importance: implications for nationally declining birds

Impacts of sheep ticks Ixodes ricinus on livestock, gamebirds and wildlife are of concern across Europe. The present study describes livestock and tick management by 36 farmers from three upland sites of conservation importance in North Wales, where farmers consider that ticks have increased during the last 25 years. Sheep, average densities of 2.0 animals per ha were treated with pour-on acaricides in spring, again in July, and also when removed from the moor in autumn. Given acaricide efficacy rates, sheep were susceptible to tick bites for half the period on the moor. Sheep from 17 farms were examined for ticks. Infestations were similar between farms and in relation to the acaricide used, averaging 9.3 ticks per sheep, although they were lower where the interval between successive acaricide treatments was shorter. Repeated sampling of sheep and red grouse chicks showed no annual difference in tick burdens on grouse chicks, which averaged 6.2 ticks per chick, although there were three-fold fewer ticks on sheep in 2018 than in previous years. Tick bite rates on sheep and grouse were higher than elsewhere in the U.K. Most farmers interviewed would aim to improve their tick management using longer-lasting acaricides and treating sheep more frequently, although they would need advice and financial help, which is currently unavailable via Government funded agri-environment schemes.

Quality of Life among Mastectomy Patients Using External Breast Prostheses

Background

Most women who undergo mastectomy for breast cancer use external breast prostheses. Yet, little is known about patterns of use, satisfaction levels, and quality of life associated with their use as compared to other options.

Patients and Methods

We report longitudinal, self-report questionnaire data regarding prosthetic use from 592 Italian mastectomy patients. Women who report satisfaction with their prostheses are compared on medical, demographic, and quality of life variables to a matched sample of women who report dissatisfaction. We also compare matched samples of women who do not use prostheses and women who had reconstruction to prosthetic users.

Results

Most women used and were satisfied with their prostheses. However, there was a small group of women who were dissatisfied. These women reported greater disruption to their sense of feminility and worse quality of life in some areas. We found few differences between prosthetic users and women who used either of the other two options available following mastectomy - taking no action to restore the appearance of the amputated breast or having reconstructive surgery.

Conclusions

No one technique for restoring the appearance of the mastectomized breast is necessary to optimize quality of life for all women. Physicians should describe the options to women, along with the average satisfaction rates for women choosing those options, and help women to make the best personal decisions.

Development of the "Recovery from Eating Disorders for Life" Food Guide (REAL Food Guide) - a food pyramid for adults with an eating disorder

BACKGROUND

There is limited evidence to inform nutrition and dietetic interventions for individuals with eating disorders even though it is recommended as an essential part of multidisciplinary management. There is minimal guidance, an absence of standardised nutrition educational material, and no research on how best to educate patients on healthy eating and how to achieve nutrition adequacy. Therefore the REAL Food Guide was developed.

METHODS

The REAL Food Guide is a pyramid with four layers and key nutrition messages beside each layer that was conceived to address gaps in nutrition education and intervention for individuals with eating disorders. Written and verbal consumer feedback was obtained from consumers receiving treatment regarding the acceptability and usefulness of the REAL Food Guide. A unique database was developed to reflect the types of foods and realistic portion sizes that patients are likely to select. This database was used for nutrition modelling to assess the nutrition adequacy of three meal patterns (meat containing, vegetarian and semi-vegan) for both weight maintenance and weight regain. Each meal pattern was compared to the Nutrient Reference Values for Australia and New Zealand.

RESULTS

Nutritional analysis demonstrated nutritional adequacy of meal patterns for energy, macronutrients and most micronutrients when the recommended number of serves from the REAL Food Guide were assessed. All meal patterns were adequate in micronutrients except for the semi-vegan meal pattern that was inadequate in vitamin D. Feedback from individuals with eating disorders demonstrates the nutrition education tool was acceptable to them as they felt it was more helpful for their recovery than general nutrition guidelines.

CONCLUSION

The REAL Food Guide is a comprehensive and user-friendly guide that clinicians can use to educate patients about components of a balanced and healthy diet. The guide can educate all eating disorder clinicians, including those who are new to the field, about the basics of nutrition. Clinicians using the guide can be confident that, if followed, patient's energy and nutritional requirements will be met and important nutrition education messages are reinforced, that are tailored to the beliefs and concerns of individuals with eating disorders.

Exploring the perceived usefulness of practical food groups in day treatment for individuals with eating disorders

BACKGROUND/AIM

Recovery from eating disorders is a challenging process. Emerging literature suggests that occupational therapists may provide a useful contribution in delivering purposeful eating-related interventions as a potential treatment to support sustained cognitive and behavioural changes for individuals with eating disorders. This study aimed to evaluate participants' perceptions of the contribution of occupational therapy practical food groups (food based outings and cooking groups) in supporting their functional recovery.

METHODS

Individuals attended practical food groups as part of standard treatment at an outpatient eating disorders day program. Ninety-nine participants completed questionnaires at discharge and up to three follow-up points (6, 12 and 24 months). Questions related to practical food groups were analysed, exploring participants' experiences and perceived usefulness of groups using rating-scale and open-ended questions. Open-ended responses were analysed using thematic analysis. Descriptive statistics were calculated for responses to rating-scale questions.

RESULTS

At discharge, participants rated the importance and usefulness of practical food groups as high (4.73 and 4.43 on 5-point scales, respectively), but tended to rate their enjoyment of the groups lower (3.50 on a 5-point scale). Some skill transfer was typically reported by participants at discharge (3.92 on a 5-point scale). One core theme, 'success through participation', emerged from qualitative comments. Six subthemes were also identified: helpful components of practical food groups; perceived benefit of exposure; impact of applying cognitive and behavioural skills; challenges affecting participation; facilitating adaptation; and influence of eating disorders on challenging feared foods.

CONCLUSION

This study highlights that participation in practical food groups was perceived as useful in assisting individuals to improve eating behaviours and, in some circumstances, transfer these skills into their lives outside of day program. Results suggest that occupational therapists may have an important contribution in delivering these interventions to support recovery and facilitate application of adaptive coping strategies.

Implementation of the Needs Assessment Tool for patients with interstitial lung disease (NAT:ILD): facilitators and barriers

A Needs Assessment Tool (NAT) was developed previously to help clinicians identify the supportive/palliative needs of people with interstitial lung disease (ILD) (NAT:ILD). This letter presents barriers and facilitators to clinical implementation. Data from (1) a focus group of respiratory clinicians and (2) an expert consensus group (respiratory and palliative clinicians, academics, patients, carers) were analysed using Framework Analysis. Barriers related to resources and service reconfiguration, and facilitators to clinical need, structure, objectiveness, flexibility and benefits of an ‘aide-memoire’. Identified training needs included communication skills and local service knowledge. The NAT:ILD was seen as useful, necessary and practical in everyday practice.

CrossFitter’s knee: patellofemoral chondral injury following high-intensity functional training

We present a case series of patients with patellofemoral joint (PFJ) chondral injuries presenting as anterior knee pain secondary to participation in high-intensity functional training programmes. We aim to highlight PFJ chondral injuries as a potential complication of military servicemen engaging in high-intensity functional training programmes. This may allow medical staff to identify the injuries early, and highlight this possible injury mechanism to Physical Training staff to help educate participants and mitigate the risk of injury.

Leucocyte depleting filters and cardiothoracic surgery

Leucocyte filtration technology is now beginning to be used in cardiothoracic surgery. The leucocyte depletion of banked homologous blood has been shown to reduce its immunosuppressive effects, along with a range of other benefits. Use of such a blood product appears to be an attractive option during cardiopulmonary bypass (CPB) as this procedure is recognized as causing immune disturbance and long-term immunosuppression.

White-cell removal filters also appear to have a novel application in the reduction of neutrophil-mediated damage associated with CPB procedures. A strong database from animal work has been recently supplemented by human data that shows clinical benefits from autologous white-cell removal by filtration.

The household economic burden of eating disorders and adherence to treatment in Australia

BACKGROUND

This study investigated the household economic burden of eating disorders and cost-related non-adherence to treatment in Australia.

METHODS

Multi-centre prospective observational study using a structured questionnaire. Ninety participants were recruited from two clinic settings in New South Wales, Australia and from the community using social media. The primary outcome measures were household economic burden of illness measured in terms of out-of-pocket expenditure, household economic hardship and cost-related non-adherence.

RESULTS

The pattern of out-of-pocket expenditure varied by diagnosis, with Bulimia Nervosa associated with the highest total mean expenditure (per three months). Economic hardship was reported in 96.7% of participants and 17.8% reported cost-related non-adherence. Those most likely to report cost-related non-adherence had a longer time since diagnosis. Cost-related non-adherence and higher out-of-pocket expenditure were associated with poorer quality of life, a more threatening perception of the impact of the illness and poor self-reported health.

CONCLUSIONS

This study is the first to empirically and quantitatively examine the household economic burden of eating disorders from the patient perspective. Results indicate that households experience a substantial burden associated with the treatment and management of an eating disorder. This burden may contribute to maintaining the illness for those who experience cost-related non-adherence and by negatively influencing health outcomes. Current initiatives to implement sustainable and integrated models of care for eating disorders should strive to minimise the economic impact of treatment on families.

Quantitative assessment of new MRI-based measurements to differentiate low and high stages of pelvic organ prolapse using support vector machines

INTRODUCTION AND HYPOTHESIS

The objective of this study was to quantitatively assess the ability of new MRI-based measurements to differentiate low and high stages of pelvic organ prolapse. New measurements representing pelvic structural characteristics are proposed and analyzed using support vector machines (SVM).

METHODS

This retrospective study used data from 207 women with different types and stages of prolapse. Their demographic information, clinical history, and dynamic MRI data were obtained from the database. New MRI measurements were extracted and analyzed based on these reference lines: pubococcygeal line (PCL), mid-pubic line (MPL), true conjugate line (TCL), obstetric conjugate line (OCL), and diagonal conjugate line (DCL). A classification model using SVM was designed to assess the impact of the features (variables) in classifying prolapse into low or high stage.

RESULTS

The classification model using SVM can accurately identified anterior prolapse with very high accuracy (>0.90), and apical and posterior prolapse with good accuracy (0.80 - 0.90). Two newly proposed MRI-based features were found to be significant in the identification of anterior and posterior prolapse: the angle between TCL and MPL for anterior prolapse, and the angle between DCL and PCL for posterior prolapse. The overall accuracy of posterior prolapse identification increased from 47% to 80% when the newly proposed MRI-based features were taken into consideration.

CONCLUSIONS

The proposed MRI-based measurements are effective in differentiating low and high stages of pelvic organ prolapse, particularly for posterior prolapse.