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Schopf K, Schneider S, Meyer AH, Lennertz J, Humbel N, Bürgy NM, Wyssen A, Biedert E, Isenschmid B, Milos G, Claussen M, Trier S, Whinyates K, Adolph D, Teismann T, Margraf J, Assion HJ, Überberg B, Juckel G, Müller J, Klauke B, Munsch S. Eating disorder treatment in routine clinical care: A descriptive study examining treatment characteristics and short-term treatment outcomes among patients with anorexia nervosa and bulimia nervosa in Germany and Switzerland. PLoS One 2023; 18:e0280402. [PMID: 37390075 PMCID: PMC10313003 DOI: 10.1371/journal.pone.0280402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 12/27/2022] [Indexed: 07/02/2023] Open
Abstract
This descriptive study examined patient characteristics, treatment characteristics, and short-term outcomes among patients with Anorexia Nervosa (AN) and Bulimia Nervosa (BN) in routine clinical care. Results for patients receiving full-time treatment were contrasted with results for patients receiving ambulatory treatment. Data of a clinical trial including 116 female patients (18-35 years) diagnosed with AN or BN were subjected to secondary analyses. Patients were voluntarily admitted to one of nine treatment facilities in Germany and Switzerland. Patients received cognitive-behavioral interventions in accordance with the national clinical practice guidelines for the treatment of EDs under routine clinical care conditions, either as full-time treatment or ambulatory treatment. Assessments were conducted after admission and three months later. Assessments included a clinician-administered diagnostic interview (DIPS), body-mass-index (BMI), ED pathology (EDE-Q), depressive symptoms (BDI-II), symptoms of anxiety (BAI), and somatic symptoms (SOMS). Findings showed that treatment intensity differed largely by setting and site, partly due to national health insurance policies. Patients with AN in full-time treatment received on average 65 psychotherapeutic sessions and patients with BN in full-time treatment received on average 38 sessions within three months. In comparison, patients with AN or BN in ambulatory treatment received 8-9 sessions within the same time. Full-time treatment was associated with substantial improvements on all measured variables for both women with AN (d = .48-.83) and BN (d = .48-.81). Despite the relatively small amount of psychotherapeutic sessions, ambulatory treatment was associated with small increases in BMI (d = .37) among women with AN and small improvements on all measured variables among women with BN (d = .27-.43). For women with AN, reduction in ED pathology were positively related to the number of psychotherapeutic sessions received. Regardless of diagnosis and treatment setting, full recovery of symptoms was rarely achieved within three months (recovery rates ranged between 0 and 4.4%). The present study shows that a considerable amount of patients with EDs improved after CBT-based ED treatment in routine clinical care within three months after admission. Intensive full-time treatment may be particularly effective in quickly improving ED-related pathology, although full remission of symptoms is typically not achieved. A small amount of ambulatory sessions may already produce considerable improvements in BN pathology and weight gain among women with AN. As patient characteristics and treatment intensity differed largely between settings, results should not be interpreted as superiority of one treatment setting over another. Furthermore, this study shows that treatment intensity is quite heterogeneous, indicating the possibility for increasing effectiveness in the treatment of EDs in routine clinical care.
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Affiliation(s)
- Kathrin Schopf
- Mental Health Research and Treatment Center, Ruhr University Bochum, Bochum, Germany
| | - Silvia Schneider
- Mental Health Research and Treatment Center, Ruhr University Bochum, Bochum, Germany
| | - Andrea Hans Meyer
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Fribourg, Fribourg, Switzerland
| | | | - Nadine Humbel
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Fribourg, Fribourg, Switzerland
| | - Nadine-Messerli Bürgy
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Fribourg, Fribourg, Switzerland
- Institute of Psychology, Clinical Child and Adolescent Psychology, University of Lausanne, Lausanne, Switzerland
| | - Andrea Wyssen
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Esther Biedert
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Fribourg, Fribourg, Switzerland
| | - Bettina Isenschmid
- Center for Eating Disorders and Obesity, Clinic Zofingen, Zofingen, Switzerland
| | - Gabriella Milos
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital, Zurich, Switzerland
| | - Malte Claussen
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | | | - Dirk Adolph
- Mental Health Research and Treatment Center, Ruhr University Bochum, Bochum, Germany
| | - Tobias Teismann
- Mental Health Research and Treatment Center, Ruhr University Bochum, Bochum, Germany
| | - Jürgen Margraf
- Mental Health Research and Treatment Center, Ruhr University Bochum, Bochum, Germany
| | - Hans-Jörg Assion
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, LWL-Klinik Dortmund, Dortmund, Germany
| | - Bianca Überberg
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, LWL-Klinik Dortmund, Dortmund, Germany
| | - Georg Juckel
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital Bochum, Ruhr University Bochum, Bochum, Germany
| | - Judith Müller
- Christoph-Dornier-Klinik for Psychotherapy, Münster, Germany
| | - Benedikt Klauke
- Christoph-Dornier-Klinik for Psychotherapy, Münster, Germany
| | - Simone Munsch
- Department of Psychology, Clinical Psychology and Psychotherapy, University of Fribourg, Fribourg, Switzerland
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Irish M, Dalton B, Potts L, McCombie C, Shearer J, Au K, Kern N, Clark-Stone S, Connan F, Johnston AL, Lazarova S, Macdonald S, Newell C, Pathan T, Wales J, Cashmore R, Marshall S, Arcelus J, Robinson P, Himmerich H, Lawrence VC, Treasure J, Byford S, Landau S, Schmidt U. The clinical effectiveness and cost-effectiveness of a 'stepping into day treatment' approach versus inpatient treatment as usual for anorexia nervosa in adult specialist eating disorder services (DAISIES trial): a study protocol of a randomised controlled multi-centre open-label parallel group non-inferiority trial. Trials 2022; 23:500. [PMID: 35710394 PMCID: PMC9201798 DOI: 10.1186/s13063-022-06386-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 05/09/2022] [Indexed: 12/02/2022] Open
Abstract
Background Anorexia nervosa (AN) is a serious and disabling mental disorder with a high disease burden. In a proportion of cases, intensive hospital-based treatments, i.e. inpatient or day patient treatment, are required, with day patient treatment often being used as a ‘step-down’ treatment after a period of inpatient treatment. Demand for such treatment approaches has seen a sharp rise. Despite this, the relative merits of these approaches for patients, their families, and the NHS and wider society are relatively unknown. This paper describes the rationale for, and protocol of, a two-arm multi-centre open-label parallel group non-inferiority randomised controlled trial, evaluating the effectiveness and cost-effectiveness of these two intensive treatments for adults with severe AN: inpatient treatment as usual and a stepped care day patient approach (the combination of day patient treatment with the option of initial inpatient treatment for medical stabilisation). The main aim of this trial is to establish whether, in adults with severe AN, a stepped care day patient approach is non-inferior to inpatient treatment as usual in relation to improving body mass index (BMI) at 12 months post-randomisation. Methods 386 patients with a Diagnostic and Statistical Manual 5th edition diagnosis of severe AN or related disorder, with a BMI of ≤16 kg/m2 and in need of intensive treatment will be randomly allocated to either inpatient treatment as usual or a stepped care day patient approach. Patients in both groups will receive treatment until they reach a healthy weight or get as close to this point as possible. Assessments will be conducted at baseline (prior to randomisation), and at 6 and 12 months post-randomisation, with additional monthly symptom monitoring. The primary outcome will be BMI at the 12-month post-randomisation assessment. Other outcomes will include psychosocial adjustment; treatment motivation, expectations and experiences; cost-effectiveness; and carer burden. Discussion The results of this study will provide a rigorous evaluation of two intensive treatment approaches which will inform future national and international treatment guidelines and service provision. Trial registration ISRCTN ISRCTN10166784. Registered 28 February 2020. ISRCTN is a primary registry of the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) network and includes all items from the WHO Trial Registration Data Set.
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Affiliation(s)
- Madeleine Irish
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK
| | - Bethan Dalton
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK
| | - Laura Potts
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK
| | - Catherine McCombie
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK
| | - James Shearer
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK
| | - Katie Au
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Nikola Kern
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Sam Clark-Stone
- Gloucestershire Health and Care NHS Foundation Trust, Gloucester, UK
| | - Frances Connan
- Central and North West London NHS Foundation Trust, London, UK
| | | | | | | | - Ciarán Newell
- Dorset HealthCare University NHS Foundation Trust, Poole, UK
| | - Tayeem Pathan
- Surrey and Borders Partnership NHS Foundation Trust, Leatherhead, UK
| | - Jackie Wales
- Leicestershire Adult Eating Disorders Service, Leicestershire Partnership NHS Trust, Bennion Centre, Glenfield Hospital, Leicester, UK
| | - Rebecca Cashmore
- Leicestershire Adult Eating Disorders Service, Leicestershire Partnership NHS Trust, Bennion Centre, Glenfield Hospital, Leicester, UK
| | - Sandra Marshall
- Leicestershire Adult Eating Disorders Service, Leicestershire Partnership NHS Trust, Bennion Centre, Glenfield Hospital, Leicester, UK
| | - Jon Arcelus
- Institute of Mental Health, University of Nottingham, Jubilee Campus, Triumph Road, Nottingham, NG7 2TU, UK
| | - Paul Robinson
- Division of Medicine, University College London, 5 University Street, London, WC1E, 6JF, UK
| | - Hubertus Himmerich
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Vanessa C Lawrence
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK
| | - Janet Treasure
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Sarah Byford
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK
| | - Sabine Landau
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK. .,South London and Maudsley NHS Foundation Trust, London, UK.
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Rapid response is predictive of treatment outcomes in a transdiagnostic intensive outpatient eating disorder sample: a replication of prior research in a real-world setting. Eat Weight Disord 2021; 26:1345-1356. [PMID: 32507929 PMCID: PMC7903880 DOI: 10.1007/s40519-020-00939-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/25/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE There is a growing call to identify specific outcome predictors in real-world eating disorder (ED) treatment settings. Studies have implicated several ED treatment outcome predictors [rapid response (RR), weight suppression, illness duration, ED diagnosis, and psychiatric comorbidity] in inpatient settings or randomized controlled trials of individual outpatient therapy. However, research has not yet examined outcome predictors in intensive outpatient programs (IOP). The current study aimed to replicate findings from randomized controlled research trials and inpatient samples, identifying treatment outcome predictors in a transdiagnostic ED IOP sample. METHOD The current sample comprised 210 consecutive unique IOP patient admissions who received evidence-based ED treatment, M(SD)Duration = 15.82 (13.38) weeks. Weekly patient measures of ED symptoms and global functioning were obtained from patients' medical charts. RESULTS In relative weight analysis, RR was the only significant predictor of ED symptoms post treatment, uniquely accounting for 45.6% of the predicted variance in ED symptoms. In contrast, baseline ED pathology was the strongest unique predictor of end-of-treatment global functioning, accounting for 15.89% of predicted variance. Baseline factors did not differentiate patients who made RR from those who did not. CONCLUSIONS Consistent with findings in more controlled treatment settings, RR remains a robust predictor of outcome for patients receiving IOP-level treatment for EDs. Future work should evaluate factors that mediate and moderate RR, incorporating these findings into ED treatment design and implementation. LEVEL OF EVIDENCE Level IV, uncontrolled intervention.
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Kan C, Hawkings YR, Cribben H, Treasure J. Length of stay for anorexia nervosa: Systematic review and meta-analysis. EUROPEAN EATING DISORDERS REVIEW 2021; 29:371-392. [PMID: 33548148 DOI: 10.1002/erv.2820] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 11/23/2020] [Accepted: 12/22/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Evidence regarding global trends in length of stay for patients with anorexia nervosa is limited. The aim of this study is to conduct a meta-analysis examining the length of stay for anorexia nervosa patients globally, and to investigate moderators of the variance. METHOD Medline, EMBASE and PsycINFO were searched for studies published up to January 2019. Two independent reviewers assessed the eligibility of each report based on predefined inclusion criteria. A meta-analysis was performed to calculate a pooled mean length of stay using the random-effects model. Subgroup analyses and meta-regression were conducted to explore potential sources of heterogeneity between studies. RESULTS Of 305 abstracts reviewed, 71 studies met the inclusion criteria, generating 111 datasets. The pooled mean length of stay (95% confidence interval) was 76.3 days (73.3, 79.4) using the random-effects model, with marked variation across countries and time. Heterogeneity between studies was explained by age and admission body mass index. CONCLUSIONS This meta-analysis found that although clinical features do contribute to length of admissions for anorexia nervosa, there are also global and temporal variations. Future research should provide an in-depth analysis of why and how this variation exists and what the impact is on the well-being of people with anorexia nervosa.
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Affiliation(s)
- Carol Kan
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Hannah Cribben
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Janet Treasure
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Walker DC, Heiss S, Donahue JM, Brooks JM. Practitioners' perspectives on ethical issues within the treatment of eating disorders: Results from a concept mapping study. Int J Eat Disord 2020; 53:1941-1951. [PMID: 32918314 DOI: 10.1002/eat.23381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/03/2020] [Accepted: 08/25/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Treating patients with eating disorders (EDs) is associated with an array of ethical concerns, including balancing patients' health and autonomy, access to care, and use of harm-reduction versus recovery-oriented treatment models. The primary aim of the current study is to gain a better understanding of ethical issues faced by ED practitioners by using a concept mapping, or Q-sort, approach. METHOD A total of 12 practitioners completed the brainstorming phase and generated statements regarding ethical issues they faced while treating patients with EDs. A subsequent 38 practitioners completed a sorting task, where they created and labeled piles, into which they grouped each statement. Of those 38 participants, 30 rated both the frequency with which they encountered each ethical issue and its impact on patient care. RESULTS A total of six clusters emerged: Insufficient Level of Care, Lack of Evidence-Based Practice, Insurance Barriers, Family Involvement, Patient Autonomy, and Limited Access to Expertise. Lack of Evidence-Based Practice, Insurance Barriers, and Insufficient Level of Care was the most frequent problem faced by ED practitioners, whereas Insurance Barriers and Patient Autonomy had the greatest impact. DISCUSSION Findings outline frequent and impactful areas of ethical concern that arise when treating patients diagnosed with EDs. Practitioners most commonly reported that patient- and insurance-driven factors limited patient access to appropriate care. Regulations supporting the provision of evidence-based care should be emphasized in public health policy and advocacy efforts, given their impact in limiting the delivery of adequate patient care.
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Affiliation(s)
| | - Sydney Heiss
- Department of Psychology, University at Albany, State University of New York, Albany, New York, USA
| | - Joseph M Donahue
- Department of Psychiatry, University of California, San Diego, La Jolla, California, USA
| | - Julia M Brooks
- Department of Psychology, University of Illinois at Chicago, Chicago, Illinois, USA
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6
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Parks EH. Psychotherapeutic Treatment of Co-Occurring Eating Disorders and Posttraumatic Stress Disorder. Psychiatr Ann 2018. [DOI: 10.3928/00485713-20180913-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Strandjord SE, Sieke EH, Richmond M, Khadilkar A, Rome ES. Medical stabilization of adolescents with nutritional insufficiency: a clinical care path. Eat Weight Disord 2016; 21:403-410. [PMID: 26597679 DOI: 10.1007/s40519-015-0245-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/07/2015] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Nutritional insufficiency (NI) is a potential consequence of restrictive eating disorders. NI patients often require hospitalization for refeeding to restore medical stability and prevent complications such as refeeding syndrome. Limited information is available on the optimal approach to refeeding. In this study, we describe an inpatient NI care path and compare treatment outcomes at an academic medical center and a community hospital. METHODS A retrospective chart review was conducted on inpatients treated using a standardized NI care path at either the academic site, from August 2012 to July 2013 (n = 51), or the community site, from August 2013 to July 2014 (n = 39). Demographic information, eating disorder history, and treatment variables were recorded for each patient. Data were compared using the Kruskal-Wallis test and Fisher's exact test. RESULTS Patients admitted to the community site had shorter hospital stays than patients admitted to the academic site (IQR 2-4 vs. 2-7 days, p = 0.03). All patients were discharged in <14 days with a median stay of 3 days. The median initial calorie prescription was 2200 calories for both groups. No clinical cases of refeeding syndrome occurred, with only one patient developing hypophosphatemia during refeeding. CONCLUSIONS A standardized care path with a higher-calorie intervention allows for short-term hospitalization of NI patients without increasing the risk of refeeding syndrome, regardless of treatment site. This study demonstrates the efficiency and safety of treating NI patients on a regular medical floor at a community hospital.
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Affiliation(s)
- Sarah E Strandjord
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Mail Code NA21, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Erin H Sieke
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Mail Code NA21, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Miranda Richmond
- Office of Civic Education Initiatives Internship Program, Cleveland Clinic, 25875 Science Park Drive/AC121, Beachwood, OH, 44122, USA
| | - Arjun Khadilkar
- Office of Civic Education Initiatives Internship Program, Cleveland Clinic, 25875 Science Park Drive/AC121, Beachwood, OH, 44122, USA
| | - Ellen S Rome
- Department of General Pediatrics, Cleveland Clinic Children's Hospital, 9500 Euclid Ave/A120, Cleveland, OH, 44195, USA
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Galsworthy-Francis L, Allan S. Cognitive Behavioural Therapy for anorexia nervosa: A systematic review. Clin Psychol Rev 2014; 34:54-72. [DOI: 10.1016/j.cpr.2013.11.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 11/07/2013] [Accepted: 11/18/2013] [Indexed: 10/26/2022]
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Smith C, Fogarty S, Touyz S, Madden S, Buckett G, Hay P. Acupuncture and Acupressure and Massage Health Outcomes for Patients with Anorexia Nervosa: Findings from a Pilot Randomized Controlled Trial and Patient Interviews. J Altern Complement Med 2014; 20:103-12. [DOI: 10.1089/acm.2013.0142] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Caroline Smith
- Centre for Complementary Medicine Research, University of Western Sydney, Penrich, New South Wales, Australia
| | - Sarah Fogarty
- Centre for Complementary Medicine Research, University of Western Sydney, Penrich, New South Wales, Australia
| | - Stephen Touyz
- School of Psychology, University of Sydney, Sydney, Australia
| | - Sloane Madden
- Department of Psychological Medicine, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Geoff Buckett
- School of Medicine, University of Western Sydney, Penrith, New South Wales, Australia
| | - Phillipa Hay
- School of Medicine & Centre for Health Research, University of Western Sydney, Sydney, Australia
- James Cook University, Townsville, Australia
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Sly R, Mountford VA, Morgan JF, Lacey JH. Premature termination of treatment for anorexia nervosa: differences between patient-initiated and staff-initiated discharge. Int J Eat Disord 2014; 47:40-6. [PMID: 24323526 DOI: 10.1002/eat.22190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To investigate treatment drop-out by comparing clinical indicators of patients whose discharge was initiated by staff with those who initiated discharge themselves. METHOD Ninety participants with anorexia completed questionnaires at admission and four weeks into hospitalized treatment. Weight data was collected over this same period. At discharge, participants were categorized into completer (n = 38) or patient-initiated (n = 36) /staff-initiated (n = 16) premature termination groups. RESULTS Significant differences between staff-initiated and patient-initiated discharge groups were found at admission. Staff initiated groups were on average older (p = .035), and more likely to have had prior compelled treatment (p = .039). At 4 weeks those in the patient-initiated group had put on weight at a faster rate (p = .032) and reported a decrease in alliance (p = .017). At discharge, staff initiated discharge demonstrated greater time in treatment (p = .001), greater weight gain (p = .027), and a higher discharge BMI (p = .013). At discharge, staff-initiated drop-outs had comparable end-of-treatment outcomes to those who completed treatment as planned. DISCUSSION There are key differences between those who prematurely discharge themselves from treatment, compared to those who are prematurely discharged by clinical staff. Future research into drop-out needs to take into account and recognize these differences.
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Affiliation(s)
- Richard Sly
- School of Nursing Sciences, University of East Anglia, Norwich, United Kingdom, NR7 4TJ; Eating Disorders Research Team, St George's, University of London, London, United Kingdom, SW17 0RE
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Sly R, Morgan JF, Mountford VA, Lacey JH. Predicting premature termination of hospitalised treatment for anorexia nervosa: the roles of therapeutic alliance, motivation, and behaviour change. Eat Behav 2013; 14:119-23. [PMID: 23557806 DOI: 10.1016/j.eatbeh.2013.01.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 12/18/2012] [Accepted: 01/30/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study aims to investigate treatment drop-out, and the associated roles of motivation, alliance, and behaviour change exhibited over the first four weeks of hospitalised treatment for anorexia. METHODS 90 participants meeting DSM-IV criteria for anorexia nervosa completed questionnaires at admission, and four weeks into treatment. Weight data was collected over this same time period. At the end of treatment, participants were categorised into completer or premature termination groups. RESULTS The overall rate of premature termination was 57.8%. Those who prematurely terminated treatment demonstrated lower discharge BMI (p<.0005), and weight gain (p<.0005) than those who completed. Therapeutic alliance proved significantly different between outcome groups at admission (p=.004). DISCUSSION End-of-treatment outcomes for those who do not complete treatment are invariably poor. Therapeutic alliance appears to be a particularly important factor in this area.
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Affiliation(s)
- Richard Sly
- Population Health Sciences and Education, St. George's University of London, London, UK.
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Bourion-Bedes S, Baumann C, Kermarrec S, Ligier F, Feillet F, Bonnemains C, Guillemin F, Kabuth B. Prognostic value of early therapeutic alliance in weight recovery: a prospective cohort of 108 adolescents with anorexia nervosa. J Adolesc Health 2013; 52:344-50. [PMID: 23299014 DOI: 10.1016/j.jadohealth.2012.06.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/23/2012] [Accepted: 06/26/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To determine whether patients' perception of early therapeutic alliance (TA) could predict time to achieve a target weight among adolescents undergoing treatment for anorexia nervosa. METHOD TA was assessed in a prospective cohort recruited from both inpatient and outpatient settings by self-administered and validated questionnaires. Kaplan-Meier survival curves were compared by log rank test, and Cox regression was used to test whether patients' perception of early TA predicted time to achieve a target weight. RESULTS In total, 108 patients were included, and 79.6% achieved a target weight. Better patient perception of early TA increased the hazard ratio (HR) of achieving a target weight (HR = 2.7, 95% confidence interval: 1.7-4.4, p < .001) such as being in the inpatient setting by 6.7. Being very severely underweight at admission decreased the HR of achieving the target weight. CONCLUSION Patients' perception of early TA is a good predictor of achieving a target weight. Because TA is a modifiable construct, it could be a target for intervention.
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Ornstein RM, Lane-Loney SE, Hollenbeak CS. Clinical outcomes of a novel, family-centered partial hospitalization program for young patients with eating disorders. Eat Weight Disord 2012; 17:e170-7. [PMID: 23086252 DOI: 10.1007/bf03325344] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIM Eating disorders (ED) in children and younger adolescents are becoming more evident, but there is a small evidence base for their management in this population. We hypothesized that a new family-centered partial hospital program for young patients would be effective in promoting weight gain, as well as improvement in psychiatric symptoms. METHODS A retrospective chart review of 56 patients treated in the program between August 2008 and November 2009 was performed. Historical data, anthropometric variables and scores from psychological instruments [Children's Eating Attitudes Test (ChEAT), Children's Depression Inventory (CDI), and Revised Children's Manifest Anxiety Scale (RCMAS)] were collected on admission and at discharge. After exclusion, 30 patients were available for statistical analysis, using paired t-tests. The primary outcome variables were improvement in weight and change in total ChEAT score. Secondary outcomes included improvements in the CDI and RCMAS scores. Multivariate analysis included linear regression models that controlled for patient-specific fixed effects. RESULTS The cohort was 87% female with a mean age of 12.8±2 years; 60% were diagnosed with ED not otherwise specified. Two-thirds had a co-morbid depressive and/or anxiety disorder. Change in weight was significant (p<0.0001), as were improvements on total ChEAT (p<0.0001), CDI (p=0.0002), and RCMAS (p<0.0001) scores. No historical factors were correlated with improvement, nor was use of psychotropic medications. Length of stay in weeks significantly predicted greater weight gain (p=0.004, R2=0.26). CONCLUSIONS Patients treated in a family-centered partial hospital program had significant improvements in weight and psychological parameters. This approach holds significant promise for the management of young ED patients.
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Affiliation(s)
- R M Ornstein
- Department of Pediatrics, Division of Adolescent Medicine and Eating Disorders, Penn State Hershey Medical Center, Hershey, PA 17033, USA.
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Hartmann A, Weber S, Herpertz S, Zeeck A. Psychological treatment for anorexia nervosa: a meta-analysis of standardized mean change. PSYCHOTHERAPY AND PSYCHOSOMATICS 2011; 80:216-26. [PMID: 21494063 DOI: 10.1159/000322360] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 10/28/2010] [Indexed: 01/29/2023]
Abstract
BACKGROUND For the German treatment guidelines for eating disorders, the literature on psychological treatment of anorexia nervosa (AN) was reviewed systematically. As a common meta-analysis of randomized clinical trials proved to be impossible, a review of all available clinical trials was conducted, statistically integrating standardized mean change scores. Research questions comprised differential effects of therapeutic techniques and settings as well as determining which weight gains could be expected. METHODS After an extensive literature search, studies were selected, rated by 3 independent raters. Weight gain as the main outcome criterion was transformed into standardized mean change scores. Effect sizes were checked for homogeneity. RESULTS 57 studies containing 84 treatment arms and 2,273 patients could be integrated. Studies differed considerably in quality. The strongest bias identified was reporting selectively on completers or failures, versus intention-to-treat samples. No significant differences between effect sizes could be identified concerning treatment setting, technique or patient characteristics. If treatment time is taken into account, inpatient treatment produced a faster weight gain than outpatient treatment. CONCLUSION The study describes weight gains which can be reached in outpatient and inpatient settings. It yielded no salient results speaking for a certain therapy technique, setting or procedure. Treatment guidelines for psychological treatment of AN still have to rely on lower level evidence.
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Affiliation(s)
- Armin Hartmann
- Department of Psychosomatic Medicine and Psychotherapy, University of Freiburg, Freiburg, Germany. armin.hartmann @ uniklinik-freiburg.de
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Yu J, Stewart Agras W, Halmi KA, Crow S, Mitchell J, Bryson SW. A 1-year follow-up of a multi-center treatment trial of adults with anorexia nervosa. Eat Weight Disord 2011; 16:e177-81. [PMID: 22290033 DOI: 10.1007/bf03325129] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To examine maintenance of recovery following treatment in an adult anorexia nervosa (AN) population. METHOD One year follow-up of a randomized clinical trial with 122 participants treated with: cognitive behavioral therapy (CBT), drug therapy (fluoxetine), or a combination (CBT+fluoxetine) for 12 months. Participants were assessed at baseline, end of treatment, and follow-up. The primary outcomes were weight and the global scores from the Eating Disorder Examination (EDE) separately and combined. RESULTS Fifty-two participants completed the follow-up. Mean weight increased from end of treatment to follow-up. Seventy-five percent (75%) of those weight recovered at end of treatment maintained this recovery at follow-up. Recovery of eating disorder psychopathology was stable from end of treatment to follow-up, with 40% of participants with a global EDE score within normal range. Using the most stringent criteria for recovery, only 21% of the completer sample was recovered. DISCUSSION The findings suggest that while adults with AN improve with treatment and maintain these improvements during follow-up, the majority is not recovered. Additionally, further research is needed to understand barriers to treatment and assessment completion.
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Affiliation(s)
- J Yu
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA 94305-5722, USA.
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Vocks S, Schulte D, Busch M, Grönemeyer D, Herpertz S, Suchan B. Changes in neuronal correlates of body image processing by means of cognitive-behavioural body image therapy for eating disorders: a randomized controlled fMRI study. Psychol Med 2011; 41:1651-1663. [PMID: 21205361 DOI: 10.1017/s0033291710002382] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Previous neuroimaging studies have demonstrated abnormalities in visual body image processing in anorexia and bulimia nervosa, possibly underlying body image disturbance in these disorders. Although cognitive behavioural interventions have been shown to be successful in improving body image disturbance in eating disorders, no randomized controlled study has yet analysed treatment-induced changes in neuronal correlates of visual body image processing. METHOD Altogether, 32 females with eating disorders were randomly assigned either to a manualized cognitive behavioural body image therapy consisting of 10 group sessions, or to a waiting list control condition. Using functional magnetic resonance imaging, brain responses to viewing photographs of one's own and another female's body taken from 16 standardized perspectives while participants were wearing a uniform bikini were acquired before and after the intervention and the waiting time, respectively. RESULTS Data indicate a general blood oxygen level dependent signal enhancement in response to looking at photographs of one's own body from pre- to post-treatment, whereas exclusively in the control group activation decreases from pre- to post-waiting time were observed. Focused activation increases from pre- to post-treatment were found in the left middle temporal gyrus covering the coordinates of the extrastriate body area and in bilateral frontal structures including the middle frontal gyrus. CONCLUSIONS Results point to a more intense neuronal processing of one's own body after the cognitive behavioural body image therapy in cortical regions that are responsible for the visual processing of the human body and for self-awareness.
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Affiliation(s)
- S Vocks
- Department of Clinical Psychology and Psychotherapy, Ruhr-University, Bochum, Germany.
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Hart S, Abraham S, Franklin R, Russell J. Weight changes during inpatient refeeding of underweight eating disorder patients. EUROPEAN EATING DISORDERS REVIEW 2010; 19:390-7. [PMID: 24081714 DOI: 10.1002/erv.1052] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
AIM To describe patterns of weight change in patients admitted to a specialised eating disorder program with established protocols for inpatient refeeding. METHODS Weight records between January 2000 and December 2006 were categorised using Body Mass Index (BMI) at first admission (BMI ranges < 14.0, 14.1-17.49, 17.5-18.9 kg/m(2)). Total weight gained, number of days of inpatient treatment and rate of weekly weight gain were examined. RESULTS In total there were 247 patients representing 414 admissions. The rate of weight gain was 0.77, 0.63 and 0.53 kg/week, respectively, for each BMI group. Twenty patients (8.1%) in the refeeding program did not gain weight. CONCLUSION Weight gain in underweight patients is highly variable. A greater understanding of the processes that contribute to weight gain, and establishment of best practice in achieving weight gain in patients needs to be determined. This data provide detailed information about expectations for refeeding without artificial feeding.
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Affiliation(s)
- Susan Hart
- Accredited Practising Dietitian, Department of Obstetrics and Gynaecology, University of Sydney, Royal North Shore Hospital, Australia.
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Sly R, Bamford B. Why are we waiting? The relationship between low admission weight and end of treatment weight outcomes. EUROPEAN EATING DISORDERS REVIEW 2010; 19:407-10. [PMID: 24081716 DOI: 10.1002/erv.1061] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Inpatient eating disorder units are increasingly being asked to admit patients at lower BMI's, often delaying hospital treatment until medically unavoidable. This paper aims to explore the impact of this trend on treatment outcome. Eighty-two adults with anorexia nervosa admitted to a national inpatient eating disorder ward were assessed for BMI at admission, length of hospitalisation, discharge BMI and re-admission within 1-year post-treatment. In the current study, admission BMI was unrelated to amount of weight gain during treatment or to length of hospital stay. As such patients admitted at lower BMI's had significantly lower BMI's on discharge from treatment. Low admission BMI's were related to significantly higher likelihoods of re-admission within 1 year. This study provides strong evidence for the benefit of early treatment episodes and with more successful treatment outcomes being related to higher weights at start of treatment.
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Affiliation(s)
- Richard Sly
- Department of Mental Health, St. Georges, University of London, London; South-West London and St. Georges NHS Trust, London.
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Collin P, Power K, Karatzias T, Grierson D, Yellowlees A. The effectiveness of, and predictors of response to, inpatient treatment of anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2010; 18:464-74. [DOI: 10.1002/erv.1026] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Delinsky SS, St Germain SA, Thomas JJ, Craigen KE, Fagley WH, Weigel TJ, Levendusky P, Becker AE. Naturalistic study of course, effectiveness, and predictors of outcome among female adolescents in residential treatment for eating disorders. Eat Weight Disord 2010; 15:e127-35. [PMID: 21150248 DOI: 10.1007/bf03325292] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Few empirical data address naturalistic outcomes of residential eating disorder (ED) treatment. Study aims were to evaluate course, effectiveness, and predictors of outcome in a residential treatment program. We evaluated 80 consecutively admitted female adolescents with the SCID-IV. Primary outcomes were treatment completion, subsequent readmission, clinical global impressions, and changes in body weight. Mean length of stay was 51 days, and 80% of patients were discharged according to treatment plans. Mean expected body weight (EBW) for AN patients increased from 80% to 91%. Patients reported significant improvements in ED symptoms, depression, and quality of life. Low admission %EBW and previous psychiatric hospitalizations were associated with premature termination. Overall, findings support that residential treatment is largely acceptable to patients, and that residential care may provide an opportunity for substantive therapeutic gains.
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Affiliation(s)
- S S Delinsky
- Klarman Eating Disorders Center, McLean Hospital, 115 Mill St., Belmont, MA 02478, USA.
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Sly R. What's in a name? Classifying ‘the dropout’ from treatment for anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2009; 17:405-7. [DOI: 10.1002/erv.964] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Treat TA, McCabe EB, Gaskill JA, Marcus MD. Treatment of anorexia nervosa in a specialty care continuum. Int J Eat Disord 2008; 41:564-72. [PMID: 18570196 DOI: 10.1002/eat.20571] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Inpatient hospitalization has been a mainstay of treatment for anorexia nervosa (AN), but decreasing lengths of inpatient stay have prompted the development of alternative care-continuum models. This study characterizes the 6-month outcomes of 71 patients with AN who completed an inpatient-treatment protocol (approximately 5 weeks), followed by a day-hospital program (DHP) (approximately 3 weeks). METHOD Data were derived from chart reviews and questionnaire data were collected during routine clinical care. RESULTS On discharge from DHP, 35.2% of patients showed excellent outcomes, whereas 23.9% exhibited poor outcomes. At 6 months after DHP discharge, 47.9% of the patients were successful in maintaining outpatient treatment status. Patients with successful 6-month outcomes were admitted to inpatient at a higher weight, had fewer previous hospitalizations, were younger, were rated by inpatient staff as more committed to treatment, endorsed less AN psychopathology during inpatient admission, and showed greater weight gain during DHP. Number of previous hospitalizations and weight gain immediately after inpatient discharge predicted 89.2% of outcome classifications 6 months after DHP discharge. CONCLUSION These findings highlight both the potential benefits of this care-continuum model for patients who previously have not been hospitalized and the pressing need to develop alternative treatment strategies for patients with more chronic AN.
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Affiliation(s)
- Teresa A Treat
- Department of Psychology, Yale University, New Haven, CT 06520-8205, USA.
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Clinical practice guidelines for treating restrictive eating disorder patients during medical hospitalization. Curr Opin Pediatr 2008; 20:390-7. [PMID: 18622192 DOI: 10.1097/mop.0b013e32830504ae] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Anorexia nervosa is a life-threatening complex psychiatric disorder that often requires patients to be medically hospitalized. In order to help provide consistent high-quality care to inpatients medically hospitalized for nutritional deficiency, a clinical practice guideline for these patients was created at Children's Hospital Boston. This paper reviews essential components of the clinical practice guideline for patients with restrictive eating disorders. RECENT FINDINGS There is considerable variability in admission practices, inpatient treatment and discharge criteria for patients with anorexia nervosa. Weight restoration is one critical factor in treatment, and research suggests that some medical complications are reversible with weight restoration. Weight gain during hospitalization is associated with better short-term outcomes, which indicate patients are continuing toward recovery. However, patients must be closely monitored during nutritional rehabilitation to avoid complications. SUMMARY The clinical practice guideline for patients with restrictive eating disorders outlines the care patients receive during the course of their hospitalization. The clinical practice guideline has been effective in helping patients to meet weight-gain goals. Clinical practice guideline outcome data could be used to compare protocols on a national level and help establish best practices for the inpatient medical treatment for these patients.
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Dean HY, Touyz SW, Rieger E, Thornton CE. Group motivational enhancement therapy as an adjunct to inpatient treatment for eating disorders: a preliminary study. EUROPEAN EATING DISORDERS REVIEW 2008; 16:256-67. [DOI: 10.1002/erv.851] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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McHugh MD. Readiness for change and short-term outcomes of female adolescents in residential treatment for anorexia nervosa. Int J Eat Disord 2007; 40:602-12. [PMID: 17610253 DOI: 10.1002/eat.20425] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine if readiness for change (RFC) at admission predicted length of stay (LOS) and short-term outcomes among female adolescents in residential treatment for anorexia nervosa (AN). METHOD Using a prospective cohort design to collect data from participants (N = 65) at admission and discharge, Kaplan-Meier survival analysis and Cox regression tested whether RFC on admission predicted time in LOS to a favorable short-term outcome--a composite endpoint based on minimum criteria for weight gain, drive for thinness, depression, anxiety, and health-related quality of life (HRQOL). RESULTS Participants with low RFC had a mean survival time to a favorable short-term outcome of 59.4 days compared to 34.1 days for those with high RFC (log rank = 8.44, df = 1, p = .003). The probability of a favorable short-term outcome was 5.30 times greater for participants with high RFC. CONCLUSION Readiness for change is a useful predictor of a favorable short-term outcome and should be considered in the assessment profile of patients with AN.
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Affiliation(s)
- Matthew D McHugh
- The Center for Health Outcomes and Policy Research, School of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104, USA.
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Mewes R, Tagay S, Senf W. Weight curves as predictors of short-term outcome in anorexia nervosa inpatients. EUROPEAN EATING DISORDERS REVIEW 2007; 16:37-43. [DOI: 10.1002/erv.807] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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