A randomised controlled feasibility trial of intermittent theta burst stimulation with an open longer-term follow-up for young people with persistent anorexia nervosa (RaISE): Study protocol

OBJECTIVE

We present the protocol of a feasibility randomised controlled trial (RCT) of intermittent theta burst stimulation (iTBS) for young people with anorexia nervosa (AN). Effective first-line psychological therapies exist for young people with AN, but little is known about how to treat those who do not respond. Non-invasive neuromodulation, such as iTBS, could address unmet treatment needs by targeting neurocircuitry associated with the development and/or maintenance of AN.

DESIGN

Sixty-six young people (aged 13-30 years) with persistent AN will be randomly allocated to receive 20 sessions of real or sham iTBS over the left dorsolateral prefrontal cortex in addition to their usual treatment. Outcomes will be measured at baseline, post-treatment (1-month post-randomisation) and 4-months post-randomisation (when unblinding will occur). Additional open follow-ups will be conducted at 12- and 24-months post-randomisation. The primary feasibility outcome is the proportion of participants retained in the study at 4-months. Secondary outcomes include AN symptomatology, other psychopathology, quality of life, service utilisation, neurocognitive processes, and neuroimaging measures.

DISCUSSION

Findings will inform the development of a future large-scale RCT. They will also provide exploratory data on treatment efficacy, and neural and neurocognitive predictors and correlates of treatment response to iTBS in AN.

EDIFY (Eating Disorders: Delineating Illness and Recovery Trajectories to Inform Personalised Prevention and Early Intervention in Young People): project outline

EDIFY (Eating Disorders: Delineating Illness and Recovery Trajectories to Inform Personalised Prevention and Early Intervention in Young People) is an ambitious research project aiming to revolutionise how eating disorders are perceived, prevented and treated. Six integrated workstreams will address key questions, including: What are young people's experiences of eating disorders and recovery? What are the unique and shared risk factors in different groups? What helps or hinders recovery? How do the brain and behaviour change from early- to later-stage illness? How can we intervene earlier, quicker and in a more personalised way? This 4-year project, involving over 1000 participants, integrates arts, design and humanities with advanced neurobiological, psychosocial and bioinformatics approaches. Young people with lived experience of eating disorders are at the heart of EDIFY, serving as advisors and co-producers throughout. Ultimately, this work will expand public and professional perceptions of eating disorders, uplift under-represented voices and stimulate much-needed advances in policy and practice.

A UK-wide survey of healthcare professionals' awareness, knowledge and skills of the impact of food insecurity on eating disorder treatment

OBJECTIVE

Food insecurity (FI) is associated with significant adverse effects on health and well-being and increasingly recognised as a global problem. The current study explored the impact of FI on eating disorder (ED) clinical practice in the UK, aiming to assess healthcare professionals' (HCPs) knowledge, skills and views on the topic of FI in their patients.

DESIGN

This study was an exploratory, mixed-methods, descriptive analysis of online survey data collected from ED HCPs in the UK between September and October 2022.

MEASURES

A 15-item survey with rating and open-ended questions was circulated to ED professional organisations in the UK. Descriptive statistics were used to summarise quantitative data, including perceived prevalence of FI in ED clinical practice and confidence in knowledge on the topic. Descriptive content analyses provided insight into perspectives on FI screening and aspects to be included in guidance and resources.

RESULTS

93 ED HCPs completed the survey (40.9 % psychologists). Findings demonstrated healthcare providers' limited knowledge on FI and its relation to EDs, while they increasingly perceive it in their patients, as well as a general lack of available resources on how to address FI in ED treatment. HCPs stressed the need for practical guidance and formal training for dealing with FI in their patients, as well as implementing routine screening.

CONCLUSION

These findings provide both important directions for future research and clinical applications related to screening, assessment, treatment and support of food-insecure patients with EDs.

Altered mesoaccumbens and nigro-striatal dopamine physiology is associated with stereotypy development in a non-rodent species

Stress-induced changes in mesoaccumbens dopamine neurophysiology have been associated with the development of stereotypic behaviour in in-bred strains of laboratory rodents. This experiment evaluated whether similar changes are associated with environmentally-induced stereotypic behaviour in a higher-vertebrate species, the horse. D1- and D2-like dopamine receptor densities (B(max)) and dissociation constants (K(d)) were measured in control (n=9) and stereotypy (n=9) horses in the nucleus accumbens, caudate nucleus, putamen, substantia nigra and ventral tegmentum brain regions. Results revealed that stereotypy horses had significantly higher (P<0.05) dopamine D1 and D2 receptor densities (B(max)) in the nucleus accumbens compared to non-stereotypy controls. D1 receptor densities (B(max)) and D2 receptor affinity (K(d)) were also significantly lower in the caudate nucleus brain region of stereotypy horses (P<0.05). No other significant results were observed. These results demonstrate that stereotypy horses have increased activity within the mesoaccumbens dopamine pathway and, thus, that the development of environmentally-induced stereotypy may be associated with changes in motivational systems within the animal.

The specificity of polygalacturonase-inhibiting protein (PGIP): a single amino acid substitution in the solvent-exposed beta-strand/beta-turn region of the leucine-rich repeats (LRRs) confers a new recognition capability

Two members of the pgip gene family (pgip-1 and pgip-2) of Phaseolus vulgaris L. were expressed separately in Nicotiana benthamiana and the ligand specificity of their products was analysed by surface plasmon resonance (SPR). Polygalacturonase-inhibiting protein-1 (PGIP-1) was unable to interact with PG from Fusarium moniliforme and interacted with PG from Aspergillus niger; PGIP-2 interacted with both PGs. Only eight amino acid variations distinguish the two proteins: five of them are confined within the beta-sheet/beta-turn structure and two of them are contiguous to this region. By site-directed mutagenesis, each of the variant amino acids of PGIP-2 was replaced with the corresponding amino acid of PGIP-1, in a loss-of-function approach. The mutated PGIP-2s were expressed individually in N.benthamiana, purified and subjected to SPR analysis. Each single mutation caused a decrease in affinity for PG from F.moniliforme; residue Q253 made a major contribution, and its replacement with a lysine led to a dramatic reduction in the binding energy of the complex. Conversely, in a gain-of-function approach, amino acid K253 of PGIP-1 was mutated into the corresponding amino acid of PGIP-2, a glutamine. With this single mutation, PGIP-1 acquired the ability to interact with F.moniliforme PG.

Counselling in primary care: a randomised controlled trial

A randomised controlled trial of the effectiveness of counselling (In-House Counselled (IHC) group) compared to routine advice from General Practitioners (Routine Treatment (RT) group) was conducted with three practices and a total of 188 patients in East Sussex. Changes in interpersonal problems using the 32 item Inventory of Interpersonal Problems, symptoms of psychological distress using the Symptom Index and self esteem using Repertory Grids were compared between groups at four months and after a further four month follow-up. A questionnaire monitoring patient service satisfaction was given to those who had received In-House counselling. The number of counselling sessions, early withdrawals and refusers was also monitored. In order to facilitate interprofessional communication, the three counsellors and a GP representative from each practice met monthly for an Action Learning group, led by an external facilitator to provide a forum to discuss working practices. The group met six times for two and a half hours. An audit of the participants' medical notes was carried out at the end of the study to establish any changes in subsequent use of medical services and prescribing patterns. The results show that patients within both groups improved considerably, in line with similar studies. The IHC group was significantly less likely to be referred out to mental health services. However, there was no statistical difference between the groups on any of the measures or in changes in subsequent service use or prescribing patterns. This may have been a result of Action Learning Group producing more psychologically minded GPs. Patients in the IHC group were overwhelmingly in favour of counselling and stated that it had helped them with a variety of psychological problems.

Memories of metallothionein

Metallothionein (MT) has provided nature with a small molecule which exhibits multiple facets. The distinct arrangement of cysteine residues which occurs within the two domains of MT confers predisposed metal specificity upon each domain. Furthermore, subtle changes in primary sequence may be built onto the metal cluster scaffold. These not only bestow immunodistinction but may also potentially allow specific members of this family such as MT-III to fulfill unique biological roles. An understanding of how the structures of MT molecules predetermine their biochemical characteristics may allow the design of novel metal-binding molecules specific for the metal ion of choice. Already, using nature as a blueprint, a semi-specific cadmium-binding molecule has been constructed from a polymer of mammalian C-terminal domains. This novel protein has been used to protect tobacco plants from cadmium toxicity. In addition, modeling of biologically active determinants which are located on the external face of MT-III may facilitate the design of small synthetic molecules which mimic the biological activity of MT-III and prevent the distressing effects of memory and speech loss associated with Alzheimer's disease. Memories of metallothionein may yet be something worth remembering!

X-ray analysis of HIV-1 proteinase at 2.7 A resolution confirms structural homology among retroviral enzymes

Knowledge of the tertiary structure of the proteinase from human immunodeficiency virus HIV-1 is important to the design of inhibitors that might possess antiviral activity and thus be useful in the treatment of AIDS. The conserved Asp-Thr/Ser-Gly sequence in retroviral proteinases suggests that they exist as dimers similar to the ancestor proposed for the pepsins. Although this has been confirmed by X-ray analyses of Rous sarcoma virus and HIV-1 proteinases, these structures have overall folds that are similar to each other only where they are also similar to the pepsins. We now report a further X-ray analysis of a recombinant HIV-1 proteinase at 2.7 A resolution. The polypeptide chain adopts a fold in which the N- and C-terminal strands are organized together in a four-stranded beta-sheet. A helix precedes the single C-terminal strand, as in the Rous sarcoma virus proteinase and also in a synthetic HIV-1 proteinase, in which the cysteines have been replaced by alpha-aminobuytric acid. The structure reported here provides an explanation for the amino acid invariance amongst retroviral proteinases, but differs from that reported earlier in some residues that are candidates for substrate interactions at P3, and in the mode of intramolecular cleavage during processing of the polyprotein.

The structure of a synthetic pepsin inhibitor complexed with endothiapepsin

The conformation of a synthetic polypeptide inhibitor, bound to the active site of the fungal aspartic proteinase endothiapepsin (EC 3.4.23.6), has been determined by X-ray diffraction at 0.20-nm resolution and refined to an agreement factor of 0.20. The inhibitor: Pro Thr Glu Phe-R-Phe Arg Glu (R = -CH2NH-) is based on a chromogenic substrate of pepsin (EC 3.4.23.1). It has, in place of the scissile bond, a reduced peptide group which is resistant to hydrolysis and mimics the tetrahedral transition state. The inhibitor binds in an extended conformation with the reduced bond close to the essential aspartate side-chains of the enzyme. The hydrogen bonds and hydrophobic interactions between the enzyme and the inhibitor do not induce large conformational changes.

High resolution X-ray analyses of renin inhibitor-aspartic proteinase complexes

Inhibitors of the conversion of angiotensinogen to the vasoconstrictor angiotensin II have considerable value as antihypertensive agents. For example, captopril and enalapril are clinically useful as inhibitors of angiotensin-converting enzyme. This has encouraged intense activity in the development of inhibitors of kidney renin, which is a very specific aspartic proteinase catalysing the first and rate limiting step in the conversion of angiotensinogen to angiotensin II. The most effective inhibitors such as H-142 and L-363,564 have used non-hydrolysable analogues of the proposed transition state, and partial sequences of angiotensinogen (Table 1). H-142 is effective in lowering blood pressure in humans but has no significant effect on other aspartic proteinases such as pepsin in the human body (Table 1). At present there are no crystal structures available for human or mouse renins although three-dimensional models demonstrate close structural similarity to other spartic proteinases. We have therefore determined by X-ray analysis the three-dimensional structures of H-142 and L-363,564 complexed with the aspartic proteinase endothiapepsin, which binds these inhibitors with affinities not greatly different from those measured against human renin (Table 1). The structures of these complexes and of that between endothiapepsin and the general aspartic proteinase inhibitor, H-256 (Table 1) define the common hydrogen bonding schemes that allow subtle differences in side-chain orientations and in the positions of the transition state analogues with respect to the active-site aspartates.

Crystallographic studies of reduced bond inhibitors complexed with an aspartic proteinase

To aid in the design of an effective inhibitor to human renin, it is essential to have a detailed knowledge of how this aspartic proteinase interacts with its substrate, angiotensinogen. Human renin shows a stringent specificity toward the Leu-Val bond in its natural substrate. The minimal length for an effective substrate has been characterised as an octapeptide sequence derived from the amino terminal portion of angiotensinogen (residues 6----13): His-Pro-Phe-His-Leu-Val-Ile-His (Leu-Val is the scissile bond). This suggests that renin has a fairly extensive active site cleft, as has been observed in homologous enzymes whose three-dimensional structures have been solved using x-ray diffraction methods. The homologous fungal aspartic proteinase, endothiapepsin, has been cocrystallised with human renin inhibitors of the type His-Pro-Phe-His-Leu-R-Val-Ile-His, where R indicates a reduced carbonyl analogue of the scissile peptide bond. The three-dimensional crystallographic structures of two complexes of endothiapepsin with an inhibitor have been solved. The details of inhibitor binding at the active site cleft of endothiapepsin are described. These data allow a rational approach to the design of novel renin inhibitors, through studies of these inhibitors in a three-dimensional model of human renin constructed in our laboratory.