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.

Is this the 'new normal'? A mixed method investigation of young person, parent and clinician experience of online eating disorder treatment during the COVID-19 pandemic

INTRODUCTION

Prior to the COVID-19 pandemic, research in virtual care for young people with eating disorders was preliminary and implementation rare. This study explored the experience of young people, parents and clinicians when therapy was transitioned to virtual provision as a result of the UK lockdown in March 2020.

METHODS

A mixed-method approach was used in this study. Online questionnaires that included a mixture of rating (Likert scale) and free-text response questions were completed by 53 young people with any eating disorder, 75 parents and 23 clinicians. Questions focused on the experience of online treatment as well as the impact on engagement, perceived treatment efficacy and preferences around treatment mode in the future. Likert scale questions were analysed using a summary approach. Free-text responses were analysed qualitatively using reflexive thematic analysis.

RESULTS

Responses to rating scale questions indicate satisfaction with treatment, good engagement and ability to manage technology. Young people who had transitioned care, rather than started care virtually in lockdown, rated therapy as less effective. However, individual accounts of experience were more varied. Reflexive thematic analysis of free-text responses identified key themes of 1) Making it work, 2) Home as a therapeutic space, and 3) Disrupted connection and 4) Into the future.

CONCLUSIONS

These results have implications for ongoing care during the pandemic and for future implementation of virtual care in the treatment of young people with eating disorders. Particular issues arising are the trade-off between accessibility and therapeutic engagement and depth and need for consideration of equal access to treatment in socially unequal societies.

The impact of COMT, BDNF and 5-HTT brain-genes on the development of anorexia nervosa: a systematic review

PURPOSE

The genetic aspect of anorexia nervosa (AN) involving specific genes of the central-nervous-system has not yet been clearly understood. The aim of this systematic review is to assess the impact of three candidate genes of the brain: catechol-O-methyltransferase, brain-derived neurotrophic factor (BDNF) and serotonin transporter protein, on the susceptibility to AN and identify whether a clear connection persists between each of the gene-polymorphisms and AN.

METHODS

A total of 21 articles were selected for this review conforming to the PRISMA guidelines. Detailed keyword combinations were implemented within specific databases such as MEDLINE, SCIENCEDIRECT and PUBMED.

RESULTS

The catechol-O-methyltransferase gene-polymorphism did not show any change in phenotypic variation between AN and control subjects; but the familial association was rather strong with an over-transmission of the H allele. The latter also correlated with several dimensions of the Temperament and Character Inventory (TCI) scale. A notable relation was indicated between BDNF gene-polymorphism and anorexia-restrictive in terms of phenotypic distribution; the Met66-allele also depicted high association with anorexic behavioral traits. The 5-HTTLPR gene-polymorphism was found to be significantly associated with AN susceptibility with an over-transmission of the S-allele from parents to offspring.

CONCLUSION

The systematic review distinctively emphasized the genetic contribution of the brain-genes on the development of AN. Despite significant study findings, no clear and standardized genetic route was determined to be the cause of AN development. Future research is needed on these specific genes to closely monitor the genetic polymorphisms and their mechanism on AN susceptibility.

LEVEL OF EVIDENCE

I, systematic review.

What is the evidence for using bed rest as part of hospital treatment of severe anorexia nervosa?

Bed rest is commonly used on medical and paediatric wards as part of nursing management of the physically compromised patient with severe anorexia nervosa. The aim of this study was to review the evidence base of bed rest as an intervention in the management of severe anorexia nervosa. We searched MEDLINE, PubMed, Embase, PsychInfo, CINAHL, HMIC, AMED, HBE, BNI and guidelines written in English until April 2018 using the following terms: bed rest and anorexia nervosa. After exclusion of duplicates, three guidelines and eight articles were included. The papers were methodologically heterogeneous, and therefore, quantitative summary was not possible. There have been no randomised controlled trials to compare the benefits and harms of bed rest as the focus of intervention in the treatment of anorexia nervosa. Several papers showed that patients have a strong preference for less restrictive approaches. These are also less intensive in nursing time. Negative physical consequences were described in a number of studies: these included lower heart rate, impaired bone turn over and increased risk of infection. We found no evidence to support bed rest in hospital treatment of anorexia nervosa. The risks associated with bed rest are significant and include both physical and psychological harm, and these can be avoided by early mobilisation. Given the established complications of bed rest in other critically ill patient populations, it is difficult to recommend the enforcement of bed rest for patients with anorexia nervosa. Future research should focus on safe early mobilisation, which would reduce complications and improve patient satisfaction.

Can we improve service efficiency in CAMHS using the CAPA approach without reducing treatment effectiveness?

Health-care systems are under increasing pressure to deliver more care with similar or even less resources and there is concern that this may be achieved at the cost of reduced clinical effectiveness. In Child and Adolescent Mental Health Services (CAMHS), the Choice and Partnership Approach (CAPA) has been widely adopted as a way of increasing the efficient use of limited service resources. Some evaluations have reported increased patient flow and reduced waiting times, but it remains unknown whether such changes have been achieved at a cost of clinical effectiveness. This article describes a pragmatic multi-method evaluation of a CAMHS service reporting service outcomes (client satisfaction, waiting times, and patient flow) and clinical outcomes (clinician-rated clinical outcomes and goals achieved by families). Results showed improved service outcomes (high levels of client satisfaction and reduced waiting times) and an increase in patient flow (49 cases increased to 72 cases over an equivalent time period). Clinical outcomes showed no reduction in effectiveness and a significant improvement against the agreed goals of the intervention. The evaluation suggested that a well-structured goal-focused patient flow system may improve services by increasing patient flow while maintaining high satisfaction levels, without negatively impacting clinical effectiveness.

Subjective Cognitive Impairment: Functional MRI During Divided Attention and Measurement of Amyloid Load Using 11C-PIB PET

Background:

Evidence suggests that healthy older adults with subjective memory complaints are at increased risk of dementia. Subjective Cognitive Impairment (SCI) may precede Mild Cognitive Impairment (MCI) in the clinical continuum of Alzheimer's disease (AD). Attentional deficits may be present early in AD, and associated functional changes have been reported in both MCI and AD. In the present study, activation during divided attention in SCI subjects was investigated using functional magnetic resonance imaging (fMRI). Additionally, amyloid uptake was investigated using 11C-PIB with positron emission tomography (PET).

Methods:

Brain activation in 11 SCI subjects and 10 controls was compared during a divided attention task using fMRI. Additionally, five SCI subjects and 14 cognitively normal healthy controls underwent 11C-PIB PET scanning. Criteria for diagnosis of SCI were:1.

Results:

There were no differences in performance between SCI and control groups in terms of cognitive or behavioural measures. However, SCIs had increased activation in left medial temporal lobe, and bilateral thalamus, posterior cingulate and caudate. One SCI subject and one control subject had a pattern of 11C-PIB uptake similar to that seen in AD.

Conclusions:

The activation changes identified in SCI may relate to compensatory increased activation in the face of early AD pathology. Larger, longitudinal studies are needed to determine the extent and significance of PIB uptake in SCI.

Erythrocyte zinc content in critically ill patients

Abnormalities in thyroid hormone metabolism are common in critically ill patients. However, it is not known if these patients are truly hypothyroid at tissue level. Erythrocyte zinc has been shown to be a tissue marker of thyroid hormone status. In this study we have measured the erythrocyte zinc in critically ill patients. In this observational study we measured the zinc content of young erythrocytes in blood samples from 33 healthy subjects, 26 hypothyroid patients, four hyperthyroid patients, and 44 patients in the intensive care unit--22 of these were admitted after a major surgical procedure (surgical group) and the other 22 patients had a variety of conditions (non-surgical group). Erythrocytes were separated according to age by centrifugation. Plasma thyroid hormone concentrations were abnormal in 70% of the critically ill group. Erythrocyte zinc was significantly lower in hyperthyroid patients and higher in hypothyroid patients. In the non-surgical patients, erythrocyte zinc of young cells (median 256 micromol/L of cells) was significantly higher than (p<0.01) the corresponding cells in the healthy controls (202 micromol/L of cells), whereas in the surgical group it was not different (197 micromol/L of cells). We conclude that in non-surgical critically ill patients, erythrocyte zinc content is higher, suggesting that these patients may be hypothyroid at tissue level.