A naturalistic examination of feeling fat: Characteristics, predictors, and the relationship with eating disorder behaviors.

OBJECTIVE: Although literature implicates feeling fat in the maintenance of binge-spectrum eating disorders (EDs; e.g., bulimia nervosa, binge-ED), research in this area is small, nascent, and relies on retrospective self-report. The current study sought to understand the temporal pattern of feeling fat and its role as a precipitant and consequence of ED behaviors. METHODS: Totally 106 treatment-seeking adults with binge-spectrum EDs completed 7-14-day ecological momentary assessments. They rated feeling fat, negative affect states, and reported on ED behaviors six times per day. Multilevel models evaluated whether feeling fat mediates prospective links between negative affect states and ED behaviors, assessed if negative affect states mediate the prospective association of feeling fat on ED behaviors, and examined the bidirectional prospective association between feeling fat and ED behaviors. RESULTS: Feeling fat was highest in the early morning (6-8:59 a.m.). Individuals with binge-ED-spectrum EDs demonstrated greater variability in feeling fat than those with bulimia nervosa-spectrum EDs who had stable and high levels of feeling fat. Guilt, sadness, anxiety, and the overall NA at Time 2 mediated the prospective associations between at Time 1 feeling fat and Time 3 dietary restraint, actual dietary restriction, and compensatory exercise. There was a bidirectional prospective association between feeling fat and binge eating. DISCUSSION: Feeling fat serves as a proximal predictor and mediator of the prospective association between guilt and binge eating. Feeling fat and binge eating mutually reinforce each other. PUBLIC SIGNIFICANCE: Little is understood regarding the experience of feeling fat in natural environments among individuals with binge-spectrum eating disorders. We found that the risk for having the experience of feeling fat is high in the morning and evening. Feeling fat triggers guilt, anxiety, and sadness which in turn, increases engagement in dietary restraint/restriction and compensatory exercise. Feeling fat also triggers binge eating, and binge eating leads to feelings of fatness.

Weight status is associated with clinical characteristics among individuals with bulimia nervosa.

Recent studies have found increasing rates of overweight and obesity in bulimia nervosa (BN). However, the relationships between body mass index (BMI) and BN symptoms and other clinically relevant constructs are unknown. Participants (N = 152 adults with BN) were assigned to three groups by BMI: group with no overweight or obesity (NOW-BN; BMI <25; N = 32), group with overweight (OW-BN; BMI ≥25 and <30; N = 66), and group with obesity (O-BN; BMI ≥30; N = 54). We compared the groups on demographics, diet and weight histories, body esteem, BN symptoms, and depression using chi square, analysis of variance, analysis of covariance, and Poisson regression models. The O-BN group was older (d = 0.57) and OW-BN and O-BN groups had greater proportions of race/ethnic minorities than NOW-BN group. The O-BN group was significantly younger at first diet (d = 0.41) and demonstrated significantly higher cognitive dietary restraint (d = 0.31). Compared to NOW-BN, O-BN participants had lower incidence of objective binge eating (incidence rate ratio [IRR] = 4.86) and driven exercise (IRR = 7.13), and greater incidence of vomiting (IRR = 9.30), laxative misuse (IRR = 4.01), and diuretic misuse (d = 2.08). O-BN participants also experienced higher shape (d = 0.41) and weight (d = 0.42) concerns than NOW-BN and OW-BN, although NOW-BN experienced higher shape (d = 0.44) and weight (d = 0.39) concerns than OW-BN. Groups did not differ on depression scores. These results were replicated when examining BMI as a continuous predictor across the full sample, with the exception of objective binge eating and driven exercise, which were not significantly associated with BMI. Individuals with BN and comorbid obesity have distinct clinical characteristics. Existing interventions may need to be adapted to meet clinical needs of these individuals.

Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness.

BACKGROUND: Globally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high-income countries, implementing them in low/middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking. We aimed to identify all perioperative safety and QI interventions applied at scale in LMICs and evaluate their implementation mechanisms using implementation theory. METHODS: Systematic scoping review of perioperative QI interventions in LMICs from 1960 to 2020. Studies were identified through Medline, EMBASE and Google Scholar. Data were extracted in two phases: (1) abstract review to identify the range of QI interventions; (2) studies describing scale-up (three or more sites), had full texts retrieved and analysed for; implementation strategies and scale-up frameworks used; and implementation outcomes reported. RESULTS: We screened 45 128 articles, identifying 137 studies describing perioperative QI interventions across 47 countries. Only 31 of 137 (23%) articles reported scale-up with the most common intervention being the WHO Surgical Safety Checklist. The most common implementation strategies were training and educating stakeholders, developing stakeholder relationships, and using evaluative and iterative strategies. Reporting of implementation mechanisms was generally poor; and although the components of scale-up frameworks were reported, relevant frameworks were rarely referenced. CONCLUSION: Many studies report implementation of QI interventions, but few report successful scale-up from single to multiple-site implementation. Greater use of implementation science methodology may help determine what works, where and why, thereby aiding more widespread scale-up and dissemination of perioperative QI interventions.

Real-time predictors of body dissatisfaction in females with binge eating: an ecological momentary assessment study.

PURPOSE: Body dissatisfaction (BD) is supported as a maintenance factor for eating disorders (EDs) characterized by binge eating (BE). Although it is traditionally conceptualized as a trait construct, ecological momentary assessment (EMA) studies have shown that it fluctuates within-day and that momentary elevations in BD prospectively predict near-time ED behaviors. However, less is known about the contextual factors that precipitate these fluctuations in BD. METHODS: The current study thus sought to examine whether certain internal (i.e., negative affect, shape/weight-related cognitions) and environmental (i.e., attending social events, being exposed to thin-ideal media, spending time on social media) factors prospectively predict momentary elevations in BD in females with BE. Participants (n = 25) completed an EMA protocol over 14 days. RESULTS: Data on BD and internal and environmental factors were analyzed using generalized estimating equations. Results showed that (1) greater than one's usual negative affect and shape/weight-related cognitions, and (2) spending time on social media prospectively predicted momentary elevations in BD. Interestingly, attending social events prospectively predicted momentary reductions in BD. CONCLUSION: These findings may have important implications for conceptualizing and managing BD to prevent ED behaviors. LEVEL OF EVIDENCE: Level II, controlled trial without randomization.

Implementation Strategies and the Uptake of the World Health Organization Surgical Safety Checklist in Low and Middle Income Countries: A Systematic Review and Meta-analysis.

OBJECTIVES: To identify the implementation strategies used in World Health Organization Surgical Safety Checklist (SSC) uptake in low- and middle-income countries (LMICs); examine any association of implementation strategies with implementation effectiveness; and to assess the clinical impact. BACKGROUND: The SSC is associated with improved surgical outcomes but effective implementation strategies are poorly understood. METHODS: We searched the Cochrane library, MEDLINE, EMBASE and PsycINFO from June 2008 to February 2019 and included primary studies on SSC use in LMICs. Coprimary objectives were identification of implementation strategies used and evaluation of associations between strategies and implementation effectiveness. To assess the clinical impact of the SSC, we estimated overall pooled relative risks for mortality and morbidity. The study was registered on PROSPERO (CRD42018100034). RESULTS: We screened 1562 citations and included 47 papers. Median number of discrete implementation strategies used per study was 4 (IQR: 1-14, range 0-28). No strategies were identified in 12 studies. SSC implementation occurred with high penetration (81%, SD 20%) and fidelity (85%, SD 13%), but we did not detect an association between implementation strategies and implementation outcomes. SSC use was associated with a reduction in mortality (RR 0.77; 95% CI 0.67-0.89), all complications (RR 0.56; 95% CI 0.45-0.71) and infectious complications (RR 0.44; 95% CI 0.37-0.52). CONCLUSIONS: The SSC is used with high fidelity and penetration is associated with improved clinical outcomes in LMICs. Implementation appears well supported by a small number of tailored strategies. Further application of implementation science methodology is required among the global surgical community.

Perioperative Research into Memory (PRiMe): Cognitive impairment following a severe burn injury and critical care admission, part 1.

INTRODUCTION: An investigation into long-term cognitive impairment and Quality of Life (QoL) after severe burns. METHODS: A proof of principle, cohort design, prospective, observational clinical study. Patients with severe burns (>15% TBSA) admitted to Burns ICU for invasive ventilation were recruited for psychocognitive assessment with a convenience sample of age and sex-matched controls. Participants completed psychological and QoL questionnaires, the Cogstate® electronic battery, Hopkins Verbal Learning, Verbal Fluency and Trail making tasks. RESULTS: 15 patients (11M, 4F; 41±14 years; TBSA 38.4%±18.5) and comparators (11M, 4F; 40±13 years) were recruited. Burns patients reported worse QoL (Neuro-QoL Short Form v2, patient 30.1±8.2, control 38.7±3.2, p=0.0004) and cognitive function (patient composite z-score 0.01, IQR -0.11 to 0.33, control 0.13, IQR 0.47-0.73, p=0.02). Compared to estimated premorbid FSIQ, patients dropped an equivalent of 8 IQ points (p=0.002). Cognitive function negatively correlated with burn severity (rBaux score, p=0.04). QoL strongly correlated with depressive symptoms (Rho=-0.67, p=0.009) but not cognitive function. CONCLUSIONS: Severe burns injuries are associated with a significant, global, cognitive deficit. Patients also report worse QoL, depression and post-traumatic stress. Perceived QoL from cognitive impairment was more closely associated with depression than cognitive impairment.

Revised Baux Score and updated Charlson comorbidity index are independently associated with mortality in burns intensive care patients.

PURPOSE: The purpose of the current study was to utilise established scoring systems to analyse the association of (i) burn injury severity, (ii) comorbid status and (iii) associated systemic physiological disturbance with inpatient mortality in patients with severe burn injuries admitted to intensive care. METHODS: Case notes of all patients with acute thermal injuries affecting ≥15% total body surface area (TBSA) admitted to the Burns Intensive Care Unit (BICU) at Chelsea and Westminster Hospital during a 10-year period were retrospectively reviewed. Revised Baux Score, Belgian Outcome in Burn Injury (BOBI) Score, Abbreviated Burn Severity Index (ABSI), APACHE II Score, Sequential Organ Failure Assessment (SOFA) Score and Updated Charlson Comorbidity Index (CCI) were computed for each patient and analysed for association with inpatient mortality. RESULTS: Ninety mechanically ventilated patients (median age 45.7 years, median % TBSA burned 36.5%) were included. 72 patients had full thickness burns and 35 patients had inhalational injuries. Forty-four patients died in hospital while 46 survived to discharge. In a multivariate logistic regression model, only the Revised Baux Score (p<0.001) and updated CCI (p=0.014) were independently associated with mortality. This gave a ROC curve with area under the curve of 0.920. On multivariate cox regression survival analysis, only the Revised Baux Score (p<0.001) and the updated CCI (p=0.004) were independently associated with shorter time to death. CONCLUSION: Our data suggest that the Revised Baux Score and the updated CCI are independently associated with inpatient mortality in patients admitted to intensive care with burn injuries affecting ≥15% TBSA. This emphasises the importance of comorbidities in the prognosis of patients with severe burn injuries.

Geographical analysis of socioeconomic factors in risk of domestic burn injury in London 2007-2013.

PURPOSE: This study aims to explore the geographical distribution of burn injuries in Greater London and the association of socioeconomic factors in areas at risk. METHODS: Data on burn injury cases classified as occurring in patients' own homes in Greater London and admitted to a specialised burns service for ≥1 day during a 7-year period were obtained from the International Burn Injury Database (iBID). Age- and gender-adjusted standardised incidence ratios (SIRs) were calculated for each Lower Layer Super Output Area (LSOA) in Greater London. Bayesian methods were used to calculate relative risks as best estimates of spatially-smoothed SIRs. RESULTS: Of a total of 2911 admissions to specialised burns services in Greater London in the study period, 2100 (72.1%) cases occurred in patients' own homes. Percentage of ethnic minorities (p=0.005), Income Deprivation Affecting Children Index (p<0.001), Health Deprivation and Disability Score (p=0.031), percentage of families with 3 or more children (p=0.004) and Barriers to Housing and Services Score (p=0.001) remained independently associated with the relative risk of paediatric domestic burn injury in a multivariate linear regression model. Percentage of ethnic minorities (p<0.001), Health Deprivation and Disability Score (p<0.001) and Barriers to Housing and Services Score (p=0.036) remained independently associated with the relative risk of adult domestic burn injury in a multivariate linear regression model. CONCLUSIONS: Socioeconomic factors are associated with an increased risk of burn injury in Greater London, but may be more important in children than adults. The specific factors identified are ethnicity, poor general health, household structure, housing issues and income deprivation affecting children.

The psychological and neurocognitive consequences of critical illness. A pragmatic review of current evidence.

Mortality rates alone are no longer a sufficient guide to quality of care. Due to medical advances, patients are surviving for longer following critical illness and major surgery; therefore, functional outcomes and long-term quality of life are of increasing consequence. Post-operative cognitive dysfunction has been acknowledged as a complication following anaesthesia for many years, and interest in persistent cognitive dysfunction following a critical illness is growing. Psychological and neurocognitive sequelae following discharge from intensive care are acknowledged to occur with sufficient significance to have recently coined the term 'the post-intensive care syndrome'. Rehabilitation following critical illness has been highlighted as an important goal in recently published national UK guidelines, including the need to focus on both physical and non-physical recovery. Neuropsychological and cognitive consequences following anaesthesia and critical illness are significant. The exact pathophysiological mechanisms linking delirium, cognitive dysfunction and neuropsychological symptoms following critical illness are not fully elucidated but have been studied elsewhere and are outside the scope of this article. There is limited evidence as yet for specific peri-operative preventative strategies, but early management and rehabilitation strategies following intensive care discharge are now emerging. This article aims to summarise the issues and appraise current options for management, including both neuroprotective and neurorehabilitative strategies in intensive care.

Local inflammation and hypoxia abolish the protective anticontractile properties of perivascular fat in obese patients.

BACKGROUND: Inflammation in adipose tissue has been implicated in vascular dysfunction, but the local mechanisms by which this occurs are unknown. METHODS AND RESULTS: Small arteries with and without perivascular adipose tissue were taken from subcutaneous gluteal fat biopsy samples and studied with wire myography and immunohistochemistry. We established that healthy adipose tissue around human small arteries secretes factors that influence vasodilation by increasing nitric oxide bioavailability. However, in perivascular fat from obese subjects with metabolic syndrome (waist circumference 111+/-2.8 versus 91.1+/-3.5 cm in control subjects, P<0.001; insulin sensitivity 41+/-5.9% versus 121+/-18.6% in control subjects, P<0.001), the loss of this dilator effect was accompanied by an increase in adipocyte area (1786+/-346 versus 673+/-60 mum(2), P<0.01) and immunohistochemical evidence of inflammation (tumor necrosis factor receptor 1 12.4+/-1.1% versus 6.7+/-1%, P<0.001). Application of the cytokines tumor necrosis factor receptor-alpha and interleukin-6 to perivascular fat around healthy blood vessels reduced dilator activity, resulting in the obese phenotype. These effects could be reversed with free radical scavengers or cytokine antagonists. Similarly, induction of hypoxia stimulated inflammation and resulted in loss of anticontractile capacity, which could be rescued by catalase and superoxide dismutase or cytokine antagonists. Incubation with a soluble fragment of adiponectin type 1 receptor or inhibition of nitric oxide synthase blocked the vasodilator effect of healthy perivascular adipose tissue. CONCLUSIONS: We conclude that adipocytes secrete adiponectin and provide the first functional evidence that it is a physiological modulator of local vascular tone by increasing nitric oxide bioavailability. This capacity is lost in obesity by the development of adipocyte hypertrophy, leading to hypoxia, inflammation, and oxidative stress.