Enhanced cognitive behaviour therapy (CBT-E) for severe and extreme anorexia nervosa in an outpatient eating disorder unit at a public hospital: a quality-assessment study.

BACKGROUND: The aim of this quality-assessment study was to determine the outcome of patients with severe and extreme anorexia nervosa (AN) in a real-world outpatient setting. METHODS: Twenty-one adults with AN and a body mass index (BMI) of < 16 were recruited from consecutive referrals to an outpatient clinic at a public hospital in Western Norway. All enrolled patients were provided with enhanced cognitive behaviour therapy (CBT-E) to treat their AN, commencing between January 2013 and December 2016. Their BMI was recorded at baseline, at the end of CBT-E and 1 year after the end of treatment. RESULTS: Ten patients completed the CBT-E treatment and achieved a large weight gain with the change remaining stable at follow-up. Eleven patients did not complete the treatment but had a significant increase in BMI at the premature end of treatment. One year after end of therapy 14/21 (66.7%) of the patients had BMI above 18.5 kg/m2. No severe complications were observed during therapy. CONCLUSIONS: Although 52.4% of the patients did not complete outpatient CBT-E, the findings of this quality-assessment study support previous findings indicating that CBT-E may represent a valid alternative to inpatient treatment in patients with severe and extreme AN.

The clinical impairment assessment questionnaire: validation in Italian patients with eating disorders.

BACKGROUND: The Clinical Impairment Assessment (CIA) is a measure of functional impairment secondary to eating disorder symptoms. AIM: The aim of this study was to examine the psychometric proprieties of the Italian-language version of the CIA. METHODS: The tool was translated into Italian and administered to 259 Italian-speaking in- and outpatients with eating disorders and 102 healthy controls. The clinical group also completed the Eating Disorder Examination Questionnaire (EDE-Q) and the Brief Symptom Inventory (BSI). RESULTS: Confirmatory factor analysis revealed a good fit for the original three-factor structure. Internal consistency was high for both the global CIA and all subscale scores, and test-retest reliability was acceptable. The high correlation between CIA and EDE-Q and BSI confirmed the convergent validity of the instrument. T test indicated higher raw scores on CIA in patients with eating disorders than healthy controls, and a cut-off score of 16 on the CIA discriminated between eating disorder and general psychopathology scores. Finally, global CIA and subscale scores were significantly higher in patients who reported objective bulimic episodes, purging behaviours, and excessive exercising than in those who did not; in underweight than in not-underweight patients, and in inpatients than outpatients, confirming the good known-groups validity of the tool. CONCLUSIONS: Overall, the study showed the good psychometric properties of the Italian version of the CIA, and validated its use in Italian-speaking eating disorder patients. LEVEL OF EVIDENCE: Level V, Descriptive study.

Care coordination for children with special health care needs: a cohort study.

BACKGROUND: Care coordination is widely recognized as a key element of care for patients with chronic and complex medical conditions and their families. In care for children with special health care needs the Family Pediatrician (FP) plays a central role as care coordinator. This study aims to evaluate the FPs' activities of care coordination for children with special health care needs in the pediatric primary care setting, using an on-line measurement tool. METHODS: Within the prospective cohort study SpeNK (Special Needs Kids), newborns and children with special health care needs were recruited at discharge from three hospital facilities in Bologna province, from October 1st 2012 to September 30th 2014. Their FPs were invited to complete a questionnaire (SpeNK-FP) at each encounter for the patient during a 9-month period after hospital discharge. SpeNK-FP was developed by adapting the Care Coordination Measurement Tool (CCMT©) developed by Antonelli et al., to the Italian organizational context. The outcome of interest, derived from the questionnaire, is inappropriate use of services. RESULTS: Forty FPs completed assessments for 49 children at each of 382 clinical encounters. The majority of children (71.4%) had special health care needs, without complicating social issues. FPs reported "no need for care coordination" in 50.8% of the encounters and 41.1% of records about patient needs requiring care coordination. The most common activity implemented to meet children's needs was telephone contact with a medical provider. According to FPs, 80% of encounters prevented inappropriate services use. In multivariate regression, pediatric-specialist contact (telephone or in person) was associated with reduced odds of physician report of preventable hospitalization (OR = 0.06, 95% CI 0.01-0.42, p = 0.005). CONCLUSIONS: The study shows the potential for FPs in Italy to serve as care coordinators and facilitate the implementation of integrated care pathways for children with special health care needs.

Measuring parents' perspective on continuity of care in children with special health care needs.

INTRODUCTION: Children with special health care needs are an exponentially growing population needing integrated health care programmes that involve primary, community, hospital and tertiary care services. The aims of the study are (1) to develop and validate the Special Needs Kids Questionnaire (SpeNK-Q) designed to measure parents' perspective on continuity of care for children with special health care needs and (2) to evaluate the continuity of care based on parental experiences in this population. METHODS: SpeNK-Q was derived from a previous qualitative study and was based on Haggerty's constructs of informational, management and relational continuity. Parents of preterm birth children completed the 20-item SpeNK-Q at the second or subsequent planned follow-up visit after the child's hospital discharge. Principal component analysis was used to examine the structure of the instrument. RESULTS: Principal component analysis of 101 questionnaires administered allowed us to identify five factors explaining 60.2% of item variance: informational continuity; coordination of care; continuity of family-paediatrician relationship; family support; information on care plan. CONCLUSIONS AND DISCUSSION: SpeNK-Q proved to be a psychometrically promising instrument. Its utilisation could improve the identification of areas for service development, the delivery of coordinated care and support policy makers in redesigning integrated services.

Mental health services use and management of eating disorders in an Italian Department of Mental Health.

OBJECTIVE: To investigate the clinical characteristics of patients with eating disorders referred to Community Mental Health Centers (CMHCs) in the Department of Mental Health of Bologna, Italy, and to evaluate the number and type of interventions delivered. METHODS: Adult patients with eating disorders who had a first contact with CMHCs between January 1, 2007 and December 31, 2012 were extracted from Bologna Local Health Authority database. Moreover, the hospital discharge records of patients were linked to the mental health information system of Bologna. RESULTS: Among the 276 patients with eating disorders identified, 59 (21.4%) were diagnosed as anorexia nervosa, 77 (27.9%) as bulimia nervosa and 140 (50.7%) as eating disorders not otherwise specified. The mean age of the sample was 37.3 (SD = 13.4), with no significant differences among the three diagnostic groups. The number of CMHCs outpatients increased each year from 2007 to 2011 and decreased in 2012. The proportion of new patients by year comprised about 50% of the total of patients. Psychotherapy accounted for about 10% of the interventions. Day-hospital and hospital admissions concerned 6.1 and 11.6% of the sample. CONCLUSIONS: CMHCs are part of the system of care outlined by the Regional policies for eating disorders and are responsible for providing the first level of outpatient care to adults. To date, there is the need to extend our monitoring across the whole system of care, to assess the implementation of specific and effective strategies to decrease the age of access of patients and to improve the quality of care delivered with the inclusion of evidence-based treatments in the process of care.

Assessment of physical activity in anorexia nervosa and treatment outcome.

PURPOSE: The aim of this study was to compare objective and subjective assessments of physical activity (PA) in patients with anorexia nervosa and its effect on treatment outcome. METHODS: Both Actiheart (AH) and International Physical Activity Questionnaire (IPAQ) were used to assess PA in 52 female patients with anorexia nervosa during the first week of inpatient treatment. RESULTS: No correspondence between PA estimated by IPAQ, which had a tendency to underestimate PA, and that measured using AH emerged. However, a significant association was found between the change in Eating Disorder Examination global score at the end of the treatment and light PA measured by AH (beta = -0.12, t = -2.44, P = 0.019), but not that estimated by IPAQ. CONCLUSIONS: PA in patients with anorexia nervosa is underestimated by subjective assessment when compared with objective measurement. Only time spent in light PA, assessed objectively with AH, showed a negative association with improvement in eating disorder psychopathology.

Socio-economic factors associated with infant mortality in Italy: an ecological study.

INTRODUCTION: One issue that continues to attract the attention of public health researchers is the possible relationship in high-income countries between income, income inequality and infant mortality (IM). The aim of this study was to assess the associations between IM and major socio-economic determinants in Italy. METHODS: Associations between infant mortality rates in the 20 Italian regions (2006-2008) and the Gini index of income inequality, mean household income, percentage of women with at least 8 years of education, and percentage of unemployed aged 15-64 years were assessed using Pearson correlation coefficients. Univariate linear regression and multiple stepwise linear regression analyses were performed to determine the magnitude and direction of the effect of the four socio-economic variables on IM. RESULTS: The Gini index and the total unemployment rate showed a positive strong correlation with IM (r = 0.70; p < 0.001 and r = 0.84; p < 0.001 respectively), mean household income showed a strong negative correlation (r = -0.78; p < 0.001), while female educational attainment presented a weak negative correlation (r = -0.45; p < 0.05). Using a multiple stepwise linear regression model, only unemployment rate was independently associated with IM (b = 0.15, p < 0.001). CONCLUSIONS: In Italy, a high-income country where health care is universally available, variations in IM were strongly associated with relative and absolute income and unemployment rate. These results suggest that in Italy IM is not only related to income distribution, as demonstrated for other developed countries, but also to economic factors such as absolute income and unemployment. In order to reduce IM and the existing inequalities, the challenge for Italian decision makers is to promote economic growth and enhance employment levels.

Resting energy expenditure assessment in anorexia nervosa: comparison of indirect calorimetry, a multisensor monitor and the Müller equation.

The aim of this study was to compare the estimations provided by three different means of measuring the resting energy expenditure (REE) in anorexia nervosa (AN) patients. REE was measured, after 24 h of refeeding, using a portable multisensor body monitor [SenseWear Pro2 Armband (SWA)], FitMate™ method and the Müller equation for individuals with body mass index < 18.5, the latter being based on dual-energy X-ray absorptiometry assessment of body composition. The mean differences between REE values estimated by SWA and those provided by the Müller equation and the FitMate™ method were significantly different from zero in both cases. In contrast, the mean differences between FitMate™ method and Müller equation were weakly significantly different from zero, and a significant correlation was noted between these two methods. In conclusion, the SWA does not appear to be an alternative to FitMate™ and Müller equation methods for assessing REE in AN patients.

Resting Energy Expenditure in Anorexia Nervosa: Measured versus Estimated.

Introduction. Aim of this study was to compare the resting energy expenditure (REE) measured by the Douglas bag method with the REE estimated with the FitMate method, the Harris-Benedict equation, and the Müller et al. equation for individuals with BMI < 18.5 kg/m(2) in a severe group of underweight patients with anorexia nervosa (AN). Methods. 15 subjects with AN participated in the study. The Douglas bag method and the FitMate method were used to measure REE and the dual energy X-ray absorptiometry to assess body composition after one day of refeeding. Results. FitMate method and the Müller et al. equation gave an accurate REE estimation, while the Harris-Benedict equation overestimated the REE when compared with the Douglas bag method. Conclusion. The data support the use of the FitMate method and the Müller et al. equation, but not the Harris-Benedict equation, to estimate REE in AN patients after short-term refeeding.