Comparing changes in eating disorder psychopathology and comorbid symptoms over treatment in anorexia nervosa and atypical anorexia nervosa in a partial hospitalization program.

OBJECTIVE: The objective of this study is to compare treatment trajectories in anorexia nervosa (AN) and atypical AN. METHOD: Adolescents and adults with AN (n = 319) or atypical AN (n = 67) in a partial hospitalization program (PHP) completed diagnostic interviews and self-report questionnaires measuring eating disorder (ED), depression, and anxiety symptoms throughout treatment. RESULTS: Premorbid weight loss did not differ between diagnoses. Individuals with atypical AN had more comorbid diagnoses, but groups did not differ on specific diagnoses. ED psychopathology and comorbid symptoms of depression/anxiety did not differ at admission between groups nor did rate of change in ED psychopathology and comorbid symptoms of depression/anxiety from admission to 1-month. From admission to discharge, individuals with atypical AN had a faster reduction in ED psychopathology and comorbid symptoms of depression and anxiety (ps < 0.05; rs = 0.01-0.32); however, there were no group differences in ED psychopathology or depression symptoms at discharge (ps>.50; ds = .01-.30). Individuals with atypical AN had lower anxiety at discharge compared to individuals with AN (p = 0.05; d = .4). Length of stay did not differ between groups (p = 0.11; d = .21). DISCUSSION: Groups had similar ED treatment trajectories, suggesting more similarities than differences. PHP may also be effective for AAN. PUBLIC SIGNIFICANCE: This study supports previous research that individuals with AN and atypical AN have more similarities than differences. Results from this study indicate that individuals with AN and atypical AN have similar treatment outcomes for both ED psychopathology and depressive symptoms; however, individuals with atypical AN have lower anxiety symptoms at discharge compared to individuals with AN. AN and atypical AN also have more symptom similarity at admission and throughout treatment, which challenges their current designation as distinct disorders.

Parental perceptions of participation in young adult-focused eating disorder treatment.

BACKGROUND: Eating disorders (ED) are serious mental illnesses affecting young adults (YA). Parent-supported treatment for this age cohort is an important consideration given the unique developmental needs and norms of familial social support, but more research is needed to understand parental perceptions of treatment involvement. METHODS: 33 parent-supports of YA with ED completed self-report assessments at admission and discharge of participation in brief, intensive, young-adult focused eating disorder treatment. Assessments measured programme satisfaction, parental self-efficacy, and parent and YA report of eating disorder-related psychopathology. Repeated measures ANOVAs were used to examine pre-post outcome differences and between group differences among parent-supports and their YA (i.e., the patients) on eating disorder psychopathology, clinical impairment, and family functioning using the EDEQ/P-EDEQ Global, P-CIA/CIA, and Family Assessment Device Family Functioning scales. Group differences across time points were examined with paired sample t-tests adjusted for multiple comparisons. Changes in parental self-efficacy were examined separately using two-tailed paired sample t-tests. RESULTS: Parents reported high acceptability and learning, improvements in self-efficacy, and significant reductions of YA psychopathology at post-treatment. Parents reported comparable reductions in ED psychopathology post-treatment, but significantly greater reductions in clinical impairment compared to YA. Measures of family functioning did not improve for either parent or YA at post-treatment. CONCLUSION: Results from this study suggest that parental involvement in a YA programme is feasible and acceptable from a parental perspective and improves parental self-efficacy.

Early weight gain as a predictor of weight restoration in avoidant/restrictive food intake disorder.

BACKGROUND: Previous research has demonstrated that early weight gain in family-based treatment (FBT) is predictive of remission for adolescents with anorexia nervosa (AN). However, no published data has addressed if early weight gain is also predictive of reaching weight restoration (i.e., 95% EBW) in patients with avoidant/restrictive food intake disorder (ARFID). Furthermore, no studies have evaluated the performance of the statistical models used to predict weight restoration at the end of treatment. This study sought to examine whether early weight gain in ARFID is predictive of weight restoration at 20 weeks using ROC analysis. Additionally, this study assessed how accurately the model classified patients and what types of misclassifications occurred. METHODS: Participants (n = 130, 57.7% cisgender female 70.0% white) received virtual outpatient FBT. Receiver operating characteristics (ROC) were used to predict successful weight restoration at end of treatment, using early weight gain as the predictor. Twenty weeks was considered as the end of treatment, to align with the definition of end of treatment in FBT clinical trials. ROC analyses demonstrated that gaining at least 6.2 pounds by week 5 of treatment was the strongest predictor of achieving 95% EBW at 20 weeks (AUC = 0.72 [0.63, 0.81]). ROC analyses misclassified 35% of patients; the most common misclassification was predicting that a patient would not achieve 95% EBW when they actually did (61.6%). A logistical regression model, which included the patients' %EBW at admission in addition to early weight gain as a predictor, outperformed the ROC analyses (AUC = 0.90 [0.85, 0.95]) and provided additional context by showing the probability that a patient would succeed. CONCLUSION: Taken together, research demonstrates that early weight gain is a useful predictor of 95% EBW at 20 weeks of treatment for patients with ARFID who require weight restoration. Furthermore, results suggest that statistical models need to take into account additional information, such as %EBW at admission, along with early weight gain in order to more accurately predict which patients will reach weight restoration at week 20.

Results from this study indicate that when patients with avoidant/restrictive food intake disorder (ARFID) gain weight steadily at the beginning of treatment, it helps them reach 95% expected body weight (EBW) by week 20 of treatment. The more weight the patients gain each week early on, the better their chances of getting to 95% EBW by week 20. However, there are two important things to consider: how much the patients weigh when they start treatment (starting %EBW) and how much weight they gain each week. Both of these factors affect the chances of reaching 95% EBW by week 20. Thus, this study highlights the goals for gaining weight at the start of treatment need to be different for each person, depending on how much they weigh when they begin. This may help patients with ARFID reach the goal of being at 95% EBW within 20 weeks.

Outcome assessment of office Plastibell circumcision in infants utilizing interactive electronic health record.

OBJECTIVE: To assess the outcomes of office-based circumcision performed using Plastibell devices in infants, utilizing the MyChart interactive electronic health record (iEHR) system to monitor the progress and identify potential complications. METHODS: This is a prospective cohort study conducted between March 2021 to April 2022 on all infants undergoing office based Plastibell circumcision. Parents were encouraged to submit concerns via MyChart and to submit photos if the ring has not fallen by post-procedure day 7. Telehealth or in-person clinic visits were then made accordingly. Postoperative complications were collected and compared with existing literature. RESULTS: Of the 234 consecutive infants, the average age was 33 days (9-126 days) and the average weight was 4.35 kg (2.5-7.25 kg). A total of 170 parents (73%) responded to MyChart messages. Fourteen (6%) complications necessitating local intervention were identified: excessive fussiness (1), bleeding (2), ring retention (11) including 2 incomplete skin division requiring repeat dorsal block and surgical completion, fibrinous adhesion (3), and proximal ring migration (6). The photo and messages submitted through iEHR facilitated early patient return for intervention. Additionally, 17 parents submitted photos which were expected postprocedural findings and were reassured through iEHR, thus omitting unnecessary return visits. The 2 patients with incomplete skin division occurred early in the series using the included cotton ties. Subsequent procedures were performed with double 0-Silk ties (n = 218) without similar finding. CONCLUSION: The interactive utilization of iEHR communication in the post-circumcision period identified proximal bell migration and bell trapping, allowed earlier intervention and reduced complications. LEVEL OF EVIDENCE: Level 1.

Evaluating differences in setting expected body weight for children and adolescents in eating disorder treatment.

OBJECTIVE: Weight restoration or weight gain is a common goal in eating disorder treatment. However, approaches to determine expected body weight (EBW) vary. A standardized approach based on normative data for a patient's age and gender uses weight associated with median BMI (mBMI). An individualized approach predicts EBW based on a patient's individual growth trajectory. Little research has examined differences in these approaches. METHOD: Weight and clinical data were collected from patients ages 6-20 enrolled in virtual eating disorder treatment. EBW associated with mBMI was compared with EBW using the individualized approach. Linear mixed effects models examined differences in weight, eating disorder symptoms, depression, and anxiety, and whether EBW approach varied by patient characteristics. RESULTS: Patients (N = 609) were on average age 15.6 (2.29), 85% were cisgender female, and predominantly diagnosed with anorexia nervosa (83.1%). The individualized approach led to significantly higher EBW on average (mean difference = 8.4 lbs [SE: .75]; p < .001) compared to mBMI; 70% of patients had a higher EBW using the individualized approach. Notably, EBW varied based on gender and diagnosis and it took longer on average to achieve individualized EBW. Time was the strongest predictor of changes in psychosocial outcomes and there were no significant differences by EBW approach. DISCUSSION: Results from this study indicate that an individualized approach led to significantly higher EBWs compared with using mBMI. As underestimation of EBW may lead to higher risk of relapse, eating disorder professionals should consider using an individualized approach for setting EBW. PUBLIC SIGNIFICANCE: For eating disorder patients who need to gain weight, accurately estimating target body weight for eating disorder treatment is critical to recovery and preventing relapse. An individualized, patient-centered approach to estimating target body weight more accurately estimated target body weight than the standardized, median body mass index approach. Using an individualized approach to treatment may improve a patient's likelihood of full recovery.

Effectiveness of delivering evidence-based eating disorder treatment via telemedicine for children, adolescents, and youth.

Barriers limit access to eating disorder treatment. Evidence-based treatment delivered using telemedicine could expand access. This study determined the effectiveness of enhanced Family-Based Treatment (FBT+) delivered using telemedicine for children and adolescents with eating disorders. Participants had a confirmed eating disorder diagnosis, lived in states where treatment was available, and lived with a family member willing to participate. Virtual FBT+ was administered by a five-person team including a therapist, dietitian, medical provider, peer mentor, and family mentor for up to 12 months. Measures were recorded at baseline and varying frequencies throughout treatment. Weight was self-reported. Eating disorder symptoms were assessed with the Eating Disorder Examination-Questionnaire Short Form (EDE-QS) and depression and anxiety were measured using the Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7). Caregiver burden and self-efficacy were measured using the Burden Assessment Scale, and Parent Versus Eating Disorder scale. The majority of patients (N = 210; 6 to 24 years old [mean 16 · 1 years]) were cisgender female (83%) White, (71%), required weight restoration (78%), and had anorexia nervosa, restricting type (63%). After 16 weeks, patients on weight restoration gained on average 11 · 3 [9 · 86, 12 · 8] pounds and the average change in EDE-QS score was -6 · 31 [-8 · 67, -4 · 10] points. Similar reductions were seen for depression (-2 · 62 [-4 · 24, -1 · 04]), anxiety (-1 · 44 [-1 · 12, 0 · 78]), and caregiver burden (-4 · 41 [2 · 45, 6 · 31]). Caregiver self-efficacy increased by 4 · 56 [3 · 53, 5 · 61] points. Patients and caregivers reported satisfaction with treatment. Virtual FBT+ for eating disorders can transcend geographical and psychosocial treatment barriers, expanding access to evidence-based eating disorder treatment.

Peer Ethnicity as a Mediator in the Relationship Between Ethnic Identity and Body Appreciation in Black College-Aged Women.

Strong ethnic identity is recognized as a protective factor against body image concern and eating pathology in Black women as they tend to hold cultural values in line with an acceptance of a variety of body shapes and sizes. Reinforcement of these cultural ideals may occur via same-race peer relationships. The current study examined the mediating role of same-race versus other-race peers in the relationship between ethnic identity and body appreciation in Black women. Participants were 139 Black undergraduate women (Mage = 18.94 years, MBMI = 25.33) who completed validated measures of ethnic identity and body appreciation and reported on the ethnic makeup of their friends. We conducted mediation analysis examining the role of same-race peers on the relationship between ethnic identity and body appreciation. Same-race peers mediated the relationship between ethnic identity and body appreciation, where having a greater percentage of friends increased both ethnic identity and body appreciation in Black women. The influence of same-race peers should be considered in the development of culturally informed prevention and intervention efforts for eating pathology in Black women.

Associations of suicide risk with emotional reactivity, dysregulation, and eating disorder treatment outcomes.

INTRODUCTION: Emotional processes play a role in both suicide risk and eating disorders (EDs), which are often comorbid. However, limited research has explored how emotional processes relate to suicide risk in EDs and the prognostic value of suicide risk for ED treatment. Thus, the current study examined associations between emotion dysregulation and reactivity with suicide risk in patients with EDs, and determined if suicide risk predicts ED treatment outcomes. METHODS: Participants (n = 201) were adults in an ED partial hospitalization program who completed measures at admission, 1-month post-admission, and discharge. RESULTS: When controlling for depressive symptoms, limited access to adaptive emotion regulation strategies, difficulties engaging in goal-oriented behaviors, and engaging in impulsive behavior when experiencing negative emotions (i.e., emotion dysregulation) were associated with suicide attempt frequency. Depressive symptoms were associated with suicide risk severity, while emotion dysregulation and reactivity were not. Importantly, patients with elevated suicide risk at admission improved comparably to other risk categories across treatment, despite presenting with greater ED symptoms at admission. CONCLUSION: Emotion dysregulation and depression are salient factors when examining suicide risk in patients with EDs. Suicide risk and attempt history may not negatively impact ED treatment outcomes when using emotion-focused treatment.

Peer mentorship to improve outcomes in patients on hemodialysis (PEER-HD): a randomized controlled trial protocol.

BACKGROUND: Patients receiving in-center hemodialysis experience disproportionate morbidity and incur high healthcare-related costs. Much of this cost stems from potentially avoidable hospitalizations. Peer mentorship has been used effectively to improve outcomes for patients with complex chronic diseases. We propose testing the efficacy of peer mentorship on hospitalization rates among patients receiving hemodialysis. METHODS: This is a multicenter parallel group randomized controlled pragmatic trial of patients treated at hemodialysis facilities in Bronx, NY and Nashville, TN. The study has two phases. Phase 1 will enroll and train 16 hemodialysis patients (10 in Bronx, NY and 6 in Nashville TN) to be mentors using a program focused on enhancing self-efficacy, dialysis self-management and autonomy-supportive communication skills. Phase 2 will enroll 200 high risk adults receiving hemodialysis (140 in Bronx, NY and 60 in Nashville, TN), half of whom will be randomized to intervention and half to usual care. Intervention participants are assigned to weekly telephone calls with trained mentors (see Phase 1) for a 3-month period. The primary outcome of Phase 1 will be engagement of mentors with training and change in knowledge scores and autonomy skills from pre- to post-training. The primary outcome of Phase 2 will be the composite count of ED visits and hospitalizations at the end of study follow-up in patient participants assigned to intervention as compared to those assigned to usual care. Secondary outcomes for Phase 2 include the change over the trial period in validated survey scores measuring perception of social support and self-efficacy, and dialysis adherence metrics, among intervention participants as compared to usual care participants. DISCUSSION: The PEER-HD study will test the feasibility and efficacy of a pragmatic peer-mentorship program designed for patients receiving hemodialysis on ED visit and hospitalization rates. If effective, peer-mentorship holds promise as a scalable patient-centered intervention to decrease hospital resource utilization, and by extension morbidity and cost, for patients receiving maintenance in-center hemodialysis. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03595748 ; 7/23/2018. TRIAL SPONSOR: National Institutes of Diabetes, Digestive and Kidney Disease (NIDDK) 5R18DK118471. FUNDING: Funding for this study was provided by the National Institutes of Diabetes, Digestive and Kidney Disease: R18DK118471. STUDY STATUS: This is an ongoing study and not complete. We are still collecting data for observational follow-up on participants. RELATED ARTICLES: No related articles for this study have been submitted to any journal. The study sponsor and funders had no role in the design, analysis or interpretation of this data. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Pilot study of a water load test as a measure of gastric interoception in anorexia nervosa.

PURPOSE: Research and clinical experience suggest that individuals with anorexia nervosa (AN) have deficits in gastric interoception, which has been hypothesized to maintain restrictive eating. Behavioral water load tasks (WLTs) have the capability to noninvasively assess gastric interoception; however, to date, no studies have examined WLTs in AN. Thus, the present proof-of-concept pilot study explored the preliminary validity of a WLT in individuals with AN. METHODS: Participants were n = 10 individuals with AN and n = 10 matched-control women (CW). Participants completed self-report questionnaires before and after a WLT, in which participants were asked to drink water until "completely full". RESULTS: Participants with AN drank significantly less water than CW (AN = 240(109.14) milliliters (ml), CW = 398.00(149.21) ml, p = 0.02, Cohen's d = 1.21), but reported greater increases in negative affect pre- to-post-WLT (p = 0.04, partial eta2 = 0.21). Correlations between WLT performance and interoceptive sensibility in AN and CW participants supported the convergent validity of the WLT. CONCLUSION: Preliminary results support the potential utility of the WLT as a behavioral measure of gastric interoception in patients with AN. Future research should examine how response to the WLT changes over the course of intervention and how results are related to treatment outcome. LEVEL OF EVIDENCE: Level IV: Evidence obtained from multiple time series analysis such as case studies. (NB: Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

Temperament-based treatment for young adults with eating disorders: acceptability and initial efficacy of an intensive, multi-family, parent-involved treatment.

BACKGROUND: Adult eating disorder treatments are hampered by lack of access and limited efficacy. This open-trial study evaluated the acceptability and preliminary efficacy of a novel intervention for adults with eating disorders delivered to young adults and parent-supports in an intensive, multi-family format (Young Adult Temperament-Based Treatment with Supports; YA-TBT-S). METHODS: 38 YA-TBT-S participants (m age = 19.58; SD 2.13) with anorexia nervosa (AN)-spectrum disorders, bulimia nervosa (BN)-spectrum disorders, and avoidant/restrictive food intake disorder (ARFID) completed self-report assessments at admission, discharge, and 12-month follow-up. Assessments measured program satisfaction, eating disorder psychopathology and impairment, body mass index (BMI), and trait anxiety. Outcomes were analyzed using linear mixed effects models to examine changes in outcome variables over time. RESULTS: Treatment was rated as highly satisfactory. 53.33% were in partial or full remission at 12-month follow-up. 56% of participants received other treatment within the 12-month follow-up period, suggesting that YA-TBT-S may be an adjunctive treatment. Participants reported reductions in ED symptomatology (AN and BN), increases in BMI (AN and ARFID), and reductions in clinical impairment (AN and ARFID) at 12-month follow-up. CONCLUSIONS: YA-TBT-S is a feasible and acceptable adjunctive treatment for young adults with a broad range of ED diagnoses and may be a method for involving parents in ED treatment in ways that are acceptable to both parents and YA. Further evaluation of efficacy is needed in larger samples, and to compare YA-TBT-S to other ED treatment approaches. Plain English summary Eating disorders are costly and dangerous psychiatric disorders that affect millions of individuals each year. Despite their risks and societal costs, currently available treatments are limited. This study examined the acceptability and efficacy of Young Adult, Temperament-Based Treatment with Supports (YA-TBT-S), a new treatment program for adults with eating disorders. YA-TBT-S was rated highly, and a significant portion of participants improved based on ratings collected 12 months after program participation. Those with anorexia nervosa (AN) and bulimia nervosa (BN) showed significant reductions in eating disorder pathology, and those with AN and avoidant/restrictive food intake disorder (ARFID) showed increases in BMI over time.

Interoceptive Awareness and Suicidal Ideation in a Clinical Eating Disorder Sample: The Role of Body Trust.

Previous research has demonstrated that both suicidal ideation (SI) and eating disorders (EDs) are associated with poor interoceptive awareness (IA). Suicidality research has demonstrated that the IA dimension of lower body trust is associated with SI, suicide plans, and suicide attempts. Similarly, in ED samples, recent research supports that low body trust has been the most robust dimension of IA associated with eating pathology. However, to date, research is lacking in how dimensions of IA may be associated with SI in an ED sample, above and beyond the impact of eating pathology on SI. Thus, in a clinical ED sample, the present study sought to determine which IA dimensions predict the presence and severity of SI, above and beyond ED symptoms. Participants (N = 102) completed a clinical interview assessing SI and self-report assessments including the Multidimensional Assessment of Interoceptive Awareness (MAIA). Results demonstrated that patients with current SI reported greater ED psychopathology, lower MAIA Attention Regulation, MAIA Self-Regulation, and MAIA Trusting scores compared to patients without SI. Higher ED psychopathology and lower MAIA Attention Regulation, Self-Regulation, and Trusting subscale scores were all significantly associated with the presence of SI. However, only low MAIA Trusting scores predicted the presence of SI, above and beyond covariates (age, depression, and eating pathology). No MAIA subscales were correlated with the severity of SI. Consistent with previous research, results suggest low MAIA Trusting scores may be associated with SI in ED samples and highlight the need for future research on mechanisms of these associations.

Intolerance of Uncertainty and Eating Disorder Symptoms Over the Course of Intensive Treatment.

There is a critical need to identify processes that may influence outcome in existing treatments for eating disorders (EDs). Intolerance of uncertainty (IU), which refers to excessive distress regarding uncertain situations, is a well-established feature of anxiety disorders. Emerging work suggests that IU decreases over the course of cognitive-behavioral treatments and may relate to better treatment outcomes. As some literature has suggested IU may functionally maintain ED symptoms, testing whether changes in IU over treatment relate to outcome may result in the identification of novel treatment targets. This study aimed to build upon past work documenting links between IU and ED symptoms by exploring changes in IU over treatment and links between early change in IU (1-month) and discharge symptoms. Participants (N = 274) receiving partial hospitalization treatment completed the Eating Pathology Symptoms Inventory and Intolerance of Uncertainty Scale at admission, 1-month post-admission, and discharge. Results suggested that IU significantly reduced from admission to discharge and that reductions in IU scores from admission to 1-month related to cognitive restraint, dietary restriction, and body image at discharge. However, this pattern did not hold for exercise, binge eating, or purging. Altogether, these results replicate past work supporting IU as a common feature across ED diagnoses and provide initial data suggesting that targeting IU early in treatment may enhance treatment outcomes.

Validating the visceral sensitivity index in an eating disorder sample.

OBJECTIVE: Individuals with eating disorders (EDs) often have difficulty tolerating uncomfortable body sensations. As such, anxiety sensitivity specific to gastrointestinal (GI) sensations, has relevance for EDs. However, to date, no validated measures of this construct exist in EDs. Thus, the present study sought to validate the visceral sensitivity index (VSI), a 15-item measure originally validated in an irritable bowel syndrome sample, in an ED sample and explore associations with ED symptoms. METHOD: Two hundred and sixty-six adolescents (n = 116) and adults (n = 150) in an ED partial hospital program completed the VSI and related measures at admission. Confirmatory factor analysis examined the factor structure of the VSI and hierarchical regression analyses explored associations between the VSI and ED symptoms. RESULTS: The original version of the VSI had adequate model fit. An alternative 13-item model removing specific items with poor fit and less theoretical relevance to EDs also demonstrated good fit. The 15-item and 13-item VSI had strong internal consistency (α = .93-.94), and correlation results supported the convergent and divergent validity of both versions. Higher visceral sensitivity was associated with elevated body dissatisfaction, cognitive restraint, purging, restricting, and excessive exercise (p-values <.05), beyond length of illness, body mass index, and trait anxiety. DISCUSSION: Results support the relevance of GI-specific anxiety in EDs and suggest that the original 15-item VSI and modified 13-item VSI have strong psychometric properties in an ED sample. Given comparable model fit and psychometric properties, both versions of the VSI may be used for future ED research.

Randomized Controlled Trial for the Effect of Vitamin D Supplementation on Vascular Stiffness in CKD.

BACKGROUND AND OBJECTIVES: Vitamin D is implicated in vascular health in CKD. This study compared placebo, calcifediol, and calcitriol treatment with changes in vascular stiffness, BP, proteinuria, mineral metabolism parameters, C-reactive protein, and fibroblast growth factor 23 in patients with stable CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a double-blind, randomized controlled trial in out-patient CKD clinics in Vancouver, Canada, from February of 2011 to August of 2014, enrolling 119 patients with an eGFR of 15-45 ml/min per 1.73 m2. Change in pulse wave velocity (PWV) was measured after 6 months of treatment with a fixed dose of oral calcifediol (5000 IU 25-hydroxyvitamin D3), calcitriol (0.5 µg 1,25-dihydroxyvitamin D3), or placebo, thrice weekly. RESULTS: Eighty-seven participants were evaluated. Mean age was 66 years, 71% were men, 40% were diabetic, and mean baseline PWV was 11.5 m/s (SD=3.9 m/s). After 6 months, the PWV decreased in the calcifediol group (mean change, -1.1; 95% confidence interval [95% CI], -2.2 to 0.1 m/s), remained unchanged in the calcitriol group (mean change, 0.2; 95% CI, -0.9 to 1.4 m/s), and increased in the placebo group (mean change, 1.1; 95% CI, -0.1 to 2.2 m/s). The overall P value for between-arm changes was 0.03. Absolute PWV change was significantly different between groups (P=0.04): the combined vitamin D treatment group saw decreased PWV (mean change, -0.4; 95% CI, -1.2 to 0.4 m/s) whereas the placebo group saw increased PWV (mean change, +1.1; 95% CI, -0.1 to 2.2 m/s). The treatment group demonstrated significantly decreased serum parathyroid hormone (mean difference, -0.5; 95% CI, -0.7 to -0.3 ln[pg/ml]; P<0.001) and increased calcium (mean difference, 0.4; 95% CI, -0.1 to 0.7 mg/dl; P=0.02). In observational analysis, participants in the highest 25-hydroxyvitamin D tertile at trial end had significant decreases in PWV (mean change, -1.0; 95% CI, -2.0 to 0.0 m/s) compared with the middle and lowest tertiles (P<0.01). Side effects were minor and rare. CONCLUSIONS: Six months of supplemental vitamin D analogs at fixed doses may achieve a reduction of PWV in patients with advanced CKD. Because the treatment effect was attenuated when baseline PWV was included as a covariate, these findings should be replicated in larger populations and further studied.

From West End to Eastside: The Vancouver HIV/AIDS Epidemic, 1983-2013.

Traditional histories of AIDS have used a few major American urban centres as proxies for the North American epidemic more broadly and have tended to frame the epidemic as a quintessentially gay and American experience. A careful examination of how the epidemic unfolded in Vancouver, British Columbia, however, reveals considerable differences, including the relative absence of local gay activist traditions prior to HIV/AIDS and the relative prominence of interventions such as Insite, North America's first sanctioned needle exchange program and safe injection site. An investigation of such differences emphasizes the local character of the epidemic and adds a Canadian perspective to the existing AIDS historiography.

A randomized control trial to assess the impact of vitamin D supplementation compared to placebo on vascular stiffness in chronic kidney disease patients.

BACKGROUND: Vitamin D deficiency is associated with cardiovascular (CV) risk in multiple populations, including those with chronic kidney disease (CKD). The active form of the hormone (1,25 OH2D3) binds to receptors in multiple organs. CKD patients are deficient in both 25 Vitamin D and 1,25 OH2D3. Clinical trial data demonstrating the benefits of vitamin D formulations are limited, and fail to show significant benefits on CV outcomes, and have compared different compounds, in various populations, and focused on a variety of outcomes. A understanding of the mechanism by which different vitamin D compounds confer CV protection in CKD is important for the design of future studies. METHODS/DESIGN: This 3 arm randomized prospective double-blinded placebo-controlled study examining the impact of calcitriol (1,25 OH2D3) and 25-hydroxyvitamin D3 supplementation compared to placebo on vascular stiffness, as measured by pulse wave velocity (PWV). Patients are enrolled from 2 tertiary care institutions if they meet inclusion criteria (stable estimated glomerular filtration rate (eGFR) between 15-45ml/min, <±5ml/min change in previous 6 months), on stable doses of renin-angiotensin aldosterone system blockade. For those already receiving vitamin D therapies, a 3 month washout period before randomization is mandatory. Treatment duration is 6 months; medications are given thrice weekly in fixed doses. The primary outcome measure is Vascular stiffness, measured non-invasively by pulse wave velocity (PWV). Other measurements include BP, kidney function and serial blood levels of biomarkers. The primary analysis will compare any vitamin D therapy versus placebo for the primary outcome defined as the change of PWV from baseline to 6 months. Analysis of covariance will be used to detect differences between vitamin D preparations in the magnitude of reduction in PWV. DISCUSSION: This study is novel in that we are using a robust study design in CKD patients (not on dialysis) comparing placebo to different forms of vitamin D supplementation in fixed doses, irrespective of baseline values. We hope to demonstrate the biological mechanistic effect of vitamin D supplementation on vascular function in order for this information to be used in designing larger randomized controlled trials. TRIAL REGISTRATION: Current Controlled Trials NCT01247311. Date of Registration: November 12, 2010.