Metacognitive interpersonal therapy-eating disorders versus cognitive behavioral therapy for eating disorders for non-underweight adults with eating disorders: study protocol for a pilot pre-registered randomized controlled trial.

Eating disorders (ED) are serious disorders characterized by an alteration of eating habits and excessive concern about weight and body shapes (Fairburn, 2002), accompanied by significant impairment inequality of life, high mortality rates and serious organic consequences (Jenkins et al., 2011; Treasure et al., 2015; 2020). Although evidence-based psychological therapies for nonunderweight ED presentations such as cognitive behavioral therapy for eating disorders (CBT-ED) are widely available, there is substantial scope for improvements, particularly in terms of efficacy and adherence. One option is to develop interventions to address elements of pathology not fully addressed by existing empirical supported treatments, such as incorporating techniques aimed at addressing interpersonal problems and personality disorder features into existing treatment delivery. We adapted Metacognitive Interpersonal Therapy, a psychological intervention supported by evidence for treating personality disorders and integrated it with existing CBT techniques for eating disorders (MIT-ED). MIT-ED targets aspects of ED that are not included in the transdiagnostic CBT-E model such as poor metacognition, or maladaptive interpersonal schemas. This is a pre-registered (Protocol number: 0000781) pilot randomized clinical trial aimed at assessing acceptability and feasibility of MIT-ED and establishing preliminary evidence of effectiveness for future larger studies. Twenty patients (10 in each arm) will be randomized to 20 sessions of individual psychotherapy, either MIT-ED or CBTE. Repeated follow-ups will be collected up to 24 months. Participants are recruited at a private outpatient clinic for ED treatment. Acceptability will be assessed via session attendance, completion rates and preliminary outcomes. The primary outcome is ED pathology assessed with the Eating Disorder Examination Questionnaire-6. Other ED outcomes assessed will be eating disorder attitudes, clinical impairment and binge eating pathology. Secondary treatment outcomes are anxiety, depression, and global symptomatology. We will also assess emotional awareness, emotion regulation and therapeutic alliance. Based on previous studies of MIT for personality disorders we hypothesize that MIT-ED will be acceptable to patients, evidenced by high treatment adherence and retention. We hypothesize that MIT-ED will be associated with reductions in eating disorder pathology, at least equivalent to CBT-E. Results will be used to inform the study design, sampling, likely effect sizes and choice of outcome measures for future larger trials of MIT-ED in ED samples.

Closing the Gap: A Resident-Led Quality Improvement Project to Improve Colorectal Cancer Screening in Primary Care Community Clinics.

BACKGROUND: Despite the prevalence and mortality associated with colorectal cancer (CRC), 67.4% of US adults aged 50 to 75 years received recommended screening tests in 2016. OBJECTIVE: We created a quality improvement project in resident-run outpatient clinics to increase CRC screening rates to ≥ 50% from 2016 to 2018, with emphasis on vulnerable patient populations. METHODS: We applied a comprehensive, multidisciplinary approach involving internal medicine and family medicine residents and staff from various hospital network departments, selecting 4 clinics to participate whose screening rates were below our network's average of 41%. Our intervention consisted of a needs assessment, resident-led educational sessions for clinicians, staff, and patients, use of fecal immunochemical tests as a first screening option, and application of care gap analysts at each clinic to answer patients' screening questions and to follow up regarding their screening status. RESULTS: We obtained approximately 100 patient surveys from each clinic, a 100% staff completion rate (68 of 68), and a 90% clinician completion rate (85 of 94). Staff and clinician surveys revealed concerns about reducing patient screening fears, inconsistent documentation of screening outcomes, and need for education about CRC prevention, early detection, and screening recommendations. Patient surveys revealed educational deficits and concerns about perceived screening obstacles (eg, transportation and insurance). While CRC screening rates increased across all participating clinics, one clinic experienced an increase from 23% to 48%. CONCLUSIONS: Our multitargeted approach in primary care residency practices yielded increased CRC screening rates in vulnerable patient populations.

Early Results of Fecal Microbial Transplantation Protocol Implementation at a Community-based University Hospital.

INTRODUCTION: Clostridium difficile (CD) is a serious and increasingly prevalent healthcare-associated infection. The pathogenesis of CD infection (CDI) involves the acquisition of CD with a concurrent disruption of the native gut flora. Antibiotics are a major risk although other contributing factors have also been identified. Clinical management combines discontinuation of the offending antibiotic, initiation of CD-specific antibiotic therapy, probiotic agent use, fecal microbiota transplantation (FMT), and surgery as the "last resort" option. The aim of this study is to review short-term clinical results following the implementation of FMT protocol (FMTP) at our community-based university hospital. METHODS: After obtaining Institutional Review Board and Infection Control Committee approvals, we implemented an institution-wide FMTP for patients diagnosed with CDI. Prospective tracking of all patients receiving FMT between July 1, 2015, and February 1, 2017, was conducted using REDCap™ electronic data capture system. According to the FMTP, indications for FMT included (a) three or more CDI recurrences, (b) two or more hospital admissions with severe CDI, or (c) first episode of complicated CDI (CCDI). Risk factors for initial infection and for treatment failure were assessed. Patients were followed for at least 3 months to monitor for cure/failure, relapse, and side effects. Frozen 250 mL FMT samples were acquired from OpenBiome (Somerville, MA, USA). After 4 h of thawing, the liquid suspension was applied using colonoscopy, beginning with terminal ileum and proceeding distally toward mid-transverse colon. Monitored clinical parameters included disease severity (Hines VA CDI Severity Score or HVCSS), concomitant medications, number of FMT treatments, non-FMT therapies, cure rates, and mortality. Descriptive statistics were utilized to outline the study results. RESULTS: A total of 35 patients (mean age 58.5 years, 69% female) were analyzed, with FMT-attributable primary cure achieved in 30/35 (86%) cases. Within this subgroup, 2/30 (6.7%) patients recurred and were subsequently cured with long-term oral vancomycin. Among five primary FMT failures (14% total sample), 3 (60%) achieved medical cure with long-term oral vancomycin therapy and 2 (40%) required colectomy. For the seven patients who either failed FMT or recurred, long-term vancomycin therapy was curative in all but two cases. For patients with severe CDI (HVCSS ≥3), primary and overall cure rates were 6/10 (60%) and 8/10 (80%), respectively. Patients with CCDI (n = 4) had higher HVCSS (4 vs. 3) and a mortality of 25%. Characteristics of patients who failed initial FMT included older age (70 vs. 57 years), female sex (80% vs. 67%), severe CDI (80% vs. 13%), and active opioid use during the initial infection (60% vs. 37%) and at the time of FMT (60% vs. 27%). The most commonly reported side effect of FMT was loose stools. CONCLUSIONS: This pilot study supports the efficacy and safety of FMT administration for CDI in the setting of a community-based university hospital. Following FMTP implementation, primary (86%) and overall (94%) nonsurgical cure rates were similar to those reported in other studies. The potential role of opioids as a modulator of CDI warrants further clinical investigation.

Scleroderma renal crisis or thrombotic thrombocytopenic purpura: seeing through the masquerade.

SCLERODERMA: renal crisis (SRC), a somewhat rare but serious complication of systemic scleroderma, is one of only a few known rheumatologic emergencies; it presents in as many as 10% of patients with scleroderma. Before the use of angiotensin converting enzyme (ACE) inhibitors to treat SRC, the mortality rate for SRC was extremely high-as much as 90% after 1 year. However, the mortality rate has significantly improved with the early and aggressive use of ACE inhibitors. SRC typically includes acute renal failure and accelerated hypertension. Patients may report headache, changes in vision, fever, dyspnea, and encephalopathy. Laboratory study results can show elevated creatinine levels, thrombocytopenia, and microangiopathic hemolytic anemia (MAHA) with schistocytes on blood smear. Given this clinical and laboratory presentation, SRC can easily be mistaken for TTP in clinical practice, as we demonstrate in 2 presentations of similar cases of SRC, the first in a 36-year-old Caucasian woman and the second in a 54-year-old Caucasian woman. In both cases, SRC masqueraded as TTP, and both patients were almost mistakenly treated for TTP until the clinical picture changed and certain laboratory test and kidney biopsy results confirmed otherwise.

CT pulmonary angiography: an over-utilized imaging modality in hospitalized patients with suspected pulmonary embolism.

AIMS: To determine if computed tomographic pulmonary angiography (CTPA) was overemployed in the evaluation of hospitalized patients with suspected acute pulmonary embolism (PE). METHODS: Data were gathered retrospectively on hospitalized patients (n=185) who had CTPA for suspected PE between June and August 2009 at our institution. RESULTS: CTPA was done in 185 hospitalized patients to diagnose acute PE based on clinical suspicion. Of these, 30 (16.2%) patients were tested positive for acute PE on CTPA. The Well's pretest probability for PE was low, moderate, and high in 77 (41.6%), 83 (44.9%), and 25 (13.5%) patients, respectively. Out of the 30 PE-positive patients, pretest probability was low in 2 (6.6%), moderate in 20 (66.7%), and high in 8 (26.6%) (p=0.003). Modified Well's criteria applied to all patients in our study revealed 113 (61%) with low and 72 (39%) with high clinical pretest probability. When modified Well's criteria was applied to 30 PE-positive patients, 10 (33.3%) and 20 (66.6%) were found to have low and high pretest probability, respectively (p=0.006). D-dimer assay was done in 30 (16.2%) of the inpatients with suspected PE and all of them were found to have elevated levels. A lower extremity duplex ultrasound confirmed deep venous thrombosis in 17 (9.1%) of the patients with suspected PE, at least 1 week prior to having CTPA. CONCLUSION: Understanding the recommended guidelines, evidence-based literature, and current concepts in evaluation of patients with suspected acute PE will reduce unnecessary CTPA examinations.

Serum magnesium is an independent predictor of frequent readmissions due to acute exacerbation of chronic obstructive pulmonary disease.

INTRODUCTION: Predictors of readmission for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are not well defined. Identifying modifiable predictors may help reduce the burden of readmissions. This study was done to evaluate the role of serum magnesium in frequent readmissions. METHODS: One hundred patients admitted with a diagnosis of AECOPD to a tertiary care center from April 2004 to March 2006 were retrospectively followed from the time of index admission until the next admission or death. Number of admissions was calculated for the year after index admission, and frequent readmission was defined as > or =3 per year. Patients with other respiratory diseases, renal failure, and congestive heart failure were excluded. Serum magnesium was assayed at the time of admission by the colorimetric method. Logistic regression analysis was used to find independent risk factors for readmission. RESULTS: The mean age of patients was 71.9 (+/-10.9 standard deviation (SD)) years. Fifty-seven were females. Ninety percent were current or ex-smokers. The median duration of time to next admission was 108 days (range 2-842). A total of 87 patients were readmitted at least once during the first year of follow-up, while 5% died; 23% had frequent readmissions; 85% had received pneumococcal vaccine within 5 years; and 29% received influenza vaccine in the current season. Frequency of readmissions was not influenced by the administration of inhaled or oral steroids, and diuretics at the time of discharge. Vaccination did not protect against frequent readmissions. The sole predictor of frequent readmissions was serum magnesium level (1.77+/-0.19 vs. 1.86+/-0.24mEq/L; adjusted odds ratio 0.003, 95% Confidence intervals <0.001-0.55; p=0.03). CONCLUSIONS: Lower serum magnesium level independently predicts readmission for AECOPD. This is an easily modifiable risk factor.