Assessing the appropriateness of the level of care for morbidly obese subjects: validation of the CASCO-R scale.

AIM: Aim of this study was to validate the Comprehensive Appropriateness Scale for the Care of Obesity in Rehabilitation (CASCO-R) and to determine the cut-off score for indicating the most appropriate health care setting for patients with obesity. METHODS: The CASCO-R scale was developed according to the available scientific literature and expertise of an expert panel working for a Consensus document endorsed by the Italian Society of Obesity (SIO) and the Italian Society for the Study of Eating Disorders (SISDCA). 16 Italian centres, specialized in the treatment of obesity, characterised by different settings of care (specialist outpatient service, day-hospital service, intensive inpatient rehabilitation), participated in the study. RESULTS: 449 obese subjects were enrolled in the study (30.5% males and 69.5% females): 38.3% from outpatient services, 20.7% from day-hospital services and 40.9% from intensive inpatient rehabilitation units. After 2-month of treatment, a workload summary sheet, including medical and nursing interventions, number of expert advices and diagnostic procedures, and adverse clinical events (ACEs) was fulfilled for each patient. Statistically significant correlation was found between the CASCO-R scale score, overall workload and ACEs. The CASCO-R scale demonstrated also an excellent performance in terms of internal validity and test-retest analysis. Three total score cut-off have been proposed: >25 for inpatient intensive rehabilitation; 20-25 for day-hospital service; <20 for outpatient treatment. CONCLUSIONS: In conclusion, the CASCO-R scale was demonstrated to be a valid tool for assessing the appropriateness of the choice of the level of care. Hence, it can be used to verify the proper allocation of patients, as it was well correlated with measures of workload and the incidence of ACEs.

Defecatory disorders in anorexia nervosa: a clinical study.

BACKGROUND: Defecatory disorders in patients with eating disorders have been overlooked. We evaluated the prevalence and type of defecatory disorders in patients with anorexia nervosa. METHODS: The aim of our questionnaire-based study was to determine the prevalence of constipation and faecal incontinence (FI) in patients with anorexia nervosa attending our dedicated eating disorders outpatient clinics and whether length of illness and low body mass index (BMI) exacerbate both constipation and FI. The Wexner constipation score (WCS), Altomare's obstructed defecation score (OD score) and the faecal incontinence severity index (FISI) were used to evaluate constipation and incontinence. A WCS ≥5, OD score ≥10 and a FISI ≥10 were considered clinically relevant. RESULTS: Eighty-five patients (83 females; mean age 28 years ± 13) with anorexia nervosa (study group) and mean BMI of 16 ± 2 kg/m(2) (range 14-19 kg/m(2)) were studied. This group was compared to 57 healthy volunteers (control group) with mean BMI of 22 ± 3 kg/m(2) (range 20-27 kg/m(2)). In the study group, 79/85 (93%) patients suffered from defecatory disorders defined as at least one abnormal score, either WCS, OD score or FISI, compared to 7/57 (12%) controls (p < 0.001). Constipation (defined as WCS ≥5) was present in 70/85 (83%) patients with anorexia and in 7/57 (12%) controls (p = 0.001), while obstructed defecation syndrome (defined as OD score ≥10) was present in 71/85 (84%) patients with anorexia and 7/57 (12%) controls (p < 0.001). In patients with anorexia, the mean WCS score was 10 ± 5 standard deviation (SD) (3 ± 2 SD in controls; p < 0.001), and the mean OD score was 12 ± 4 SD (3 ± 4 SD in controls; p < 0.001). Overall, 62/85 (73%) patients with anorexia had FI defined as FISI score ≥10, and the mean FISI score in anorexia patients was 12 ± 9 SD. A combination of constipation and FI (either both WCS and FISI abnormal or both OD score and FISI abnormal) was present in 55/85 (64%) and 8/85 (9%) presented with FI alone. Moreover, all results are influenced by the severity of the disease measured by BMI and duration. The percentage of defecatory disorders rises from 75 to 100% when BMI is <18 kg/m(2) and from 60 to 75% when the duration of illness is ≥5 years (p < 0.001 and p = 0.021, respectively). CONCLUSIONS: Defecatory disorders are associated with anorexia nervosa and increased with the duration and severity of the illness.

[Obesity and Eating Disorders. Indications for the different levels of care. An Italian Expert Consensus Document]. / Documento di Consensus. Obesità e Disturbi dell'Alimentazione Indicazioni per i diversi livelli di trattamento.

This paper is an Italian Expert Consensus Document on multidimensional treatment of obesity and eating disorders. The Document is based on a wide survey of expert opinion. It presents, in particular, considerations regarding how clinicians go about choosing the most appropriate site of treatment for a given patient suffering from obesity and/or eating disorders: outpatient, partial hospitalization, residential rehabilitation centre, inpatient hospitalization. In a majority of instances obesity and eating disorders are long-term diseases and require a multiprofessional team-approach. In determining an initial level of care or a change to a different level of care, it is essential to consider together the overall physical condition, medical complications, disabilities, psychiatric comorbidity, psychology, behaviour, family, social resources, environment, and available services. We first created a review manuscript, a skeleton algorithm and two rating scales, based on the published guidelines and the existing research literature. As the second point we highlighted a number of clinical questions that had to be addressed in the specific context of our National Health Service and available specialized care units. Then we submitted eleven progressive revisions of the Document to the experts up to the final synthesis that was approved by the group. Of course, from point to point, some of the individual experts would differ with the consensus view. The document can be viewed as an expert consultation and the clinical judgement must always be tailored to the particular needs of each clinical situation. We will continue to revise the Document periodically based on new research information and on reassessment of expert opinion to keep it up-to-date. The Document was not financially sponsored.

Psychopathological and clinical features of outpatients with an eating disorder not otherwise specified.

In order to investigate similarities and differences between Eating Disorder Not Otherwise Specified (EDNOS) and Anorexia Nervosa (AN) and Bulimia Nervosa (BN), we studied a consecutive series of 189 female outpatients attending two Eating Disorder Units. The data were collected by means of interviews (Eating Disorder Examination, EDE 12.0D), the Structured Diagnostic Interview for DSM III-R, (SCID), and self-reported questionnaires (Beck Depression Inventory, BDI, and State and Trait Anxiety Inventory, STAI 1-2). The diagnosis of EDNOS was as frequent as that of AN and BN (43.8% versus 43.2%). There were no significant differences between EDNOS and AN/BN patients in terms of their general and specific psychopathological features, but significant differences were observed between bulimic-like and anorectic-like EDNOS patients, as well as between those with AN and BN. In conclusion, in our clinical setting, the patients with EDNOS and those with typical eating disorders have similar psychopathological features, thus suggesting that EDNOS patients should be further divided into two groups, anorectic-like (similar to AN) and bulimic-like (similar to BN) patients.

Fluoxetine and fluvoxamine combined with individual cognitive-behaviour therapy in binge eating disorder: a one-year follow-up study.

BACKGROUND: : The treatment of binge eating disorder (BED) is still the object of debate. In the present study, the effectiveness of antidepressant drugs (fluoxetine - FLX - 60 mg/day, fluvoxamine - FLV -300 mg/day), cognitive-behavioural therapy (CBT) and combined treatments (CBT + FLX, CBT + FLV) has been evaluated in a randomized, clinical trial. Results at the end of the active treatment (in the 24th week) and 1-year follow-up outcomes have been evaluated. METHODS: One hundred eight (44 M, 64 F) BED patients were randomly assigned to either CBT, FLX (60 mg/day), FLV (300 mg/day), CBT + FLX or CBT + FLV, for 24 weeks. At the beginning (T0), at the end (T1) of treatment and after 1 year (T2), body mass index (BMI) and eating attitude and behaviours (by EDE 12.0D) were assessed. RESULTS: At T1, BMI and EDE scores were significantly reduced in CBT, CBT + FLX and CBT + FLV, but not in the FLX and FLV treatment groups. In the CBT + FLV group, a greater (p < 0.05) reduction of EDE total scores was observed, when compared to CBT + FLX or CBT treatment groups. At T2, BMI was significantly higher than at T1, but still significantly lower than at T0 in the CBT, CBT + FLX and CBT + FLV groups, while EDE scores remained unchanged from T1 in all treatment groups. CONCLUSIONS: CBT was more effective than FLX or FLV in the treatment of BED. The addition of FLX to CBT does not seem to provide any clear advantage, while the addition of FLV could enhance the effects of CBT on eating behaviours. Modifications of eating behaviours are maintained at the 1-year follow-up, although the lost weight was partly regained.

5-HT2A receptor gene polymorphisms in anorexia nervosa and bulimia nervosa.

To examine the distribution of different polymorphisms in genes of the 5-HT system in patients with anorexia nervosa (AN) and bulimia nervosa (BN), we analyzed the distribution of a polymorphism (-1438G/A) and the presence of known mutations in 5-HT2A and 5-HT2C receptor genes in 168 Italian female patients affected by AN and BN. Patients with AN restricting type (ANr) only, unlike those with AN binge eating/purging type (ANp) and BN purging type (BNp), showed a statistically significant difference in 5-HT2A-1438A/A genotype frequency with respect to controls. With regard to the other polymorphisms, no differences were found in the studied groups with respect to controls. 5-HT2A promoter polymorphism is probably implicated in the susceptibility to eating disorders and its involvement is more significant in ANr, when compared with ANp and BNp.

Cognitive-behavioral therapy versus combined treatment with group psychoeducation and fluoxetine in bulimic outpatients.

A series of 51 female bulimic outpatients, aged 23.4+/-3.9, were assigned either to Cognitive-Behavioral Therapy (CBT) or combined Group Psychoeducation and Fluoxetine (GPF) treatment. The Eating Disorder Examination (EDE) was performed at the beginning of treatment and after 6 months, together with the administration of self reported questionnaires for depression (BDI) and Anxiety (STAI). A significant (p<0.001) reduction of the number of monthly binge episodes (from 25.0+/-12.9 to 6.2+/-3.8 and from 24.8+/-9.1 to 8.0+/-4.3) for CBT and GPF respectively were observed. Similar reductions were obtained in the number of episodes of compensatory behaviors. Both treatments reduced depression and anxiety (p<0.001) while CBT only determined a significative improvement of EDE scores. The data obtained suggest that GPF is as effective as CBT in reducing bulimic symptomatology but its long-term efficacy should be evaluated in a follow-up study.

[Psychopathological and clinical features among the ambulatory population of obese patients]. / Caratteristiche psicopatologiche e cliniche di una popolazione ambulatoriale di pazienti obesi.

Aim of the present study is the evaluation of psychopathological and clinical features of these outpatients followed by the Outpatient Clinic of the Section of Metabolic Diseases and Diabetes, University of Florence. 84 obese patients and 217 non-obese control subjects were studied using the Structured Clinical Interview for DSM-III-R (SCID), and applying DSM-IV criteria for Binge Eating Disorder. BITE self-reported questionnaire, STAI inventory and Ham-D rating scale were also used. Lifetime prevalence of Binge Eating Disorder in obese patient was 11.9%, markedly lower than that reported in studies on North American samples. Prevalence of depressive disorder (Major Depression and Dysthymia) was significantly higher (p < 0.005) in obese patients than in control subjects. This confirms the important relationships between eating and mood disorders. The prevalence of subclinical eating disorders resulted to be significantly higher in obese patients (p < 0.01) when compared with control subjects. Significant correlations (p < 0.01) of BITE scores were observed with STAI and Ham-D scores, but not with body mass index. These results underline the need for an accurate psychopathological assessment in obese patients, in order to formulate a correct diagnosis and plan adequate therapeutical interventions.