Knowledge of non-contraceptive benefits of and willingness to consider taking oral contraceptive pills among a low-risk female population: a cross-sectional study.

BACKGROUND: In addition to its widely-appreciated contraceptive applications, the oral contraceptive pill (OCP) conveys both oncological and non-oncological benefits. Oncological benefits include a decreased risk of endometrial, ovarian, and colorectal cancer. Non-oncological benefits include reducing androgenic effects and alleviating menstruation-related problems. This study aimed to ascertain knowledge levels of non-contraceptive benefits and risks of OCP use among participants without contraindications to OCPs. This study also assessed factors associated with participants being more likely to consider taking OCPs. METHODS: 263 women aged 21 to 40 years old with no contraindications for OCP usage participated in this study. An anonymous questionnaire collected sociodemographic information and assessed participants' knowledge of the non-contraceptive benefits and risks associated with OCP use. Multivariate linear regression was used to assess factors associated with knowledge levels. Multivariate logistic regression was used to investigate factors associated with being more likely to consider taking OCPs among women who did not presently take them. RESULTS: Multivariate logistic regression revealed that participants who were more knowledgeable overall about the non-contraceptive benefits of OCPs were more likely to consider taking OCPs (coefficient = 0.184, p-value = 0.00). Knowledge of both oncological and non-oncological benefits of OCP use was relatively poor, especially among older women. Current OCP users were found to be more knowledgeable about their benefits. CONCLUSIONS: As women with greater knowledge of non-contraceptive benefits of OCPs are more likely to consider taking them, knowledge gaps regarding OCPs should be filled, so that more women may reap the non-contraceptive benefits of OCPs.

A sample of women with a low risk profile for oral contraceptive pills in Singapore demonstrated poor overall knowledge of their non-contraceptive benefits. Greater knowledge of the non-contraceptive benefits of oral contraceptive pills was associated with a greater willingness to consider taking oral contraceptive pills.

Associations between the COVID-19 pandemic and women's fertility intentions: a multi-country, cross-sectional (I-SHARE) study.

INTRODUCTION: The COVID-19 pandemic, together with the subsequent social distancing measures, could lead to shifts in family and fertility planning. This study aimed to explore the associations between the COVID-19 pandemic and changes in fertility intentions among an international sample of reproductive-aged women. METHODS: A multi-country, cross-sectional study based on data from 10 672 women aged 18-49 years who participated in the International Sexual Health And REproductive Health (I-SHARE) study, which organised an international online survey between July 2020 and February 2021. Factors associated with changes in fertility intentions were explored using multinomial probit regression models. Cluster-robust standard errors were used to calculate model parameters. RESULTS: Of 10 672 included reproductive-aged women, 14.4% reported changing their fertility intentions due to the pandemic, with 10.2% postponement and 4.2% acceleration. Women who had ever been isolated/quarantined were more likely to postpone their fertility intentions (adjusted odds ratio (AOR)=1.41; 95% CI 1.18 to 1.69) compared with those who had not; women who lived with a steady partner were more likely to want children sooner (AOR=1.57; 95% CI 1.10 to 2.23) compared with those who did not; and those who reported a higher frequency of getting angry, feeling frustrated, or worrying about their finances were more likely to postpone their fertility intentions. The main findings were robust in the sensitivity analyses. CONCLUSIONS: Most women who changed fertility intentions because of the pandemic have postponed intentions to expand their families. The pandemic-induced exposures were associated with these postponements.

Lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI+) healthcare in Singapore: perspectives of non-governmental organisations and clinical year medical students.

PURPOSE: International studies document that lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI+) patients face significant health disparities. Studies exploring the attitudes, knowledge, preparedness and comfort levels of healthcare students towards LGBTQI+ health have been conducted in the United States, United Kingdom and Malaysia. This study aims to investigate stigma in healthcare for LGBTQI+ patients in Singapore, and possible upstream factors within medical education. METHODS: This mixed-methods study adopts a convergent parallel design. The Health Stigma and Discrimination Framework was referenced to devise in-depth interviews with representatives from 13 LGBTQI-affirming non-governmental organisations, analysed through thematic analysis. 320 clinical medical students were surveyed about attitudes, knowledge, comfort, preparedness, and perceived importance of/towards LGBTQI+ health, analysed via descriptive statistics and multivariate regression. RESULTS: Prevailing stigma in Singaporean society against LGBTQI+ individuals is exacerbated in healthcare settings. Doctors were cited as unfamiliar or uncomfortable with LGBTQI+ health, possibly from lack of training. Among medical students surveyed, the median composite attitudes, comfort and preparedness index was 3.30 (Interquartile Range (IQR) = 0.50), 3.17 (IQR = 0.83), 2.50 (IQR = 1.00) respectively. Only 12.19% of students answered all 11 true-false questions about LGBTQI+ health correctly. CONCLUSION: Medical students in Singapore have scored sub-optimally in their knowledge and preparedness towards LGBTQI+ health, while interpersonal and structural stigma in healthcare towards LGBTQI+ people in Singapore negatively affects health and wellbeing. These findings are an impetus to improve medical training in this area. High scores among medical students in attitudes, comfort and perceived importance of LGBTQI+ topics demonstrate that there is space for LGBTQI+ health in the local medical education curriculum. Curricular interventions can prioritise content knowledge, communication skills and sensitivity.

Intimate partner violence before and during the COVID-19 lockdown: findings from a cross-sectional study in Singapore.

BACKGROUND: The coronavirus diseases 2019 (COVID-19) pandemic resulted in lockdowns worldwide, with reports suggesting a concomitant increase in the incidence of intimate partner violence (IPV). This study was part of the International Sexual and Reproductive Health (I-SHARE) Consortium, examining IPV and its correlates before and during lockdown in April 2020. METHODS: This cross-sectional observational study, conducted online during August-September 2020, recruited 259 participants from Singapore who reported having a steady partner. Alongside socio-demographic data before and during COVID-19 lockdown, the respondents self-reported their encounters with partner violence. Partner violence was measured using an adapted six-item version of the WHO IPV scale. RESULTS: Data revealed an incidence of 17.2%, 25.0%, 16.7%, 17.6%, 17.5% and 18.5% of restriction of contact with others, verbal abuse, restriction of access to finances, physical violence, pressured sex and forced sex, respectively, before COVID-19 lockdown. During lockdown, incidences of these forms of violence were 17.4%, 19.8%, 14.7%, 13.5%, 14.7% and 15.2%, respectively. Multivariable analyses showed that being younger, being non-heterosexual, and having more children and adolescents at home were significantly associated with partner violence both before and during lockdown. Analyses also revealed that being of Chinese ethnicity and having a monthly income above SGD3000 were not significantly correlated to partner violence before lockdown but emerged as significant during lockdown. CONCLUSIONS: Some sociodemographic factors were associated with violence regardless of lockdown, while other factors were exacerbated by lockdown. Interventions should consider these key correlates of partner-based violence, ensuring adequate and appropriate support for vulnerable populations both within and outside of lockdown contexts.

COVID-19 and the shifting organisation of sex work markets in Singapore.

While past studies have sought to capture how the COVID-19 pandemic has impacted on the health and sexual lives of sex workers internationally, less attention has been paid to the reorganisation of sex markets as a result of COVID-19. We conducted a sequential exploratory mixed methods study using in-depth interviews, cyber ethnography and surveyor-administered structured surveys among sex workers. We report two key findings on how the pandemic has impacted sex markets in Singapore. First, the organisation of sex markets shifted as a result of lockdown and associated movement control measures. This shift was characterised by the out-migration of sex workers, the reduction in supply and demand for in-person sex work, and a shift towards online spaces. Second, we found that sex workers experienced greater economic hardship as a result of such changes. Given the potential shifts in sex markets as a result of the pandemic, we adopt a World Health Organisation Health Workplace Framework and Model to identify interventions to improve the occupational safety and health of sex workers in a post-COVID-19 era.

Partnership status, living arrangements, and changes in sexual behaviour and satisfaction during the COVID-19 lockdown: insights from an observational, cross-sectional online survey in Singapore.

Background The SARS-CoV-2 (coronavirus disease 2019; COVID-19) pandemic and its concomitant movement control measures have had a profound impact on the world. In spite of its potential impact on sexual health, there is a lack of research on how the pandemic and its movement control measures have impacted sexual wellbeing among Singaporeans. Methods This observational, cross-sectional study was conducted from August to September 2020. Participants were recruited through an online survey instrument promoted through social media. Respondents self-reported their sexual behaviours and levels of sexual satisfaction prior to and during the COVID-19 pandemic movement control measures. Results We recruited a total of 562 participants, of whom 338 (60.1%) ever had a sexual experience. Singles (n=106, 31.4%) and those not living with their partners (n=115, 34.0%) reported a greater decrease in partnered sexual activities but a greater increase in individual sexual activities such as masturbation, sending and receiving nudes and watching pornography, relative to those who were living with their partners (n=117, 34.6%). Multivariable analyses indicated that relative to singles, those who were not living with their partners were more likely to experience a decrease in sexual satisfaction (adjusted prevalence ratio [aPR]=1.42, 95% CI [1.07, 1.90]), whereas those who were living with their partners were less likely to experience a decrease in sexual satisfaction (aPR=0.45, 95% CI [0.25, 0.81]). Conclusions Interventions may focus on enhancing sexual wellness by educating on and supporting individual or partnered sexual activities that may vary along the lines of partnership status and living arrangements during the implementation of movement control measures.

Statistical Process Control Charts for Monitoring Next-Generation Sequencing and Bioinformatics Turnaround in Precision Medicine Initiatives.

PURPOSE: Precision oncology, such as next generation sequencing (NGS) molecular analysis and bioinformatics are used to guide targeted therapies. The laboratory turnaround time (TAT) is a key performance indicator of laboratory performance. This study aims to formally apply statistical process control (SPC) methods such as CUSUM and EWMA to a precision medicine programme to analyze the learning curves of NGS and bioinformatics processes. PATIENTS AND METHODS: Trends in NGS and bioinformatics TAT were analyzed using simple regression models with TAT as the dependent variable and chronologically-ordered case number as the independent variable. The M-estimator "robust" regression and negative binomial regression were chosen to serve as sensitivity analyses to each other. Next, two popular statistical process control (SPC) approaches which are CUSUM and EWMA were utilized and the CUSUM log-likelihood ratio (LLR) charts were also generated. All statistical analyses were done in Stata version 16.0 (StataCorp), and nominal P < 0.05 was considered to be statistically significant. RESULTS: A total of 365 patients underwent successful molecular profiling. Both the robust linear model and negative binomial model showed statistically significant reductions in TAT with accumulating experience. The EWMA and CUSUM charts of overall TAT largely corresponded except that the EWMA chart consistently decreased while the CUSUM analyses indicated improvement only after a nadir at the 82nd case. CUSUM analysis found that the bioinformatics team took a lower number of cases (54 cases) to overcome the learning curve compared to the NGS team (85 cases). CONCLUSION: As NGS and bioinformatics lead precision oncology into the forefront of cancer management, characterizing the TAT of NGS and bioinformatics processes improves the timeliness of data output by potentially spotlighting problems early for rectification, thereby improving care delivery.

Delineating patterns of sexualized substance use and its association with sexual and mental health outcomes among young gay, bisexual and other men who have sex with men in Singapore: a latent class analysis.

BACKGROUND: Young gay, bisexual, and other men who have sex with men (YMSM) are vulnerable to the risks associated with sexualized substance use. This is a novel study in Singapore that aims to classify patterns of sexualized substance use among YMSM, and investigate its association with sexual and mental health outcomes. METHODS: In this cross-sectional study among 570 YMSM aged 18 to 25 years old, latent class analysis (LCA) conducted to identify classes with similar patterns of sexualized substance use, across which measures of inconsistent condom use, recent STI diagnoses, past suicide ideation and depression severity were compared. RESULTS: LCA revealed three classes of YMSM based on types of substances ever used in sexualized contexts, which we labelled as 'substance-naive', 'substance-novice', and 'chemsex'. Substance-naive participants (n = 404) had only ever used alcohol, while substance-novice participants (n = 143) were primarily amyl nitrite users with a small proportion who reported using chemsex-related drugs. Chemsex participants (n = 23) comprised individuals who had mostly used such drugs. Those in the chemsex group were more likely to report recent unprotected anal sex with casual partners (aPR = 3.28, 95%CI [1.85, 5.79]), depression severity (aß = 3.69, 95%CI [0.87, 6.51]) and a history of suicide ideation (aPR = 1.64, 95%CI [1.33, 2.03]). CONCLUSIONS: Findings of this study highlight how the use of varying substances in sexualized contexts may be classified and characterized by different sexual and mental health outcomes. Health promotion efforts should be differentiated accordingly to address the risks associated with sexualized substance use among YMSM.

The Impact of the Coronavirus Disease (COVID-19) on the Health and Social Needs of Sex Workers in Singapore.

We evaluated the impact of the coronavirus disease (COVID-19) on the sex work industry and assessed how it has impacted the health and social conditions of sex workers in Singapore. We conducted a sequential exploratory mixed methods study amidst the COVID-19 pandemic from April to October 2020, including in-depth interviews with 24 stakeholders from the sex work industry and surveyor-administered structured surveys with 171 sex workers. COVID-19 had a substantial impact on sex workers' income. The illegality of sex work, stigma, and the lack of work documentation were cited as exclusionary factors for access to alternative jobs or government relief. Sex workers had experienced an increase in food insecurity (57.3%), housing insecurity (32.8%), and sexual compromise (8.2%), as well as a decrease in access to medical services (16.4%). Being transgender female was positively associated with increased food insecurity (aPR = 1.23, 95% CI [1.08, 1.41]), housing insecurity (aPR = 1.28, 95% CI [1.03, 1.60]), and decreased access to medical services (aPR = 1.74, 95% CI [1.23, 2.46]); being a venue-based sex worker was positively associated with increased food insecurity (aPR = 1.46, 95% CI [1.00, 2.13]), and being a non-Singaporean citizen or permanent resident was positively associated with increased housing insecurity (aPR = 2.59, 95% CI [1.73, 3.85]). Our findings suggest that COVID-19 has led to a loss of income for sex workers, greater food and housing insecurity, increased sexual compromise, and reduced access to medical services for sex workers. A lack of access to government relief among sex workers exacerbated such conditions. Efforts to address such population health inequities should be implemented.

Social capital and chemsex initiation in young gay, bisexual, and other men who have sex with men: the pink carpet Y cohort study.

BACKGROUND: Young gay, bisexual, and other men who have sex with men (YMSM) are especially vulnerable to the risks associated with sexualized substance use, or 'chemsex'. Engaging in chemsex established as a major risk factor for Human Immunodeficiency Virus (HIV) acquisition, and is thus a public health issue of increasing urgency. This paper attempts to explore the association between measures of social capital and patterns of sexualized substance use among a sample of YMSM in Singapore. METHODS: Results of this study were derived from baseline data of the Pink Carpet Y Cohort Study in Singapore, comprising a sample of 570 HIV-negative YMSM aged 18 to 25 years old. Latent class analysis was employed to identify classes with similar patterns of sexualized substance use, and multinomial logistic regression was employed to examine associations between class membership and proxy measures of social capital, including age of sexual debut, bonding and bridging social capital, connectedness to the lesbian, gay, bisexual and transgender community, and outness. RESULTS: Latent class analysis revealed three classes of YMSM based on their histories of sexualized substance use, which we labelled as 'alcohol', 'poppers', and 'chemsex'. Multivariable analyses revealed that participants who were older (aOR = 1.19, p = 0.002) and who identified as gay (aOR = 2.43, p = 0.002) were more likely to be in the poppers class compared to the alcohol class. Participants with a later age of sexual debut were increasingly less likely to be in the poppers (aOR = 0.93, p = 0.039) and chemsex classes (aOR = 0.85, p = 0.018), compared to the alcohol class. CONCLUSIONS: Varying measures of social capital such as an earlier age of exposure to sexual networks may predispose YMSM to greater opportunities for sexualized substance use. Future interventions should target YMSM who become sexually active at an earlier age to reduce the risks associated with sexualized substance use.

Therapist written goodbye letters: evidence for therapeutic benefits in the treatment of anorexia nervosa.

BACKGROUND: Despite their use in clinical practice, there is little evidence to support the use of therapist written goodbye letters as therapeutic tools. However, preliminary evidence suggests that goodbye letters may have benefits in the treatment of anorexia nervosa (AN). AIMS: This study aimed to examine whether therapist written goodbye letters were associated with improvements in body mass index (BMI) and eating disorder symptomology in patients with AN after treatment. METHOD: Participants were adults with AN (n = 41) who received The Maudsley Model of Anorexia Treatment for Adults (MANTRA) in a clinical trial evaluating two AN out-patient treatments. As part of MANTRA, therapists wrote goodbye letters to patients. A rating scheme was developed to rate letters for structure and quality. Linear regression analyses were used to examine associations between goodbye letter scores and outcomes after treatment. RESULTS: Higher quality letters and letters that adopted a more affirming stance were associated with greater improvements in BMI at 12 months. Neither the overall quality nor the style of goodbye letters were associated with improvements in BMI at 24 months or reductions in eating disorder symptomology at either 12 or 24 months. CONCLUSIONS: The results highlight the potential importance of paying attention to the overall quality of therapist written goodbye letters in the treatment of AN, and adopting an affirming stance.

Parents' prioritised outcomes for trials investigating treatments for paediatric severe infection: a qualitative synthesis.

OBJECTIVE: To identify parents' prioritised outcomes by combining qualitative findings from two trial feasibility studies of interventions for paediatric suspected severe infection. DESIGN: Qualitative synthesis combining parent interview data from the Fluids in Shock (FiSh) and Fever feasibility studies. Parents had experience of their child being admitted to a UK emergency department or intensive care unit with a suspected infection. PARTICIPANTS: n=: 85 parents. FiSh study: n=41 parents, 37 mothers, 4 fathers, 7 were bereaved. Fever study: n=44 parents, 33 mothers, 11 fathers, 7 were bereaved. RESULTS: In addition to survival, parents prioritised short-term outcomes including: organ and physiological functioning (eg, heart rate, breathing rate and temperature); their child looking and/or behaving more like their normal self; and length of time on treatments or mechanical support. Longer term prioritised outcomes included effects of illness on child health and development. We found that parents' prioritisation of outcomes was influenced by their experience of their child's illness, survival and the point at which they are asked about outcomes of importance in the course of their child's illness. CONCLUSIONS: Findings provide insight into parent prioritised outcomes to inform the design of future trials investigating treatments for paediatric suspected or proven severe infection as well as core outcome set development work.

Restricted fluid bolus volume in early septic shock: results of the Fluids in Shock pilot trial.

OBJECTIVE: To determine the feasibility of Fluids in Shock, a randomised controlled trial (RCT) of restricted fluid bolus volume (10 mL/kg) versus recommended practice (20 mL/kg). DESIGN: Nine-month pilot RCT with embedded mixed-method perspectives study. SETTING: 13 hospitals in England. PATIENTS: Children presenting to emergency departments with suspected infection and shock after 20 mL/kg fluid. INTERVENTIONS: Patients were randomly allocated (1:1) to further 10 or 20 mL/kg fluid boluses every 15 min for up to 4 hours if still in shock. MAIN OUTCOME MEASURES: These were based on progression criteria, including recruitment and retention, protocol adherence, separation, potential trial outcome measures, and parent and staff perspectives. RESULTS: Seventy-five participants were randomised; two were withdrawn. 23 (59%) of 39 in the 10 mL/kg arm and 25 (74%) of 34 in the 20 mL/kg arm required a single trial bolus before the shock resolved. 79% of boluses were delivered per protocol in the 10 mL/kg arm and 55% in the 20 mL/kg arm. The volume of study bolus fluid after 4 hours was 44% lower in the 10 mL/kg group (mean 14.5 vs 27.5 mL/kg). The Paediatric Index of Mortality-2 score was 2.1 (IQR 1.6-2.7) in the 10 mL/kg group and 2.0 (IQR 1.6-2.5) in the 20 mL/kg group. There were no deaths. Length of hospital stay, paediatric intensive care unit (PICU) admissions and PICU-free days at 30 days did not differ significantly between the groups. In the perspectives study, the trial was generally supported, although some problems with protocol adherence were described. CONCLUSIONS: Participants were not as unwell as expected. A larger trial is not feasible in its current design in the UK. TRIAL REGISTRATION NUMBER: ISRCTN15244462.

Restricted fluid bolus versus current practice in children with septic shock: the FiSh feasibility study and pilot RCT.

BACKGROUND: There has been no randomised controlled trial (RCT) of fluid bolus therapy in paediatric sepsis in the developed world despite evidence that excess fluid may be associated with harm. OBJECTIVES: To determine the feasibility of the Fluids in Shock (FiSh) trial - a RCT comparing restricted fluid bolus (10 ml/kg) with current practice (20 ml/kg) in children with septic shock in the UK. DESIGN: (1) Qualitative feasibility study exploring parents' views about the pilot RCT. (2) Pilot RCT over a 9-month period, including integrated parental and staff perspectives study. SETTING: (1) Recruitment took place across four NHS hospitals in England and on social media. (2) Recruitment took place across 13 NHS hospitals in England. PARTICIPANTS: (1) Parents of children admitted to a UK hospital with presumed septic shock in the previous 3 years. (2) Children presenting to an emergency department with clinical suspicion of infection and shock after 20 ml/kg of fluid. Exclusion criteria were receipt of > 20 ml/kg of fluid, conditions requiring fluid restriction and the patient not for full active treatment (i.e. palliative care plan in place). Site staff and parents of children in the pilot were recruited to the perspectives study. INTERVENTIONS: (1) None. (2) Children were randomly allocated (1 : 1) to 10- or 20-ml/kg fluid boluses every 15 minutes for 4 hours if in shock. MAIN OUTCOME MEASURES: (1) Acceptability of FiSh trial, proposed consent model and potential outcome measures. (2) Outcomes were based on progression criteria, including recruitment and retention rates, protocol adherence and separation between the groups, and collection and distribution of potential outcome measures. RESULTS: (1) Twenty-one parents were interviewed. All would have consented for the pilot study. (2) Seventy-five children were randomised, 40 to the 10-ml/kg fluid bolus group and 35 to the 20-ml/kg fluid bolus group. Two children were withdrawn. Although the anticipated recruitment rate was achieved, there was variability across the sites. Fifty-nine per cent of children in the 10-ml/kg fluid bolus group and 74% in the 20-ml/kg fluid bolus group required only a single trial bolus before shock resolved. The volume of fluid (in ml/kg) was 35% lower in the first hour and 44% lower over the 4-hour period in the 10-ml/kg fluid bolus group. Fluid boluses were delivered per protocol (volume and timing) for 79% of participants in the 10-ml/kg fluid bolus group and for 55% in the 20-ml/kg fluid bolus group, mainly as a result of delivery not being completed within 15 minutes. There were no deaths. Length of hospital stay, paediatric intensive care unit (PICU) transfers, and days alive and PICU free did not differ significantly between the groups. Two adverse events were reported in each group. A questionnaire was completed by 45 parents, 20 families and seven staff were interviewed and 20 staff participated in focus groups. Although a minority of site staff lacked equipoise in favour of more restricted boluses, all supported the trial. CONCLUSIONS: Even though a successful feasibility and pilot RCT were conducted, participants were not as unwell as expected. A larger trial is not feasible in its current design in the UK. FUTURE WORK: Further observational work is required to determine the epidemiology of severe childhood infection in the UK in the postvaccine era. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15244462. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 51. See the NIHR Journals Library website for further project information.

A qualitative feasibility study to inform a randomised controlled trial of fluid bolus therapy in septic shock.

OBJECTIVE: The Fluids in Shock (FiSh) Trial proposes to evaluate whether restrictive fluid bolus therapy (10 mL/kg) is more beneficial than current recommended practice (20 mL/kg) in the resuscitation of children with septic shock in the UK. This qualitative feasibility study aimed to explore acceptability of the FiSh Trial, including research without prior consent (RWPC), potential barriers to recruitment and participant information for a pilot trial. DESIGN: Qualitative interview study involving parents of children who had presented to a UK emergency department or been admitted to a paediatric intensive care unit with severe infection in the previous 3 years. PARTICIPANTS: Twenty-one parents (seven bereaved) were interviewed 16 (median) months since their child's hospital admission (range: 1-41). RESULTS: All parents said they would have provided consent for the use of their child's data in the FiSh Trial. The majority were unfamiliar with RWPC, yet supported its use. Parents were initially concerned about the change from currently recommended treatment, yet were reassured by explanations of the current evidence base, fluid bolus therapy and monitoring procedures. Parents made recommendations about the timing of the research discussion and content of participant information. Bereaved parents stated that recruiters should not discuss research immediately after a child's death, but supported a personalised postal 'opt-out' approach to consent. CONCLUSIONS: Findings show that parents whose child has experienced severe infection supported the proposed FiSh Trial, including the use of RWPC. Parents' views informed the development of the pilot trial protocol and site staff training. TRIAL REGISTRATION NUMBER: ISRCTN15244462-results.

Evidence that Illness-Compatible Cues Are Rewarding in Women Recovered from Anorexia Nervosa: A Study of the Effects of Dopamine Depletion on Eye-Blink Startle Responses.

In anorexia nervosa (AN), motivational salience is attributed to illness-compatible cues (e.g., underweight and active female bodies) and this is hypothesised to involve dopaminergic reward circuitry. We investigated the effects of reducing dopamine (DA) transmission on the motivational processing of AN-compatible cues in women recovered from AN (AN REC, n = 17) and healthy controls (HC, n = 15). This involved the acute phenylalanine and tyrosine depletion (APTD) procedure and a startle eye-blink modulation (SEM) task. In a balanced amino acid state, AN REC showed an increased appetitive response (decreased startle potentiation) to illness-compatible cues (underweight and active female body pictures (relative to neutral and non-active cues, respectively)). The HC had an aversive response (increased startle potentiation) to the same illness-compatible stimuli (relative to neutral cues). Importantly, these effects, which may be taken to resemble symptoms observed in the acute stage of illness and healthy behaviour respectively, were not present when DA was depleted. Thus, AN REC implicitly appraised underweight and exercise cues as more rewarding than did HC and the process may, in part, be DA-dependent. It is proposed that the positive motivational salience attributed to cues of emaciation and physical activity is, in part, mediated by dopaminergic reward processes and this contributes to illness pathology. These observations are consistent with the proposal that, in AN, aberrant reward-based learning contributes to the development of habituation of AN-compatible behaviours.

Written case formulations in the treatment of anorexia nervosa: Evidence for therapeutic benefits.

OBJECTIVE: Case formulation is a core component of many psychotherapies and formulation letters may provide an opportunity to enhance the therapeutic alliance and improve treatment outcomes. This study aimed to determine if formulation letters predict treatment satisfaction, session attendance, and symptom reductions in anorexia nervosa (AN). It was hypothesized that higher quality formulation letters would predict greater treatment satisfaction, a greater number of attended sessions, and greater improvement in eating disorder symptoms. METHOD: Patients were adult outpatients with AN (n = 46) who received Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) in the context of a clinical trial. A Case Formulation Rating Scheme was used to rate letters for adherence to the MANTRA model and use of a collaborative, reflective, affirming stance. Analyses included linear regression and mixed models. RESULTS: Formulation letters that paid attention to the development of the AN predicted greater treatment acceptability ratings (p = 0.002). More reflective and respectful letters predicted greater reductions in Eating Disorder Examination scores (p = 0.003). DISCUSSION: Results highlight the potential significance of a particular style of written formulation as part of treatment for AN. Future research should examine applicability to other psychiatric disorders. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:874-882).

Two-year follow-up of the MOSAIC trial: A multicenter randomized controlled trial comparing two psychological treatments in adult outpatients with broadly defined anorexia nervosa.

OBJECTIVE: This study reports follow-up data from a multicenter randomized controlled trial (n = 142) comparing the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) with Specialist Supportive Clinical Management (SSCM) in outpatients with broadly defined anorexia nervosa (AN). At 12 months postrandomization, all patients had statistically significant improvements in body mass index (BMI), eating disorder (ED) symptomatology and other outcomes with no differences between groups. MANTRA was more acceptable to patients. The present study assessed whether gains were maintained at 24 months postrandomization. METHODS: Follow-up data at 24 months were obtained from 73.2% of participants. Outcome measures included BMI, ED symptomatology, distress, impairment, and additional service utilization during the study period. Outcomes were analyzed using linear mixed models. RESULTS: There were few differences between groups. In both treatment groups, improvements in BMI, ED symptomatology, distress levels, and clinical impairment were maintained or increased further. Estimated mean BMI change from baseline to 24 months was 2.16 kg/m(2) for SSCM and 2.25 kg/m(2) for MANTRA (effect sizes of 1.75 and 1.83, respectively). Most participants (83%) did not require any additional intensive treatments (e.g., hospitalization). Two SSCM patients became overweight through binge-eating. DISCUSSION: Both treatments have value as outpatient interventions for patients with AN. © 2016 Crown copyright. International Journal of Eating Disorders. (Int J Eat Disord 2016; 49:793-800).

The Effects of Acute Dopamine Precursor Depletion on the Reinforcing Value of Exercise in Anorexia Nervosa.

This study investigated whether dopaminergic systems are involved in the motivation to engage in behaviours associated with anorexia nervosa (AN), specifically, the drive to exercise. Women recovered from AN (AN REC, n = 17) and healthy controls (HC, n = 15) were recruited. The acute phenylalanine/tyrosine depletion (APTD) method was used to transiently decrease dopamine synthesis and transmission. The effect of dopamine precursor depletion on drive to exercise was measured using a progressive ratio (PR) exercise breakpoint task. Both groups worked for the opportunity to exercise, and, at baseline, PR breakpoint scores were higher in AN REC than HC. Compared to values on the experimental control session, APTD did not decrease PR breakpoint scores in AN REC, but significantly decreased scores in HC. These data show that women recovered from AN are more motivated to exercise than HC, although in both groups, activity is more reinforcing than inactivity. Importantly, decreasing dopamine does not reduce the motivation to exercise in people recovered from AN, but in contrast, does so in HC. It is proposed that in AN, drive to exercise develops into a behaviour that is largely independent of dopamine mediated reward processes and becomes dependent on cortico-striatal neurocircuitry that regulates automated, habit- or compulsive-like behaviours. These data strengthen the case for the involvement of reward, learning, habit, and dopaminergic systems in the aetiology of AN.