Pro-anorexia coaches prey on individuals with eating disorders.

OBJECTIVE: While studies have focused on pro-ana communities and pro-anorexia websites, no research has been conducted on the presence of pro-anorexia coaches within these communities. This study aimed to gain insight into the modus operandi of pro-anorexia coaches. METHOD: First, three fake profiles were used to attempt interaction with pro-anorexia coaches (n = 31). Second, an online questionnaire on experiences with pro-anorexia coaches was completed by 79 respondents. Third, a follow-up in-depth interview was conducted with 14 of these respondents. RESULTS: The results show that pro-anorexia coaches' behavior fits a five-staged model which has similarities to stages of online grooming. They focus on (1) building trust and developing a dependency relationship with the aim of (2) obtaining sexually explicit materials. Subsequently, they (3) increase pressure, (4) utilize blackmail methods with acquired content, and (5) groom respondents to meet in person. DISCUSSION: Pro-anorexia coaches deliberately abuse vulnerable young people who suffer from eating disorders to receive sexually explicit material or to meet face-to-face with a sexual intention. This study shows that the modus operandi of pro-ana coaches is similar to online grooming. Clinical professionals need to be aware of this practice to detect victims and potential victims in order to support and treat them. Prevention is invaluable to further combat pro-anorexia coaches and protect potential victims. PUBLIC SIGNIFICANCE: Individuals with an eating disorder are avid internet users. A minority frequent pro-anorexia websites and fora seeking help in losing weight. This study showed that pro-anorexia coaches prey on these individuals, often to obtain sexually explicit content. The modus operandi of pro-anorexia coaches shows similarities to online grooming. Awareness of this phenomenon and the way in which pro-anorexia coaches operate is valuable for clinicians, parents, and teachers.

[Microbiome and psychiatry: autism as an example]. / Microbioom en psychiatrie: autisme als voorbeeld.

BACKGROUND: The microbiome plays an important role in medicine. In psychiatry, it is also useful to examine the microbiome in relation to the pathogenesis and treatment of psychopathology. Nowadays, during consultation, patients and their relatives more frequently ask questions regarding the microbiome, as well as microbiome-based therapies.
AIM: To give an overview of the current knowledge regarding the relationship between microbiome, behaviour and psychiatric disorders in general, and autism in particular.
METHOD: A narrative literature review based on searches in the PubMed and psycinfo databases with the keywords: microbiota, microbiome, microorganisms, mental disorders, psychiatric disorder, autism spectrum disorder, autistic disorder, autistic and autism.
RESULTS: The number of publications concerning the bidirectional relationship between gut microbiota composition and behavior is considerable. The composition of the gut microbiome affects human behavior via subtle, finely regulated, system biological bidirectional influence. Placebo-controlled research into the effects of microbiome interventions is currently limited.
CONCLUSION: It is too early to make definitive statements about the possibilities of diagnosis and therapy aimed at the microbiome in psychiatric disorders. Further scientific research is necessary. How microbiota play a crucial role in host biochemical homeostasis is, however, becoming increasingly clearer.

Correction: Investigation of common, low-frequency and rare genome-wide variation in anorexia nervosa.

The fortieth author's name was listed incorrectly. The correct presentation is A Keski-Rahkonen.

Investigation of common, low-frequency and rare genome-wide variation in anorexia nervosa.

Anorexia nervosa (AN) is a complex neuropsychiatric disorder presenting with dangerously low body weight, and a deep and persistent fear of gaining weight. To date, only one genome-wide significant locus associated with AN has been identified. We performed an exome-chip based genome-wide association studies (GWAS) in 2158 cases from nine populations of European origin and 15 485 ancestrally matched controls. Unlike previous studies, this GWAS also probed association in low-frequency and rare variants. Sixteen independent variants were taken forward for in silico and de novo replication (11 common and 5 rare). No findings reached genome-wide significance. Two notable common variants were identified: rs10791286, an intronic variant in OPCML (P=9.89 × 10-6), and rs7700147, an intergenic variant (P=2.93 × 10-5). No low-frequency variant associations were identified at genome-wide significance, although the study was well-powered to detect low-frequency variants with large effect sizes, suggesting that there may be no AN loci in this genomic search space with large effect sizes.

[Patients and physicians creating a research agenda together: the method of the British James Lind Alliance]. / Patiënten en dokters maken samen een onderzoeksagenda.

The British James Lind Alliance (JLA) has developed a method to allow practitioners, patients and family members together to develop a research agenda for a disease or a form of treatment. In a 'priority setting partnership', they gradually establish a top-10 list of the most important unanswered research questions. Input from patients and their relatives is given the same weight when determining priorities as that from practitioners. More than 50 of these top-10 lists have been created so far, one of which was created in the Netherlands. The JLA method combines elements of the two very different methods currently prevailing in the Netherlands: the dialog model, developed by the VU and the 'health care evaluation agenda', developed by the Dutch Association of Medical Specialists. The JLA method is quite practicable and leads to new research questions. The biggest advantage is that it leads to a dialogue between creators and users of knowledge about what the relevant research questions are.

[Measuring changes during the treatment of eating disorders: a comparison of two types of questionnaires]. / Het meten van verandering tijdens behandeling voor eetstoornissen: een vergelijking van algemene en specifieke vragenlijst.

BACKGROUND: In mental health care routine outcome monitoring (ROM) has become an important part of everyday clinical practice in the Netherlands. It is important that the questionnaires involved are sensitive to therapeutic change. The Brief Symptom Inventory (BSI) is a generic instrument that is widely used and that seems to be responsive to therapeutic change. However, in relation to patients with an eating disorder, more valuable information might be obtained from a questionnaire that is better geared to the primary symptoms of the eating disorder.
AIM: To find out whether the BSI and the Eating Disorder Examination Questionnaire (EDE-Q), which is a questionnaire designed to measure eating disorder psychopathology, reveal different degrees of therapeutic change in patients with an eating disorder.
METHOD: The sample consisted of 1062 patients seeking treatment for an eating disorder (DSM-IV). We performed an analysis of variance (2 x 2 design) in order to detect any difference between the two instruments regarding their sensitivity to change at the two time points. Patients were divided into four categories: recovered, improved, unchanged or deteriorated. We used a chi-squares test to determine whether the two questionnaires differed with regard to the proportions they gave for improved and recovered patients.
RESULTS: The analyses revealed that in this patient group the EDE-Q was more sensitive to change than the BSI. The percentage of patients in the categories 'recovered' and 'improved' was higher in the EDE-Q than in the BSI. The same practice emerged with regards to the various subtypes of eating disorders.
CONCLUSION: It does seem to matter what type of questionnaire is used to measure the course and outcome of treatment. When responsiveness to change is being measured, it is important to use an instrument that assesses the symptoms that are the primary focus of treatment. If the primary aim is to reduce eating disorder symptoms, then the best type of questionnaire to use is one that assesses eating disorder psychopathology.

Cost-utility of an internet-based intervention with or without therapist support in comparison with a waiting list for individuals with eating disorder symptoms: a randomized controlled trial.

OBJECTIVE: To investigate the cost-utility of the internet-based intervention "Featback" provided with different levels of therapist support, in comparison to a waiting list. METHOD: This economic evaluation was conducted from a societal perspective and was part of a randomized controlled trial in which participants (N = 354) with self-reported ED symptoms were randomized to: (1) 8 weeks of Featback, consisting of psychoeducation and a fully automated monitoring- and feedback system, (2) Featback with low-intensity (weekly) therapist support, (3) Featback with high-intensity (three times a week) therapist support, and (4) a waiting list. Participants were assessed at baseline, postintervention, and 3-month follow-up. Cost-utility acceptability curves were constructed. RESULTS: No significant differences between the study conditions were found regarding quality-adjusted life-years (P = 0.55) and societal costs (P = 0.45), although the mean costs per participant were lowest in the Featback condition with low-intensity therapist support (€1951), followed by Featback with high-intensity therapist support (€2032), Featback without therapist support (€2102), and the waiting list (€2582). Featback seemed to be cost-effective as compared to the waiting list. No clear preference was found for Featback with or without therapist support. DISCUSSION: A fully automated Internet-based intervention for ED symptoms with no, low-, or high-intensity therapist support represented good value for money when compared to a waiting list. This finding may have important implications for clinical practice, as both the unguided- and guided intervention could allow for more efficient care and widespread dissemination, potentially increasing the accessibility and availability of mental health care services for individuals with ED symptoms. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1068-1076).

2016 Comprehensive Update of the Banff Working Group on Liver Allograft Pathology: Introduction of Antibody-Mediated Rejection.

The Banff Working Group on Liver Allograft Pathology reviewed and discussed literature evidence regarding antibody-mediated liver allograft rejection at the 11th (Paris, France, June 5-10, 2011), 12th (Comandatuba, Brazil, August 19-23, 2013), and 13th (Vancouver, British Columbia, Canada, October 5-10, 2015) meetings of the Banff Conference on Allograft Pathology. Discussion continued online. The primary goal was to introduce guidelines and consensus criteria for the diagnosis of liver allograft antibody-mediated rejection and provide a comprehensive update of all Banff Schema recommendations. Included are new recommendations for complement component 4d tissue staining and interpretation, staging liver allograft fibrosis, and findings related to immunosuppression minimization. In an effort to create a single reference document, previous unchanged criteria are also included.

[EDNOS is an eating disorder of clinical relevance, on a par with anorexia and bulimia nervosa]. / Eetstoornissen niet anderszins omschreven: een echte eetstoornis.

BACKGROUND: The category 'eating disorder 'not otherwise specified'' (EDNOS) in DSM-IV is restricted to eating disorders of clinical severity that do not completely fulfil the criteria for anorexia and bulimia nervosa. The EDNOS category is, by definition, often regarded as a a residual category and in principle designed to incorporate a small group of patients with atypical characteristics. Health insurance companies argue that the treatment of patients diagnosed with EDNOS should not be treated in mental health institutions and therefore should not get their treatment costs reimbursed by the insurance companies. The most important argument of the insurance companies is that patients in the EDNOS category do not display serious psychiatric symptoms. AIM: The aim of this paper is to show that EDNOS is an eating disorder category of clinical relevance. The article provides a critical overview of literature on EDNOS which studies the prevalence, severity and course of the disorder. We also discuss to what extent the fifth version of dsm solves the problems relating to this residual category. METHOD: We reviewed the literature. RESULTS: The classification given in DSM-IV is not an accurate reflection of clinical reality. Half of the patients presenting with an eating disorder and seeking treatment do meet the criteria for EDNOS. The duration and the severity of eating disorder psychopathology, the presence of comorbidity, the mortality, and the use of the mental health care services by individuals with an eating disorder appear to be very similar in EDNOS patients and in patients with anorexia and bulimia nervosa. Eating disorder classifications can be regarded as snapshots taken throughout the course of an illness. Over of the years patients can be afflicted with various subtypes of an eating disorder. DSM-5 places fewer patients in the EDNOS category that did DSM-IV. CONCLUSION: In the latest version of dsm, namely DSM-5, the number of patients with an eating disorder classified as EDNOS has declined. There appears to be sufficient scientific evidence for EDNOS to be considered as an eating-disorder category of clinical severity, comparable to anorexia and bulimia nervosa. In our view, patients classified as having EDNOS should be offered regular treatment in mental health institutions.

[Criteria for admitting patients with anorexia nervosa as inpatients to a general hospital; survey among internists]. / Criteria voor opname van volwassenen met anorexia nervosa op een interne afdeling van een algemeen ziekenhuis; enquête onder internisten.

BACKGROUND: Anorexia nervosa (an) is associated with a number of life-threatening complications. Sometimes there are good reasons for admitting an anorexia nervosa patient to a general hospital for treatment as an inpatient. Therefore, there needs to be optimal collaboration between psychiatrists treating the patient and the medical staff at the general hospital. AIM: To obtain insight into the admission criteria and other possible factors that play a role in the physician's decision to admit a patient with anorexia nervosa for inpatient treatment in a general hospital. METHOD: Internists and residents-internal medicine completed a questionnaire about admission criteria and, where applicable, about threshold values for these criteria. The physicians were also asked to judge two case vignettes. In addition, they were questioned about other factors that influenced their views on the admission of patients with anorexia nervosa to a general hospital and about their attitude to this patient-group, their experience of treating patients with anorexia nervosa and their awareness of a need for a guideline. The data were collected at the annual Dutch congress for internists at Maastricht. RESULTS: In total 78 congress attendees responded to the questionnaire; 47% were internist and 53% were resident-in-training. Agreement was greatest with regard to the following admission criteria (top 5): 1. serum potassium (threshold value <2.5 mmol/l was the criterion selected most); 2. arrhythmia; 3. hypoglycemia; 4. heart rate (threshold value <40 bpm was chosen most); 5. prolonged qt interval on an ECG. According to the two fictitious cases, the reason for admitting a patient with anorexia nervosa with milder symptoms was influenced by 'attitude'. Half of the respondents pointed out that the patient's cooperation plays a role in the decision to admit a patient with an eating disorder. CONCLUSION: Respondents reached a consensus regarding several admission criteria but the threshold values they gave varied substantially. Attitude towards the patient-group can sometimes influence the decision to admit a patient with anorexia nervosa to a general hospital. Internists and residents-in-training indicated they require detailed, carefully compiled guidelines which take into consideration the expected results and which emphasise the importance of obtaining the patient's cooperation.

A genome-wide association study of anorexia nervosa.

Anorexia nervosa (AN) is a complex and heritable eating disorder characterized by dangerously low body weight. Neither candidate gene studies nor an initial genome-wide association study (GWAS) have yielded significant and replicated results. We performed a GWAS in 2907 cases with AN from 14 countries (15 sites) and 14 860 ancestrally matched controls as part of the Genetic Consortium for AN (GCAN) and the Wellcome Trust Case Control Consortium 3 (WTCCC3). Individual association analyses were conducted in each stratum and meta-analyzed across all 15 discovery data sets. Seventy-six (72 independent) single nucleotide polymorphisms were taken forward for in silico (two data sets) or de novo (13 data sets) replication genotyping in 2677 independent AN cases and 8629 European ancestry controls along with 458 AN cases and 421 controls from Japan. The final global meta-analysis across discovery and replication data sets comprised 5551 AN cases and 21 080 controls. AN subtype analyses (1606 AN restricting; 1445 AN binge-purge) were performed. No findings reached genome-wide significance. Two intronic variants were suggestively associated: rs9839776 (P=3.01 × 10(-7)) in SOX2OT and rs17030795 (P=5.84 × 10(-6)) in PPP3CA. Two additional signals were specific to Europeans: rs1523921 (P=5.76 × 10(-)(6)) between CUL3 and FAM124B and rs1886797 (P=8.05 × 10(-)(6)) near SPATA13. Comparing discovery with replication results, 76% of the effects were in the same direction, an observation highly unlikely to be due to chance (P=4 × 10(-6)), strongly suggesting that true findings exist but our sample, the largest yet reported, was underpowered for their detection. The accrual of large genotyped AN case-control samples should be an immediate priority for the field.

Donor hemosiderosis does not affect liver function and regeneration in the setting of living donor liver transplantation.

Living donor liver transplantation (LDLT) demands a careful assessment of abnormal findings discovered during the evaluation process to determine if there will be any potential risks to the donor or recipient. Varying degrees of elevated hepatic iron levels are not uncommonly seen in otherwise healthy individuals. We questioned whether mild expression of hemosiderin deposition presents a safety concern when considering outcomes of living donation for both the donor and the recipient. We report on three LDLT patients who were found to have low- to moderate-grade hemosiderin deposition on liver biopsy. All other aspects of their evaluation proved satisfactory, and the decision was made to proceed with donation. There were no significant complications in the donors, and all demonstrated complete normalization of liver function postoperatively, with appropriate parenchymal regeneration. The recipients also had unremarkable postoperative recovery. We conclude that these individuals can be considered as potential donors after careful evaluation.

Clinical features and natural history of hepatocellular adenomas: the impact of obesity.

BACKGROUND: Hepatocellular adenoma is a benign tumour associated with bleeding and malignant transformation. Obesity has been linked to hepatic tumourigenesis. AIM: To evaluate the presentation of hepatocellular adenoma in obesity, and the impact of obesity on the clinical course. METHODS: Records of 60 consecutive patients (between 2005 and 2010) with a diagnosis of hepatocellular adenoma from a single tertiary centre were analysed. RESULTS: Fifty six of 60 patients were women, median age was 36years, 75% had history of contraceptive use, 18% were overweight and 55% were obese (BMI ≥30kg/m(2) ). Majority (63%) were asymptomatic; seven patients presented with bleeding. Single (28%) and multiple adenomas (72%) were encountered; size ranged from 1 to 19.7cm. Obesity was more often associated with multiple adenomas (85% vs. 48%, P=0.005), bilobar distribution (67% vs. 33%, P=0.01), lower serum albumin (P=0.007) and co-morbidities of fatty liver (P=0.006), diabetes (P=0.003), hypertension (P=0.006) and dyslipidemia (P=0.03). During median follow-up of 2.6years, there were no instances of bleeding, malignant transformation or death. Thirty four patients underwent therapeutic intervention (17 surgical resection, nine transarterial embolization and eight both interventions sequentially). The rate of complete resection of adenoma(s) was significantly lower in obese patients (8% vs. 69%, P=0.004). In the 26 patients without intervention, tumour size progression was more frequently observed in obese patients (33% vs. 0%, P=0.05). Three of 15 obese patients (20%) lost ≥5% body weight and there was no progression in the liver lesions. CONCLUSIONS: Obesity and features of metabolic syndrome were frequently observed in hepatocellular adenoma. Multiple and bilobar adenomas were more frequent in obese patients. Among patients who were conservatively managed, tumour progression was more often associated with obesity.

Association study in eating disorders: TPH2 associates with anorexia nervosa and self-induced vomiting.

Twin studies suggest that genetic factors play a substantial role in anorexia nervosa (AN) and self-induced vomiting (SV), a key symptom that is shared among different types of eating disorders (EDs). We investigated the association of 25 single nucleotide polymorphisms (SNPs), capturing 71-91% of the common variance in candidate genes, stathmin (STMN1), serotonin receptor 1D (HTR1D), tryptophan hydroxylase 2 (TPH2) and brain-derived neurotrophic factor (BDNF), with AN and EDs characterized by regular SV. The first allele frequencies of all the SNPs were compared between a Dutch case group (182 AN, 149 EDs characterized by SV) and 607 controls. Associations rendering P-values < 0.05 from this initial study were then tested for replication in a meta-analysis with two additional independent ED case-control samples, together providing 887 AN cases, 306 cases with an ED characterized by SV and 1914 controls. A significant effect for the minor C-allele of tryptophan hydroxylase 2 rs1473473 was observed for both AN [odds ratio (OR) = 1.30, 95% CI 1.08-1.57, P < 0.003] and EDs characterized by SV (OR = 1.52, 95% CI 1.28-2.04, P < 0.006). In the combined case group, a dominant effect was observed for rs1473473 (OR = 1.38, 95% CI 1.16-1.64, P < 0.0003). The meta-analysis revealed that the tryptophan hydroxylase 2 polymorphism rs1473473 was associated with a higher risk for AN, EDs characterized by SV and for the combined group.

Sex differences in sum scores may be hard to interpret: the importance of measurement invariance.

In most assessment instruments, distinct items are designed to measure a trait, and the sum score of these items serves as an approximation of an individual's trait score. In interpreting group differences with respect to sum scores, the instrument should measure the same underlying trait across groups (e.g., male/female, young/old). Differences with respect to the sum score should accurately reflect differences in the latent trait of interest. A necessary condition for this is that the instrument is measurement invariant. In the current study, the authors illustrate a stepwise approach for testing measurement invariance with respect to sex in a four-item instrument designed to assess disordered eating behavior in a large epidemiological sample (1,195 men and 1,507 women). This approach can be applied to other phenotypes for which group differences are expected. Any analysis of such variables may be subject to measurement bias if a lack of measurement invariance between grouping variables goes undetected.

Histopathologic outcome of neoadjuvant image-guided therapy of hepatocellular carcinoma.

BACKGROUND AND AIMS: The best curative treatment for hepatocellular carcinoma (HCC) is liver transplant (LT), with the limitation to either a solitary lesion < 5 cm or up to three lesions < 3 cm each. Arresting tumor growth or downstaging to make patients eligible for LT can be obtained by neoadjuvant treatments such as transarterial chemoembolization (TACE), selective internal radiation therapy (SIRT), chemical or radiofrequency ablation (RFA). We evaluated the histopathologic response in explant specimens to neoadjuvant image-guided therapy of HCC prior to LT. METHODS: Twenty-eight patients with 39 HCC nodules eligible for LT underwent neoadjuvant image-guided therapy 1-393 days prior to transplant. Treatment included TACE (5 nodules), SIRT (7 nodules), RFA (12 nodules), chemical ablation (3 nodules) combined TACE and acetic acid injection (1 nodule) and combined TACE and RFA (11 nodules). 19/28 patients not transplanted within 30 days had interval MRI and 3 patients with progressive disease were retreated. RESULTS: Residual viable tumor was seen in 42% of patients with post-treatment imaging. Explant pathology revealed viable tumor in 35 of 39 (90%) treated nodules and somewhere in the explanted liver in all patients. Viability and/or progression of the treated tumor was noted in 5/5 nodules treated with TACE, 6/7 with SIRT, 11/12 with RFA, 2/3 with chemical ablation and 11/12 with combined treatment. CONCLUSION: Viable local or remote tumor was identified on explanted liver in the majority of patients with HCC after neoadjuvant therapy, despite apparent successful treatment on MRI.

Hepatic involvement in a liver transplant recipient with disseminated cryptococcosis.

Cryptococcosis occurs primarily in immunocompromised patients such as organ transplant recipients. Central nervous system and pulmonary infections are documented most frequently; hepatic involvement is rarely reported. We report a case of early hepatic cryptococcosis in a 54-year-old male liver transplant recipient. Two weeks after orthotopic liver transplant, he was readmitted with fever, malaise, diarrhea, and progressive pulmonary infiltrates. On admission, liver-associated enzymes were decreased from those at discharge after transplantation. Blood and bronchoalveolar lavage cultures were positive for Cryptococcus neoformans. Despite treatment with amphotericin B and flucytosine, the patient developed both marked cholestasis and transaminase elevation. A liver biopsy performed 22 days after admission revealed numerous yeast-like organisms in hepatic sinusoids consistent with C. neoformans. Despite treatment, the patient died 55 days after admission and 66 days after transplantation. Our case illustrates hepatic involvement of cryptococcal infection within the first month following transplantation.

Genetic influences on disordered eating behaviour are largely independent of body mass index.

OBJECTIVE: Prior studies suggest eating disorders and related characteristics are moderately to substantially heritable. We are interested in identifying the genes underlying disordered eating behaviour (DEB), and want to know how much of the genetic influence underlying DEB is attributable to genetic influences on body mass index (BMI). METHOD: Bivariate analyses were performed, in adolescent twins and siblings, to estimate the genetic and environmental contributions for DEB, BMI, and their overlap. RESULTS: Shared genetic risk factors explained the overlap between BMI and DEB (genetic correlation was 0.43 in women, 0.51 in men). DEB was highly heritable in women (a(2) = 0.65; a(2) independent of BMI = 0.53) and moderately heritable in men (a(2) = 0.39; a(2) independent of BMI = 0.29). BMI was highly heritable in both men (a(2) = 0.76) and women (a(2) = 0.80). CONCLUSION: The entire correlation between DEB and BMI was explained by shared genetic risk, but the majority of genetic influences on DEB were due to genetic effects independent of BMI.

Maladaptive core beliefs and eating disorder symptoms.

This study compared maladaptive core beliefs of eating-disordered groups (full and subthreshold syndrome) and healthy controls and investigated the association between eating disorder symptoms and core beliefs. Participants were compared on self-report measures of core beliefs (YSQ) and eating disorder psychopathology (BITE). Anorexia nervosa (AN; both subtypes) and bulimia nervosa (BN) patients had significantly more core beliefs than healthy controls. Binge eating disorder (BED) patients had intermediate scores between AN and BN on the one hand and healthy controls on the other hand. No correlation was found between core beliefs and frequency of binge eating. Frequency of vomiting, laxative misuse and fasting was positively associated with all domains of core beliefs. Patients with eating disorders have some core beliefs which are not directly related to eating, weight or shape. Frequency of purging and fasting behaviors is associated with more severe maladaptive core beliefs. Our data demonstrate the importance of identifying purging and fasting as significant clinical markers.