Laxatives

It was decided a priori that the instrument should have certain properties to ensure it would function as an easy-to-use measure of psychosocial impairment secondary to eating disorder features. First, it needed to be a self-report questionnaire. Second, it needed to be compatible with a current-state measure of eating disorder features so that together the two instruments would provide an assessment of psychopathology and its resulting impairment. The Eating Disorder Examination Questionnaire (EDE-Q) (Fairburn & Beglin, 1994 (link)) was chosen as the measure of eating disorder psychopathology as it is widely used and has been extensively validated (Peterson & Mitchell, 2005 ). Thus the new measure of impairment, named the Clinical Impairment Assessment (CIA), was designed to have the same Likert-style response format as the EDE-Q and the same time frame (covering the previous 28 days) so that respondents could easily move from completing one instrument to the completion of the other. Third, it was decided that the CIA should be relatively brief so that the two instruments could be completed together in a short period of time (approximately 10 min). Fourth, to maximise clinical utility, it was decided that the instrument should generate a single, readily-calculated, overall score indicative of the severity of secondary impairment, although the possibility of generating domain-specific scores was to be explored. Lastly, it was decided to focus exclusively on secondary psychosocial impairment rather than the physical effects of eating disorder psychopathology as the subjective physical consequences of an eating disorder (e.g., weakness, feeling faint or cold, palpitations, muscle twitches and spasms) are mostly non-specific in character and difficult for the individual to ascribe to their way of eating.
Two main considerations governed decision-making regarding the content of the CIA. First, it needed to assess the influence of all the main elements of eating disorder psychopathology on a person's functioning. Hence it was decided that the CIA should open with the following stem question: “Over the past month, to what extent have your eating habits, exercising or feelings about your eating, shape or weight affected…”. We decided not to include purging in the stem question as “eating habits” includes vomiting and laxative misuse in most patients' minds and, having just completed the EDE-Q, participants will have these forms of behaviour in their mind. Second, it was decided that the CIA should ask about the main aspects of life that are affected by eating disorder psychopathology. These were identified by KB, ZC, CGF and RLP on the basis of their clinical experience, the content of generic measures of health-related quality of life, and the responses of eating disorder patients to exploratory interviews focused on the presence and nature of any secondary psychosocial impairment that they were experiencing (Bohn, 2006 ). Examples of impairment within the identified domains of life were specified resulting in the eventual development of a 22-item instrument with 7 items directed at effects on mood and self-perception, 4 at effects on cognitive functioning, 7 at impairment of interpersonal functioning, and 4 at effects on work performance. Each item was rated on a 4-point Likert scale, where 0 (“Not at all”) was equivalent to no impairment and 3 (“A lot”) to severe impairment. The total score (‘global CIA score’) was designed to provide an overall index of severity of current secondary psychosocial impairment. This preliminary version of the CIA was evaluated using data collected in the context of a treatment trial.

Data were collected by interviewing the patient, family member, doctor, or nurses by using a standard questionnaire performed in Swahili and English language either before surgery or postoperatively, depending on the patient’s status. The information included in the socio-demographic details comprised name, age, sex, marital status, occupation, education, etc. In an attempt to calculate the distance from the hospital, the complete residential address of the patient was recorded. We defined surgical acute abdomen as abdominal pain due to a surgical cause that necessitated admission to the surgical unit. The time of onset was defined as the period when the first abdominal symptom began, and the time of presentation was the time of admission to the hospital. The pre-hospital interval was the time difference between onset and presentation. Delayed presentation was defined as a pre-hospital interval of > 24 h. We enquired in detail about the events between the onset of symptoms and admission to MNH. This included any primary treatment received during the pre-hospital interval and the response to it, the nature of the provider/’patient/family member/doctor, place of treatment (traditional healers, pharmacy/nursing home, private hospital, primary health center), and form of treatment (antibiotic, analgesic, antacid, laxative, intravenous fluids, etc.) The events during the pre-hospital interval were identified and classified as related to the patient and family, to the medical personnel, or other reasons such as late referral, off-duty hours, public holidays, etc. The signs and symptoms at the presentation time were noted and a detailed history was recorded. The provisional diagnosis and clinical decision made by the attending healthcare professional at the time of admission to MNH were recorded.

12 patients received therapy with FMT plus PEN (80%). The guardians of the 12 patients refused immunological interventions, considering the adverse effects of corticosteroids and immunosuppressants, and they agreed to FMT as first-line therapy. The number of FMT infusions was grouped into single (1 day) or multiple infusions (2-10 days continuously). No bowel preparation (cleanup or laxative administration) was performed before the FMT. The donor feces were collected 1 h pre-FMT, attenuated, and mingled with sterile normal saline (1 mg of feces was attenuated with 5ml of saline). Samples were filtered through sterile gauze, and a 100mL fresh fecal microbiota suspension was prepared for the FMT. The fecal suspension was poured into a sterile cup for the FMT procedure within 1 h. The routes of administration included colonoscopy and enema. Fecal microbiota transplantation (FMT) were performed by colonoscopy (Figures 2A, B). Fecal microbiota transplantation (FMT) were performed by retention enema (Figures 2C, D). After infusion, the patients were asked to hold a fixed position (>25° semi-reclining or hip-up position) for at least 4 h. The FMT procedure followed a uniform standard for each patient. All the patients in the FMT group received fresh fecal suspensions.

The study included 168 obese women (BMI ≥ 30 kg/m²) with BED or subthreshold BED, aged 18–68 years (M = 41, SD = 12.6), who were referred between 2014 and 2017 for CBT to Novarum, a specialist treatment centre for obesity and eating disorders in Amsterdam, the Netherlands.
Diagnostic assessment included an initial telephone screening on eating disorder symptoms and other psychiatric symptoms and, if applicable, retrievement of information about former psychological treatments. Subsequently, a clinical interview by either a licensed and trained psychologist or psychiatrist was conducted, in which the presence of BED or subthreshold BED was determined, as well as relevant psychiatric comorbidity. The assessment for eating disorders included a semi-structured diagnostic interview based on the SCID-I eating disorder module as part of the Structured Clinical Interview for DSM-IV, Patient Edition (SCID-P) [42 ] including specific questions regarding criteria for binge eating as established in the Eating Disorder Examination (EDE) interview [43 ]. The diagnostic formulation and proposed treatment options were then confirmed by a multidisciplinary team. As DSM-5 was introduced in the Netherlands on January 2017, the former DSM-IV diagnosis of all participants were revised (by the psychiatrist of the research team) using the DSM-5 criteria for BED and subthreshold BED (as described by the DSM-5 category Other Specified Feeding and Eating Disorders (OSFED)).
Patients engaging in compensatory bulimic behaviors like vomiting or laxative misuse were not eligible for this study, nor were patients who were currently in concurrent treatment for BED or weight loss programs. Other exclusion criteria were severe comorbid psychiatric disorders (e.g. psychotic disorders, severe mood disorders, suicidality or substance use disorders), mental retardation and current pregnancy.
A total of 168 patients participated in the study, 156 of which completed their treatment program. 12 patients dropped out of treatment because of current life events, patient’s feeling that either the therapy did not meet their expectation in relief from complaints or the unilateral belief that she had already improved sufficiently. In some cases, the therapist thought a comorbid disorder required attention first. Of the 156 treatment completers, 7 patients were excluded from analysis due to missing data on one of the primary outcome variables, the EDE-Q global score or EDE-Q self-reported binge eating frequency. Remaining patients with normative EDE-Q global scores both at admission and discharge (n = 9) were not included in the analyses since improvement for this group was not applicable, leaving 140 patients for further analyses.
This study protocol was approved by the Medical Ethical Review Committee (METC) of the Amsterdam Medical Centre (AMC). All participants gave informed written consent before enrolment and received 15 euro compensation for their willing participation.