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Recent evidence from case reports suggests that a ketogenic diet may be effective for bipolar disorder. However, no clinical trials have been conducted to date. To assess the recruitment and feasibility of a ketogenic diet intervention in bipolar disorder. Euthymic individuals with bipolar disorder were recruited to a 6-8 week trial of a modified ketogenic diet, and a range of clinical, economic and functional outcome measures were assessed. Study registration number: ISRCTN61613198. Of 27 recruited participants, 26 commenced and 20 completed the modified ketogenic diet for 6-8 weeks. The outcomes data-set was 95% complete for daily ketone measures, 95% complete for daily glucose measures and 95% complete for daily ecological momentary assessment of symptoms during the intervention period. Mean daily blood ketone readings were 1.3 mmol/L (s.d. = 0.77, median = 1.1) during the intervention period, and 91% of all readings indicated ketosis, suggesting a high degree of adherence to the diet. Over 91% of daily blood glucose readings were within normal range, with 9% indicating mild hypoglycaemia. Eleven minor adverse events were recorded, including fatigue, constipation, drowsiness and hunger. One serious adverse event was reported (euglycemic ketoacidosis in a participant taking SGLT2-inhibitor medication). The recruitment and retention of euthymic individuals with bipolar disorder to a 6-8 week ketogenic diet intervention was feasible, with high completion rates for outcome measures. The majority of participants reached and maintained ketosis, and adverse events were generally mild and modifiable. A future randomised controlled trial is now warranted.

Aims1. For all eligible general adult psychiatry and substance misuse inpatients at the Royal Edinburgh Hospital (REH) to be offered appointments at a pilot onsite sexual and reproductive health (SRH) clinic.2. To evaluate the need for this novel service using eligibility rates and attendance levels.MethodsEligibility of all inpatients on a substance misuse ward considered at admission, and a space in the clinic offered if appropriate. Reminder added to the clerking proforma.Eligibility of general adult psychiatry (GAP) inpatients considered by their multidisciplinary team (MDT) weekly. Team 1 to trial this at ward round, and team 2 to trial it at rapid rundown.A patient leaflet was created to explain the clinic.ResultsGeneral adult psychiatry: In team 1, 82% (120/147) of patients were considered by the MDT over 20 weeks, and in team 2, 65% (53/82) over 10 weeks. Of all GAP patients considered, 48% (83/173) were deemed eligible. Of those, 70% (61/83) were asked if they wished to attend, usually by the junior doctor leading the QI project. Thirty-six percent (22/61) of those booked into the clinic, of which 82% attended.Substance misuse ward: Over 15 weeks, 85% (82/97) of patients admitted to the substance misuse ward were considered, deemed eligible and offered a space in the clinic at admission, of whom 15 accepted and 4 attended.ConclusionNearly half of GAP inpatients were eligible to attend, with the total likely to be higher over time, as mental state improved. A high level of demand was demonstrated for SRH services in this population, where research also suggests a higher level of need and lower levels of access.During weeks when the QI leads were absent, it was not recorded that any patients were considered at ward rounds or rapid rundowns. It was difficult to implement a process for this whilst the clinic was still at the pilot stage. The incorporation of a reminder into the ward round template would ensure that this is always considered.A very high proportion of substance misuse patients were eligible for this clinic, highlighting higher levels of capacity. The main challenges for attendance were a high discharge rate, presence of withdrawal symptoms, and extensive passes off the ward.

Background Bipolar disorder is a serious mental illness, which requires new strategies for prevention and management. Recent evidence suggests that a ketogenic diet may be an effective intervention. This research aimed to explore the feasibility and acceptability of a ketogenic diet intervention for bipolar disorder, fidelity to its behavioural components and the experiences of the participants and research clinicians involved. Methods A mixed-methods process evaluation was conducted. Semi-structured telephone interviews were carried out with 15 participants 1–2 months after completing a 6–8 week modified ketogenic diet intervention, and 4 research clinicians from the study team following the completion of data collection. Data were thematically analysed. Fidelity checklists completed by research dietitians were analysed using descriptive count and percentage statistics. Findings are reported post-hoc, following the analysis and publication of the main pilot study findings. Reporting was guided by the COREQ checklist. Results Five themes were identified in the qualitative data: (1) ‘ Encouraging entry and supporting exit’ (e.g. recognising and managing participants’ varied motives and expectations, including around weight loss and symptom alleviation); (2) ‘ Challenging but potentially transformational ,’ which reflects that while it can be difficult to initiate and maintain a ketogenic diet day-to-day, many participants perceived physical and psychological benefits (e.g. significant weight loss, mood stability and enhanced ability to focus); (3) ‘Intervention facilitators ,’ including a range of behavioural (e.g. goal setting), social (e.g. family and dietitians) and technological (e.g. apps for monitoring) support mechanisms; (4) ‘Intervention barriers’ (e.g. dietary preferences, concerns about the diet and its impact, the testing burden and capacity of the delivery team); and (5) ‘The wider context’ (e.g. the cost of living and sociocultural expectations) was a crucial factor explaining differential experiences. Overall, descriptive analyses indicated moderate-to-good fidelity to the behaviour change components of the study. Conclusion We provide novel insight into the experiences of people living with bipolar disorder initiating and following a ketogenic diet, as well as those of research clinicians who support the intervention. Future trials may benefit from increased clinical research capacity, better-defined entry and exit routes, additional interpersonal support, and greater understanding of how social and societal factors impact participation. Trial registration Study registration number: ISRCTN61613198 (02/03/22).

Preliminary evidence suggests that a ketogenic diet may be effective for bipolar disorder. To assess the impact of a ketogenic diet in bipolar disorder on clinical, metabolic and magnetic resonance spectroscopy outcomes. Euthymic individuals with bipolar disorder ( = 27) were recruited to a 6- to 8-week single-arm open pilot study of a modified ketogenic diet. Clinical, metabolic and MRS measures were assessed before and after the intervention. Of 27 recruited participants, 26 began and 20 completed the ketogenic diet. For participants completing the intervention, mean body weight fell by 4.2 kg ( < 0.001), mean body mass index fell by 1.5 kg/m ( < 0.001) and mean systolic blood pressure fell by 7.4 mmHg ( < 0.041). The euthymic participants had average baseline and follow-up assessments consistent with them being in the euthymic range with no statistically significant changes in Affective Lability Scale-18, Beck Depression Inventory and Young Mania Rating Scale. In participants providing reliable daily ecological momentary assessment data ( = 14), there was a positive correlation between daily ketone levels and self-rated mood ( = 0.21, < 0.001) and energy ( = 0.19 < 0.001), and an inverse correlation between ketone levels and both impulsivity ( = -0.30, < 0.001) and anxiety ( = -0.19, < 0.001). From the MRS measurements, brain glutamate plus glutamine concentration decreased by 11.6% in the anterior cingulate cortex ( = 0.025) and fell by 13.6% in the posterior cingulate cortex ( = <0.001). These findings suggest that a ketogenic diet may be clinically useful in bipolar disorder, for both mental health and metabolic outcomes. Replication and randomised controlled trials are now warranted.

AimsNICE guidelines and Maudsley prescribing guidelines both stipulate that patients over the age of 65 prescribed lithium or antipsychotic medication should have their bloods and physical parameters monitored regularly. There is currently no provision from the community mental health teams in Edinburgh to provide this monitoring, which falls to the patients GP. Following an initial data collection, it was found that there was no monitoring advice being provided on immediate discharge letters (IDLs) for patients discharged from two functional old age psychiatry inpatient wards at the Royal Edinburgh Hospital. This patient group often have comorbid medical conditions and therefore monitoring of their psychotropic medication is especially important. The aim of the QI project was for 100% of patients discharged from thesewards on lithium or antipsychotic medication to have appropriate advice documented on their immediate discharge letter (IDL) with regards to medication monitoring.MethodData were collected monthly by reviewing the notes of all discharged patients to determine the frequency at which medication monitoring advice was documented on IDLs from the two wards. A proposed new template for discharge letters which included advice on medication monitoring was discussed and agreed with the old age psychiatry team in Edinburgh. This was disseminated to the appropriate medical staff members and was included in induction packs for junior doctors. Following this a new “canned text” template was implemented to automatically populate the discharge letter with advice depending on whether they were antipsychotics/lithium/neither.ResultIDLs for 91 patients discharged between May 2020 and February 2021 were reviewed. Baseline data showed that 0% of patients (n = 15) had appropriate monitoring advice documented on their IDL. Following initial introduction of monitoring advice to the induction pack for junior doctors, the mean frequency of completed advice on IDLs was 50.9% across 6 months. Following implementation of the canned text, the frequency of completed advice on discharge letters for February 2021 was 100% (n = 7).ConclusionThis QI project has been successful in improving the rate of appropriate advice for antipsychotic and lithium monitoring being provided on immediate discharge letters. It is hoped that this will help reduce adverse effects associated with antipsychotics and lithium in older psychiatric patients. Further work could be done on determining the frequency that the advised monitoring is being carried out.

Medical students have a duty to report on substandard care

Parents hope Series, bedtimes don't clash By NICOLE MORELLA and TERRI NEEDHAM Staff Writers No doubt cries of \"but mom\" will be heard throughout the area from desperate young Yankees and Mets fans who want to put off bedtime for the historic Subway Series. [...] some Central Jersey school principals are even taking steps to let parents know that bending the rules - even for this monumental rivalry - is not good for students.

Accelerated biological aging due to differences in socially patterned exposures has been proposed as a mechanism underlying racial and ethnic disparities in morbidity and mortality. Research exploring this hypothesis has been limited by a lack of consensus regarding the measurement of biological aging. The goal of this study is to examine self-reported race and ethnicity as a predictor of 13 measures of epigenetic aging. Data are from the National Health and Nutrition Examination Survey (1999-2002), a nationally representative study of US residents aged two months and older. The analytic sample includes 2,402 adults aged 50-84 with epigenetic data. The exposure is self-reported race and ethnicity, and the outcomes are 13 measures of epigenetic aging trained on different aging phenotypes. In linear regression models controlling for age, age-squared, gender, and nativity, White respondents had higher epigenetic aging than Black respondents (the reference group) for six out of seven measures trained on chronological age (Hannum: b = 1.98, 95% CI = 1.43, 2.54; Horvath: b = 0.75, 95% CI = 0.09, 1.40; Weidner: b = 1.15, 95% CI = 0.30, 2.01; Vidal-Bralo: b = 2.30, 95% CI = 1.76, 2.84; SkinBlood: b = 0.85, 95% CI = 0.28, 1.43; Zhang: b = 0.58, 95% CI = 0.40, 0.76) and for one measure trained on telomere length (b = -0.17, 95% CI = -0.20, -0.14). In contrast, White respondents had lower epigenetic aging than Black respondents for three out of four measures trained on physiological age (GrimAge: b = -1.33, 95% CI = -2.01, -0.64; DunedinPoAm: b = -0.03, 95% CI = -0.04, -0.01; GrimAge2: b = -1.97, 95% CI = -2.74, -1.20) and for one measure trained on stem cell divisions (b = -0.01, 95% CI = -0.01, -0.01). Fewer differences in epigenetic aging were observed when comparing Mexican American, other Hispanic, and another race or ethnicity respondents to Black respondents. White respondents had higher epigenetic aging than Black respondents for measures trained on chronological age, whereas the opposite was true for measures trained on physiological age. More work is needed to validate measures of epigenetic aging in non-White populations and to determine whether these measures are associated with health-related outcomes similarly across racial and ethnic groups.