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Draffin K, Hamilton J, Godsil S, Rudolph S, Crowe T, Newton R. Comparison of a low carbohydrate intake and standard carbohydrate intake on refeeding hypophosphatemia in children and adolescents with anorexia nervosa: a pilot randomised controlled trial. J Eat Disord 2022; 10:50. [PMID: 35413883 PMCID: PMC9006566 DOI: 10.1186/s40337-021-00519-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nutritional rehabilitation for patients with anorexia nervosa involves balancing the need for weight gain whilst mitigating the risk of refeeding syndrome. Graded caloric increases and restriction of calories from carbohydrate have been used to minimise the risk of developing refeeding hypophosphatemia. There is little evidence to support the recommended nutrient composition, specifically the recommended carbohydrate intake that is safe in this population. The aim of this pilot study was to compare the effect of a low and a standard carbohydrate feeding protocol on serum phosphate levels in children and adolescents with anorexia nervosa. METHODS A pilot study of 23 children and adolescents with anorexia nervosa admitted for medical stabilisation to the adolescent ward of a tertiary hospital was undertaken. Participants were commenced on an oral feeding protocol and were randomly allocated to isocaloric meal plans that were either low carbohydrate (< 40% total energy from carbohydrate) or standard carbohydrate (50-60% total energy from carbohydrate). Serum phosphate levels were monitored daily across the first week and twice weekly thereafter. Clinical status, including weight gain, was monitored throughout admission. RESULTS 52% (n = 12) of participants were allocated to the low carbohydrate group and 48% (n = 11) were allocated to the standard carbohydrate group. No patients in either of the diet groups developed refeeding hypophosphatemia in the first seven days of admission. Weight gain during the first week was significantly higher in the standard carbohydrate diet (1.4 kg/wk ± 0.5) compared to the low carbohydrate diet (0.6 kg/wk ± 0.9), p value 0.03. Participants from both diet groups were largely orally fed with less than 10% of the total number of meals and/or snacks across both groups provided as nutrition supplement drinks, either orally or enterally. CONCLUSION This pilot study supports that a standard carbohydrate intake (providing 50-60% of total energy from carbohydrate) optimises nutritional rehabilitation without increasing the risk of refeeding hypophosphatemia in adolescent inpatients with anorexia nervosa. CTN: ACTRN12621000300875. Plain English Summary: People with eating disorders who are underweight or malnourished, such as patients with anorexia nervosa, are at risk of refeeding syndrome when they receive treatment and return to regular eating. Refeeding syndrome may cause fluid and electrolyte shifts. This can occur as a result of the reintroduction of carbohydrates, and can have potentially life-threatening consequences if not managed appropriately. Refeeding hypophosphatemia is one of the early markers of refeeding syndrome. This study compared patients who were provided a low carbohydrate diet (40% total energy from carbohydrate) to those who were provided a standard carbohydrate diet (50-60% total energy from carbohydrate) to see if patients from either group were more at risk of developing refeeding syndrome. No patients in either of the diet groups developed refeeding hypophosphatemia. This pilot study may help to ensure that when patients get treated for their eating disorder in hospital, they can return to a normal diet as soon as possible with close medical monitoring.
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Lasfar M, Eveno AL, Huas C, Godart N. [Diversity of hospital care for anorexia nervosa in psychiatry in France]. Encephale 2021; 48:517-529. [PMID: 34728068 DOI: 10.1016/j.encep.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/18/2021] [Accepted: 04/30/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Hospitalization is rare in anorexia nervosa (AN) and local application of indications is heterogeneous. However, no study has evaluated the effect of these different treatment modalities on the mean length of stay. Our objective was to describe the context and modalities of a wide range of hospital care programs offered to patients with anorexia nervosa in eleven specialized French psychiatric centers for patients from childhood to adulthood. This work was carried out within the framework of the EVHAN (Evaluation of Hospitalization for AN, Eudract number: 2007-A01110-53, registered in Clinical trials) research program. The EVHAN program comprises five main lines: weight objectives at discharge, the practice or not of a separation period, the use of clear nutritional dietary objectives (cognitive/behavioral), the intensity of family involvement in treatment, and the existence or absence of a stabilization phase before ending inpatient treatment. These main lines will make it possible to study the impact of treatment modalities on the future of patients in the short and medium term (at discharge and at 1-year follow-up). METHODS The eleven centers are located in France (Bordeaux, Nantes, Paris and Ile-de-France, Rouen and Saint-Étienne). Various staff members (psychiatrists, somatic doctors, nurses, dieticians, psychologists) from each center were interviewed using a semi-structured questionnaire. Data on operating modalities and context of care were collected and analyzed. RESULTS Four of the eleven centers were exclusively child/adolescent centers, and seven of 11 were adolescent (from 11, 13 or 16 years) and young adult centers. All centers offered a graduated approach from outpatient to full hospitalization. The majority had a number of beds allocated for patients with eating disorders. The criteria for hospitalization were homogeneous with respect to somatic and/or psychic severity prefiguring the consensus criteria defined by the French Health Authority (HAS) in 2010. Child/adolescent units used the weight curve to set weight objectives at discharge (between the 10th and 50th percentiles). Most adult units used weight objectives at discharge corresponding to a body mass index between 17 and 20kg/m2. Nine centers used a written or oral care contract. One unit did not separate the patient from her/his usual environment, the others had a practice gradient of partial separation and total separation times. These were either short, lasting a maximum of 3 weeks, or long, lasting more than 3 weeks. Conversely, patients were not isolated within the unit, and benefited from a rich social life, depending on her/his physical condition. The patient's family was in contact with the team and fully supported. The longest periods of separation involved adolescents and adults. Nutritional support varied from a group approach (meals in the dining room, standardized meals of the care center) to very individualized approaches within a specific framework. All the units reported meeting with families at least once during the hospitalization; with the patient's parents for child/adolescent patients and/or unmarried patients and with the husband/wife for married patients. The majority of the centers requested a phase of weight stabilization, whatever the age before hospital discharge. CONCLUSION There is international and national consensus regarding the indications for hospitalization, and the main lines of multidisciplinary care to be developed within this framework. However, local application of these indications was heterogeneous resulting in diverse modalities of hospital care for anorexia nervosa in France. Specialized teams have developed management strategies arising from their "team culture". The complexity of the anorexic pathology, due to the psyche-soma intrication and the diversity of age groups, highlights the complexity of care available. The impact of this diversity of hospital care on patient outcomes will be studied as a result of this work.
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Affiliation(s)
- M Lasfar
- CHU de Rouen, Service de psychopathologie et médecine de l'adolescent, 76000 Rouen, France
| | - A-L Eveno
- Cabinet médical, 14 ter rue Françoise d'Amboise, 56000 Vannes, France
| | - C Huas
- Fondation Santé des Étudiants de France, Direction générale, 8, rue E. Deutsch-de-la-Meurthe, 75014 Paris, France; CESP, Inserm U1018, University Paris-Sud, Université Paris-Saclay, UVSQ, Villejuif, France
| | - N Godart
- UFR des Sciences de la Santé Simone Veil (UVSQ), Praticienne Hospitalière, Fondation Santé des Étudiants de France, Clinique E Rist, 8, rue E. Deutsch-de-la-Meurthe, 75014 Paris, France.
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Schefft M, Noda A, Godbout E. Aligning Patient Safety and Stewardship: A Harm Reduction Strategy for Children. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2021; 7:138-151. [PMID: 38624879 PMCID: PMC8273156 DOI: 10.1007/s40746-021-00227-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
Purpose of review Review important patient safety and stewardship concepts and use clinical examples to describe how they align to improve patient outcomes and reduce harm for children. Recent findings Current evidence indicates that healthcare overuse is substantial. Unnecessary care leads to avoidable adverse events, anxiety and distress, and financial toxicity. Increases in antimicrobial resistance, venous thromboembolism, radiation exposure, and healthcare costs are examples of patient harm associated with a lack of stewardship. Studies indicate that many tools can increase standardization of care, improve resource utilization, and enhance safety culture to better align safety and stewardship. Summary The principles of stewardship and parsimonious care can improve patient safety for children.
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Affiliation(s)
- Matthew Schefft
- Department of Pediatrics, Division of Hospital Medicine, Children’s Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Children’s Hospital of Richmond at VCU, 1001 E Marshall St, Richmond, VA 23298 USA
| | - Andrew Noda
- Department of Pharmacy, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Emily Godbout
- Department of Pediatrics, Division of Infectious Disease, Children’s Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Lascar R, Letranchant A, Hirot F, Godart N. [What factors explain the length of hospitalization for anorexia nervosa: A systematic review]. Encephale 2021; 47:362-368. [PMID: 33752870 DOI: 10.1016/j.encep.2020.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The cost of hospital treatment for anorexia nervosa (AN) is very high given its duration. Identifying factors related to length of hospital stay (LOS) would make it possible to consider targeted therapeutic strategies that, by optimizing care, would reduce their duration and costs. The objective of this work is to identify the factors related (predictive and associated) to LOS for AN. METHODS Systematic review of existing literature up to October 2020, based on Pubmed, according to PRISMA recommendations (Preferred Reported Items for Systematic reviews and Meta-Analysis). Factors related to LOS have been described in two categories: factors related to clinical aspects ; and factors related to therapeutic aspects and management modalities. We distinguished predictive factors (identified as pre-hospitalization or contemporaneous with hospital admission) and associated factors (observed during hospitalization) for each category. RESULTS Thirteen articles were selected. Samples from the selected studies ranged from 35 to 381 subjects, mostly women with restrictive type AN (R-AN), but some samples included all types of AN, or focused on purging-type forms. The mean age at admission ranged from 13.6 years (Standard Deviation-SD:±1.6) to 30.3 years (SD :±13.9), corresponding to adolescent, adult or mixed samples. Mean body mass indices at admission ranged from 12.3 (SD±1.4) to 16.6 (SD:±2.1). The duration of disease progression ranged from 11.7 months±2.2 to 9.7 years. Mean LOS are short for studies conducted in pediatrics or in medical services (ranging from 13.0 days [SD±7.3] to 22.1 days [SD±9.4]); they are more variable for studies conducted in psychiatry: from 15.6 days (SD±1.0) to 150.2 days (SD±80.8). Among the factors related to an increase in LOS, clinical predictors included: older age at onset or admission; longer duration of the disorder; low minimum body weight during AN; low BMI at admission; purgative form of anorexia nervosa; and high levels of dietary symptoms (asceticism and ineffectiveness dimensions on Eating Disorder Inventory-2). Therapeutic and management modality predictive factors were: a higher number of hospitalizations for AN; the use of enteral nutrition (nasogastric or percutaneous gastric tube) on admission or during hospitalization; the use of intravenous renutrition coupled with oral renutrition; hospitalization far from the patient's home; absence of hospital care in psychiatry after medical stabilization in a somatic unit; compulsory hospitalization. Associated factors were: the presence of psychiatric comorbidities; greater weight gain during hospitalization. Among the factors related to a decrease in LOS, the clinical predictive factor were: greater self-confidence at admission (measured by the Eating Disorder Recovery Self-Efficacy Questionnaire). Therapeutic and management modality predictors included: increased caloric intake of oral renutrition on admission; intake of oral nutritional supplements on admission; and hospitalization in urban areas. The associated factor was: compliance with the weight contract in the adolescent population. DISCUSSION Factors related to an increase in LOS are explained by: higher resistance to treatment, higher severity of the disease, the time required for weight gain in services using cognitive-behavioural therapy, complications associated with renutrition modalities such as parenteral renutrition, difficulties in organising outpatient follow-up which require better consolidation of inpatient treatment and the lack of multidisciplinary care in medical services. Factors related to a decrease in LOS are due to: faster weight gain, the presence of a greater number of outpatient follow-up structures close to the hospital and better adherence to treatment to complete the weight contract. CONCLUSIONS Taking these factors into account during hospitalization for AN would help optimize care, duration and costs. This situation therefore requires the development of therapeutic trials targeting the identified factors in order to reduce LOS in the treatment of AN.
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Affiliation(s)
- R Lascar
- Faculté de médecine de Nice, UNS Santé, 28, avenue de Valombrose, 06107 Nice, France; Faculté de médecine, université Paris Sud XI, 63, rue Gabriel Péri, 94270 le Kremlin-Bicêtre, France.
| | - A Letranchant
- Département de psychiatrie, Institut Mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France
| | - F Hirot
- Service hospitalo-universitaire de santé mentale de l'adolescent et du jeune adulte, Fondation Santé Des Étudiants de France, Paris, France; UFR Health Sciences Simone Veil, UVSQ, Saint-Quentin en Yvelynes, France; CESP, Inserm 1178, Paris-Sud University, UVSQ, Paris-Saclay University, Villejuif, France
| | - N Godart
- Département de psychiatrie, Institut Mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France
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Abstract
Anorexia nervosa (AN) is an eating disorder that is difficult to treat, and relapse is common. This article addresses management strategies and nursing interventions for adolescents diagnosed with AN.
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Affiliation(s)
- Kathleen Peterson
- Kathleen Peterson is a professor of nursing at The College at Brockport, State University of New York. Rebecca Fuller is a level III clinical nurse at Golisano Children's Hospital, University of Rochester in N.Y
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Ibrahim A, Cutinha D, Ayton A. What is the evidence for using bed rest as part of hospital treatment of severe anorexia nervosa? EVIDENCE-BASED MENTAL HEALTH 2019; 22:77-82. [PMID: 31003978 PMCID: PMC10270425 DOI: 10.1136/ebmental-2018-300064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 02/18/2019] [Accepted: 02/25/2019] [Indexed: 11/04/2022]
Abstract
Bed rest is commonly used on medical and paediatric wards as part of nursing management of the physically compromised patient with severe anorexia nervosa. The aim of this study was to review the evidence base of bed rest as an intervention in the management of severe anorexia nervosa. We searched MEDLINE, PubMed, Embase, PsychInfo, CINAHL, HMIC, AMED, HBE, BNI and guidelines written in English until April 2018 using the following terms: bed rest and anorexia nervosa. After exclusion of duplicates, three guidelines and eight articles were included. The papers were methodologically heterogeneous, and therefore, quantitative summary was not possible. There have been no randomised controlled trials to compare the benefits and harms of bed rest as the focus of intervention in the treatment of anorexia nervosa. Several papers showed that patients have a strong preference for less restrictive approaches. These are also less intensive in nursing time. Negative physical consequences were described in a number of studies: these included lower heart rate, impaired bone turn over and increased risk of infection. We found no evidence to support bed rest in hospital treatment of anorexia nervosa. The risks associated with bed rest are significant and include both physical and psychological harm, and these can be avoided by early mobilisation. Given the established complications of bed rest in other critically ill patient populations, it is difficult to recommend the enforcement of bed rest for patients with anorexia nervosa. Future research should focus on safe early mobilisation, which would reduce complications and improve patient satisfaction.
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Affiliation(s)
- Ali Ibrahim
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, London, UK
| | - Darren Cutinha
- Maudsley Centre for Child and Adolescent Eating Disorders, South London and Maudsley NHS Foundation Trust, London, London, UK
| | - Agnes Ayton
- Cotswold House, Oxford Health NHS Foundation Trust Adult Mental Health Services, Oxford, Oxfordshire, UK
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Górowska-Kowolik K, Chobot A, Kwiecień J. Breath test using 13C methacetin does not seem to be useful in the assessment of liver function in girls with anorexia nervosa: a case control study. BMC Gastroenterol 2018; 18:126. [PMID: 30103687 PMCID: PMC6090712 DOI: 10.1186/s12876-018-0856-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 08/01/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Anorexia nervosa (AN) concerns approximately up to 1.8% of the pediatric female population. One of the complications that can occur in the course of this disease is acute liver failure. This study's objective was to assess the usefulness of the 13C labeled Methacetin Breath Test (MBT) in the diagnostics of the liver function in girls with eating disorders. METHODS For the study 81 girls aged 12 to 17 years were recruited, including 41 patients with confirmed diagnosis of AN (mean age 14.7 ± 1.48 years) and 40 age-matched controls. The diagnosis was based on the present Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Weight and height were measured in all study participants and the Body Mass Index (BMI) was calculated. In the study and control group laboratory tests assessing the liver function and the MBT were performed. RESULTS In all controls the anthropometric as well as laboratory liver function parameters were normal. In the study group 25 patients (61%) had BMI below the lower limit for age. The total percentage of 13CO2 recovery in the 120th minute of the test did not exceed the lower limit in patients and controls. A result of the 13CO2 cumulative recovery above the upper normal range was found in 18 girls with AN (44% of the study group) and 2 controls (5%). Patients with AN were characterized by significantly higher 13CO2 cumulative dose recovery after ingestion of the substrate in comparison to the control group in all time points of the test. CONCLUSIONS The obtained results confirm a significant stimulation of the liver metabolism of 13C labeled methacetin in female patients with AN. The increased cumulative dose recovery of the substrate in girls with AN impacts the credibility of this measurement and implies a risk of false negative results.
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Affiliation(s)
- Katarzyna Górowska-Kowolik
- Department of Pediatric Gastroenterology and Hepatology, Clinical Hospital No 1 in Zabrze of the Medical University of Silesia in Katowice, Katowice, Poland
| | - Agata Chobot
- Department of Pediatric Gastroenterology and Hepatology, Clinical Hospital No 1 in Zabrze of the Medical University of Silesia in Katowice, Katowice, Poland
| | - Jarosław Kwiecień
- Department of Pediatrics, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
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Bravender T, Elkus H, Lange H. Inpatient medical stabilization for adolescents with eating disorders: patient and parent perspectives. Eat Weight Disord 2017; 22:483-489. [PMID: 27052407 DOI: 10.1007/s40519-016-0270-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 03/05/2016] [Indexed: 10/22/2022] Open
Abstract
PURPOSE The serious physical complications of eating disorders in adolescents may necessitate inpatient medical stabilization, yet little is known about how patients and their parents perceive the hospitalization experience. METHODS We identified 82 patients admitted to a large urban hospital for medical stabilization between January 1, 2010 and June 30, 2013. Twenty-three patients and 32 parents completed directed telephone interviews. Respondents rated components of the inpatient protocol using five-point Likert scales and answered open-ended questions regarding hospitalization. Quantitative and qualitative analyses were performed. RESULTS The mean age of patients at admission was 14.9 years (range 9-21) and the average stay was 8.4 days (range 2-25). Patients rated "massage therapy" most helpful and "cell phone limits" least helpful. Parents rated "nursing staff" most helpful and "seeing other patients in the hospital" least helpful. Protocol components viewed differently by parents and patients included parents more strongly endorsing "staff supervision of meals" (4.34 vs 2.82, p < 0.001) and "limits on physical activity" (4.34 vs 3.23, p = 0.001). The two most common themes identified in open-ended questions were need for hospitalization as a signifier of eating disorder severity and desire for mental health services on the medical unit. Parents emphasized the value of dietician-directed meal planning. CONCLUSIONS Inpatient medical stabilization for adolescent eating disorders may play an important role not only in addressing acute medical complications, but also in activating the patient and family regarding the need for ongoing treatment. Parents particularly appreciate staff supervision of meals and having a respite from meal planning.
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Affiliation(s)
- Terrill Bravender
- Division of Adolescent Medicine, Department of Pediatrics, University of Michigan, 1500 E. Medical Center Drive, D2215, Ann Arbor, MI, 48109-5318, USA.
| | - Hannah Elkus
- The Ohio State University College of Medicine, 410 W 10th Avenue, Columbus, OH, 43210, USA
| | - Hannah Lange
- The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43202, USA
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DiVasta AD, Feldman HA, Rubin CT, Gallagher JS, Stokes N, Kiel DP, Snyder BD, Gordon CM. The ability of low-magnitude mechanical signals to normalize bone turnover in adolescents hospitalized for anorexia nervosa. Osteoporos Int 2017; 28:1255-1263. [PMID: 27909781 PMCID: PMC9769086 DOI: 10.1007/s00198-016-3851-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/21/2016] [Indexed: 12/24/2022]
Abstract
UNLABELLED We sought to determine whether low-magnitude mechanical stimulation (LMMS) normalizes bone turnover among adolescents hospitalized for anorexia nervosa (AN). Brief, daily LMMS prevents the decline in bone turnover typically seen during bed rest in AN. LMMS may have application for patients with AN in the inpatient setting to protect bone health. INTRODUCTION Malnourished adolescents with AN requiring medical hospitalization are at high risk for rapid reduction in skeletal quality. Even short-term bed rest can suppress normal patterns of bone turnover. We sought to determine whether LMMS normalizes bone turnover among adolescents hospitalized for complications of AN. METHODS In this randomized, double-blind trial, we prospectively enrolled adolescent females (n = 41) with AN, age 16.3 ± 1.9 years (mean ± SD) and BMI 15.6 ± 1.7 kg/m2. Participants were randomized to stand on a platform delivering LMMS (0.3 g at 32-37 Hz) or placebo platform for 10 min/day for 5 days. Serum markers of bone formation [bone-specific alkaline phosphatase (BSAP)], turnover [osteocalcin (OC)], and bone resorption [serum C-telopeptides (CTx)] were measured. From a random coefficients model, we constructed estimates and confidence intervals for all outcomes. RESULTS BSAP decreased by 2.8% per day in the placebo arm (p = 0.03) but remained stable in the LMMS group (p = 0.51, pdiff = 0.04). CTx did not change with placebo (p = 0.56) but increased in the LMMS arm (+6.2% per day, p = 0.04; pdiff = 0.01). Serum OC did not change in either group (p > 0.70). CONCLUSIONS Bed rest during hospitalization for patients with AN is associated with a suppression of bone turnover, which may contribute to diminished bone quality. Brief, daily LMMS prevents a decline in bone turnover during bed rest in AN. Protocols prescribing strict bed rest may not be appropriate for protecting bone health for these patients. LMMS may have application for these patients in the inpatient setting.
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Affiliation(s)
- A D DiVasta
- Division of Adolescent Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA.
- Division of Gynecology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
| | - H A Feldman
- Clinical Research Program, Boston Children's Hospital, Boston, MA, USA
| | - C T Rubin
- Department of Biomedical Engineering, State University of New York Stony Brook, Stony Brook, NY, USA
| | - J S Gallagher
- Division of Adolescent Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - N Stokes
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - D P Kiel
- Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - B D Snyder
- Department of Orthopedic Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - C M Gordon
- Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Strandjord SE, Sieke EH, Richmond M, Khadilkar A, Rome ES. Medical stabilization of adolescents with nutritional insufficiency: a clinical care path. Eat Weight Disord 2016; 21:403-410. [PMID: 26597679 DOI: 10.1007/s40519-015-0245-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/07/2015] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Nutritional insufficiency (NI) is a potential consequence of restrictive eating disorders. NI patients often require hospitalization for refeeding to restore medical stability and prevent complications such as refeeding syndrome. Limited information is available on the optimal approach to refeeding. In this study, we describe an inpatient NI care path and compare treatment outcomes at an academic medical center and a community hospital. METHODS A retrospective chart review was conducted on inpatients treated using a standardized NI care path at either the academic site, from August 2012 to July 2013 (n = 51), or the community site, from August 2013 to July 2014 (n = 39). Demographic information, eating disorder history, and treatment variables were recorded for each patient. Data were compared using the Kruskal-Wallis test and Fisher's exact test. RESULTS Patients admitted to the community site had shorter hospital stays than patients admitted to the academic site (IQR 2-4 vs. 2-7 days, p = 0.03). All patients were discharged in <14 days with a median stay of 3 days. The median initial calorie prescription was 2200 calories for both groups. No clinical cases of refeeding syndrome occurred, with only one patient developing hypophosphatemia during refeeding. CONCLUSIONS A standardized care path with a higher-calorie intervention allows for short-term hospitalization of NI patients without increasing the risk of refeeding syndrome, regardless of treatment site. This study demonstrates the efficiency and safety of treating NI patients on a regular medical floor at a community hospital.
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Affiliation(s)
- Sarah E Strandjord
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Mail Code NA21, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Erin H Sieke
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Mail Code NA21, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Miranda Richmond
- Office of Civic Education Initiatives Internship Program, Cleveland Clinic, 25875 Science Park Drive/AC121, Beachwood, OH, 44122, USA
| | - Arjun Khadilkar
- Office of Civic Education Initiatives Internship Program, Cleveland Clinic, 25875 Science Park Drive/AC121, Beachwood, OH, 44122, USA
| | - Ellen S Rome
- Department of General Pediatrics, Cleveland Clinic Children's Hospital, 9500 Euclid Ave/A120, Cleveland, OH, 44195, USA
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Ridout KK, Kole J, Fitzgerald KL, Ridout SJ, Donaldson AA, Alverson B. Daily Laboratory Monitoring is of Poor Health Care Value in Adolescents Acutely Hospitalized for Eating Disorders. J Adolesc Health 2016; 59:104-9. [PMID: 27338666 PMCID: PMC11346632 DOI: 10.1016/j.jadohealth.2016.03.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/01/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE This study investigates how the clinical practice guideline-recommended laboratory monitoring for refeeding syndrome impacts management and outcomes of adolescents with eating disorders hospitalized for acute medical stabilization and examines the value of laboratory monitoring (defined as the patient health outcomes achieved per dollar spent). METHODS A retrospective chart review of medical admissions in a children's hospital between October 2010 and February 2014 was performed. Encounters were identified using International Classification of Diseases, Ninth Revision codes of eating disorders as primary or secondary diagnoses. Exclusion criteria included systemic diseases associated with significant electrolyte abnormalities. Chart abstraction was performed using a predetermined form. Costs were estimated by converting hospital-fixed Medicaid charges using a statewide cost-to-charge ratio. RESULTS Of the 196 patient encounters, there were no cases of refeeding syndrome. A total of 3,960 key recommended laboratories were obtained; 1.9% were below normal range and .05% were critical values. Of these, .28% resulted in supplementation; none were associated with a change in inpatient management. Total laboratory costs were $269,250.85; the calculated health care value of this monitoring is 1.04 × 10(-8) differential outcomes per dollar spent. CONCLUSIONS This study provides evidence to suggest that daily laboratory monitoring for refeeding syndrome is a poor health care value in the management of adolescents hospitalized for acute medical stabilization with eating disorders. This initial analysis suggests that starting at a relatively low caloric level and advancing nutrition slowly may negate the need for daily laboratory assessment, which may have important implications for current guidelines.
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Affiliation(s)
- Kathryn K Ridout
- Department of Psychiatry and Human Behavior, Mood Disorders Research Program, Laboratory for Clinical and Translational Neuroscience, Butler Hospital, Providence, Rhode Island; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Jonathan Kole
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kelly L Fitzgerald
- Department of Medical Education, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Samuel J Ridout
- Department of Psychiatry and Human Behavior, Mood Disorders Research Program, Laboratory for Clinical and Translational Neuroscience, Butler Hospital, Providence, Rhode Island; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Abigail A Donaldson
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island; Department of Pediatrics, Division of Adolescent Medicine, Hasbro Children's Hospital, Providence, Rhode Island
| | - Brian Alverson
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island; Department of Pediatrics, Division of Hospitalist Medicine, Hasbro Children's Hospital, Providence, Rhode Island
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Leitner M, Burstein B, Agostino H. Prophylactic Phosphate Supplementation for the Inpatient Treatment of Restrictive Eating Disorders. J Adolesc Health 2016; 58:616-20. [PMID: 26774639 DOI: 10.1016/j.jadohealth.2015.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 11/01/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The medical stabilization of adolescent patients with restrictive eating disorders can be associated with refeeding syndrome, a potentially fatal complication preceded by refeeding hypophosphatemia (RH). Whether RH can be prevented by routine prophylactic phosphate supplementation has not been previously examined. This study sought to determine the safety and efficacy of a refeeding strategy that incorporates prophylactic phosphate supplementation to prevent RH. METHODS Retrospective chart data were collected for patients aged younger than 18 years with restrictive eating disorders admitted to a tertiary pediatric inpatient ward between January 2011 and December 2014. All patients were refed with a standardized protocol that included prophylactic oral phosphate supplementation (1.0 ± .2 mmol/kg/day). RESULTS During the 4-year study period, 75 admissions (70 patients) were included for analysis. The mean age and percent median body mass index of included patients were 15.3 years and 83.5%, respectively. Seven out of 75 (9%) had percent median body mass index of <70% and 26 out of 75 (35%) had percent body weight loss >20%. All patients were normophosphatemic at the time of admission (mean serum phosphate 1.24 ± .2 mmol/L). Serial laboratory evaluation revealed that all supplemented patients maintained serum phosphate levels >1.0 mmol/L during the initial 7 days of refeeding. Eleven patients became mildly hyperphosphatemic (range 1.81-2.17 mmol/L) with no associated clinical consequences. Additional analysis of 11 patients presenting with hypophosphatemia before refeeding revealed that with supplementation, phosphate values normalized by Day 1, and this group experienced no further RH episodes during initial refeeding. CONCLUSIONS Prophylactic oral phosphate supplementation appears safe, and no episodes of RH occurred in patients with restrictive eating disorders undergoing inpatient refeeding.
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Affiliation(s)
- Maya Leitner
- Division of Adolescent Medicine, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Brett Burstein
- Division of Pediatric Emergency Medicine, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Holly Agostino
- Division of Adolescent Medicine, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada.
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13
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Fernández-del-Valle M, Larumbe-Zabala E, Morande-Lavin G, Perez Ruiz M. Muscle function and body composition profile in adolescents with restrictive anorexia nervosa: does resistance training help? Disabil Rehabil 2015; 38:346-53. [DOI: 10.3109/09638288.2015.1041612] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | - Eneko Larumbe-Zabala
- Clinical Research Institute, Texas Tech University Health Sciences Center, TX, USA,
| | - Gonzalo Morande-Lavin
- Department of Psychiatry and Psychology, Hospital Infantil Universitario Niño Jesus, Spain, and
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Fernandez-del-Valle M, Larumbe-Zabala E, Villaseñor-Montarroso A, Cardona Gonzalez C, Diez-Vega I, Lopez Mojares LM, Perez Ruiz M. Resistance training enhances muscular performance in patients with anorexia nervosa: a randomized controlled trial. Int J Eat Disord 2014; 47:601-9. [PMID: 24810684 DOI: 10.1002/eat.22251] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 10/12/2013] [Accepted: 12/30/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Low-intensity exercise applied in anorexia nervosa patients has been shown to have a harmless effect on body composition and to effect short-term improvements in muscular strength and agility. The aim of this study was to determine the effects of a high-intensity resistance training program designed for adolescents to improve strength and agility in anorexia nervosa restricting-type patients (AN-R). METHODS From a total of 36 female patients with AN-R, one group (intervention, n = 18) underwent a supervised high-intensity resistance training program lasting 8 weeks, and the other group with no exercise (control, n = 18). Body weight, body mass index, whole-body muscular strength, and agility were assessed before, after, and 4 weeks after training (detraining). RESULTS Leg-press, bench-press, and lateral row tests improved significantly (p < 0.001) after 8 weeks of training compared with controls. Improvements were maintained after the detraining period. The training program also showed beneficial effects on agility. DISCUSSION A high-intensity resistance training program adapted to the recommendations for adolescents in AN-R patients was effective and safe, improving muscular strength in the whole body and the ability to perform daily tasks. However, long-term maintenance of gains seems to be linked to the continuance of training or the use of a maintenance program.
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Rocks T, Pelly F, Wilkinson P. Nutrition therapy during initiation of refeeding in underweight children and adolescent inpatients with anorexia nervosa: a systematic review of the evidence. J Acad Nutr Diet 2014; 114:897-907. [PMID: 24512952 DOI: 10.1016/j.jand.2013.11.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 11/20/2013] [Indexed: 01/08/2023]
Abstract
Restoration of weight and nutritional rehabilitation are recognized as fundamental steps in the therapeutic treatment of children and adolescent inpatients with anorexia nervosa (AN). However, current recommendations on initial energy requirements for this population are inconsistent, with a clear lack of empirical evidence. Thus, the aim of our study was to systematically review, assess, and summarize the available evidence on the effect of differing nutrition therapies prescribed during refeeding on weight restoration in hospitalized children and adolescents (aged 19 years and younger) with diagnosed AN. Searches were conducted in Scopus, Web of Science, Global Health (CABI), PubMed, and the Cochrane database for articles published in English up to May 2012, and complemented by a search of the reference lists of key publications. Seven observational studies investigating a total of 403 inpatients satisfied the inclusion criteria. The range of prescribed energy intakes varied from 1,000 kcal to >1,900 kcal/day with a progressive increase during the course of hospitalization. It appeared that additional tube feeding increased the maximum energy intake and led to greater interim or discharge weight; however, this was also associated with a higher incidence of adverse effects. Overall, the level of available evidence was poor, and therefore consensus on the most effective and safe treatment for weight restoration in inpatient children and adolescents with AN is not currently feasible. Further research on refeeding methods is crucial to establish the best practice approach to treatment of this population.
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Palma RFM, Santos JED, Ribeiro RPP. Evolução nutricional de pacientes com transtornos alimentares: experiência de 30 anos de um Hospital Universitário. REV NUTR 2013. [DOI: 10.1590/s1415-52732013000600006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Descrever a evolução do estado nutricional e dos parâmetros bioquímicos de pacientes com anorexia nervosa e bulimia nervosa internados para tratamento durante seguimento em serviço especializado. MÉTODOS: Foram revisados todos os prontuários dos pacientes em seguimento pelo serviço de 1982 a 2011, que foram internados para tratamento. Dados sociodemográficos, peso, altura e exames bioquímicos foram coletados no início e final da internação. RESULTADOS: No período referido, 83 pacientes com diagnóstico de anorexia ou bulimia nervosa foram internados para tratamento. A maioria era do sexo feminino (95,2%) raça branca (94,0%), solteira (76,0%) e sem filhos (78,3%). O diagnóstico predominante foi de anorexia nervosa (85,5%), sobretudo em seu tipo restritivo (54,2%). O índice de massa corporal médio dos pacientes adultos (n=41) evoluiu de 16,53±4,9 para 17,47±4,3kg/m² (p<0,05). Para as crianças e adolescentes (n=38), passou de 13,78±2,57 para 15,11±2,99kg/m² (p<0,05). Os valores médios da maioria dos parâmetros bioquímicos estavam dentro do limite da normalidade e, apenas o betacaroteno, manteve-se em níveis médios acima da normalidade no início e final da internação. Os valores de albumina, hematócrito, lipoproteína de alta densidade e potássio melhoraram ao final da internação (p<0,05). CONCLUSÃO: A hospitalização integral, apesar das dificuldades e da complexidade inerentes ao tratamento dos transtornos alimentares, considerando-se principalmente a resistência frente à recuperação do peso, pode proporcionar melhoria no estado nutricional e normalização de diversos parâmetros bioquímicos.
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Gorgulho AA, Pereira JLB, Krahl S, Lemaire JJ, De Salles A. Neuromodulation for eating disorders: obesity and anorexia. Neurosurg Clin N Am 2013; 25:147-57. [PMID: 24262906 DOI: 10.1016/j.nec.2013.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Extremes of eating disorders (ED) have become prevalent in both developed and developing countries. Available therapies, though largely effective, fail in a substantial number of patients and carry considerable side effects. Morbid obesity and anorexia nervosa (AN) represent important causes of morbidity and mortality among young adults. Morbid obesity affects disproportionate numbers of children. AN is also important for its high mortality in young adults. The challenges of effectively treating AN are well recognized. In this article, important aspects of ED are reviewed in detail and novel approaches to the treatment of ED are proposed.
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Affiliation(s)
- Alessandra A Gorgulho
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; HCor Neuroscience, Hospital do Coração, Rua Abilio Soares, 250, Paraiso, São Paulo 05005-000, Brazil
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Surgenor LJ, Maguire S. Assessment of anorexia nervosa: an overview of universal issues and contextual challenges. J Eat Disord 2013; 1:29. [PMID: 24999408 PMCID: PMC4081667 DOI: 10.1186/2050-2974-1-29] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 06/03/2013] [Indexed: 02/07/2023] Open
Abstract
AIM Anorexia Nervosa (AN) is a complex and clinically challenging syndrome. Intended for specialist audiences, this narrative review aims to summarise the available literature related to assessment in the adult patient context, synthesising both research evidence and clinical consensus guidelines. METHOD We provide a review of the available literature on specialist assessment of AN focusing on common trajectories into assessment, obstacles accessing assessment, common presenting issues and barriers to the assessment process, the necessary scope of assessment, and tools and techniques. It describes the further step of synthesising assessment information in ways that can inform resultant care plans. RESULTS In addition to assessment of core behaviours and diagnostic skills, considerations for the expert assessor include the functions of primary care, systemic and personal barriers, knowledge of current assessment tools and research pertaining to comorbid pathology in AN, assessing severity of illness, role of family at assessment, as well as medical, nutritional and compulsory elements of assessment. CONCLUSION Comprehensive assessment of AN in the current healthcare context still remains largely the remit of the specialist ED clinician. Assessment should remain an on-going process, paying particular attention to available empirical evidence, thereby reducing the gap between research and practice.
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Affiliation(s)
- Lois J Surgenor
- Department of Psychological Medicine, University of Otago at Christchurch, 4 Oxford Terrace, Christchurch 8140, New Zealand
| | - Sarah Maguire
- Centre for Eating and Dieting Disorders, University of Sydney, 92-94 Parramatta Road, Camberdown, New South Wales 2050, Australia
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Rocks T, Pelly F, Wilkinson P. Nutritional management of anorexia nervosa in children and adolescent inpatients: The current practice of Australian dietitians. Nutr Diet 2013. [DOI: 10.1111/1747-0080.12058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Tetyana Rocks
- School of Health and Sport Sciences; University of the Sunshine Coast; Sippy Downs Queensland Australia
| | - Fiona Pelly
- School of Health and Sport Sciences; University of the Sunshine Coast; Sippy Downs Queensland Australia
| | - Paul Wilkinson
- Accreditation, Recognition and Education Services; Dietitians Association of Australia; Canberra Australian Capital Territory Australia
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Bourion-Bedes S, Baumann C, Kermarrec S, Ligier F, Feillet F, Bonnemains C, Guillemin F, Kabuth B. Prognostic value of early therapeutic alliance in weight recovery: a prospective cohort of 108 adolescents with anorexia nervosa. J Adolesc Health 2013; 52:344-50. [PMID: 23299014 DOI: 10.1016/j.jadohealth.2012.06.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/23/2012] [Accepted: 06/26/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To determine whether patients' perception of early therapeutic alliance (TA) could predict time to achieve a target weight among adolescents undergoing treatment for anorexia nervosa. METHOD TA was assessed in a prospective cohort recruited from both inpatient and outpatient settings by self-administered and validated questionnaires. Kaplan-Meier survival curves were compared by log rank test, and Cox regression was used to test whether patients' perception of early TA predicted time to achieve a target weight. RESULTS In total, 108 patients were included, and 79.6% achieved a target weight. Better patient perception of early TA increased the hazard ratio (HR) of achieving a target weight (HR = 2.7, 95% confidence interval: 1.7-4.4, p < .001) such as being in the inpatient setting by 6.7. Being very severely underweight at admission decreased the HR of achieving the target weight. CONCLUSION Patients' perception of early TA is a good predictor of achieving a target weight. Because TA is a modifiable construct, it could be a target for intervention.
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21
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Chu ES, Gaudiani JL, Mascolo M, Statland B, Sabel A, Carroll K, Mehler PS. ACUTE center for eating disorders. J Hosp Med 2012; 7:340-4. [PMID: 22271490 DOI: 10.1002/jhm.1906] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 11/17/2011] [Accepted: 11/27/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs. METHODS We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder. The first 2 years of patient characteristics and outcomes are reported. RESULTS From October 2008 through December 2010, the ACUTE unit had 76 admissions of which 62 were for medical stabilization, comprising 54 patients. Eighty-nine percent of patients were female. The mean age was 27 years old (range 17-65). The mean body mass index on admission was 12.9 kg/m(2) (standard deviation [SD] 2.0). At admission, patients were hyponatremic, anemic, and leukopenic, with low bone density, but had normal albumin levels. The mean body mass index on discharge was 13.1 ± 1.9 kg/m(2). Median length of stay was 16 days (interquartile range [IQR] 9-29 days). Eighteen percent were discharged to home and eighty-two percent were discharged to inpatient psychiatric eating disorder units. Inpatient mortality was zero. DISCUSSION Patients with this degree of severe malnutrition due to eating disorders are medically complex and relatively uncommon. Regionalized subspecialty centers of excellence, in which a multidisciplinary team is led by practitioners of hospital medicine who have developed expertise in a rare condition, may improve clinical outcomes, optimize healthcare resources, and provide unique professional and academic opportunities for the clinicians involved.
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Affiliation(s)
- Eugene S Chu
- Division of Hospital Medicine, Department of Medicine, Boulder Community Hospital, Denver, Colorado, USA
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22
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Kerem NC, Riskin A, Averin E, Srugo I, Kugelman A. Respiratory acidosis in adolescents with anorexia nervosa hospitalized for medical stabilization: a retrospective study. Int J Eat Disord 2012; 45:125-30. [PMID: 21321988 DOI: 10.1002/eat.20911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2010] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To examine the effect of malnutrition due to anorexia nervosa (AN) on venous blood gases of adolescents with AN hospitalized for medical stabilization. METHOD This retrospective study included 45 adolescents with recent onset (<1 year) AN diagnosed by DSM-IV criteria and excluded subjects with a history of lung disease. RESULTS Mean (± SD) age at hospitalization was 15.0 ± 2.0 years; time from onset of symptoms was 6.8 ± 3.0 months; body mass index (BMI) was 15.2 ± 1.5 kg/m(2) ; and minimal nocturnal heart rate (MNHR) was 39.8 ± 7.2 beats/min. On admission, pH was 7.32 ± 0.02, pCO(2) was 53.8 ± 4.6 mm Hg, and HCO(3) was 28.1 ± 2.1 mEq/l. Significant changes (p < .001) occurred during the relatively short hospitalization (9.7 ± 5.1 days): venous pH increased, pCO(2) decreased, HCO(3) decreased, MNHR increased, and heart rate orthostasis decreased. Mild respiratory acidosis (pH < 7.35 and pCO(2) > 45 mm Hg) was observed in 78% of the patients on admission and only in 35% at discharge (p = .0003). Positive correlations were found between % of weight loss and pCO(2) on admission and between BMI on admission and the delta pCO(2) during hospitalization. DISCUSSION Mild respiratory acidosis is common in adolescents with recently diagnosed AN, hospitalized for medical stabilization. Respiratory acidosis improves with bed rest and refeeding. The clinical significance of these findings should be further evaluated.
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Affiliation(s)
- Nogah C Kerem
- Department of Pediatrics, Bnai Zion Medical Center, The Bruce Rappaport Faculty of Medicine, Haifa, Israel
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Medical treatment for burn patients with eating disorders: a case report. PLASTIC SURGERY INTERNATIONAL 2011; 2011:370981. [PMID: 22567240 PMCID: PMC3335636 DOI: 10.1155/2011/370981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 09/22/2010] [Accepted: 01/11/2011] [Indexed: 11/18/2022]
Abstract
There have been many cases of burn patients who also suffer from psychiatric problems, including eating disorders. We present a case of a 38-year-old female with an eating disorder and depression who became light-headed and fell, spilling boiling water from a kettle on herself at home sustaining partial thickness and full thickness burns over 5% of her total body surface area: left buttock and right thigh and calf. Eating disorders (in the present case, anorexia nervosa) cause emaciation and malnutrition, and consent for hospitalization from the patient and/or family is often difficult. During the medical treatment of burns for these patients, consideration not only of physical symptoms caused by malnutrition but also the psychiatric issues is required. Therefore, multifaceted and complex care must be given to burn patients with eating disorders.
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Hartsperger ML, Blöchl F, Stümpflen V, Theis FJ. Structuring heterogeneous biological information using fuzzy clustering of k-partite graphs. BMC Bioinformatics 2010; 11:522. [PMID: 20961418 PMCID: PMC3247861 DOI: 10.1186/1471-2105-11-522] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Accepted: 10/20/2010] [Indexed: 11/25/2022] Open
Abstract
Background Extensive and automated data integration in bioinformatics facilitates the construction of large, complex biological networks. However, the challenge lies in the interpretation of these networks. While most research focuses on the unipartite or bipartite case, we address the more general but common situation of k-partite graphs. These graphs contain k different node types and links are only allowed between nodes of different types. In order to reveal their structural organization and describe the contained information in a more coarse-grained fashion, we ask how to detect clusters within each node type. Results Since entities in biological networks regularly have more than one function and hence participate in more than one cluster, we developed a k-partite graph partitioning algorithm that allows for overlapping (fuzzy) clusters. It determines for each node a degree of membership to each cluster. Moreover, the algorithm estimates a weighted k-partite graph that connects the extracted clusters. Our method is fast and efficient, mimicking the multiplicative update rules commonly employed in algorithms for non-negative matrix factorization. It facilitates the decomposition of networks on a chosen scale and therefore allows for analysis and interpretation of structures on various resolution levels. Applying our algorithm to a tripartite disease-gene-protein complex network, we were able to structure this graph on a large scale into clusters that are functionally correlated and biologically meaningful. Locally, smaller clusters enabled reclassification or annotation of the clusters' elements. We exemplified this for the transcription factor MECP2. Conclusions In order to cope with the overwhelming amount of information available from biomedical literature, we need to tackle the challenge of finding structures in large networks with nodes of multiple types. To this end, we presented a novel fuzzy k-partite graph partitioning algorithm that allows the decomposition of these objects in a comprehensive fashion. We validated our approach both on artificial and real-world data. It is readily applicable to any further problem.
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Affiliation(s)
- Mara L Hartsperger
- Institute of Bioinformatics and Systems Biology (MIPS), Helmholtz Zentrum München - German Research Center for Environmental Health, Ingolstädter Landstr. 1, 85764 Neuherberg, Germany.
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DiVasta AD, Walls CE, Feldman HA, Quach AE, Woods ER, Gordon CM, Alexander ME. Malnutrition and hemodynamic status in adolescents hospitalized for anorexia nervosa. ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE 2010; 164:706-13. [PMID: 20679161 PMCID: PMC3205985 DOI: 10.1001/archpediatrics.2010.138] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To determine the effects of malnutrition on hemodynamic status of adolescents hospitalized for anorexia nervosa. DESIGN Longitudinal observational study. SETTING Tertiary care pediatric hospital. Patients Thirty-eight adolescents with anorexia nervosa, aged 13 to 21 years, with a mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) of 15.9 (1.8). Intervention Subjects received standard care, including bed rest and graded nutritional therapy. A subsample of subjects (n=19) returned 11 to 57 weeks following hospitalization for a second cardiac evaluation. MAIN OUTCOME MEASURES Results from a 15-lead electrocardiogram, echocardiogram, treadmill stress test, and spinal bone mineral density measurement. RESULTS On admission, 26 subjects (68%) had sinus bradycardia. Bradycardia was less common in participants with a longer duration of illness (P=.04). Left ventricle mass was lower than predicted for age (Z score<-1.0) in 11 subjects (31%). Exercise tolerance was normal by all measures. Both heart rate and QT interval were predictors of spinal bone mineral density. In those who returned for follow-up, absolute measures of left ventricle mass did not change (P=.27). However, the corresponding Z scores declined over time (mean [SD] change, -0.9 [1.3]; P=.02). CONCLUSIONS In acutely malnourished adolescents with anorexia nervosa, few truly pathologic cardiac findings were identified. Sinus bradycardia was observed in most cases. Mild reductions in left ventricle mass and left ventricle function were seen both at baseline and at follow-up, suggesting early sparing of cardiac muscle in the face of moderate malnutrition as well as a relative delay of cardiac muscle restoration. The association of hemodynamic status with altered spinal bone mineral density emphasizes the range of systems affected by malnutrition in anorexia nervosa.
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Affiliation(s)
- Amy D DiVasta
- Department of Cardiology, Children's Hospital Boston, 333 Longwood Ave, Boston, MA 02115, USA.
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Mondello S, Italiano D, Giacobbe MS, Mondello P, Trimarchi G, Aloisi C, Bramanti P, Spina E. Glutamine-supplemented total parenteral nutrition improves immunological status in anorectic patients. Nutrition 2010; 26:677-81. [DOI: 10.1016/j.nut.2009.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 10/20/2009] [Accepted: 10/21/2009] [Indexed: 01/03/2023]
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Does aggressive refeeding in hospitalized adolescents with anorexia nervosa result in increased hypophosphatemia? J Adolesc Health 2010; 46:577-82. [PMID: 20472215 DOI: 10.1016/j.jadohealth.2009.11.207] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Revised: 11/13/2009] [Accepted: 11/18/2009] [Indexed: 11/23/2022]
Abstract
PURPOSE Concerns about refeeding syndrome have led to relatively conservative nutritional rehabilitation in malnourished inpatients with anorexia nervosa (AN), which delays weight gain. Compared to other programs, we aggressively refed hospitalized adolescents. We sought to determine the incidence of hypophosphatemia (HP) in 12-18-year-old inpatients in order to inform nutritional guidelines in this group. METHODS A 1-year retrospective chart review was undertaken of 46 admissions (29 adolescents) with AN admitted to the adolescent ward of a tertiary children's hospital. Data collected over the initial 2 weeks included number of past admissions, nutritional intake, weight, height, body mass index, and weight change at 2 weeks. Serum phosphorus levels and oral phosphate supplementation was recorded. RESULTS The mean (SD) age was 15.7 years (1.4). The mean (SD) ideal body weight was 72.9% (9.1). Sixty-one percent of admissions were commenced on 1,900 kcal (8,000 kJ), and 28% on 2,200 kcal (9,300 kJ). Four patients were deemed at high risk of refeeding syndrome; of these patients, three were commenced on rehydration therapy and one on 1,400 kcal (6,000 kJ). All patients were graded up to 2,700 kcal (11,400 kJ) with further increments of 300 kcal (1,260 kJ) as required. Thirty-seven percent developed mild HP; no patient developed moderate or severe HP. Percent ideal body weight at admission was significantly associated with the subsequent development of HP (p = .007). CONCLUSIONS These data support more aggressive approaches to nutritional rehabilitation for hospitalized adolescents with AN compared to current recommendations and practice.
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del Valle MF, Pérez M, Santana-Sosa E, Fiuza-Luces C, Bustamante-Ara N, Gallardo C, Villaseñor A, Graell M, Morandé G, Romo GR, López-Mojares LM, Ruiz JR, Lucía A. Does resistance training improve the functional capacity and well being of very young anorexic patients? A randomized controlled trial. J Adolesc Health 2010; 46:352-8. [PMID: 20307824 DOI: 10.1016/j.jadohealth.2009.09.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Revised: 09/03/2009] [Accepted: 09/09/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE We determined the effects of a 3-month low-moderate-intensity strength training program (2 sessions/week) on functional capacity, muscular strength, body composition, and quality of life (QOL) in 22 young (12-16 yrs) anorexic outpatients. METHODS Patients were randomly assigned to a training or control group (n=11 [10 females] each). Training sessions were of low intensity (loads for large muscle groups ranging between 20%-30% and 50%-60% of six repetitions maximum [6RM] at the end of the program). We measured functional capacity by the time up and go and the timed up and down stairs tests. Muscular strength was assessed by 6RM measures for seated bench and leg presses. We estimated percent body fat and muscle mass. We assessed patients' QOL with the Short Form-36 items. RESULTS The intervention was well tolerated and did not have any deleterious effect on patients' health, and did not induce significant losses in their body mass. The only studied variable for which a significant interaction (group x time) effect was found (p=.009) was the 6RM seated lateral row test. CONCLUSIONS Low-moderate-intensity strength training does not seem to add major benefits to conventional psychotherapy and refeeding treatments in young anorexic patients.
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Melchior JC, Corcos M. Parenteral nutrition and anorexia nervosa: is it useful, is it ethical? J Adolesc Health 2009; 44:410-1; author reply 411-2. [PMID: 19306803 DOI: 10.1016/j.jadohealth.2008.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2008] [Indexed: 01/10/2023]
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