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Valeriani B, Pruccoli J, Chiavarino F, Petio ML, Parmeggiani A. Nutritional Assessment of Children and Adolescents with Atypical Anorexia Nervosa: A Preliminary Longitudinal Investigation Using the 24-h Dietary Recall. CHILDREN (BASEL, SWITZERLAND) 2024; 11:427. [PMID: 38671643 PMCID: PMC11048974 DOI: 10.3390/children11040427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/18/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Atypical Anorexia Nervosa (AAN) is a Feeding and Eating Disorder characterized by fear of gaining weight and body image disturbance, in the absence of significantly low body weight. AAN may present specific clinical and psychopathological features. Nonetheless, the literature lacks data concerning the nutritional characteristics and body composition of children and adolescents with AAN and their variation over time. METHODS Case series, including 17 children and adolescents with AAN. All the patients were assessed at the first evaluation (T0) with a standardized dietary assessment (24 h Dietary Recall, 24 hDR). Nutritional data were compared with European dietary reference values (DRVs). Body composition parameters (weight, fat mass, fat-free mass) and their changes over time at two (T1) and six (T2) months were collected as well, using a Bioelectrical impedance analysis (Wunder WBA300 with four poles and foot contact; impedance frequency 50 kHz 500 μA; impedance measurement range 200~1000 Ω/0.1 Ω). RESULTS The included individuals presented eating behaviors oriented towards significantly low daily energy intake (p < 0.001) compared with DRVs set by the European Food Safety Authority (EFSA) (with low carbohydrates and fats), and increased proteins (p < 0.001). A longer latency before observation (illness duration before observation) correlated with a negative change in weight. Body composition parameters were described, with no significant changes across the six-month outpatient assessment. DISCUSSION This is the first research to systematically assess the body composition and nutritional features of a group of individuals with AAN in the developmental age. Further research should assess the effect of targeted treatment interventions on body composition and nutritional features.
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Affiliation(s)
- Beatrice Valeriani
- IRCCS-Azienda Ospedaliero-Universitaria Di Bologna, Clinical Nutrition and Metabolism Unit, 40138 Bologna, Italy;
| | - Jacopo Pruccoli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Regional Center for Feeding and Eating Disorders in the Developmental Age, Child Neurology and Psychiatry Unit, 40138 Bologna, Italy; (J.P.); (F.C.)
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy;
| | - Francesca Chiavarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Regional Center for Feeding and Eating Disorders in the Developmental Age, Child Neurology and Psychiatry Unit, 40138 Bologna, Italy; (J.P.); (F.C.)
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy;
| | - Maria Letizia Petio
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy;
| | - Antonia Parmeggiani
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Regional Center for Feeding and Eating Disorders in the Developmental Age, Child Neurology and Psychiatry Unit, 40138 Bologna, Italy; (J.P.); (F.C.)
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy;
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Minghetti S, Riva A, Arienti G, Peruzzi C, Nacinovich R. Peroneal mononeuropathy and polyneuropathy in adolescents with Anorexia Nervosa: a case report and literature review. Eur J Clin Nutr 2024; 78:280-285. [PMID: 38228867 DOI: 10.1038/s41430-024-01402-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 01/18/2024]
Abstract
Peroneal neuropathy and polyneuropathy are displayed with a variable percentage in subjects affected by eating disorders and in particular by anorexia nervosa. Actually, little is known on features of these complications during the paediatric age. We describe the case of a female adolescent with right peroneal palsy and subclinical polyneuropathy associated with anorexia nervosa (AN). We review previous research about peroneal mononeuropathy and polyneuropathy associated with AN, and we develop a diagnostic and therapeutic protocol to help clinicians recognize and treat these disorders.
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Affiliation(s)
- S Minghetti
- Department of Child Neuropsychiatry, IRCCS San Gerardo dei Tintori, Monza, Italy
| | - A Riva
- Department of Child Neuropsychiatry, IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - G Arienti
- Department of Child Neuropsychiatry, IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Brescia, Brescia, Italy
| | - C Peruzzi
- Department of Child Neuropsychiatry, IRCCS San Gerardo dei Tintori, Monza, Italy
| | - R Nacinovich
- Department of Child Neuropsychiatry, IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Abry F, Gorwood P, Hanachi M, Di Lodovico L. Longitudinal investigation of patients receiving involuntary treatment for extremely severe anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2024; 32:179-187. [PMID: 37690079 DOI: 10.1002/erv.3033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/05/2023] [Accepted: 08/29/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Involuntary treatment may be a life-saving option for extremely severe anorexia nervosa (AN) in the context of life-threatening conditions and refusal of care. The long-term outcomes of patients undergoing involuntary treatment for AN are poorly understood. This study aims to explore quality of life, long-term outcomes and attitudes towards involuntary treatment in patients involuntarily treated for extremely severe AN. METHODS 23 patients involuntarily admitted for extremely severe AN (I-AN), and 25 voluntarily admitted patients (V-AN) were compared for body mass index (BMI), residual symptoms, quality of life, and attitudes towards treatment almost four years after discharge. In I-AN, clinical variables were also compared between admission and follow-up. RESULTS At follow-up, weight restoration was higher in V-AN (p = 0.01), while differences in quality of life, BMI, and mortality rates were not significant between I-AN and V-AN (p > 0.05). In I-AN, BMI increased and weight-controlling strategies decreased at follow-up (p < 0.05). Despite negative experiences of involuntary treatment, the perception of the necessity of treatment increased from admission to follow-up (p < 0.01) and became comparable to V-AN (p > 0.05). DISCUSSION Involuntary treatment for AN does not appear to be a barrier to weight gain and clinical improvement, nor to long-term attitudes towards treatment.
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Affiliation(s)
- Florent Abry
- Clinique des Maladies Mentales et de l'Encéphale, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France
| | - Philip Gorwood
- Clinique des Maladies Mentales et de l'Encéphale, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - Mouna Hanachi
- Clinical Nutrition Unit, Paul Brousse University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Villejuif, France
- UMR Micalis Institute, INRA, Paris-Saclay University, Jouy-En-Josas, France
| | - Laura Di Lodovico
- Clinique des Maladies Mentales et de l'Encéphale, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France
- NeuroCentre Magendie, INSERM U1215, Bordeaux, France
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Andersson P, Jamshidi E, Ekman CJ, Tedroff K, Björkander J, Sjögren M, Lundberg J, Jokinen J, Desai Boström AE. Mapping length of inpatient treatment duration and year-wise relapse rates in eating disordered populations in a well-defined Western-European healthcare region across 1998-2020. Int J Methods Psychiatr Res 2023; 32:e1960. [PMID: 36710656 DOI: 10.1002/mpr.1960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 01/17/2023] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Updated international guideline recommendations for AN inpatient care rely on expert opinions/observational evidence and promote extended inpatient stays, warranting investigation using higher-level ecological evidence. METHODS The study was conducted according to Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Data encompassing 13,885 ED inpatients (5336 adolescents and 8549 adults) was retrieved from Swedish public health registries. Variables analyzed included (1) ED inpatient care opportunities, (2) unique number of ED inpatients and (3) mean length of ED-related inpatient stays in age groups 15-19 and 20-88+, across 1998-2020. RESULTS Mean length of inpatient stays was inversely correlated to relapse to ED-related inpatient care within the same year (p < 0.001, R-squaredadj = 0.5216 and p < 0.00001, R-squaredadj = 0.5090, in the 15-19 and 20-88+ age groups, respectively), independent of number of ED inpatients treated within a year in both age groups. Extending mean adolescent inpatient duration from 35 to 45 days was associated with a ∼30% reduction in the year-wise relapse rate. CONCLUSIONS Mean length of ED-related inpatient treatment stays was associated with reduced relapses to inpatient care within the same year, which could be interpreted as support for recommendations to include a stabilization phase in inpatient ED treatment.
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Affiliation(s)
- Peter Andersson
- Department of Clinical Neuroscience/Psychology, Karolinska Institute, Stockholm, Sweden
- Centre for Clinical Research Dalarna, Uppsala University, Falun, Sweden
| | - Esmail Jamshidi
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Sweden
| | - Carl-Johan Ekman
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, Stockholm, Sweden
| | - Kristina Tedroff
- Department of Women's and Children's Health/Neuropediatrics, Karolinska Institutet, Stockholm, Sweden
| | | | - Magnus Sjögren
- Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Sweden
| | - Johan Lundberg
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, Stockholm, Sweden
| | - Jussi Jokinen
- Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, Stockholm, Sweden
| | - Adrian E Desai Boström
- Department of Clinical Sciences/Psychiatry, Umeå University, Umeå, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health/Neuropediatrics, Karolinska Institutet, Stockholm, Sweden
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Dunbar EMP, Pribble C, Cueto J, Goldschmidt AB, Tortolani C, Donaldson AA. Multi-electrolyte disturbance and supplementation in severely malnourished hospitalized adolescents with restrictive eating disorders. J Eat Disord 2023; 11:202. [PMID: 37968751 PMCID: PMC10647075 DOI: 10.1186/s40337-023-00919-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/27/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND This study describes the prevalence of hypophosphatemia, hypokalemia, and/or hypomagnesemia and resulting electrolyte supplementation during refeeding in severely malnourished youths hospitalized for restrictive eating disorders. METHODS Hospitalized patients between 11-26y (N = 81) at < 75% treatment goal weight (TGW) were assessed through retrospective chart review. Outcomes were compared between participants < 70% TGW and those 70-75% TGW. Nutritional rehabilitation started at 1750 kcals/day and advanced by 500 kcal every other day until target intake was achieved. Associations between %TGW on admission; hypophosphatemia, hypokalemia, and/or hypomagnesemia; and electrolyte supplementation were examined. RESULTS Of the 24 (29.6%) participants with hypophosphatemia, hypokalemia, and/or hypomagnesemia, 7 (8.6%) received supplementation; the remainder corrected without supplementation. Participants < 70% TGW did not differ from those 70-75% TGW on rates of these conditions or need for supplementation. CONCLUSIONS Hospital-based nutritional rehabilitation did not confer increased rates of hypophosphatemia, hypokalemia, and/or hypomagnesemia or need for electrolyte supplementation in patients < 70% TGW compared to those 70-75% TGW. While additional research is needed to establish clinical practice guidelines on electrolyte management in this population, our findings suggest that nutritional rehabilitation may be reasonably undertaken without prophylactic electrolyte supplementation, even in patients < 70% TGW.
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Affiliation(s)
- Eva-Molly Petitto Dunbar
- University of California San Diego Eating Disorders Center for Treatment and Research, San Diego, CA, 92121, USA.
| | - Chase Pribble
- Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI, 02903, USA
| | - Jennifer Cueto
- Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI, 02903, USA
- Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
| | - Andrea B Goldschmidt
- University of Pittsburgh School of Medicine, 3711 O'Hara St., Pittsburgh, PA, 15213, USA
| | - Christina Tortolani
- Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI, 02903, USA
- Rhode Island College, 600 Mount Pleasant Ave., Providence, RI, 02908, USA
| | - Abigail A Donaldson
- Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI, 02903, USA
- Rhode Island Hospital, 593 Eddy St., Providence, RI, 02903, USA
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Tessema SA, Megersa SW, Abebe M, Ayalew HG, Tigabu M. A case report of anorexia nervosa in a 23-year-old Ethiopian woman. Clin Case Rep 2023; 11:e8150. [PMID: 38028046 PMCID: PMC10659915 DOI: 10.1002/ccr3.8150] [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: 08/18/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Key Clinical Messages Limited studies on AN in Africa, including Ethiopia. Internet and media have changed body image portrayal in developing countries. A need for a multidisciplinary approach to treatment, training on positive coaching styles, and future research. Abstract The Global Burden of Disease had estimated anorexia nervosa (AN) or bulimia nervosa to be 13.6 million people. The lifetime prevalence of AN ranges from 2.4 to 4.3 percent. During their lifetime, up to 4% of females and up to 0.3% of males suffer from anorexia nervosa. Studies assessing AN in Africa, including Ethiopia, are limited. This case report describes a 23-year-old female patient who presented with anorectic symptoms and signs in Ethiopia. This case report describes a 23-year-old female patient who participated in sports activities. She had a low body weight based on a BMI of 13.15 kg/m2 and lost around 10 kg within the past 6 months. She feared gaining weight or becoming fat, thus restricting food intake. The findings on psychiatric evaluation encompassing detailed history and mental state examination suggested the diagnosis of Extreme anorexia nervosa, restricting type; adult malnutrition; major depressive disorder (MDD) (in remission); low risk of aggression; low risk of suicide; severe functional impairment. The general management principles implemented in this patient included assessment of medical complications, weight restoration, psychological intervention, medication for comorbid depression, and long-term psychological and biological treatment follow-up to avoid relapse. The presented case of a 23-year-old Ethiopian female patient who is athletic shows weight-controlled sports activities and the manifestation of anorexia nervosa. Easy access to the Internet and media has changed body image portrayal in developing countries including Ethiopia. There is a need for a multidisciplinary approach involving psychiatrists, psychologists, internists, and nutritionists for the management of AN. The early screening and management of medical complications are crucial. There is a need for close monitoring of vital signs, restriction of caffeine, excess fluid, and salt, and limiting excessive exercise. Furthermore, to assess micronutrient deficiencies, vitamin supplements should be prescribed in the form of multivitamin and thiamine preparations. The need for future training about positive coaching styles for coaches is mandatory to reduce the future impacts on young athletes. There is a need for future research on eating disorders in developing countries such as Ethiopia.
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Affiliation(s)
| | - Surafel Worku Megersa
- Psychiatry departmentSt. Paul Hospital Millennium Medical CollegeAddis AbabaEthiopia
| | - Meskerem Abebe
- Psychiatry departmentSt. Paul Hospital Millennium Medical CollegeAddis AbabaEthiopia
| | | | - Melat Tigabu
- Psychiatry departmentSt. Paul Hospital Millennium Medical CollegeAddis AbabaEthiopia
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7
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Lopes HCB, Mazzolani BC, Koritar P, Cordás TA. Characterization of refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa: A systematic review. Gen Hosp Psychiatry 2023; 85:43-54. [PMID: 37778285 DOI: 10.1016/j.genhosppsych.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE To characterize and compare, through descriptive analysis, existing refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa (AN). METHODS This is a systematic review of PubMed, Cochrane, SciELO, Lilacs and BVS databases, without search period restriction. Studies were selected in accordance with pre-defined eligibility criteria and according to the Population, Intervention, Comparator, Outcome and Study Design (PICOS). RESULTS Twenty articles out of 412 found complied with PICOS eligibility criteria and were included in the final review. Most of the studies were observational or retrospective and 80% were published in the last decade. Large variability in relation to sample size, refeeding protocols and length of stay were observed between studies. CONCLUSION All included studies had several methodological limitations and heterogeneous designs, making it difficult to establish conclusive guidelines regarding the most adequate and effective refeeding protocol for under 18 years old hospitalized patients with AN. Prospective trials are necessary to straight compare standard refeeding protocols for this population.
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Affiliation(s)
- Helen Cristina Bittencourt Lopes
- Nutrition and Dietetics Service and Interdisciplinary Project for Care, Teaching, and Research on Eating Disorders in Childhood and Adolescence (PROTAD), Institute of Psychiatry, University of São Paulo, São Paulo, Brazil.
| | - Bruna Caruso Mazzolani
- Applied Physiology & Nutrition Research Group and Laboratory of Assessment and Conditioning in Rhematology, University of São Paulo, São Paulo, Brazil.
| | - Priscila Koritar
- Nutrition and Dietetics Service, Barueri City Hall, São Paulo, SP, Brazil
| | - Táki Athanássios Cordás
- AMBULIM - Eating Disorders Program, Institute and Department of Psychiatry, University of São Paulo, São Paulo, Brazil.
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Hoo P, Goldschlager R, Katsoulis J, Newnham E, Harun NS, Gwee K, Silberberg C, Russell N, Lam S, Adithama E, Cook N, Weickhardt A. Narrative review of inpatient nutritional management of anorexia nervosa with management recommendations for Australian tertiary health services. Intern Med J 2023; 53:1752-1767. [PMID: 36377308 DOI: 10.1111/imj.15958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/13/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with anorexia nervosa (AN) may experience life-threatening malnutrition-related complications requiring inpatient medical stabilisation. Several management guidelines have been developed but discrepancies exist because of limited high-level evidence. AIMS To review the evidence base for recommendations contained in Victorian health services guidelines for the nutritional management of inpatients with AN. METHODS MEDLINE and Embase databases were searched for published studies on the nutritional management of inpatients with AN, combined with a manual search through citations. Studies including patients with AN aged 16 years and older were included. Case reports, small case series of <10 patients, studies of nonmedical management and studies with an exclusive paediatric population were excluded. The search results were compared with AN inpatient medical management guidelines sourced from large tertiary health services across Victoria, Australia. RESULTS The search yielded 584 studies, subsequently reduced to nine studies using the inclusion and exclusion criteria. The results suggest that commencing refeeding at a higher caloric value allows faster weight gain and shorter hospitalisation. Enteral tube feeding is preferential to parenteral nutrition because of infrequent and milder complications. Zinc supplementation showed a doubled rate of body mass index increase compared with placebo. Comparison with Victorian health services guidelines revealed inconsistent recommendations for high-calorie refeeding and micronutrient supplementation. CONCLUSION The evidence supports high-calorie refeeding of 2000 kcal/day in AN inpatient medical management and zinc supplementation in improving the rate of weight restoration. This is inconsistently reflected in different Victorian health services guidelines. Updated national consensus guidelines could assist in improving consistency of evidence-based health care.
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Affiliation(s)
- Phoebe Hoo
- Austin Clinical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Romi Goldschlager
- Department of Psychiatry, Alfred Health, Victoria, Melbourne, Australia
| | - John Katsoulis
- General Internal Medicine Unit, Western Health, Victoria, Melbourne, Australia
| | - Evan Newnham
- General Medicine Unit, Eastern Health, Victoria, Melbourne, Australia
| | - Nur-Shirin Harun
- Department of Respiratory Medicine, The Royal Melbourne Hospital, Victoria, Melbourne, Australia
| | - Karen Gwee
- Body Image Eating Disorders Treatment and Recovery Service (BETRS), St Vincent's Hospital, Victoria, Melbourne, Australia
| | - Carol Silberberg
- Body Image Eating Disorders Treatment and Recovery Service (BETRS), St Vincent's Hospital, Victoria, Melbourne, Australia
| | - Nick Russell
- General Medicine Unit 1, Austin Health, Victoria, Melbourne, Australia
| | - Simon Lam
- General Medicine Unit 1, Austin Health, Victoria, Melbourne, Australia
| | - Esti Adithama
- General Medicine Unit 1, Austin Health, Victoria, Melbourne, Australia
| | - Natasha Cook
- General Medicine Unit 1, Austin Health, Victoria, Melbourne, Australia
| | - Andrew Weickhardt
- General Medicine Unit 1, Austin Health, Victoria, Melbourne, Australia
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Özbaran NB, Erbasan Zİ, Yılancıoğlu HY, Çek D, Taş BY, Tokmak SH, Bildik T. A follow-up and treatment model for pediatric eating disorders: examination of the clinical variables of a child and adolescent psychiatry eating disorder outpatient clinic. Front Psychiatry 2023; 14:1218604. [PMID: 37840792 PMCID: PMC10569417 DOI: 10.3389/fpsyt.2023.1218604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/07/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Anorexia nervosa and other eating disorders are common in children and adolescents and are characterized by symptoms such as food restriction, efforts to lose weight, fear of gaining weight and impaired body image. Anorexia nervosa is a life-threatening psychiatric disorder and its management in the outpatient setting can be challenging for clinicians. The aim of this study was to introduce the subunit service model developed for the multidisciplinary diagnosis and management of eating disorders in the outpatient setting and to evaluate the clinical follow-up of patients. Methods The medical records of 37 patients who were followed up by the eating disorders team at our clinic between 2018 and 2022 were reviewed. The study was designed as retrospective case study. Results A diagnosis was made according to DSM-5 and a treatment plan was developed for each case. Body mass index (BMI), Clinic Global Impression (CGI) scale scores, duration of follow-up, number of interviews and other scale scores (The Turgay Attention Deficit Hyperactivity Disorder Scale and the Autism Spectrum Screening Questionnaire Scale) of 37 patients aged 12-17 years diagnosed with an eating disorder and followed up in our clinic were statistically compared. Discussion The Eating Disorder Follow-up Model developed and applied in our clinic had a positive effect on patients BMI scores, a significant improvement in CGI scores was observed. Conclusion: We believe that this multidisciplinary system will serve as a model for other mental health centers by raising awareness and guiding mental health professionals in the follow-up and treatment of eating disorders.
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Affiliation(s)
- N. Burcu Özbaran
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, İzmir, Türkiye
| | - Zeynep İrem Erbasan
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, İzmir, Türkiye
| | | | - Didem Çek
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, İzmir, Türkiye
| | - Begüm Yuluğ Taş
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, İzmir, Türkiye
| | - Sibel Helin Tokmak
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, İzmir, Türkiye
| | - Tezan Bildik
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Ege University, İzmir, Türkiye
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Grammatikopoulou MG, Syrmou V, Lioliopoulou ML, Gkiouras K, Simopoulou T, Katsiari CG, Vassilakou T, Bogdanos DP. Anorexia Nervosa in Juvenile Systemic Lupus Erythematosus (SLE): A Causality Dilemma. CHILDREN (BASEL, SWITZERLAND) 2023; 10:697. [PMID: 37189946 PMCID: PMC10137086 DOI: 10.3390/children10040697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/26/2023] [Accepted: 04/07/2023] [Indexed: 05/17/2023]
Abstract
Juvenile-onset systemic lupus erythematosus (jSLE) is an autoimmune disorder with multifaceted clinical findings in different organ systems. Neuropsychiatric manifestations affect more than half of SLE patients, and there is increasing evidence that anorexia nervosa (AN), a feeding and eating disorder (FED) characterized by significantly reduced energy intake, is among them. Herein, a review of the literature on the potential association between jSLE and AN was performed. Reported clinical cases were identified, and putative pathophysiological mechanisms were sought that could potentially explain the observed relationship between these two pathological entities. Four reports of isolated cases and a case series including seven patients were identified. In this limited patient pool, the diagnosis of AN preceded that of SLE in the majority of cases, whereas in all cases both entities were diagnosed within a time span of two years. Many explanations for the observed relationships have been proposed. AN has been associated with the stress of chronic disease diagnosis; on the other hand, the chronic inflammation associated with AN may contribute to the development/appearance of SLE. Adverse childhood experiences, concentrations of leptin, shared autoantibodies, and genetic traits appear to be important factors in this well-established interplay. In essence, it seems important to increase clinician awareness of the concomitant development of AN and SLE and invite further research on the subject.
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Affiliation(s)
- Maria G. Grammatikopoulou
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Vasiliki Syrmou
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Maria-Lydia Lioliopoulou
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Konstantinos Gkiouras
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Theodora Simopoulou
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Christina G. Katsiari
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Tonia Vassilakou
- Department of Public Health Policy, School of Public Health, University of West Attica, 196 Alexandras Avenue, GR-11521 Athens, Greece
| | - Dimitrios P. Bogdanos
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
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11
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[Nutritional recovery of underweight adolescents with anorexia nervosa: analysis of a hospital protocol]. NUTR HOSP 2023; 40:13-18. [PMID: 36602137 DOI: 10.20960/nh.04201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Introduction Background: anorexia nervosa (AN) is a severe psychiatric pathology that has one of the highest mortality rates among mental illnesses, estimated at 5.1 deaths per 1,000 people/year, and is associated with high comorbidity, both psychiatric and somatic. Aim: to characterize hospitalized adolescents and their nutritional rehabilitation using a standardized protocol. Methods: a descriptive-retrospective study of adolescent patients hospitalized at the San Carlos of Apoquindo Clinic with a diagnosis of AN, hemodynamically stable and without refeeding syndrome criteria, between 2015 and 2021. Epidemiological, clinical, and nutritional data of the patients were analyzed. Results: of 46 patients studied, 37 were female; the average length of stay was 45.4 (SD ± 36.1) days; 53.8 % of the patients had mood disorder as psychiatric comorbidity, and the most common personality trait was obsessive-compulsive (36.9 %); the most frequent somatic comorbidity was thyroid pathology (19.2 %). The initial oral caloric intake was 1467 (SD ± 479) kcal, with an average weekly increase of 400 kcal, reaching 2430 (SD ± 457) kcal at discharge. An average body mass index (BMI%) percentage change of 7.8 % (SD ± 6.1) was obtained. Conclusions: this is the first national study that describes the nutritional rehabilitation of adolescents with AN and the length of hospitalization required to achieve it.
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12
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Galbally M, Himmerich H, Senaratne S, Fitzgerald P, Frost J, Woods N, Dickinson JE. Management of anorexia nervosa in pregnancy: a systematic and state-of-the-art review. Lancet Psychiatry 2022; 9:402-412. [PMID: 35339207 DOI: 10.1016/s2215-0366(22)00031-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 12/20/2022]
Abstract
Anorexia nervosa is a potentially severe, chronic, and relapsing mental disorder that is more common in women and girls during the reproductive years (usually defined as those aged 12-51 years). It is associated with suicide and mortality linked with the physical consequences of starvation. Although anorexia nervosa is a disorder of low prevalence, and even lower prevalence in pregnancy, it is associated with substantial risks for the mother and infant when under-recognised and undermanaged. Despite the complexity and risk of managing anorexia nervosa in pregnancy, few studies are available to guide care. We conducted a systematic review, identifying only eight studies that addressed the management of anorexia nervosa in pregnancy. These studies were case studies or case reports examining narrow aspects of management. Subsequently, we conducted a state-of-the-art review across research in relevant disciplines and areas of expertise for managing anorexia nervosa in pregnancy and synthesised the findings into recommendations and principles for multidisciplinary management of anorexia nervosa in pregnancy. These recommendations included a focus on the specialist mental health, obstetric, medical, and nutritional care required to ensure optimal outcomes for women and their infants. Despite the complexity and risks, a gap exists in the comprehensive guidelines and recommendations for managing anorexia nervosa in pregnancy. This Review provides multidisciplinary recommendations for clinical care in this area. Managing anorexia nervosa in pregnancy is an area of clinical care that requires a multidisciplinary approach and includes those experienced in managing high-risk pregnancies.
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Affiliation(s)
- Megan Galbally
- School of Clinical Sciences, Monash University, Clayton, VIC, Australia; Health Futures Institute, Murdoch University, Murdoch, WA, Australia; School of Medicine, University of Notre Dame, Fremantle, WA, Australia; Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, WA, Australia.
| | | | | | | | | | - Nicole Woods
- Community Advisory Council, Women and Newborn Health Service, King Edward Memorial Hospital, Subiaco, WA, Australia
| | - Jan E Dickinson
- Division of Obstetrics and Gynaecology, University of Western Australia, Crawley, WA, Australia; King Edward Memorial Hospital, Subiaco, WA, Australia
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Frostad S, Bentz M. Anorexia nervosa: Outpatient treatment and medical management. World J Psychiatry 2022; 12:558-579. [PMID: 35582333 PMCID: PMC9048449 DOI: 10.5498/wjp.v12.i4.558] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 08/20/2021] [Accepted: 02/22/2022] [Indexed: 02/06/2023] Open
Abstract
Anorexia nervosa (AN) is a disabling, costly and potentially deadly illness. Treatment failure and relapse are common after completing treatment, and a substantial proportion of patients develop severe and enduring AN. The time from AN debut to the treatment initiation is normally unreasonably long. Over the past 20 years there has been empirical support for the efficacy of several treatments for AN. Moreover, outpatient treatment with family-based therapy or individual psychotherapy is associated with good outcomes for a substantial proportion of patients. Early intervention improves outcomes and should be a priority for all patients. Outpatient treatment is usually the best format for early intervention, and it has been demonstrated that even patients with severe or extreme AN can be treated as outpatients if they are medically stable. Inpatient care is more disruptive, more costly, and usually has a longer waiting list than does outpatient care. The decision as to whether to proceed with outpatient treatment or to transfer the patient for inpatient therapy may be difficult. The core aim of this opinion review is to provide the knowledge base needed for performing safe outpatient treatment of AN. The scientific essentials for outpatient treatment are described, including how to assess and manage the medical risks of AN and how to decide when transition to inpatient care is indicated. The following aspects are discussed: early intervention, outpatient treatment of AN, including outpatient psychotherapy for severe and extreme AN, how to determine when outpatient treatment is safe, and when transfer to inpatient healthcare is indicated. Emerging treatments, ethical issues and outstanding research questions are also addressed.
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Affiliation(s)
- Stein Frostad
- Department of Mental Health Research, Division of Psychiatry, Haukeland University Hospital, Bergen 5021, Norway
| | - Mette Bentz
- Child and Adolescent Mental Health Centre, Capital Region of Denmark, University of Copenhagen, Copenhagen 2400, Denmark
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14
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Nagata JM, Bojorquez-Ramirez P, Nguyen A, Ganson KT, Machen VI, Cattle CJ, Buckelew SM, Garber AK. Sex differences in refeeding among hospitalized adolescents and young adults with eating disorders. Int J Eat Disord 2022; 55:247-253. [PMID: 34957571 PMCID: PMC8837601 DOI: 10.1002/eat.23660] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine sex differences in refeeding (i.e., short-term nutritional rehabilitation) outcomes among hospitalized adolescents and young adults with eating disorders. METHODS We retrospectively reviewed electronic medical records of 601 patients aged 9-25 years admitted to the University of California, San Francisco Eating Disorders Program for medical and nutritional management between May 2012 and August 2020. Descriptive statistics, crude, and adjusted linear regression models were used to assess the association between sex and nutritional outcomes and predictors of length of stay. RESULTS A total of 588 adolescents and young adults met eligibility criteria (16% male, mean [SD] age 15.96 [2.75], 71.6% anorexia nervosa, admission percent median body mass index [%mBMI] 87.1 ± 14.1). In unadjusted comparisons, there were no significant sex differences in prescribed kilocalories (kcal) per day at admission (2013 vs. 1980, p = .188); however, males had higher estimated energy requirements (EER, kcal) (3,694 vs. 2,925, p < .001). In linear regression models adjusting for potential confounders, male sex was associated with higher prescribed kcals at discharge (B = 835 kcal, p < .001), greater weight change (B = 0.47 kg, p = .021), and longer length of stay (B = 1.94 days, p = .001) than females. Older age, lower admission weight, lower prescribed kcal at admission, higher EER, and lower heart rate at admission were factors associated with longer length of stay in a linear regression model. DISCUSSION These findings support the development of individualized approaches for males with eating disorders to improve quality of care and health care efficiency among an underserved population.
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Affiliation(s)
- Jason M. Nagata
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
| | | | - Anthony Nguyen
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
| | - Kyle T. Ganson
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor St W, Toronto, ON, Canada
| | - Vanessa I. Machen
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
| | - Chloe J. Cattle
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
| | - Sara M. Buckelew
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
| | - Andrea K. Garber
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA
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15
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Proulx-Cabana S, Metras ME, Taddeo D, Jamoulle O, Frappier JY, Stheneur C. To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol. Nutrients 2022; 14:nu14010229. [PMID: 35011105 PMCID: PMC8747364 DOI: 10.3390/nu14010229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/25/2021] [Accepted: 12/30/2021] [Indexed: 02/05/2023] Open
Abstract
Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.
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Affiliation(s)
- Stephanie Proulx-Cabana
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada; (D.T.); (O.J.); (J.-Y.F.)
- Correspondence: (S.P.-C.); (C.S.)
| | - Marie-Elaine Metras
- Pharmacy Department, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada;
| | - Danielle Taddeo
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada; (D.T.); (O.J.); (J.-Y.F.)
| | - Olivier Jamoulle
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada; (D.T.); (O.J.); (J.-Y.F.)
| | - Jean-Yves Frappier
- Pediatrics Department, Division of Adolescent Medicine, Sainte-Justine University Hospital Center, 3175 Côte-Sainte-Catherine Road, Montreal, QC H3T 1C5, Canada; (D.T.); (O.J.); (J.-Y.F.)
| | - Chantal Stheneur
- CESP, UVSQ, INSERM U 1178, Paris-Saclay University, 94805 Villejuif, France
- Clinique FSEF Varennes Jarcy, Fondation Sante des Etudiants de France, 91480 Varennes-Jarcy, France
- Simone Veil Health Science Training and Research Unit, Saint-Quentin-en-Yvelines University, 78180 Montigny-le-Bretonneux, France
- Correspondence: (S.P.-C.); (C.S.)
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16
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Anorexia Nervosa-What Has Changed in the State of Knowledge about Nutritional Rehabilitation for Patients over the Past 10 Years? A Review of Literature. Nutrients 2021; 13:nu13113819. [PMID: 34836075 PMCID: PMC8619053 DOI: 10.3390/nu13113819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/19/2021] [Accepted: 10/24/2021] [Indexed: 11/16/2022] Open
Abstract
Anorexia nervosa (AN) is a psycho-metabolic disorder with a high risk of somatic complications such as refeeding syndrome (RFS) and carries the highest mortality rate of all psychiatric illnesses. To date, the consensus on the care for patients with AN has been based on recommendations for a combination of alimentation and psychotherapy. It is important to establish an initial caloric intake that will provide weight gain and minimize the risk of complications in the treatment of undernourished patients. Research over the past few years suggests that current treatment recommendations may be too stringent and should be updated. The aim of this paper is to systematize the current reports on nutritional rehabilitation in AN, to present the results of studies on the safe supplementation of patients and its potential impact on improving prognosis and the healing process. This review of literature, from 2011-2021, describes the changing trend in the nutritional protocols used and the research on their efficacy, safety, and long-term effects. In addition, it presents previous reports on the potential benefits of introducing vitamin, pro-and prebiotic and fatty acid supplementation.
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17
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Gallagher D, Parker A, Samavat H, Zelig R. Prophylactic supplementation of phosphate, magnesium, and potassium for the prevention of refeeding syndrome in hospitalized individuals with anorexia nervosa. Nutr Clin Pract 2021; 37:328-343. [PMID: 34648201 DOI: 10.1002/ncp.10786] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Medical stabilization, nutrition rehabilitation, and weight restoration, while minimizing risk for the potentially fatal complication of refeeding syndrome, are the primary goals for the treatment of hospitalized individuals with anorexia nervosa and other restrictive-type eating disorders. The purpose of this review was to examine the literature exploring the prophylactic supplementation of phosphate, magnesium, and potassium, in addition to routine thiamin and multivitamin supplementation, for the prevention of refeeding syndrome in adolescents and adults with anorexia nervosa. Through evaluation of outcomes (including serum electrolyte levels and clinical signs and symptoms such as respiratory failure, cardiac failure, peripheral edema, rhabdomyolysis, and encephalopathy), three studies found that prophylactic supplementation of potassium, magnesium, and/or phosphate were effective in preventing refeeding syndrome or refeeding hypophosphatemia (a characteristic of refeeding syndrome). Although all studies found that prophylactic supplementation was effective in preventing refeeding syndrome, refeeding approaches (including the method, amount, and duration of nutrient delivery) as well as the populations studied varied considerably, making it difficult to arrive at specific recommendations for practice. Randomized controlled trials are needed to further examine the safety and effectiveness of prophylactic supplementation of phosphate, magnesium, and potassium on the prevention of refeeding syndrome, utilizing similar feeding and supplementation protocols.
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Affiliation(s)
- Donna Gallagher
- School of Health Professions, Department of Clinical and Preventive Nutrition Sciences, Rutgers University, Highlands, New Jersey, USA
| | - Anna Parker
- School of Health Professions, Department of Clinical and Preventive Nutrition Sciences, Rutgers University, Highlands, New Jersey, USA
| | - Hamed Samavat
- School of Health Professions, Department of Clinical and Preventive Nutrition Sciences, Rutgers University, Highlands, New Jersey, USA
| | - Rena Zelig
- School of Health Professions, Department of Clinical and Preventive Nutrition Sciences, Rutgers University, Highlands, New Jersey, USA
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18
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Tong K, McMahon E, Reid-McDermott B, Byrne D, Doherty AM. SafePsych: improving patient safety by delivering high-impact simulation training on rare and complex scenarios in psychiatry. BMJ Open Qual 2021; 10:bmjoq-2021-001533. [PMID: 34497099 PMCID: PMC8438936 DOI: 10.1136/bmjoq-2021-001533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/27/2021] [Indexed: 11/06/2022] Open
Abstract
Introduction Despite an evidence base demonstrating simulation to be an effective medical education tool, it is not commonly used in postgraduate psychiatry training as it is in other medical specialties. Objective This paper outlines the development and effectiveness of a hybrid-virtual simulation-based workshop designed to improve patient care by improving clinical skills of non-consultant hospital doctors (NCHDs) in detecting and managing rare and complex psychiatric emergencies. Methods Three clinical vignettes based on near-miss psychiatric cases were developed by a multidisciplinary team of physicians and nurses in psychiatry and experts in simulation-based medical education. The workshop, ‘SafePsych’ was delivered in a simulation laboratory while and broadcast via Zoom video-conferencing platform to observers. Debriefing followed each clinical scenario. Participants completed preworkshop and postworkshop questionnaires to evaluate clinical knowledge. Results The workshop was attended by consultants (n=12) and NCHDs in psychiatry and emergency medicine (n=19), and psychiatric nurses (n=5). In the psychiatry NCHD group, test scores significantly improved following the workshop (p<0.001). There were significant improvements in the test scores with a mean difference of 2.56 (SD 1.58, p<0.001). Feedback from participants and observers was positive, with constructive appraisals to improve the virtual element of the workshop. Conclusion Simulation-based training is effective in teaching high risk, rare complex psychiatric cases to psychiatry NCHDs. Further exploration of the learning needs of nursing staff is required. Future workshop delivery is feasible in the COVID-19 environment and beyond, using a virtual element to meet social distancing requirements while enhancing the reach of the training.
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Affiliation(s)
- Kezanne Tong
- National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Ireland
| | - Eimear McMahon
- School of Medicine, National University of Ireland Galway, University Road, Galway, Ireland.,Department of Psychiatry, University Hospital Galway, Galway, Ireland
| | - Bronwyn Reid-McDermott
- School of Medicine, National University of Ireland Galway, University Road, Galway, Ireland
| | - Dara Byrne
- Irish Centre for Applied Patient Safety and Simulation, National University of Ireland - Galway, Galway, Ireland
| | - Anne M Doherty
- Department of Psychiatry, University College Dublin, School of Medicine, Dublin, Ireland .,Department of Psychiatry, Mater Misericordiae University Hospital, Dublin, Ireland
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19
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Etemadi S, Sun GX, Leung SP, Siddique A, Cooper S, Ezenwa NC, Treasure J, Robinson P. The Sit Up Squat Stand test and Hand Grip Strength: What is the role of tests of muscle power in risk assessment in Anorexia Nervosa? EUROPEAN EATING DISORDERS REVIEW 2021; 29:670-679. [PMID: 33950546 DOI: 10.1002/erv.2839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/28/2021] [Accepted: 03/30/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To investigate the validity and reliability of two variants of the Sit Up Squat Stand Test (SUSS) and Hand Grip Strength (HGS) in predicting BMI and BMI risk level in hospitalised patients with Anorexia Nervosa (AN). METHODS 25 inpatients with AN were tested roughly weekly for up to 16 weeks. Muscle power was assessed by two independent researchers. RESULTS Intra-class coefficients (ICCs) indicated high Inter-Rater Reliability (IRR) for the HGS (10 participants). Cohen's Kappa showed moderate IRR for the SUSS test (25 participants). Stepwise multiple regression showed that the SUSS tests plus HGS predicted BMI and BMI risk level explaining about two-third of the variance. Each test individually had lower predictive value. There was a little difference between the two versions of the SUSS tested. CONCLUSIONS HGS and SUSS are valid and reliable measurements of muscle power in AN. Together, the SUSS tests and the HGS represent a useful and effective measure of muscle power and hence one aspect of physical risk in Anorexia Nervosa. In the light of Covid restrictions, the SUSS test is one way that physical state can be monitored on video link in a way that is hard to falsify.
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Affiliation(s)
- Sara Etemadi
- Department of Medicine, University College London (UCL), London, UK
| | | | - Sum-Ping Leung
- Department of Medicine, University College London (UCL), London, UK
| | - Arshad Siddique
- Department of Medicine, University College London (UCL), London, UK
| | - Steven Cooper
- Department of Research, Barnet, Enfield and Haringey Mental Health Trust (BEHMHT), London, UK
| | | | - Janet Treasure
- Neuroscience Division of Academic Psychiatry, Institute of Psychiatry Psychology, King's College London (KCL), London, UK
| | - Paul Robinson
- Department of Medicine, University College London (UCL), London, UK
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20
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Atti AR, Mastellari T, Valente S, Speciani M, Panariello F, De Ronchi D. Compulsory treatments in eating disorders: a systematic review and meta-analysis. Eat Weight Disord 2021; 26:1037-1048. [PMID: 33099675 PMCID: PMC8062396 DOI: 10.1007/s40519-020-01031-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/24/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION The aims of this systematic review and meta-analysis are to provide a summary of the current literature concerning compulsory treatments in patients with eating disorders (ED) and to understand whether compulsorily and involuntarily treated patients differ in terms of baseline characteristics and treatment outcomes. METHODS Relevant articles were identified following the PRISMA guidelines by searching the following terms: "treatment refusal", "forced feeding", "compulsory/coercive/involuntary/forced treatment/admission", "eating disorders", "feeding and eating disorders", "anorexia nervosa", "bulimia nervosa". Research was restricted to articles concerning humans and published between 1975 and 2020 in English. RESULTS Out of 905 articles retrieved, nine were included for the analyses allowing the comparisons between 242 compulsorily and 738 voluntarily treated patients. Mean body mass index (BMI) was slightly lower in patients compelled to treatments. Mean illness duration, BMI at discharge and BMI variation showed no significant differences between the two groups. Average length of hospitalization was 3 weeks longer among compulsory-treated patients, but this did not result in a higher increase in BMI. No significant risk difference on mortality was estimated (three studies). CONCLUSIONS Compulsory treatments are usually intended for patients having worse baseline conditions than voluntary ones. Those patients are unlikely to engage in treatments without being compelled but, after the treatments, albeit with longer hospitalisations, they do achieve similar outcomes. Therefore, we can conclude that forcing patients to treatment is a conceivable option. LEVEL OF EVIDENCE Level I, systematic review and meta-analysis.
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Affiliation(s)
- Anna Rita Atti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.
| | - Tomas Mastellari
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Stefano Valente
- Department of Mental Health, Local Health Authority of Bologna, Bologna, Italy
| | - Maurizio Speciani
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Fabio Panariello
- Department of Mental Health, Local Health Authority of Bologna, Bologna, Italy
| | - Diana De Ronchi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
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21
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Ibrahim N, Barruchet A, Moro MR, Blanchet C. Severe neutropenia in an anorexic adolescent girl: a stigma of underfeeding syndrome? Eat Weight Disord 2021; 26:1271-1275. [PMID: 32978756 DOI: 10.1007/s40519-020-01016-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
PURPOSE We describe a case of severe, prolonged neutropenia in an adolescent girl hospitalized for anorexia nervosa (AN) which occurred during a refeeding procedure in the absence of refeeding syndrome. METHODS This case report includes retrospective anamnestic, clinical and biological data from the patient's medical record. A literature review was conducted on the haematological changes described in the undernutrition and refeeding periods, and also on recent data for underfeeding syndrome in patients with anorexia nervosa. CONCLUSION Leuconeutropenia is an adaptive condition observed in undernutrition in AN, usually rapidly and completely reversible in the course of refeeding and weight gain. We describe a rare case of severe, prolonged neutropenia despite appropriate care in the absence of refeeding syndrome and without gelatinous bone marrow transformation. We suggest that neutropenia in adolescent anorexia nervosa could be a stigma of underfeeding syndrome resulting from an overly cautious refeeding strategy. LEVEL OF EVIDENCE Level V, descriptive study.
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Affiliation(s)
- N Ibrahim
- APHP, Cochin Hospital, Maison de Solenn, 75014, Paris, France
| | - A Barruchet
- APHP, Cochin Hospital, Maison de Solenn, 75014, Paris, France
| | - M R Moro
- APHP, Cochin Hospital, Maison de Solenn, 75014, Paris, France
- University of Paris, PCPP, 92100, Boulogne-Billancourt, France
- University of Paris-Saclay-UVSQ, INSERM, CESP, Team DevPsy, 94805, Villejuif, France
| | - C Blanchet
- APHP, Cochin Hospital, Maison de Solenn, 75014, Paris, France.
- University of Paris, PCPP, 92100, Boulogne-Billancourt, France.
- University of Paris-Saclay-UVSQ, INSERM, CESP, Team DevPsy, 94805, Villejuif, France.
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22
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Sahimi HBMS, Selvarajoo S, Nik Jaafar NR, Sharip S, Ismail MA, Hasni MM, Wahab NA. Adaptability of "Management of Really Sick Patients with Anorexia Nervosa" (MARSIPAN) for extreme anorexia nervosa in a developing country: A case report. Perspect Psychiatr Care 2021; 57:786-790. [PMID: 32918751 DOI: 10.1111/ppc.12614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 08/21/2020] [Accepted: 08/29/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE For the management of patients with severe eating disorders, coordinated collaboration between a multidisciplinary team is imperative. Ideally, these cases should be treated in a specialized eating disorder unit (SEDU). METHOD This case report highlights the use of an integrated approach based on "Management of Really Sick Patients with Anorexia Nervosa" report in managing a case of extreme anorexia nervosa where a SEDU is unavailable. RESULT In this case, early psychiatric team support is key in the patient's path to recovery. PRACTICE IMPLICATION This highlights the importance of having a SEDU and staff trained in eating disorder.
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Affiliation(s)
- Hajar Bt M S Sahimi
- Department of Psychiatry, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Shahlini Selvarajoo
- Department of Psychiatry, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Nik Ruzyanei Nik Jaafar
- Department of Psychiatry, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Shalisah Sharip
- Department of Psychiatry, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Mohamad Ayob Ismail
- Department of Psychiatry, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Mohd Muhaimin Hasni
- Department of Psychiatry, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Norasyikin A Wahab
- Endocrine Unit, Department of Internal Medicine, Faculty of Medicine, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
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Williams R, Smith M, Wright D. Anorexia: a literature review of young people's experiences of hospital treatment. Nurs Child Young People 2021; 33:10-17. [PMID: 33283489 DOI: 10.7748/ncyp.2020.e1313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2020] [Indexed: 06/12/2023]
Abstract
Anorexia nervosa is characterised by significantly low body weight, a fear of weight gain and persistent efforts to prevent the restoration of normal weight. It has potentially life-threatening physical and psychological complications, and many young people with anorexia present to hospital in a seriously compromised physical condition. While their physical symptoms require urgent treatment, addressing their emotional and psychological needs is equally important if they are to progress towards recovery. However, the conflicting thoughts common in anorexia mean that young people often feel highly ambivalent about treatment, which makes the disorder particularly challenging to treat. This article details a literature review undertaken to explore the perceptions and experiences of young people who have received hospital treatment for anorexia, with the aim of offering children's nurses insights into how they can optimally support these patients. The findings demonstrate the importance of listening to young people, treating them as individuals and understanding their experiences, in addition to addressing their physical health needs.
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Affiliation(s)
- Rhona Williams
- Faculty of Health and Social Work, Midwifery and Child Health, University of Hull, Hull, England
| | - Matthew Smith
- Children's and Adolescent Services, Hull University Teaching Hospitals NHS Trust, Hull, England
| | - David Wright
- Midwifery and Child Health, University of Hull, Hull, England
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24
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Guinhut M, Godart N, Benadjaoud MA, Melchior JC, Hanachi M. Five-year mortality of severely malnourished patients with chronic anorexia nervosa admitted to a medical unit. Acta Psychiatr Scand 2021; 143:130-140. [PMID: 33247947 DOI: 10.1111/acps.13261] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 11/20/2020] [Accepted: 11/22/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Anorexia nervosa (AN) is associated with one of the highest mortality rates of any psychiatric disorder but limited mortality data were reported for those with extremely severe malnutrition. This study aimed to estimate standardized mortality ratio (SMR), investigate predictive factors of mortality and causes of death among a sample of patients with AN admitted to a specialized clinical nutrition unit (CNU) because of extremely severe malnutrition. METHODS Between 11/27/1997 and 01/15/2014, vital status was determined for 384 patients admitted for AN at the first time in the CNU. Sociodemographic, anamnestic, and clinical data were collected. We calculated the SMR. Univariate and multivariate Cox regression analyses were performed to identify mortality predictors. RESULTS Crude mortality rate was 11.5%. (44 deaths) and SMR 15.9 [CI 95% (11.6-21.4)], 5.2 years post inpatient treatment. Mortality predictors at the time of hospitalization were as follows: older age, occurrence of an in-hospital suicide attempt, transfer to medical intensive care unit and the following somatic complications: frank anemia, dysnatremia, infectious and cardiac complications. Other predictors of mortality were: past or present history of discharge against medical advice, hematological comorbidities (not related to AN). A longer inpatient length of stay was a protective factor. CONCLUSION Very severely malnourished patients with AN hospitalized in a medical unit because of extremely severe somatic issues have a medium-term mortality rate higher than the general population and even higher than patients in tertiary specialized ED units. This study highlights predictive factors of mortality that will help clinicians in recognizing and managing patients at risk of death.
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Affiliation(s)
| | - Nathalie Godart
- Fondation Santé des Etudiants de France, Paris, France.,CESP, INSERM, UMR 1018, Paris-Saclay University, Paris, France
| | | | - Jean-Claude Melchior
- Clinical Nutrition Unit, Paul Brousse Hospital, APHP, Villejuif, France.,Paris-Saclay University, France
| | - Mouna Hanachi
- Clinical Nutrition Unit, Paul Brousse Hospital, APHP, Villejuif, France.,Paris-Saclay University, France.,UMR Micalis Institut, INRA, Jouy-En-Josas, France
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Ponzo V, Pellegrini M, Cioffi I, Scaglione L, Bo S. The Refeeding Syndrome: a neglected but potentially serious condition for inpatients. A narrative review. Intern Emerg Med 2021; 16:49-60. [PMID: 33074463 PMCID: PMC7843537 DOI: 10.1007/s11739-020-02525-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022]
Abstract
The Refeeding Syndrome (RFS) is a potentially serious, but still overlooked condition, occurring in individuals who are rapidly fed after a period of severe undernourishment. RFS derives from an abnormal electrolyte and fluid shifts leading to many organ dysfunctions. Symptoms generally appear within 2-5 days of re-feeding and may be absent/mild or severe and life threating, depending on the pre-existing degree of malnutrition and comorbidities. The lack of a standard definition and the nonspecificity of the symptoms make both incidence estimate and diagnosis difficult. In 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) proposed a unifying definition for the RFS and its severity classification. The awareness of the condition is crucial for identifying patients at risk, preventing its occurrence, and improving the management. The objectives of this narrative review were to summarize the current knowledge and recommendations about the RFS and to provide useful tips to help physicians to recognize and prevent the syndrome.
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Affiliation(s)
- Valentina Ponzo
- Department of Medical Sciences, University of Torino, c.so AM Dogliotti 14, 10126, Turin, Italy
| | - Marianna Pellegrini
- Department of Medical Sciences, University of Torino, c.so AM Dogliotti 14, 10126, Turin, Italy
| | - Iolanda Cioffi
- Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Luca Scaglione
- Internal Medicine Unit, Città della Salute e della Scienza Hospital of Torino, Turin, Italy
| | - Simona Bo
- Department of Medical Sciences, University of Torino, c.so AM Dogliotti 14, 10126, Turin, Italy.
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Richardson C, Huniewicz P, Paslakis G. Retrospective analysis of hypophosphatemia rates and other clinical parameters in patients with eating disorders. EUROPEAN EATING DISORDERS REVIEW 2020; 29:193-203. [PMID: 33247867 DOI: 10.1002/erv.2810] [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: 05/18/2020] [Revised: 10/19/2020] [Accepted: 11/13/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To retrospectively assess medical services of a specialist inpatient eating disorders (EDs) unit. METHOD We retrospectively evaluated clinical parameters of 288 inpatients classified as 'moderately' or 'significantly' medically compromised between 1 January 2016 and 30 June 2019. RESULTS We analysed 288 patients (mean age 32.5 [SD = 11.4] years, 96% women, 76% with anorexia nervosa). Average length of stay was 38.4 (SD = 28.4) days. Average admission body mass index (BMI) was 14.8 (SD = 1.8) kg/m2 , and 16.1 (SD = 1.9) kg/m2 at 4 weeks. At admission, 82% of patients were considered significantly medically compromised, while 6% were deemed moderately compromised. Only 5% of patients required transfer to intensive care unit. Prevalence of hypophosphatemia was 17.7%; rates did not increase significantly between years despite more assertive re-feeding processes. There was no association between risk classification at admission and change in BMI at 4 weeks (F(2,166) = 0.588, p = 0.557). BMI at admission was found to be significantly associated with clinical outcome (β = 0.92, p < 0.001). DISCUSSION Hypophosphatemia rates did not increase despite more assertive re-feeding over 3 years. Our results provide support for a model of treatment that simultaneously addresses the medical and psychiatric sequelae of patients with severe EDs.
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Affiliation(s)
- Candice Richardson
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Paulina Huniewicz
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Georgios Paslakis
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Ekezie W, Murray RL, Agrawal S, Bogdanovica I, Britton J, Leonardi-Bee J. Quality of smoking cessation advice in guidelines of tobacco-related diseases: An updated systematic review. Clin Med (Lond) 2020; 20:551-559. [PMID: 33199319 PMCID: PMC7687319 DOI: 10.7861/clinmed.2020-0359] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Tobacco smoking is a major risk factor for a wide range of diseases, and smoking cessation significantly reduces these risks. Clinical guidelines for diseases associated with smoking should therefore include guidance on smoking cessation. This review updated evidence on the proportion of clinical guidelines that do so. We conducted a systematic review investigating clinical guidelines and recommendations developed by UK national or European transnational medical specialty associations and societies between January 2014 and October 2019 on 16 diseases to be at least twice as common among smokers than non-smokers. Outcomes of interest were the reporting of smoking as a risk factor, and the inclusion either of smoking cessation advice or referral to other cessation guidance. We compared our findings with an earlier review of guidelines published between 2000 and 2013. We identified 159 clinical guidelines/recommendations. Over half (51%) made no mention of smoking, while 43% reported smoking as a risk factor for the development of the disease, 31% recommended smoking cessation and 19% provided detailed information on how to deliver smoking cessation support. These proportions were similar to those in our earlier review. Smoking cessation continues to be neglected in clinical management guidance for diseases caused by smoking.
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Guinhut M, Melchior JC, Godart N, Hanachi M. Extremely severe anorexia nervosa: Hospital course of 354 adult patients in a clinical nutrition-eating disorders-unit. Clin Nutr 2020; 40:1954-1965. [PMID: 33023762 DOI: 10.1016/j.clnu.2020.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 09/04/2020] [Accepted: 09/08/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS The clinical nutrition-eating disorders-unit in Raymond Poincaré Hospital is a reference center for the management of severe malnutrition and its complications in patients with anorexia nervosa (AN). The purpose of this study is to specify socio-demographic, anamnesic and clinical characteristics of AN patients hospitalized for extreme malnutrition, to identify types and prevalence of medical complications presented during their hospitalization for refeeding and the evolution of patients nutritional status. METHODS Demographic, clinical and paraclinical data of 354 severely malnourished AN patients were collected, during their first hospitalization in the unit, between November 1997 and January 2014, through medical records. The prevalence of medical complications was compared between the 2 AN subtypes (restricting and binging-purging). RESULTS 339 patients were female and mean age was 28.7 ± 10.7 years old. Duration of AN was 9.5 ± 9 years, 173 (48.9%) patients had a restricting AN subtype. BMI at admission was 12.2 ± 1.6 kg/m2, 280 (79.3%) patients had already been hospitalized for AN in other hospitals before. Psychiatric comorbidities were present in 168 (47.5%) patients. Associated somatic comorbidities concerned 70 (19.8%) patients. Outcomes during hospitalization were marked by 4.1 ± 3.9 kg weight gain on 36.9 ± 30.5 days. Enteral nutrition was provided in 304 (85.9%) patients. Main medical complications during hospitalization were: anemia (79%), neutropenia (53.9%), hypertransaminasemia (53.7%), osteoporosis (46.3%), hypokalemia (39.5%), hypophosphatemia (26%), hypoglycemia (13.8%), infectious complications (24.3%), cardiac dysfunction (7.1%), and proven gelatinous bone marrow transformation (6.5%). Hypokalemia was more frequent in binging-purging subtype. Lympho-neutropenia and hypertransaminasemia were more frequent in restricting subtype. During their hospitalization, 35 (10%) patients were referred to medical intensive care unit and 5 patients died. CONCLUSIONS AN patients hospitalized for severe malnutrition in a specialized clinical nutrition unit have severe and frequent medical complications. Psychiatric comorbidities are also frequent and could complicate medical care. A specialized and multidisciplinary management of these patients is therefore essential.
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Affiliation(s)
- Marie Guinhut
- Clinical Nutrition Unit, Raymond Poincaré Hospital, Garches, France; Paris-Descartes University, Paris, France.
| | - Jean-Claude Melchior
- Clinical Nutrition Unit, Raymond Poincaré Hospital, Garches, France; Paris-Saclay University, France
| | - Nathalie Godart
- Fondation de Santé des Etudiants de France, Paris, France; CESP, INSERM, UMR 1018, UVSQ, Université Paris-Saclay, Paris, France
| | - Mouna Hanachi
- Clinical Nutrition Unit, Raymond Poincaré Hospital, Garches, France; Paris-Saclay University, France
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29
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Ambwani S, Cardi V, Albano G, Cao L, Crosby RD, Macdonald P, Schmidt U, Treasure J. A multicenter audit of outpatient care for adult anorexia nervosa: Symptom trajectory, service use, and evidence in support of "early stage" versus "severe and enduring" classification. Int J Eat Disord 2020; 53:1337-1348. [PMID: 32064663 DOI: 10.1002/eat.23246] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND We explored the utility of "staging" anorexia nervosa (AN) by duration of illness and psychological wellbeing. We also investigated 12-month symptom trajectories and service usage in a large cohort of patients with AN assessed for outpatient treatment. METHOD We conducted secondary analyses on data from a multisite clinical trial of adults with AN (n = 187) recruited from 22 NHS England specialist eating disorder (ED) services into a digital treatment augmentation study. Clinical outcomes and service use were measured at postintervention (six weeks), 6 and 12 months. We grouped patients into two categories: "early stage" (illness duration <3 years; n = 60) and "severe and enduring" stage (SE-AN; n = 41) indicated by distress (Depression Anxiety and Stress Scales, DASS ≥60) and illness duration (≥7 years). RESULTS At 12 months, patients reported large improvements in body mass index, small to moderate improvements in ED symptoms, mood, and work/social adjustment, and 23.6% met criteria for recovery. However, patients classified as SE-AN reported higher rates of accessing intensive services, higher ED symptomatology, and poorer work/social adjustment at baseline, and lower rates of improvement in work/social adjustment at 12 months compared to "early stage" respondents. DISCUSSION Although present findings suggest overall symptomatic improvements, exploratory results highlight marked differences in course and service use between people at different stages of AN, suggesting a need to consider staging for clinical decision-making. Further research differentiating between clinical subtypes of AN and adoption of a more personalized approach may ensure that services and care pathways better fit patient needs.
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Affiliation(s)
- Suman Ambwani
- Department of Psychology, Dickinson College, Carlisle, Pennsylvania, USA
| | - Valentina Cardi
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Gaia Albano
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Department of Psychology, Educational Sciences and Human Movement, University of Palermo, Palermo, Italy
| | - Li Cao
- Sanford Center for Biobehavioral Research, Fargo, North Dakota, USA.,Department of Psychiatry and Behavioral Sciences, University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota, USA
| | - Ross D Crosby
- Sanford Center for Biobehavioral Research, Fargo, North Dakota, USA.,Department of Psychiatry and Behavioral Sciences, University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota, USA
| | - Pamela Macdonald
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Janet Treasure
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Hemmingsen SD, Lichtenstein MB, Hussain AA, Sjögren JM, Støving RK. Case report: cognitive performance in an extreme case of anorexia nervosa with a body mass index of 7.7. BMC Psychiatry 2020; 20:284. [PMID: 32503476 PMCID: PMC7275539 DOI: 10.1186/s12888-020-02701-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/28/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Studies show that adult patients with anorexia nervosa display cognitive impairments. These impairments may be caused by illness-related circumstances such as low weight. However, the question is whether there is a cognitive adaptation to enduring undernutrition in anorexia nervosa. To our knowledge, cognitive performance has not been assessed previously in a patient with anorexia nervosa with a body mass index as low as 7.7 kg/m2. CASE PRESENTATION We present the cognitive profile of a 35-year-old woman with severe and enduring anorexia nervosa who was diagnosed at the age of 10 years. She was assessed with a broad neuropsychological test battery three times during a year. Her body mass index was 8.4, 9.3, and 7.7 kg/m2, respectively. Her general memory performance was above the normal range and she performed well on verbal and design fluency tasks. Her working memory and processing speed were within the normal range. However, her results on cognitive flexibility tasks (set-shifting) were below the normal range. CONCLUSIONS The case study suggests that it is possible to perform normally cognitively despite extreme and chronic malnutrition though set-shifting ability may be affected. This opens for discussion whether patients with anorexia nervosa can maintain neuropsychological performance in spite of extreme underweight and starvation. TRIAL REGISTRATION ClinicalTrials.gov, NCT02502617. Registered 20 July 2015.
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Affiliation(s)
- Simone Daugaard Hemmingsen
- Centre for Eating Disorder, Odense University Hospital, Odense, Denmark. .,Research Unit for Medical Endocrinology, Odense University Hospital, Odense, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,Open Patient data Explorative Network (OPEN), Odense, Denmark. .,The Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark.
| | - Mia Beck Lichtenstein
- Centre for Telepsychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Alia Arif Hussain
- grid.466916.a0000 0004 0631 4836Eating Disorder Unit, Mental Health Centre Ballerup, Mental Health Services in the Capital Region of Denmark, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jan Magnus Sjögren
- grid.466916.a0000 0004 0631 4836Eating Disorder Unit, Mental Health Centre Ballerup, Mental Health Services in the Capital Region of Denmark, Copenhagen, Denmark ,grid.5254.60000 0001 0674 042XDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - René Klinkby Støving
- grid.7143.10000 0004 0512 5013Centre for Eating Disorder, Odense University Hospital, Odense, Denmark ,grid.7143.10000 0004 0512 5013Research Unit for Medical Endocrinology, Odense University Hospital, Odense, Denmark ,grid.10825.3e0000 0001 0728 0170Department of Clinical Research, University of Southern Denmark, Odense, Denmark ,Open Patient data Explorative Network (OPEN), Odense, Denmark ,The Research Unit, Child and Adolescent Psychiatry, Mental Health Services in the Region of Southern Denmark, Odense, Denmark
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Outcomes of an Accelerated Inpatient Refeeding Protocol in 103 Extremely Underweight Adults with Anorexia Nervosa at a Specialized Clinic in Prien, Germany. J Clin Med 2020; 9:jcm9051535. [PMID: 32438760 PMCID: PMC7291118 DOI: 10.3390/jcm9051535] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/28/2020] [Accepted: 05/13/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In mildly to moderately malnourished adolescent patients with anorexia nervosa (AN), accelerated refeeding protocols using higher initial calory supply coupled with phosphate supplements were not associated with a higher incidence of refeeding syndrome (RS). It is unclear whether this is also a feasible approach for extremely malnourished, adult AN patients. METHODS Outcomes of a clinical refeeding protocol involving a targeted initial intake of ≥2000 kcal/day, routine supplementation of phosphate and thiamine as well as close medical monitoring, were evaluated. A retrospective chart review including AN patients with a body mass index (BMI) <13 kg/m² was conducted, to describe changes in weight, BMI, and laboratory parameters (phosphate, creatine kinase, hematocrit, sodium, liver enzymes, and blood count) over four weeks. RESULTS In 103 female patients (age, mean ± standard deviation (SD) = 23.8 ± 5.3 years), BMI between admission and follow-up increased from 11.5 ± 0.9 to 13.1 ± 1.1 kg/m² and total weight gain within the first four weeks was 4.2 ± 2.0 kg (mean, SD). Laboratory parameter monitoring indicated no case of RS, but continuous normalization of blood parameters. CONCLUSIONS Combined with close medical monitoring and electrolyte supplementation, accelerated refeeding may also be applied to achieve medical stabilization in extremely underweight adults with AN without increasing the risk of RS.
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Abstract
Eating disorders are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning. Disturbed attitudes towards weight, body shape, and eating play a key role in the origin and maintenance of eating disorders. Eating disorders have been increasing over the past 50 years and changes in the food environment have been implicated. All health-care providers should routinely enquire about eating habits as a component of overall health assessment. Six main feeding and eating disorders are now recognised in diagnostic systems: anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant-restrictive food intake disorder, pica, and rumination disorder. The presentation form of eating disorders might vary for men versus women, for example. As eating disorders are under-researched, there is a great deal of uncertainty as to their pathophysiology, treatment, and management. Future challenges, emerging treatments, and outstanding research questions are addressed.
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Affiliation(s)
- Janet Treasure
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Tiago Antunes Duarte
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Serviço de Psiquiatria e Saúde Mental, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ulrike Schmidt
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
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Abstract
Eating disorders (EDs) are a group of prevalent psychiatric illnesses with an onset in early to late adolescence-a time of significant neural development, physical and psychologic growth, and self-exploration. The etiology and neurobiology of EDs are not well understood, but EDs are recognized as brain-based illnesses with serious acute and long-term consequences if undertreated or ignored. Two EDs, anorexia nervosa (AN) and bulimia nervosa (BN), have historically been the primary EDs of focus. The DSM-5 updated diagnostic criteria for these disorders added two more: binge-eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID). EDs severely impact males as well as females across the weight spectrum. Comorbidity is high; mortality rates for AN and BN are the highest in psychiatric conditions and higher than many medical conditions. Several treatment options are available to treat an ED ranging from inpatient hospitalization to outpatient services and different psychotherapy options. This chapter reviews the diagnostic criteria, clinical presentation, and treatment for these disorders. Where available, sex differences and developmental considerations will be noted. For all EDs, early recognition and swift treatment are necessary to avoid a chronic course.
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Abstract
Refeeding in anorexia nervosa is a collaborative enterprise involving multidisciplinary care plans, but clinicians currently lack guidance, as treatment guidelines are based largely on clinical confidence rather than more robust evidence. It seems crucial to identify reproducible approaches to refeeding that simultaneously maximize weight recovery and minimize the associated risks, in addition to improving long-term weight and cognitive and behavioral recovery and reducing relapse rates. We discuss here various approaches to refeeding, including, among others, where, by which route, how rapidly patients are best refed, and ways of choosing between them, taking into account the precautions or the potential effects of medication or of psychological care, to define better care plans for use in clinical practice.Conclusion: The importance of early weight gain for long-term recovery has been demonstrated by several studies in both outpatient and inpatient setting. Recent studies have also provided evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Finally, the risks of undernutrition/"underfeeding syndrome" and a maintenance of weight suppression are now better identified. Greater caution should still be applied for more severely malnourished < 70% average body weight and/or chronically ill, adult patients. What is Known: • Refeeding is a central part of the treatment in AN and should be a multidisciplinary and collaborative enterprise, together with nutritional rehabilitation and psychological support, but there are no clear guidelines on the management of refeeding in clinical practice. • The risk of a refeeding syndrome is well known and well managed in severely malnourished patients ("conservative approaches"). What is New: • There is evidence that early weight restoration has an impact on outcome, justifying an aggressive approach to refeeding in the early stages of the illness. • The risks of "underfeeding syndrome" and of a maintenance of weight suppression are now better identified and there is sufficient evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Graphical abstract.
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Resmark G, Herpertz S, Herpertz-Dahlmann B, Zeeck A. Treatment of Anorexia Nervosa-New Evidence-Based Guidelines. J Clin Med 2019; 8:E153. [PMID: 30700054 PMCID: PMC6406277 DOI: 10.3390/jcm8020153] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/20/2019] [Accepted: 01/28/2019] [Indexed: 12/30/2022] Open
Abstract
Anorexia nervosa is the most severe eating disorder; it has a protracted course of illness and the highest mortality rate among all psychiatric illnesses. It is characterised by a restriction of energy intake followed by substantial weight loss, which can culminate in cachexia and related medical consequences. Anorexia nervosa is associated with high personal and economic costs for sufferers, their relatives and society. Evidence-based practice guidelines aim to support all groups involved in the care of patients with anorexia nervosa by providing them with scientifically sound recommendations regarding diagnosis and treatment. The German S3-guideline for eating disorders has been recently revised. In this paper, the new guideline is presented and changes, in comparison with the original guideline published in 2011, are discussed. Further, the German guideline is compared to current international evidence-based guidelines for eating disorders. Many of the treatment recommendations made in the revised German guideline are consistent with existing international treatment guidelines. Although the available evidence has significantly improved in quality and amount since the original German guideline publication in 2011, further research investigating eating disorders in general, and specifically anorexia nervosa, is still needed.
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Affiliation(s)
- Gaby Resmark
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Osianderstr. 5, 72076 Tuebingen, Baden-Wuerttemberg, Germany.
| | - Stephan Herpertz
- Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr-University Bochum, Alexandrinenstr. 1-3, Nordrhein-Westfalen, 55791 Bochum, Germany.
| | - Beate Herpertz-Dahlmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of the RWTH Aachen, Neuenhofer Weg 21, Nordrhein-Westfalen, 52074 Aachen, Germany.
| | - Almut Zeeck
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Freiburg, Hauptstr. 8, Baden-Wuerttemberg, 79104 Freiburg, Germany.
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Recio-Barbero M, Fuertes-Soriano S, Cabezas-Garduño J, López-Atanes M, Peña-Rotella A, Sáenz-Herrero M. Delayed Diagnosis of an Eating Disorder in a Male Patient With Superior Mesenteric Artery Syndrome: Results From a Case Study. Front Psychiatry 2019; 10:731. [PMID: 31681041 PMCID: PMC6803474 DOI: 10.3389/fpsyt.2019.00731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/12/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Eating disorders (EDs) are serious and life-threatening mental diseases characterized by abnormal or altered eating habits. The prevalence is variable, being influenced by diverse sociocultural factors. Historically, the prevalence of EDs has been higher in women (90%), although the incidence of these disorders in men appears to be increasing. In daily medical practice, when considering the presentation of other medical complications associated to the development of an ED, few is known about its real prevalence in men. Among them, some severe gastrointestinal complications that are rarely presented, such as the superior mesenteric artery syndrome (SMAS), can produce life-threatening results. Despite that, very few cases of men presenting this pathology are reported in literature. Case Presentation: A 38-year-old man without a history of psychiatric disease was admitted to the emergency department with nausea, abdominal pain, and severe malnutrition (body mass index 15.7 kg/m2). He was diagnosed with SMAS and was studied by multiple specialists on suspicion of a probable organic origin of his thinning. The suspected diagnosis of ED was rejected for months by some professionals, as well as by the patient and his family, until it was finally diagnosed with unspecified feeding and eating disorder (USFED). Conclusion: This case represents an example of diagnostic challenge where a delayed diagnosis of an ED in a male patient was made probably due to gender bias in clinical research and practice. In the literature, numerous reports were described in women diagnosed with SMAS with a previous diagnosis of an ED; however, few cases were found in men. In this clinical case, the patient suffered a significant diagnostic delay, probably due to the lack of diagnostic suspicion given by the differences in the prevalence and clinical presentation of EDs in women and men.
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Affiliation(s)
- María Recio-Barbero
- Department of Psychiatry, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo, Spain.,Department of Neurosciences, School of Medicine and Nursing, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Sara Fuertes-Soriano
- Department of Psychiatry, Cruces University Hospital, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Janire Cabezas-Garduño
- Department of Psychiatry, Cruces University Hospital, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Mayte López-Atanes
- Department of Psychiatry, Cruces University Hospital, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Alvar Peña-Rotella
- Department of Psychiatry, Cruces University Hospital, Osakidetza-Basque Health Service, Barakaldo, Spain
| | - Margarita Sáenz-Herrero
- Department of Psychiatry, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Barakaldo, Spain.,Department of Neurosciences, School of Medicine and Nursing, University of the Basque Country (UPV/EHU), Leioa, Spain.,Department of Psychiatry, Cruces University Hospital, Osakidetza-Basque Health Service, Barakaldo, Spain
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[3-year course after successful therapy of extreme anorexia nervosa]. DER NERVENARZT 2018; 89:1063-1068. [PMID: 30109363 DOI: 10.1007/s00115-018-0592-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Anorexia nervosa is a common psychiatric disorder in adolescents and young adults and is often associated with high rates of comorbidities and a chronic course of the disease. Additionally, it still shows the highest rates of mortality among all psychiatric disorders. The case presented describes a female patient with severe and enduring anorexia nervosa who achieved remission after strict adherence to inpatient treatment and showed a full recovery in the 3‑year follow-up. Shortly after achieving a minimum weight of 25 kg (171 cm, body mass index 8.5 kg/m2) the 21-year-old, chronically ill patient was admitted to an intensive care unit. After a phase of stabilization and achieving a BMI of 10 kg/m2, she was transferred to a hospital specialized in treating eating disorders. It came to a full recovery of the patient including full weight restoration during regular follow-ups (BMI 20.0 kg/m2) and normalization of the psychopathology of the eating disorder. In a 3-year follow-up, the patient presented with an enduring and complete remission of all symptoms, which were extremely expressed during the illness.
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