Margherita Mascolo

Severe anorexia nervosa: Outcomes from a medical stabilization unit

OBJECTIVE We report data from the medical stabilization and refeeding of patients with severe anorexia nervosa admitted over a 15-month period. METHOD Through chart review and computerized data collection, we evaluated demographic and clinical data from 25 consecutive patients admitted to our medical stabilization unit from October 2008 to January 2010. RESULTS In this adult-patient population with a median body mass index (BMI) of 13.1 kg/m(2) (interquartile range, 11.0-14.4), 44% developed hypoglycemia, 76% had abnormal liver function, 83% had abnormal bone density, 45% developed refeeding hypophosphatemia, and 92% were hypothermic. Severe liver function abnormality predicted the development of hypoglycemia (p = 0.02, OR 9.78, CI: 1.55-61.65). No clinical features predicted hypophosphatemia, including admission BMI (p = 0.19), serum glucose level (p = 0.21), elevated liver function tests (p = 0.39 for AST), or initial amount of kilocalories consumed (p = 0.06). DISCUSSION Patients with the most severe cases of anorexia nervosa have a high prevalence of serious medical complications during initial refeeding.

Prospective comparison of curbside versus formal consultations

BACKGROUND Curbside consultations are commonly requested during the care of hospitalized patients, but physicians perceive that the recommendations provided may be based on inaccurate or incomplete information. OBJECTIVE To compare the accuracy and completeness of the information received from providers requesting a curbside consultation of hospitalists with that obtained in a formal consultation on the same patients, and to examine whether the recommendations offered in the 2 consultations differed. DESIGN Prospective cohort. SETTING University-affiliated, urban safety net hospital. MAIN OUTCOME MEASURES Proportion of curbside consultations with inaccurate or incomplete information; frequency with which recommendations in the formal consultation differed from those in the curbside consultation. RESULTS Curbside consultations were requested for 50 patients, 47 of which were also evaluated in a formal consultation performed on the same day by a hospitalist other than the one performing the curbside consultation. Based on information collected in the formal consultation, information was either inaccurate or incomplete in 24/47 (51%) of the curbside consultations. Management advice after formal consultation differed from that given in the curbside consultation for 28/47 patients (60%). When inaccurate or incomplete information was received, the advice provided in the formal versus the curbside consultation differed in 22/24 patients (92%, P < 0.0001). CONCLUSIONS Information presented during inpatient curbside consultations of hospitalists is often inaccurate or incomplete, and this often results in inaccurate management advice.

What the emergency department needs to know when caring for your patients with eating disorders

OBJECTIVE In this article, we will examine the most common emergency department presentations of eating disorder patients, review the pathophysiologic changes that lead to such presentations, and discuss the appropriate management of each patient. METHOD Literature review of current practices. RESULTS This article serves as a guide for ED physicians caring for patients with eating disorders. It can also serve to improve communication between mental health specialists and emergency room physicians when transferring care of a patient to the ED. DISCUSSION Patients with anorexia and bulimia nervosa present to ED with a multitude of vague complaints. It is crucial for ED physicians to recognize that such complaints stem from an underlying eating disorder to understand the pathophysiology behind such complaints. This in turn will lead to appropriate management of patient symptoms, which can often be complex for the provider and stressful for the patient.

PseudoBartter syndrome in eating disorders

OBJECTIVE PseudoBartters syndrome, a complex pattern of seemingly unrelated metabolic abnormalities, is frequently seen in patients with eating disorders, particularly those who indulge in purging behaviors. We present two cases that, despite divergent background histories and clinical presentations, possess the unifying pathophysiology that ultimately leads to this syndrome. METHOD Case report and review of literature pertaining to Bartters and PseudoBartters syndromes. RESULTS Purging behaviors commonly result in a state of profound dehydration and chloride depletion that leads to the metabolic abnormalities characteristic of inheritable sodium and chloride renal tubular transport disorders. In the eating disorder patient, these abnormalities lead to a propensity towards marked edema formation. DISCUSSION The metabolic and clinical manifestations of PseudoBartters syndrome are seen more commonly than previously thought. It is important to appreciate that a complex self-perpetuating pathophysiology leads to the hypokalemic metabolic alkalosis characteristic of PseudoBartter syndrome. The metabolic abnormalities characteristic of this phenomenon should therefore be viewed in this context and the resulting predilection towards marked edema formation should be borne in mind.

ACUTE center for eating disorders

BACKGROUND While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs. METHODS We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder. The first 2 years of patient characteristics and outcomes are reported. RESULTS From October 2008 through December 2010, the ACUTE unit had 76 admissions of which 62 were for medical stabilization, comprising 54 patients. Eighty-nine percent of patients were female. The mean age was 27 years old (range 17-65). The mean body mass index on admission was 12.9 kg/m(2) (standard deviation [SD] 2.0). At admission, patients were hyponatremic, anemic, and leukopenic, with low bone density, but had normal albumin levels. The mean body mass index on discharge was 13.1 ± 1.9 kg/m(2). Median length of stay was 16 days (interquartile range [IQR] 9-29 days). Eighteen percent were discharged to home and eighty-two percent were discharged to inpatient psychiatric eating disorder units. Inpatient mortality was zero. DISCUSSION Patients with this degree of severe malnutrition due to eating disorders are medically complex and relatively uncommon. Regionalized subspecialty centers of excellence, in which a multidisciplinary team is led by practitioners of hospital medicine who have developed expertise in a rare condition, may improve clinical outcomes, optimize healthcare resources, and provide unique professional and academic opportunities for the clinicians involved.

Severe gastric dilatation due to superior mesenteric artery syndrome in anorexia nervosa

Forty-seven year old female, with a history of anorexia nervosa, was admitted to a medical stabilization unit (ACUTE) complaining of abdominal pain exacerbated by oral intake, associated with nausea, and relieved by emesis. Admission body mass index was 10.6. Labs were notable for hepatitis and hypoglycemia. On her progressive oral refeeding plan, she suddenly developed severe abdominal pain. Computed tomography (CT) revealed gastric dilatation and superior mesenteric artery (SMA) syndrome. SMA syndrome is a rare complication of severe malnutrition resulting from compression of the duodenum between the aorta and the SMA. It is diagnosed by an upper gastrointestinal series or an abdominal CT. Gastric dilatation, in turn, is a rare complication of SMA syndrome to be included in the differential diagnoses of abdominal pain in severely malnourished patients as it is potentially life-threatening. The patient was switched to an oral liquid diet, began weight restoring, and had resolution of symptoms.

Abuse and clinical value of diuretics in eating disorders therapeutic applications

OBJECTIVE Diuretic abuse as a means of purging is common in patients with bulimia nervosa. We sought to illustrate the pathophysiologic effects of diuretics and purging on a patient with bulimia nervosas fluid and electrolyte status and to clarify the role of diuretics in the management of volume status during refeeding. METHOD We reviewed the literature pertaining to diuretic abuse, purging, bulimia nervosa, and diuretic therapy. RESULTS Purging behaviors lead to volume depletion and a state of heightened aldosterone production. Patients with bulimia nervosa commonly undergo rapid rehydration with intravenous fluid administration. In the setting of hyperaldostreronism, aggressive rehydration leads to avid salt retention and the development of marked amounts of edema. DISCUSSION Providers should understand both the background renal pathophysiology of the patient with bulimia nervosa and the mechanisms of action of diuretics to correctly use diuretics as focused therapeutic agents for this patient population.

Gastrointestinal comorbidities which complicate the treatment of anorexia nervosa

ABSTRACT Patients with anorexia nervosa often voice a multitude of symptoms in regards to their gastrointestinal tract. These complaints can complicate the treatment of their eating disorder as they distract attention from the important goal of weight restoration. Moreover, the restricting of certain food groups also makes the task of weight restoration substantially more difficult, or may result in binging. Therefore a working knowledge of common gastrointestinal comorbidities, such as celiac disease, irritable bowel syndrome, inflammatory bowel disease, and gastroparesis, is useful when treating a patient who has anorexia nervosa.

Lagophthalmos in Severe Anorexia Nervosa: A Case Series

although the majority of the cornea was nonedematous, there was marked corneal edema in the area of the GV markings with bulla noted (Figure 1). Over several weeks, the edema gradually resolved with interface haze in the area of prior edema. The visual acuity resolved to 20/40 without correction. Case 2. A 67-year-old woman with a history of Fuchs endothelial dystrophy presented with gradual onset of blurry vision of the right eye. On examination, it was found that her best-corrected visual acuity was 20/60 in the right eye and 20/30 in the left eye. There was 3 guttata with 1 edema of the right eye. There was a well-centered posterior chamber intraocular lens on the right. His left eye had 1 guttata and a 1 nuclear sclerotic cataract. An uneventful DSAEK was performed (thickness of graft unknown). On postoperative day 1, the graft was fully attached, there was 2 diffuse corneal edema present, and her visual acuity was 3/200. The edema was most prominent in the area of the purple markings (Figure 2). At postoperative week 1, the patient’s visual acuity was unchanged. Interface haze was noted at the area of the markings. At the 2-week postoperative visit, her visual acuity was 20/ 400, and her best-corrected visual acuity was 20/80. No change occurred 1 month after surgery. At postoperative week 6, the patient had a best-corrected visual acuity of 20/40 with a clear cornea.

Critical gaps in the medical knowledge base of eating disorders

Eating disorders are unique in that they inherently have much medical comorbidity both as a part of restricting-type eating disorders and those characterized by purging behaviors. Over the last three decades, remarkable progress has been made in the understanding and treatment of the medical complications of eating disorders. Yet, unfortunately, there is much research that is sorely needed to bridge the gap between current medical knowledge and more effective and evidence-based medical treatment knowledge. These gaps exist in many different clinical areas including cardiology, electrolytes, gastrointestinal and bone disease. In this paper, we discuss some of the knowledge gap areas, which if bridged would help develop more effective medical intervention for this population of patients.