A comparison of the metabolic complications and hospital course of severe anorexia nervosa by binge-purge and restricting subtypes.

This study examines adult patients with severe, life-threatening anorexia nervosa who were admitted to an inpatient, medical stabilization unit between October 1, 2008 and December 31, 2014. Specifically, the study compares anorexia nervosa, binge purge subtype (AN-BP) and anorexia nervosa, restricting subtype (AN-R) on admission measures, hospital course, and outcomes. Of the 232 patients, 46% (N = 108) had AN-BP. Patients with AN-R manifested a higher frequency of underweight-mediated medical complications, including bone marrow dysfunction, hepatic dysfunction, and hypoglycemia. Understanding the pathophysiologic differences between severe AN-R and AN-BP is essential to understanding the abnormalities seen on clinical presentation, guiding appropriate clinical treatment, and predicting medical complications during refeeding.

Rare medical manifestations of severe restricting and purging: "Zebras," missed diagnoses, and best practices.

OBJECTIVE: Medical problems that arise due to severe restricting and/or purging may be misdiagnosed or suboptimally treated, from outpatient clinics to top medical hospitals. A symptom may be presumed to be a psychological manifestation of the eating disorder and inappropriately dismissed for further medical evaluation. Alternatively, a detailed medical workup may be performed, overlooking a classic relationship between starvation and a physical finding, which delays referral to eating disorder care. This review article focuses on rare medical issues (also called "zebras" in medical training), diagnoses that may be missed in patients with eating disorders, and best practices for management, organized by organ system. METHOD: A PubMed search was performed, using search terms "eating disorder," "anorexia nervosa," and "bulimia nervosa" in combination with different words for each organ system and known medical manifestations of severe eating disorders, with high quality and relevant studies from the past 20 years cited. DISCUSSION: Adults with eating disorders may present with extreme organ dysfunction and atypical signs and symptoms of typical medical problems. Timely diagnosis, risk awareness, appropriate treatment, and avoidance of harm are all vital. With judicious management and nutritional rehabilitation, most of these complications will significantly improve or resolve. ©

Prevalence and management of oropharyngeal dysphagia in patients with severe anorexia nervosa: A large retrospective review.

OBJECTIVE: Oropharyngeal dysphagia (OPD) refers to difficulty swallowing food or a liquid bolus from the oral and pharyngeal cavities into the esophagus and increases the risk of possibly life-threatening pneumonia. Little has been reported on OPD in adults with anorexia nervosa (AN). This study includes a description of OPD in severe AN and discusses potentially effective clinical management. METHOD: Two hundred and six adults with severe AN, admitted over a five-year period to a national referral center specializing in the multidisciplinary medical stabilization of this population, were retrospectively evaluated by electronic database query and manual chart review. All patients whose initial medical assessment triggered a speech-language pathology (SLP) consultation, due to concerns for OPD, were reviewed in detail. RESULTS: Of the 206 total patients, 42 presented with symptoms of OPD and received SLP consultation. In the OPD cohort, 37 (88%) were women, with median age 32 years old, and mean admission weights of 57% ideal body weight (IBW) and body mass index (BMI) of 12 kg/m(2). Compared with those who did not have OPD, OPD patients had significantly lower BMI on admission (12 kg/m(2) vs. 13.1 kg/m(2), p < 0.001), longer stay (21 days vs. 14 days, p < 0.001), and were more medically compromised, including a greater incidence of refeeding hypophosphatemia (60.9% vs. 29.7%, p < 0.004). DISCUSSION: Clinical awareness of OPD may reduce the incidence of aspiration pneumonia and promote life-saving oral nutrition in patients with severe AN. Proper, timely evaluation and intervention may improve clinical outcomes.

Liver dysfunction in patients with severe anorexia nervosa.

OBJECTIVE: Evaluation of liver dysfunction in patients with severe anorexia nervosa (AN) has typically been limited to small case series. We report an investigation into the admission characteristics and clinical outcomes associated with liver dysfunction in a large cohort of adults hospitalized for medical stabilization of severe AN. METHODS: We retrospectively evaluated electronic medical records to quantify the cumulative incidence of elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT). We compared mean (±SD), frequencies (%), and median (IQR) values of clinical covariates of interest by incidence of liver enzyme elevation. The study included 181 adults, admitted for medical stabilization of AN, from October 1, 2008 to December 31, 2013. RESULTS: AST and ALT were mildly elevated in 27.6% of patients and severely elevated (more than three times the upper limit of normal) in 35.4% of patients. On admission, patients with severely elevated liver enzymes had a lower body mass index (BMI) (11.9 ± 1.8 kg/m(2) vs.13.3 ± 1.7 kg/m(2)), lower percentage ideal body weight (56.5% ± 7.7% vs. 63.5% ± 8.3%), and lower prealbumin (64% vs. 37%) compared with the rest of the cohort (p < 0.001). While hospitalized, patients with severely elevated liver enzymes more often developed hypoglycemia, hypophosphatemia, and experienced longer lengths of stay (p < 0.001). DISCUSSION: Elevated liver enzymes are common in our patient population with severe AN. Liver enzymes reached near normal values by the time of discharge. Severely elevated liver enzymes were associated with a lower BMI and the development of hypoglycemia.

Medical outcomes for adults hospitalized with severe anorexia nervosa: An analysis by age group.

OBJECTIVE: Relatively little has been written about the outcomes of medical stabilization, analyzed specifically across the age spectrum, in adults with severe anorexia nervosa (AN). METHOD: We retrospectively evaluated clinical parameters relevant to acuity of illness and outcomes of early refeeding in 142 adults with severe AN, admitted for definitive inpatient medical stabilization from October 1, 2008 to December 31, 2012. Patients were categorized into three age groups: 17 to 29, 30 to 40, and 41+ years. RESULTS: The study included 142 patients with median age of 28 years old (range 17-65 years). Fifty-four percent (n = 78) were under 30 years old, 23% (n = 32) between 30 and 40 years old, and 23% (n = 32) were over 40 years old. Average admission BMI did not differ among age groups, ranging from 12.7 to 13.2 kg/m(2). Of the admission parameters, only low serum albumin levels (more prevalent in older patients), high international normalized ratio (INR) levels (more prevalent in younger patients), and neutropenia (more prevalent in the <30 age group) varied with age. During hospitalization, rates of bradycardia, hypoglycemia, liver dysfunction, very low %IBW, refeeding hypophosphatemia, refeeding edema, length of stay, and discharge BMI did not differ with age. Age group was associated with rate of weekly weight gain only in patients with AN-binge purge subtype. DISCUSSION: Results demonstrate medical abnormalities and response to medical stabilization in severely ill AN patients during hospitalization were mostly similar across the age span. This information should allay fears that the effect of age will make medical stabilization more difficult.

Predictors of hypophosphatemia during refeeding of patients with severe anorexia nervosa.

OBJECTIVE: Hypophosphatemia of refeeding is one of the most dangerous complications seen during the treatment of patients with anorexia nervosa. Although easily detectable and treatable, hypophosphatemia is under-recognized as a complication of refeeding. Specific risk factors for the development of hypophosphatemia are likely to exist among patients with severe anorexia nervosa. The purpose of this study was to identify clinically useful markers that may predict the development of or protection from hypophosphatemia during refeeding. METHODS: We conducted a retrospective case-control study of 123 patients with severe anorexia nervosa admitted for medical stabilization at the ACUTE Center for Eating Disorders between October 1, 2008 and December 31, 2013. Risk factors for refeeding hypophosphatemia were determined by multivariate logistic regression from clinical parameters and laboratory values measured at the time of admission. RESULTS: The prevalence of hypophosphatemia was 33.3% (41 of 123 patients). Higher hemoglobin was the only risk factor associated with a higher odds of developing hypophosphatemia (adjusted odds ratio [aOR], 1.56 [95% confidence interval [CI], 1.12-2.18]). Statistically significant protective factors against the development of hypophosphatemia were observed with higher body mass index (aOR, 0.54 [95% CI, 0.39-0.75]), higher serum potassium (aOR, 0.29 [95% CI, 0.14-0.62]), and higher serum prealbumin (aOR, 0.91 [95% CI, 0.84-0.99]). DISCUSSION: Four independent factors associated with refeeding hypophosphatemia were identified. Identification of findings which correlate with hypophosphatemia, or the lack thereof, has the potential to facilitate appropriate triage of patients with anorexia nervosa for closer monitoring during refeeding.

Motivated to survive: high cooperativeness in severe anorexia nervosa.

This study assessed the personality of severely ill patients with anorexia nervosa, restricting (AN-R) and binge-purge subtypes (AN-BP), during hospitalization for medical stabilization. Participants (N = 37) completed the Temperament and Character Inventory, Revised. Personality domains were similar between AN-R and AN-BP with the exception of cooperativeness. AN-R patients scored higher on this dimension, suggesting that individuals with restricting anorexia may be more tolerant of treatment during early medical stabilization. Future research is needed to further elucidate this novel finding in order to identify the point at which body mass index predicts a decline in cooperativeness and the potential need for new intervention strategies.

Low prealbumin is a significant predictor of medical complications in severe anorexia nervosa.

OBJECTIVE: Prealbumin levels have been proven to correlate with hospital length of stay, wound healing, infection rates, and mortality in adults hospitalized for medical or surgical purposes, or those who have chronic illnesses. Little is known about the utility of prealbumin evaluation in adults with severe anorexia nervosa (AN). METHOD: We retrospectively evaluated prealbumin levels, along with numerous other clinical parameters relevant to illness acuity and early refeeding outcomes, in 132 adults with AN admitted for definitive inpatient medical stabilization from October 1, 2008 to December 31, 2012. Per clinical protocol, prealbumin was checked on admission and approximately weekly thereafter until discharge. RESULTS: Patients had a median age of 28 years old, a mean admission body mass index (BMI) of 12.9 kg/m(2) (S.D. 6.1), and 89% of patients were women. A total of 47% of patients had a low prealbumin at the time of admission. By discharge, 77% of patients had normalized their prealbumin levels. Patients with low admission prealbumin levels had a threefold increased risk of refeeding hypophosphatemia and a twofold increase in hypoglycemia compared with patients who had a normal admission prealbumin, independent of admission BMI. DISCUSSION: A low serum prealbumin level appeared concurrent with other markers of serious medical compromise, and was associated with two potentially life threatening complications of early refeeding: hypophosphatemia and hypoglycemia. The cause of low prealbumin remains elusive. Prealbumin should be checked in patients with severe AN prior to initiating weight restoration, as low levels may be an important harbinger of early refeeding complications.

Hematological abnormalities in severe anorexia nervosa.

Little is known about the prevalence of hematologic abnormalities in adults with severe anorexia nervosa. We report the first major analysis of hematologic dysfunction in such patients. We retrospectively analyzed the charts of 53 men and women with severe anorexia nervosa, admitted between October 2008 and December 2010 for medical stabilization to our center, which has a national referral base. Patients were predominantly female (89 %), with a median age of 28 years (range 17-65), and were hospitalized for a median duration of 15 days (I.Q.R. 9-29). Nadir body mass index during hospitalization was markedly low at 12.4 kg/m(2) (range 8.4-15.7), and the mean discharge BMI was 13.8 kg/m(2) (range 10.2-16.8). 83 % of patients were anemic (hematocrit <37 %), with only 3 (6 %) having iron deficiency. 79 % were leukopenic (WBC < 4.5 k/µL), 29 % were neutropenic (ANC < 1.0 k/µL), 25 % were thrombocytopenic (platelets < 150 k/µL), and 17 % of patients developed thrombocytosis (platelets > 400 k/µL) during their hospitalization. Eighty-nine percent of patients had resolved their neutropenia by discharge. Marked hematologic deficiencies are often present in patients with severe anorexia nervosa, generally attributed to starvation-mediated gelatinous marrow transformation which resolves with proper nutritional rehabilitation. Improved provider awareness of this association may reduce unnecessary testing and costly treatment interventions.

A Life-Affirming Palliative Care Model for Severe and Enduring Anorexia Nervosa.

Some individuals with severe and enduring anorexia nervosa experience dramatically degraded quality of life in the face of refractory illness and compulsory treatment. We propose a palliative care (PC) model for this group of patients that aims to support their unique goals of care, improve social-professional function, reduce physical suffering, and honor the whole person. Far from representing a pre-hospice model, a PC model for those with severe and enduring anorexia nervosa instead provides an alternative to current practices in hopes of meaningfully improving quality of life and outcomes.

Regardless of inequities in care, terminal anorexia nervosa exists: a response to Sharpe et al.

We are pleased that the concept of terminal anorexia nervosa is being considered in serious discussion. Our previous presentations were not intended to assess eating disorders care broadly, but solely to bring attention to the importance of end-of-life care issues for patients with anorexia nervosa. Regardless of differences in ability to access or utilize health care resources, inescapably, individuals contending with end-stage malnutrition due to anorexia nervosa who refuse further nutrition will progressively decline, and some will die as a result. Our description of these patients' last days and weeks as "terminal" and meriting thoughtful end-of-life care is consistent with how the term is used in other end-stage terminal conditions. We clearly acknowledged that precise definitions and guidelines for end-of-life care for these patients should be developed by the eating disorder and palliative care fields. Avoiding the phrase "terminal anorexia nervosa" will not make these phenomena disappear. We are sorry that some individuals are upset by this concept. Our intention is certainly not to demoralize by "triggering" fears of hopelessness or death. But these discussions will inevitably distress some people. Individuals who are adversely affected by considering these issues might well benefit from further explorations, clarifications, and discussions with their clinicians and others. Finally, we clearly applaud expanding treatment options and availability, and we strongly advocate for making every effort to provide every patient every possible option for treatment and recovery at every phase of their struggles.

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.

Ophthalmic changes in severe anorexia nervosa: a case series.

OBJECTIVE: We describe the diagnosis and management of lagophthalmos, or failure of eyelid closure, in five patients with severe anorexia nervosa (AN) who complained of dry, irritated eyes and photophobia. METHOD: Five patients with these findings are described retrospectively. RESULTS: Examination revealed lagopthalmos in the setting of ptosis and enophthalmos, with multiple other starvation-mediated medical complications. DISCUSSION: These eye findings, as complications of AN, have not been described in the literature. With careful protective measures, initiation of nutritional rehabilitation, and intensively monitored early refeeding, these patients' ocular abnormalities and associated symptoms resolved completely. Recognition of this pathology and appropriate management can prevent long-term morbidity in the form of permanent loss of visual acuity due to corneal abrasions and improve the outcomes for these patients with severe AN.

PseudoBartter syndrome in eating disorders.

OBJECTIVE: PseudoBartter's 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 Bartter's and PseudoBartter's 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 PseudoBartter's 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.

Dysphagia in severe anorexia nervosa: a case report.

OBJECTIVE: The purpose of this case report is to increase awareness among clinicians that oropharyngeal dysphagia occurs in patients with severe anorexia nervosa, placing them at risk for aspiration and impeding nutritional rehabilitation. METHOD: We describe a patient with severe anorexia nervosa who manifested symptoms of dysphagia, with resultant aspiration pneumonia, at the time of her admission for medical stabilization. RESULTS: The speech pathology team administered dysphagia therapy, using neuromuscular electrical stimulation (NMES) in conjunction with swallowing therapy. Following the course of dysphagia treatment intervention, the patient was able to tolerate an oral diet with improved swallowing function and no ongoing aspiration. DISCUSSION: Patients with severe anorexia nervosa should be screened for possible dysphagia. NMES in the treatment of dysphagia in patients with anorexia nervosa may reduce the need for enteral feeds and prolonged hospitalization.

Dysphagia in severe anorexia nervosa and potential therapeutic intervention: a case series.

OBJECTIVES: In severe anorexia nervosa, there are a litany of medical complications that affect virtually every body system, and severe weakness is a typical characteristic. To our knowledge, aspiration risk, dysphagia recognition, and dysphagia management and intervention have not been well described in the literature in regard to severe anorexia nervosa. The purpose of this case series is to increase awareness among clinicians of possible oropharyngeal dysphagia symptoms that may present in patients with severe anorexia nervosa. METHODS: We describe the cases of 3 patients with severe anorexia nervosa who presented with symptoms of dysphagia. The speech-language pathology team administered dysphagia therapy to the 3 patients utilizing neuromuscular electrical stimulation (NMES) in conjunction with swallowing therapy tasks that included strengthening exercises and compensatory strategies. RESULTS: After the course of dysphagia treatment intervention, the 3 patients were able to tolerate an oral diet with improved swallowing function and no ongoing aspiration. CONCLUSIONS: The use of NMES in conjunction with traditional swallowing exercises in the treatment of dysphagia in patients with anorexia nervosa may reduce the need for enteral feeding and prolonged hospitalization. In regard to dysphagia intervention and management within this population and across other populations, rigorous randomized controlled studies are necessary for determining the efficacy of NMES and traditional swallowing therapy implementation.

Terminal anorexia nervosa: three cases and proposed clinical characteristics.

BACKGROUND: Most individuals with eating disorders will either recover, settle into an unrecovered but self-defined acceptable quality of life, or continue to cycle from crisis to relative stability over time. However, a minority of those with severe and enduring eating disorders recognize after years of trying that recovery remains elusive, and further treatment seems both futile and harmful. No level of harm reduction proves achievable or adequately ameliorates their suffering. In this subgroup, many of those with anorexia nervosa will experience the medical consequences of malnutrition as their future cause of death. Whereas anyone who wishes to keep striving for recovery despite exhaustion and depletion should wholeheartedly be supported in doing so, some patients simply cannot continue to fight. They recognize that death from anorexia nervosa, while perhaps not welcome, will be inevitable. Unfortunately, these patients and their carers often receive minimal support from eating disorders health professionals who are conflicted about terminal care, and who are hampered and limited by the paucity of literature on end-of-life care for those with anorexia nervosa. CASE PRESENTATION: Three case studies elucidate this condition. One patient was so passionate about this topic that she asked to be a posthumous co-author of this paper. CONCLUSIONS: Consistent with literature on managing terminal illness, this article proposes clinical characteristics of patients who may be considered to have a terminal eating disorder: diagnosis of anorexia nervosa, older age (e.g. age over 30), previous participation in high quality care, and clear and consistent determination by a patient who possesses decision-making capacity that additional treatment would be futile, knowing their actions will result in death. By proposing the clinical characteristics of terminal anorexia nervosa, we hope to educate, inspire compassion, and help providers properly assess these patients and provide appropriate care. We hope that this proposal stimulates further expert consensus definitions and clinical guidelines for management of this population. In our view, these patients deserve the same attendant care and rights as all other patients with terminal illness, up to and including medical aid in dying in jurisdictions where such care is legal.

Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward.

BACKGROUND AND OBJECTIVES: Premature deaths are estimated to occur in 5-20% of patients with anorexia nervosa (AN). Among them, some patients with severe and enduring anorexia nervosa (SE-AN) will die due to the medical complications of malnutrition or to suicide. Almost no literature provides guidance to patients, clinicians, and loved ones regarding clinical characteristics of those with SE-AN who recognize and accept the fact that they will not be able to survive their disease. Consistent with general medical literature on terminal illness and based on the authors' work with patients at this phase of life, we previously described four clinical characteristics of the small group of SE-AN patients who may be considered to have a terminal eating disorder. Following publication of this article, several opinions objecting to these formulations were published. The goals of this article are to respond to the key themes of concern posed by these objections, to extend our discussion of the palliative care and associated needs of these patients and their families, and to suggest ways in which the eating disorder and palliative care fields might develop more definitive criteria and consensus guidelines for the assessment and management of these patients. METHODS: Based on a selective narrative review of the literature, our combined experiences with these patients, and clinical reasoning, we address critiques grouped around five major themes: that (1) labels such as terminal AN are dangerous; (2) since AN is a treatable disorder, no SE-AN patients should be considered terminal; (3) a terminal psychiatric condition cannot be defined; (4) the proposed definition is not specific enough; and (5) considerations regarding mental capacity in the proposed criteria do not sufficiently account for the psycho-cognitive impairments in AN. RESULTS: Our analysis responds to the critiques of our original proposed clinical characteristics of those with terminal AN. While refuting many of these critiques, we also appreciate the opportunity to refine our discussion of this complex topic and identify that there are multiple stages of SE-AN that can result in good clinical outcomes. Only when all of these have failed to provide adequate amelioration of suffering do a low number of patients progress to terminal AN. CONCLUSIONS: By further refining our discussion of terminal AN, we aim to encourage eating disorders and palliative care specialists to develop expert consensus definitions for terminal AN and to generate authoritative clinical guidance for management of this population. By validating terminal AN as a distinct condition, patients with this subcategory of SE-AN, their families, and their caregivers facing end-of-life concerns may be better able to access palliative and hospice care and related services to help improve their overall experiences at this phase of life.

Exercise electrocardiography extinguishes persistent junctional rhythm in a patient with severe anorexia nervosa.

Among psychiatric conditions, anorexia nervosa carries the highest mortality, in part due to the propensity for rhythm disturbances among patients with advanced disease. Patients with anorexia nervosa are prone to both bradycardia and tachyarrhythmias, though mortality has not been associated with the former. To date, only one case of junctional rhythm in the setting of anorexia nervosa has been previously described, which was unremitting and required prolonged hospitalization. We report a case of persistent accelerated junctional rhythm where a formal exercise electrocardiography study demonstrated rapid reversion to sinus rhythm with graded exercise. Despite a 22-day hospitalization the patient never reverted permanently to sinus rhythm. This underscores the heightened vagal tone that may be seen among patients with severe anorexia nervosa. Despite this, it may be rapidly extinguished with sympathetic overdrive during exercise. In this context, exercise electrocardiography appears to be a safe, noninvasive means of assessing cardiac conduction and chronotropic reserve in this population.

Tampon use in patients with anorexia nervosa can cause persistent vaginal bleeding: a case series.

OBJECTIVE: To describe the phenomenon of persistent vaginal bleeding in two patients with severe anorexia nervosa. METHOD: We report two cases of young women with severe anorexia nervosa reporting vaginal bleeding that persisted for months despite trials of topical and systemic conjugated estrogen therapy. RESULT: A speculum exam by a gynecologist ultimately revealed the source of the bleeding to be tampon-induced vaginal ulcers. These resolved, along with the vaginal bleeding, with vaginal estrogen cream and cessation of tampon use. DISCUSSION: Most patients with anorexia nervosa are amenorrheic due to reversion of the hypothalamic-pituitary-ovarian axis to a prepubertal state. Vaginal bleeding in patients with anorexia nervosa may trigger needless systemic hormonal treatments, radiographic studies, and multiple physician visits. A careful exam is warranted to evaluate for the presence of tampon-induced vaginal ulcer in patients with anorexia nervosa who have persistent vaginal bleeding.