Narrative review of inpatient nutritional management of anorexia nervosa with management recommendations for Australian tertiary health services.

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.

An observational outcomes study from 1966-2008, examining pregnancy and neonatal outcomes from dialysed women using data from the ANZDATA Registry.

AIMS: To conduct an observational outcomes study examining pregnancy and neonatal outcomes of dialysed women aged 15-49, from 1966-2008, using data from the ANZDATA Registry. METHODS: Data from the ANZDATA Registry were captured and analysed from 1966-2008. Specific pregnancy outcomes included: live birth (LB), spontaneous abortion, stillbirth (SB) or termination of pregnancy. Delivery and neonatal outcomes, since 2001, were also analysed. RESULTS: There were 23 700 person-years (PY) of observational data during the study period with 49 pregnancies, of which 30 (79%) resulted in a LB, once terminations were excluded. Pregnancy rates: Overall the pregnancy rate was 2.07 per 1000 PY for the study interval. A significant increase in the pregnancy rate was noted for the 1996-2008 time interval (3.3 per 1000 PY, compared with 0.54 and 0.67 in the eras 1976-1985 and 1986-1995, respectively; P = 0.004). Most pregnancies were observed in the 25-29 age group: 20-24, 25-29 and 30-34 (5.31, 5.61 and 3.87 per 1000 PY, respectively). Patients on peritoneal dialysis were less likely to achieve a pregnancy compared with haemodialysis patients (P < 0.02). Live birth rates: The overall LB rate was 1.26 per 1000 PY. The rate for each of the age brackets was as follows: 3.54 for 20-24, 3.61 for 25-29, and 2.39 per 1000 PY for 30-34, compared with 0 in the 15-19 group, and 1.22, 0.2 and 0.16 per 1000 PY among the groups 35-39, 40-44 and 45-49 years, respectively. LB rates were more favourable in the younger age groups. There was no significant era, disease, dialysis modality or race effect on LB rates. Excluding terminations, the LB rate was 79%. Age-effect on pregnancy outcomes: Pregnancy outcome was not affected by age (mean ages shown): spontaneous abortions, 28.7 years (n = 3); LB, 29.3 years (n = 24); SB, 32.4 years (n = 5); terminations 30.6 years (n = 11). Maternal mortality and complications: The preeclampsia rate was 19.4% (6/31). No post-partum maternal deaths were reported. Neonatal outcomes: Since 2001, 21 neonatal outcomes were reported. One baby developed polyhydramnios, one had a congenital malformation and one post-natal death was reported. In total 53.4% were born preterm; 65% had a birthweight <2.5 kg (low birthweight) and 35% <1.5 kg (very low birthweight). Low birthweight correlated with prematurity. CONCLUSION: Seventy-nine per cent of women achieving a pregnancy in our cohort achieved a LB, although 53.4% of babies were born preterm and 65% were of low birthweight (<2.5 kg).

Use of magnetic resonance imaging to assess renal structure and function in reflux nephropathy.

AIM: Despite numerous potential advantages, the role of magnetic resonance imaging (MRI) in depicting structural and functional abnormalities in kidney disease has not been well addressed. In reflux nephropathy in particular, nuclear scintigraphy (NS) has become the diagnostic gold standard, however, other imaging modalities may be required for adequate clinical appraisal. We therefore assessed the use of MRI in reflux nephropathy, comparing findings with those obtained using conventional imaging techniques. METHODS: Eight women with likely or proven reflux nephropathy underwent MRI scanning with structural and split functional appraisal. Results were compared with those obtained with ultrasound and NS. RESULTS: As expected, structural abnormalities were better defined with MRI than with ultrasound. NS findings were confirmed in most, but not all, MRI scans: NS and ultrasound had failed to identify scarring and cyst development in one patient. A close correlation was observed between MRI and NS renal functional estimates, regardless of whether whole kidney (r(2) = 0.87, P = 0001) or region of interest (r(2) = 0.99, P < 0001) techniques were used. Bland Altman plot analysis suggested methods were interchangeable. CONCLUSION: MRI provided more accurate diagnostic information structurally than ultrasound and MRI and split renal functional estimates correlated well with NS. It achieved in one study what otherwise required additional scans and without the need for ionizing radiation. These results suggest it should be considered as a diagnostic tool for reflux nephropathy.