Psychiatric status, prevention, and outcome in patients with burns: a prospective study.

One hundred consecutive patients admitted to the Tampa Bay Regional Burn Center were assessed to determine cause of injury, preburn psychiatric status, and outcome (survival, length of stay in the hospital, and emergence of new psychiatric or physiologic disorders). Patients with psychiatric disorders were more likely to have injuries that were preventable, and there was a trend for this group to have more emergent psychiatric disorders and longer lengths of hospital stay. We suggest that the Burn Severity Index might be revised to include the presence of preburn psychiatric disorders and then be evaluated in a larger group with use of the Burn Registry.

Athletes and eating disorders: the National Collegiate Athletic Association study.

OBJECTIVE: To present findings from a collaborative study with the National College Athletic Association regarding the prevalence of disordered eating among student athletes. METHOD: 1,445 student athletes from 11 Division 1 schools were surveyed using a 133-item questionnaire. RESULTS: Results indicated that 1.1% of the females met DSM-IV criteria for bulimia nervosa versus 0% for males. None of the student athletes met DSM-IV criteria for anorexia nervosa. 9.2% of the females were identified as having clinically significant problems with bulimia versus .01% of the males. 2.85% of the females were identified as having a clinically significant problem with anorexia nervosa versus 0% for males. 10.85% of the females reported binge eating on a weekly or greater basis versus 13.02% of the males 5.52% of the females reported purging behavior (vomiting, laxatives, diuretics) on a weekly or greater basis versus 2.04% for the males. DISCUSSION: Results from the current investigation are more conservative than previous studies of student athletes, but comparable to another large study of elite Norwegian athletes. Reasons for these differences are discussed. Clearly female athletes report more difficulty with disordered eating than male athletes. Some specific risk factors for female athletes are discussed.

Osteoporosis and eating disorders.

Osteoporosis is a common complication of anorexia nervosa. Multiple factors increase risk, including decreased body weight and fat content, elevated cortisol levels, inadequate vitamin D and calcium intake, and amenorrhea and hypoestrogenemia. There is both decreased bone formation and increased bone resorption in the osteoporosis of anorexia nervosa. Treatment includes weight normalization and supplemental calcium and vitamin D. Unlike postmenopausal osteoporosis, estrogen replacement does not prevent or correct the osteoporosis that occurs in anorexia nervosa. Patients with bulimia nervosa or an eating disorder not otherwise specified may also be at risk of osteoporosis, especially if they have had a prior episode of anorexia nervosa.

Eating pathology before and after bariatric surgery: a prospective study.

OBJECTIVE: The objectives of the study were (1) to determine the prevalence of eating pathology in patients before bariatric surgery and at follow-up; (2) to assess the relationship of presurgical eating pathology to various measures of psychopathology; and (3) to assess the relationship between presurgical eating pathology and outcome. METHOD: One hundred sixteen patients were evaluated prior to surgery and at follow-up an average of 5.5 years after surgery. RESULTS: Preoperative binge eating occurred in 52% of patients, 16% met criteria for binge eating disorder, and 10% had the night eating syndrome. All three forms of presurgical eating pathology were statistically associated with cognitive distortions. At follow-up, 33% of patients were vomiting at least weekly. There was no relationship between presurgical eating pathology and weight outcome or presence of vomiting at follow-up. DISCUSSION: Although postoperative vomiting usually does not represent purge behavior, it may represent failed attempts to binge.

Scar assessment: current problems and future solutions.

Current problems in the assessment of scars are discussed. The concept of subjective and objective aspects of scar assessment is introduced. The patient's own view of the scar (the subjective component) can currently be assessed and may be very influential in determining the patient's quality of life, irrespective of the actual physical characteristics of the scar. The objective aspects of the scar, including size, shape, texture, and pliability, are currently difficult to measure. Although the Vancouver Scar Scale has been used as the standard for objective measurements, there are problems with both the validity and reliability of this instrument. Various imaging techniques may permit more reliable and accurate methods for measuring the quantitative aspects of scars.

A vision-based technique for objective assessment of burn scars.

In this paper a method for the objective assessment of burn scars is proposed. The quantitative measures developed in this research provide an objective way to calculate elastic properties of burn scars relative to the surrounding areas. The approach combines range data and the mechanics and motion dynamics of human tissues. Active contours are employed to locate regions of interest and to find displacements of feature points using automatically established correspondences. Changes in strain distribution over time are evaluated. Given images at two time instances and their corresponding features, the finite element method is used to synthesize strain distributions of the underlying tissues. This results in a physically based framework for motion and strain analysis. Relative elasticity of the burn scar is then recovered using iterative descent search for the best nonlinear finite element model that approximates stretching behavior of the region containing the burn scar. The results from the skin elasticity experiments illustrate the ability to objectively detect differences in elasticity between normal and abnormal tissue. These estimated differences in elasticity are correlated against the subjective judgments of physicians that are presently the practice.

Comparison of habitual runners and anorexia nervosa patients.

UNLABELLED: Psychological and physiological similarities have been proposed between habitual runners and anorexia nervosa patients. METHOD: Twenty male runners, 20 female runners, and 17 anorexia nervosa patients were evaluated using several psychological measures (Minnesota Multiphasic Personality Inventory, Leyton Obsessional Inventory, and three measures of body image) and physiological measures (physical examination, anthropometric assessment, and exercise treadmill tests). RESULTS: Anorexia nervosa patients had significantly more evidence of psychopathology on all the psychological measures than either group of runners. There were suggestive similarities between female runners and anorexics on some of the body image tests. Fat content was in the normal range for both groups of runners and low in the anorexia nervosa group. Abnormalities were seen on the treadmill tests in all three groups, but there were no statistically significant differences. CONCLUSION: Despite hypothetical similarities, this study found that anorexia nervosa patients and habitual runners have few similar psychological or physiological features.

Bariatric surgery and multiple personality disorder: complexities and nuances of care.

BACKGROUND: Multiple personality disorder (MPD) can occur in patients with morbid obesity in need of bariatric surgery, though few reports noting this association exist in the literature. Herein we address MPD in morbid obesity, in the context of a patient presenting to us seeking surgical treatment of her morbid obesity. METHODS: A 31-year-old morbidly obese (BMI 49 kg/m2) Hispanic female presented in early 1994 requesting bariatric surgery. She had been a victim of violent sexual abuse as a young girl. Subsequently, she developed at least three personalities, including one male personality. RESULTS: Although she has lost nearly 45 kg after gastroplasty, her care has been complicated by her named multiple personalities. While MPD are infrequent and unfamiliar to most care providers, successful outcomes can be promoted with a proper approach. CONCLUSIONS: This patient's care illustrates that: (1) all personalities must agree to proposed operative intervention; (2) consent must be obtained from the 'true' patient; and (3) postoperative care and follow-up must address all personalities for an optimal outcome.

Outcome of gastric restriction procedures: weight, psychiatric diagnoses, and satisfaction.

BACKGROUND: Weight losses following bariatric surgery have varied widely, depending on length of follow-up and various pre-surgical characteristics of patients undergoing surgery. METHODS: One hundred thirty one patients had a detailed presurgical psychiatric evaluation. Patients were assessed clinically for 2 years after surgery and at follow-up a mean of 5.7 years after surgery. RESULTS: Mean presurgical body mass index (BMI) was 52.9 kg/m2; therefore, many patients had 'super obesity'. Two-thirds of the patients were located a mean of 5.7 years after surgery. The mean change in BMI at follow-up was 25% and the mean weight loss was 27%. One-third had excellent or good weight outcomes using the Griffen criteria. Five patients had died by follow-up. There was no relationship between age, gender, or fat content presurgically and weight loss at follow-up, although presurgical weight was associated with greater weight loss at follow-up. Weight regain began 2 years after surgery. There was no relationship between the presence or absence of a presurgical psychiatric diagnosis and weight loss at follow-up. There was also no relationship between the presence of a presurgical psychiatric diagnosis and various mental health parameters at follow-up. Satisfaction with the surgery was marginally associated with weight loss but significantly associated with improved mental and physical health. CONCLUSIONS: Mean weight losses were less than have been previously reported with gastric restriction procedures but the follow-up was longer than usually reported and many patients had 'super obesity' prior to surgery. The implications of 'super obesity' for weight loss are discussed.

Initial assessment and early treatment options for anorexia nervosa and bulimia nervosa.

This article presents the essential aspects of assessment of patients with anorexia nervosa or bulimia nervosa. The evaluation of the athlete with a suspected eating disorder is described. The choice of appropriate type and site of treatment is discussed. Throughout the article there is an emphasis on methods that can be useful in assisting the patient to acknowledge his or her illness and participate in treatment. The need to focus simultaneously on psychological and relationship issues and nutritional status is stressed.

Total body potassium and serum potassium among eating disorder patients.

OBJECTIVE: The purpose of the study was to determine body composition, including total body potassium (TBK+), serum potassium, and lean body mass (LBM), in anorexia nervosa. METHOD: TBK+ measurements, serum potassium levels, and anthropometric measurements were obtained from four anorectic patients in the first week after their hospital admission. All four patients had normal serum potassium levels but three of the four had significant depletion of total body potassium. Two methods of calculating LBM, based on TBK+ measures or anthropometric assessment, produced different results. RESULTS: TBK+ may be depleted even when serum potassium levels are normal. It was also concluded that the two methods of calculating LBM were inaccurate. DISCUSSION: Patients may be at risk for cardiac arrhythmias and other physiological abnormalities even when serum potassium is normal since TBK+ may be low. The need for comprehensive assessment of body composition based on four compartment models is discussed.

Alcohol disorders among patients with burns: crisis and opportunity.

A burn injury so severe that inpatient treatment is necessary is a crisis in any patient's life. For patients who also suffer from an alcohol use disorder, hospitalization may offer a unique opportunity to facilitate entry into appropriate treatment. In this study, 442 hospitalized patients with burns were evaluated, and 50 (11%) were diagnosed with an alcohol use disorder by DSM-III-R criteria. All but one of the injuries were deemed preventable. The average length of stay in hospital was 9 days longer for the alcohol group compared with the average stay in the burn center, resulting in additional costs of $337,500. Referral for treatment of the underlying alcohol disorder was recommended for fewer than half the patients. Thus, although the patients with alcohol use disorders had lengthy hospitalizations and were in circumstances that might permit the characteristic denial of alcoholism to be relinquished, the treatment team usually did not capitalize on this opportunity.

Posttraumatic stress disorder in patients with burns.

Among 39 patients with burns evaluated a mean of 12 months after hospital discharge, 38% met DSM-III-R criteria for post-traumatic stress disorder (PTSD) for at least 1 month. With proposed DSM-IV criteria, 43% met criteria for past or current PTSD. Analysis of specific symptom clusters of PTSD revealed that 74% of patients had been affected by a reexperience symptom for at least 1 month, but only 30% were currently experiencing flashbacks. No correlation was found between several clinical correlates (TBSA, length of hospitalization, and age) and development of PTSD. There was no correlation between presence of a DSM-III-R psychiatric diagnosis at the time of hospitalization and later development of PTSD and no correlation between whether or not a psychiatric diagnosis emerged during hospitalization and later development of PTSD. Finally, patients who had injuries that they could not prevent were no more likely to experience PTSD.

Safety and efficacy of debridement under anesthesia in patients with burns.

Burn wound debridements requiring blunt or sharp manipulations are extremely painful even when large nonanesthetic doses of morphine are used. In this study we describe the use of debridement while the patient is under anesthesia (DUA) when manipulation of the wound is required. Seventy-one debridements were performed on 46 patients. One patient required additional fluids during the DUA, but no deaths, extensive blood losses, or significant changes in nutrition attributable to the DUA occurred. The mean number of required DUAs was 1.6 per patient compared with 6.0 per patient reported in a previous study from the same burn center that involved standard parenteral analgesic doses of morphine sulfate. Patients were completely anesthetized during the procedure. Therefore, they were free of pain and were amnestic for the experience. We conclude that DUA is a safe, efficacious procedure that permits full relief from the pain usually experienced during a manipulative burn wound debridement.

Self-inflicted burns: a ten-year retrospective study.

In this 10-year retrospective survey of 2216 admissions to a regional burn center, 15 patients (0.67%) had self-inflicted burn wounds. The burns were serious, with a mean abbreviated burn severity index of 11.2, and eight patients died of their injuries. Nine patients had a documented history of psychiatric problems, seven of whom had undergone a previous psychiatric hospitalization. A psychiatric assessment was obtained for 12 patients immediately after self-immolation, and all but one had a major psychiatric disorder. Seven patients had major depression and four had chronic paranoid schizophrenia. Motives were assessed, both by chart review and by interview of five available survivors and of relatives of nonsurvivors. Fewer than half actually intended to kill themselves; equally important was the theme of attempting to control internal psychotic states.

Neuroleptic malignant syndrome associated with clozapine use.

Clozapine, an atypical antipsychotic drug, is indicated for severely ill schizophrenic patients refractory to treatment with conventional neuroleptics. One advertised advantage of clozapine is the absence of associated neuroleptic malignant syndrome (NMS). On the basis of a clinical case, the authors question this claim. They are concerned that this potentially fatal condition may be misdiagnosed if physicians are not aware of possible NMS associated with the use of clozapine.

Untreated anorexia nervosa. A case study of the medical consequences.

This case demonstrates the devastating physical sequelae of 30 years of untreated anorexia nervosa. A full array of these consequences occur in this one patient and include the following: malnutrition and hypoproteinemia, electrolyte disturbances, cortical atrophy with hydrocephalus ex vacuo, tricuspid and mitral valvular dysfunction, anemia, impaired lower gastrointestinal motility, delayed gastric emptying, disturbances in the hypothalamic pituitary target organ axes, severe osteoporosis, marked edema, and extreme muscle wasting. Other possible physical sequelae of her anorexia nervosa are discussed. Psychiatrists, as well as other physicians, should be vigilant in diagnosing this illness and treating it as early as possible. This particular patient was in the medical system for numerous admissions and workups over three decades before the correct diagnosis of anorexia nervosa was made.

Insulin-dependent diabetes mellitus and eating disorders: a prevalence study.

There have been numerous reports in the recent literature suggesting a relationship between diabetes mellitus and the eating disorders. In the current investigation, 97 pediatric diabetes patients were administered a modified version of the Eating Habits Questionnaire, which included items specific to diabetes mellitus based on DSM-III-R criteria. None of this sample were diagnosed as anorexic and only one patient was diagnosed as currently bulimic. Possible reasons for the higher prevalence rates reported for other samples are discussed.