Euglycaemic ketoacidosis in pregnant women with COVID-19: two case reports.

BACKGROUND: Euglycaemic ketoacidosis (EKA) is an infrequent but serious condition which usually follows a period of starvation, severe vomiting or illness in individuals with or without diabetes. Ketoacidosis is associated with materno-fetal morbidity and mortality necessitating prompt diagnosis and management. Physiological increases in insulin resistance render pregnancy a diabetogenic state with increased susceptibility to ketosis. COVID-19 is associated with worse clinical outcomes in patients with diabetes and is an independent risk factor for ketoacidosis in normoglycaemic individuals. CASE PRESENTATIONS: We describe two cases of SARS-CoV-2 positive pregnant women presenting with normoglycaemic metabolic ketoacidosis. Both cases were associated with maternal and fetal compromise, requiring aggressive fluid and insulin resuscitation and early delivery. CONCLUSION: We discuss possible physiology and propose a management strategy for euglycaemic ketoacidosis in pregnancy.

Food Refusal Secondary to Psychosis: A Case Series and Literature Review.

The aim of this article is to emphasize that starvation is an important potential consequence of psychosis and to provide recommendations for management of this condition. A review of the literature on food refusal and starvation in patients with psychotic illnesses was performed. Our search strategy returned 54 articles with one article meeting inclusion criteria. Additional independent research returned an additional four cases of patients with psychosis engaging in self-starvation. The cases of several patients from our institution who engaged in self-starvation behaviors as a result of psychosis are also presented. The management and outcomes of each of these 10 patients are discussed. Starvation secondary to psychosis is an important but underappreciated consequence of psychosis that can lead to serious adverse outcomes in these patients. Few cases have been reported in the literature. More study is warranted to develop evidence-based management guidelines.

[Starvation ketoacidosis during prolonged fasting of 26 days]. / Hypercétose dans un contexte de jeûne prolongé de 26 jours.

Ketosis is a metabolic situation involving an increase in blood and urine concentrations of ketones that, when prolonged, leads to acidosis. Moderate ketosis usually appears after a fast of a few hours, but its prolongation exposes to hyperketosis. Observation: A 25-year-old woman presented to the emergency department for cohercitive vomiting. She was fasting for a long time in a spiritual setting and had a restricted diet limited to water and vitamin supplements. Clinical and biological assessment was in favour of fasting ketoacidosis. Evolution was favorable with intravenous hydration, poly-ionic and micronutrient supplementation and a gradual resumption of oral feeding. Conclusion: We report the case of a patient with fasting ketoacidosis. Besides consequences of this ketoacidosis, the challenge was also in resuming oral feeding in order to avoid a potentially fatal inappropriate renutrition syndrome.

Management of hunger strike: A medical, ethical and legal conundrum.

Hunger strike is a protest where an informed person refuses essential nourishment with the intention of accomplishing a specific goal. Hunger strikes conflict with medical, ethical, humanitarian and legal values. A multidisciplinary approach is important when dealing with hunger strike patients. On one hand, there is the wish to preserve life, and on the other to respect the strikers' autonomy and their wishes, values and advanced directives (or living will). Most hunger strikes are short-lived, but in complex and prolonged circumstances, legal advice must be sought from health service solicitors and a doctor's medical indemnity organisation. There is an emergent need to have defined guidelines for the management of these hunger strikes to be followed.

Successful management and recovery following severe prolonged starvation in a dog.

OBJECTIVE: To describe the successful management of a dog following a period of prolonged food deprivation. CASE SUMMARY: A 7-year-old, intact male Labrador Retriever presented with profound weakness and loss of nearly 50% of his body weight due to severe prolonged starvation after being trapped in a well for 27 days. Electrolyte concentrations were managed with intensive intravenous supplementation during refeeding. The dog's electrolyte abnormalities resolved, wounds healed, and strength returned during the first 3 weeks of treatment. During the next 3 months, body condition score normalized and muscle mass improved. NEW OR UNIQUE INFORMATION PROVIDED: This report describes the management of a severely malnourished dog during refeeding, and highlights treatment considerations that may be important in the prevention of refeeding syndrome in such cases.

Recent Research and Personalized Treatment of Anorexia Nervosa.

Recent advances in the understanding of aetiologic elements underlying anorexia nervosa have provided valuable insights and are transforming the way this illness is treated. The aim of this article is to consider how neuropsychological understanding and new research can be used to develop a more individualized and personalized approach in the management of this serious illness.

Starvation-induced Liver Enzyme Elevation after Initiation of Feeding.

Exacerbation of liver enzymes after the initiation of feeding in malnourished patients is caused by refeeding syndrome or persistent starvation. There are no definite clinical markers for distinguishing between the two conditions. We herein report a 63-year-old woman with starvation-induced liver enzyme elevation. Her body weight was inversely associated with the liver enzyme levels after refeeding, which was a different course from refeeding syndrome. Normalization of liver enzymes ensued as the caloric intake increased and weight gain progressed. Daily changes in body weight can be a useful clinical marker for distinguishing between refeeding syndrome and starvation-induced liver enzyme elevation.

Ketoacidosis due to a Low-carbohydrate Diet in an Elderly Woman with Dementia and Abnormal Eating Behavior.

Strict restriction of carbohydrates can induce symptomatic ketoacidosis. We herein report a 76-year-old demented woman who developed ketoacidosis after 1 month of abnormal eating behavior involving selectively eating hamburger steak (estimated carbohydrate =12.7 g/day). Laboratory tests showed high-anion-gap metabolic acidosis with elevated blood ketone levels. She was successfully treated with intravenous fluids followed by oral intake of a regular diet. She remained relapse-free after correcting her eating habits. Healthcare providers should know that abnormal eating behavior in demented people can lead to an extremely-low-carbohydrate diet and cause atypical ketoacidosis unexplained by diabetes, heavy alcohol intake, or starvation conditions.

Influence of nutrition therapy on the intestinal microbiome.

PURPOSE OF REVIEW: This review describes the relationship between nutritional therapies and the intestinal microbiome of critically ill patients. RECENT FINDINGS: The intestinal microbiome of the critically ill displays a near complete loss of health-promoting microbiota with overgrowth of virulent healthcare-associated pathogens. Early enteral nutrition within 24 h of admission to the ICU has been advocated in medical and surgical patients to avoid derangements of the intestinal epithelium and the microbiome associated with starvation. Contrary to previous dogma, permissive enteral underfeeding has recently been shown to have similar outcomes to full feeding in the critically ill, whereas overfeeding has been shown to be deleterious in those patients who are not malnourished at baseline. Randomized clinical trials suggest that peripheral nutrition can be used safely either as the sole or supplemental source of nutrition even during the early phases of critical care. The use of probiotics has been associated with a significant reduction in infectious complications in the critically ill without a notable mortality benefit. SUMMARY: Focus of research is shifting toward strategies that augment the intestinal environment to facilitate growth of beneficial microorganisms, strengthen colonization resistance, and maintain immune homeostasis.

An Integrative Bio-Psycho-Social Theory of Anorexia Nervosa.

The need for novel approaches to understanding and treating anorexia nervosa (AN) is well recognized. The aim of this paper is to describe an integrative bio-psycho-social theory of maintaining factors in AN. We took a triangulation approach to develop a clinically relevant theory with face validity and internal consistency. We developed theoretical ideas from our clinical practice and reviewed theoretical ideas within the eating disorders and wider bio-psycho-social literature. The synthesis of these ideas and concepts into a clinically meaningful framework is described here. We suggest eight key factors central to understanding the maintenance and treatment resistance of anorexia nervosa: genetic or experiential predisposing factors; dysfunctional feelings processing and regulation systems; excessive vulnerable feelings; 'feared self' beliefs; starvation as a maladaptive physiological feelings regulation mechanism; maladaptive psychological coping modes; maladaptive social behaviour; and unmet physical and psychological core needs. Each of these factors serves to maintain the disorder. The concept of universal physical and psychological core needs can provide an underpinning integrative framework for working with this distinctly physical and psychological disorder. This framework could be used within any treatment model. We suggest that treatments which help address the profound lack of trust, emotional security and self-acceptance in this patient group will in turn address unmet needs and improve well-being. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: The concept of unmet physical and psychological needs can be used as an underlying integrative framework for understanding and working with this patient group, alongside any treatment model. A functional understanding of the neuro-biological, physiological and psychological mechanisms involved in anorexia nervosa can help patients reduce self-criticism and shame. Fears about being or becoming fat, greedy, needy, selfish and unacceptable ('Feared Self') drive over-compensatory self-depriving behaviour ('Anorexic Self'). Psychological treatment for anorexia nervosa should emphasize a focus on feelings and fostering experiences of acceptance and trust. Treatment for patients with anorexia nervosa needs to be longer than current clinical practice.

[Organization of medical support for troops, defending Leningrad and the people of the blockaded city].

The data on the composition of forces of medical services and organization of medical-evacuation support for troops defending the blockaded Leningrad are presented. The information about the health losses among the population of Leningrad as a result of bombing, shelling and disease is given. Extremely high rates of morbidity and mortality in residents were associated with hunger, hypothermia and emotional stress. The clinical picture of some diseases has different peculiarities because of alimentary dystrophy background. The city health service suffered huge losses: 482 medical institutions were destroyed, only about 300 people from 1.5 thousand of medical personnel in 1942 saved working capability. The health care service of the local air defense played an essential role in delivery of medical aid. The contribution of civil and military health workers in saving residents lives in the blockaded Leningrad was appreciated.

Management of patients during hunger strike and refeeding phase.

OBJECTIVE: Hunger strikers resuming nutritional intake may develop a life-threatening refeeding syndrome (RFS). Consequently, hunger strikers represent a core challenge for the medical staff. The objective of the study was to test the effectiveness and safety of evidence-based recommendations for prevention and management of RFS during the refeeding phase. METHODS: This was a retrospective, observational data analysis of 37 consecutive, unselected cases of prisoners on a hunger strike during a 5-y period. The sample consisted of 37 cases representing 33 individual patients. RESULTS: In seven cases (18.9%), the hunger strike was continued during the hospital stay, in 16 episodes (43.2%) cessation of the hunger strike occurred immediately after admission to the security ward, and in 14 episodes (37.9%) during hospital stay. In the refeed cases (n = 30), nutritional replenishment occurred orally, and in 25 (83.3%) micronutrients substitutions were made based on the recommendations. The gradual refeeding with fluid restriction occurred over 10 d. Uncomplicated dyselectrolytemia was documented in 12 cases (40%) within the refeeding phase. One case (3.3%) presented bilateral ankle edemas as a clinical manifestation of moderate RFS. Intensive medical treatment was not necessary and none of the patients died. Seven episodes of continued hunger strike were observed during the entire hospital stay without medical complications. CONCLUSIONS: Our data suggested that seriousness and rate of medical complications during the refeeding phase can be kept at a minimum in a hunger strike population. This study supported use of recommendations to optimize risk management and to improve treatment quality and patient safety in this vulnerable population.

Pathophysiology, treatment, and prevention of fluid and electrolyte abnormalities during refeeding syndrome.

Refeeding syndrome may occur after the reintroduction of carbohydrates in chronically malnourished or acutely hypermetabolic patients as a result of a rapid shift to glucose utilization as an energy source. Electrolyte abnormalities of phosphorus, potassium, and magnesium occur, leading to complications of various organ systems, and may result in death. Patients should be screened for risk factors of malnutrition to prevent refeeding syndrome. For those at risk, nutrition should be initiated and slowly advanced toward the patient's goal over several days. Electrolyte disturbances should be aggressively corrected.

Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy.

AIM: To analyzed whether laparoscopy-assisted percutaneous endoscopic gastrostomy (PEG) could be a valuable option for patients with complicated anatomy. METHODS: A retrospective analysis of twelve patients (seven females, five males; six children, six young adults; mean age 19.2 years) with cerebral palsy, spastic quadriparesis, severe kyphoscoliosis and interposed organs and who required enteral nutrition (EN) due to starvation was performed. For all patients, standard PEG placement was impossible due to distorted anatomy. All the patients qualified for the laparoscopy-assisted PEG procedure. RESULTS: In all twelve patients, the laparoscopy-assisted PEG was successful, and EN was introduced four to six hours after the PEG placement. There were no complications in the perioperative period, either technical or metabolic. All the patients were discharged from the hospital and were then effectively fed using bolus methods. CONCLUSION: Laparoscopy-assisted PEG should become the method of choice for gastrostomy tube placement and subsequent EN if PEG placement cannot be performed safely.

Hunger strike among detainees: guidance for good medical practice.

Hunger strike is a regularly reported problem in prison. Although clinical situations are rarely severe, hospitalisation is often considered. In consequence, it is not only physicians working in prisons, but also hospital medical teams who face challenges related to hunger strike, involving somatic, psychological, legal and human rights aspects. Furthermore, deontological rules must be strictly respected when delivering care, particularly in prison setting. Starvation involves metabolic changes and can cause severe, and sometimes even irreversible or fatal complications. Moreover, the phase of re-alimentation should not be trivialised, as re-feeding syndrome is a potentially fatal phenomenon. This article provides guidance for monitoring and management of patients on hunger strike.

Refeeding in the ICU: an adult and pediatric problem.

PURPOSE OF REVIEW: To describe the etiology and complications of the refeeding syndrome. RECENT FINDINGS: Complications of the refeeding syndrome can include electrolyte abnormalities, heart failure, respiratory failure, and death. This syndrome is of particular importance to critically ill patients, who can be moved from the starved state to the fed state rapidly via enteral or parenteral nutrition. There are a variety of risk factors for the development of the refeeding syndrome. All of these risk factors are tied together by starvation physiology. Case reports and case series continue to be reported, suggesting that this entity continues to exist in critically ill patients. Initiation of enteral nutrition to patients with starvation physiology should be gradual and careful monitoring of electrolytes and organ function is critical during the early stages of refeeding. SUMMARY: The refeeding syndrome remains a significant issue in critically ill patients. Knowledge of the risk factors and the clinical signs of the refeeding syndrome is important to optimize outcomes.