A weighty issue: refeeding an adolescent patient on dialysis.

BACKGROUND: For malnourished patients with end stage renal disease (ESRD) on hemodialysis (HD), refeeding is complex; true weight (dry weight) gain must be accounted for as it accrues to safely dialyze. OBJECTIVE: This case describes the challenge of following true weight to appropriately adjust treatment for a patient with ESRD on HD requiring inpatient refeeding. METHODS: A 17-year-old female presented to an adolescent clinic after referral from her nephrologist for malnutrition and disordered eating. Her weight was 38.3 kg and height was 155.2 cm (76.2% of mean estimated body mass index, MEBMI). Her history was remarkable for a diagnosis of ESRD. The patient was admitted to the inpatient disordered eating program. The patient continued HD three times a week and was followed by nephrology. The team noted that the patient's dry weight for dialysis had not yet been adjusted, leading to increasingly aggressive dialysis. The nephrology team addressed the need for reassessments of dry weight by utilizing the "crit line" method. RESULTS: Frequent assessment allowed the nephrology team to account for intensive renourishment of the patient. After a 64 day hospital stay, the patient achieved 88.1% of MEBMI, calculated using her most up to date dry weight. CONCLUSION: Among patients with malnutrition and ESRD requiring HD, it is imperative to determine a patient's dry weight at the beginning of refeeding so the treatment plan can be adjusted according to the dynamic, true weight of the patient. This case illustrates the importance of interdisciplinary teamwork when managing a patient with malnutrition and ESRD on HD.

The Reproductive Impact of Eating Disorders in Adolescents.

Eating disorders are common, chronic illnesses that frequently arise during adolescence. Because of the impact on nutrition, individuals with eating disorders have significant health consequences, including effects on reproductive health. Adolescent women with eating disorders frequently have menstrual irregularities, though the causes of these abnormalities are complex and vary depending on the type of eating disorder. Teens with eating disorders may have changes in current and future fertility, and eating disorders during pregnancy can have medical and psychologic impacts for both mother and child. Though not well researched, eating disorders in men can affect reproductive health and potentially impact fertility. Lastly, eating disorders in adolescents can have significantly deleterious, irreversible effects on bone health.

Case Report: Persistent Genital Arousal Disorder in an Adolescent Woman.

BACKGROUND: After several visits with unrelated complaints, a 16-year-old female patient disclosed symptoms of unwanted genital arousal and was diagnosed with persistent genital arousal disorder (PGAD). CASE: A 16-year-old female patient with history of depression, sexual abuse, and dysmenorrhea insistently requested etonogestrel rod removal. At 2 visits after implant removal, the patient disclosed the reason for her insistence: PGAD symptoms developed after implant insertion, although they worsened with removal. Chart review revealed selective serotonin reuptake inhibitor discontinuation before symptom onset. Normalization of sexual arousal occurred with counseling, selective serotonin reuptake inhibitor treatment, and hormonal contraception. SUMMARY AND CONCLUSION: This case highlights the importance of clinician recognition of PGAD symptoms, which adolescents might not openly disclose. Clinicians must nonjudgmentally collect medication history and sexual history, including sexual arousal and satisfaction, to make this diagnosis.

Medical Child Abuse: An Unusual "Source" of Vaginal Bleeding.

BACKGROUND: Medical child abuse (MCA) is challenging to diagnose. Although young children are often affected, adolescents can be victims through caregiver coercion. Presentation is highly variable. Diagnosis is essential because of high associated morbidity and mortality. CASE: We describe the case of a 12-year-old girl who presented to multiple subspecialty clinics with reported menorrhagia. Despite reassuring clinical examinations, the family described menorrhagia that failed to respond to standard treatment. After an urgent evaluation for reported heavy bleeding revealed only scant blood, the diagnosis of MCA was made. SUMMARY AND CONCLUSION: Vaginal bleeding is a rare presentation of MCA, but must be considered whenever reported symptomatology does not follow physiologic patterns, respond to standard medical treatment, or correspond to clinical evaluation. Prompt identification is important to prevent further harm.

Delay in an Eating Disorder Diagnosis: The Reason Was a "Shox".

BACKGROUND: Patients' underlying medical conditions might affect the presentation and progression of an eating disorder. CASE: We describe a patient with an undiagnosed, rare, genetic skeletal dysplasia with effects on body mass index that likely led to body image distortion and delayed the diagnosis of an eating disorder. SUMMARY AND CONCLUSION: It is critical to fully assess disordered eating in the context of each patient's clinical status.

Trends and Substance Use Associations With E-Cigarette Use in US Adolescents.

Concerns exist that e-cigarette use may introduce adolescents to drugs. This study explores trends and associations of inhaled tobacco use with drug use. We performed a secondary data analysis on the National Youth Risk Behavior Survey examining the inhaled tobacco and drug use patterns among US teens. Adjusted odds ratios were calculated using bivariate and multivariate analyses between inhaled tobacco use with other drug use, adjusting for age, race/ethnicity, and gender. When adjusting for gender, age, and race/ethnicity, teens who use only e-cigarettes had a higher odds than peers who do not use any inhaled tobacco products to have ever tried marijuana or alcohol, currently use marijuana or alcohol, have lifetime drug use, and misused prescription medications. Drug risk behavior appears stratified with type of inhaled tobacco used, with generally exclusive e-cigarette use linked to lowest risk and conventional and e-cigarette use associated with highest risk of drug use.

An Unusual Etiology of Hypokalemia in a Patient With an Eating Disorder.

Patients with eating disorders are at risk for electrolyte imbalances that can lead to life-threatening complications. Timely recognition and evaluation of electrolyte abnormalities, including hypokalemia, are essential. In this case report, we describe an uncommon etiology of hypokalemia in a patient with disordered eating.