Faecal calprotectin: Marker of intestinal inflammatory process in anorexia nervosa? A preliminary study.

PURPOSE: Anorexia Nervosa (AN) is a serious and potentially lethal mental disorder characterised by a deliberate quest to reduce one's weight. It can have multiple physical and psychological consequences. The clinical presentation of AN can include gastrointestinal symptoms, however, the pathophysiology of these symptoms in the context of AN remains uncertain. It is hypothesised that patients with AN may have an increase in intestinal permeability, which could lead to an increase in faecal calprotectin (fCP), a marker of intestinal inflammation. No relation between AN and elevation of fCP has been previously described in literature. METHODS: Eight patients hospitalised for AN have a dosage of fCP. RESULTS: Calprotectine was found to be elevated in 50% of cases, with or without any underlying comorbid gastrointestinal disease. Only the duration of illness tended to be associated with the increase in fCP suggesting a greater alteration as a function related to the time of denutrition. CONCLUSION: Although these findings provide insights in the potential pathophysiology of gastrointestinal symptoms in AN, further studies that evaluate the factors associated with elevated fCP in patients with AN are needed.

To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol.

Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.

Initial inpatient management of adolescents and young adults admitted with severe malnutrition due to anorexia nervosa: protocol for a systematic review.

BACKGROUND: Anorexia Nervosa (AN) is a highly prevalent disease in adolescents and young adults (AYAs). The quality of initial inpatient medical management in a patient with severe malnutrition due to AN is crucial to prevent further medical instability. This review aims to inventory evidence regarding initial refeeding and management of AYAs with AN in an inpatient setting, in order to avoid medical complications. METHODS: A systematic review will be conducted using PubMed, MEDLINE, All EBM Reviews, Embase, PsycINFO, Cochrane Database and CINAHL. The search strategy consists of terms related to anorexia, hospitalization and Pediatrics. Randomized controlled trials, case-control studies, cross-sectional and cohort studies will be included. Participants will include adolescents and adults 18-24 years old diagnosed with AN and meeting criteria for severe disease. The primary outcome will be any of the following complications: hypophosphatemia, refeeding syndrome, hypoglycemia, cardiac arrythmia, hepatic cytolysis or death. Data will be extracted and the risk of bias will be assessed by one author and reviewed by a second author. Results will be presented in a systematic narrative synthesis format. The quality of evidence for all outcomes will be evaluated using the GRADE methodology. DISCUSSION: This systematic review will examine current evidence on initial inpatient refeeding and help to document effectiveness of initial inpatient management in AYAs with severe AN in avoiding further medical complications. TRIAL REGISTRATION: This study is registered on PROSPERO under the reference number CRD42019123608 .

Severe Benzodiazepine Use Disorder in a 16-Year-Old Adolescent: A Rapid and Safe Inpatient Taper.

We describe the case of a 16-year-old boy with a 1-year history of severe benzodiazepine misuse. After being denied access to several treatment programs and hospital centers that felt unprepared to manage benzodiazepine use disorder and withdrawal in an adolescent, the patient was admitted to a tertiary pediatric unit for rapid inpatient tapering and detoxification. The patient was hospitalized for 13 days and received decreasing doses of diazepam under close monitoring of withdrawal symptoms. The taper was well tolerated, and the patient was transferred to a youth residential substance use treatment center, where he completed a successful 2-month placement. This case highlights the lack of adolescent-friendly facilities allowing safe tapering of rapid-acting benzodiazepines in North America. Given high rates of benzodiazepine misuse among youth and the risks associated with benzodiazepine misuse and withdrawal, there is a critical need for more research, provider training, and dedicated resources in this area.

In malnourished adolescent with anorexia nervosa, Cockroft-Gault formula is the most relevant formula to estimate renal function.

AIM: Serum creatinine level is the most used test to evaluate renal function in patients with anorexia nervosa (AN). We investigated which formula of glomerular filtration rate (GFR) based on simple blood sample had the best correlation with the gold standard in malnourished adolescent patients with AN. METHODS: A prospective study was conducted on 34 adolescents hospitalized for the restrictive type of AN between 2014 and 2017. The GFR was measured by isotopic technique and calculated using the Cockroft-Gault, Schwartz equations and 3 other formula. RESULTS: For the 34 AN patients, mean BMI -2.7 zscore, the mean measured GFR was 107+/-26 mL/min/1.73 m2. Among them, 35% (12/34) had a GFR under 90 mL/min/1.73 m2. The calculated GFR with Cockroft-Gault formula had the best correlation with the measured GFR (R2 = 0.852), whatever the creatinine level. No correlation was found between creatinine level and measured GFR. CONCLUSION: Kidney dysfunction is common in malnourished AN adolescents, so clinicians should always evaluate AN patients for renal impairments. Creatinine level is a poor indicator of renal function in this population. The most accurate formula to test GFR with a simple blood test is the Cockroft-Gault formula.

Excessive laboratory monitoring to prevent adolescent's refeeding syndrome: opportunities for enhancement.

PURPOSE: Anorexia nervosa (AN) is a complex medical condition affecting mainly adolescents and young adults. To monitor and prevent refeeding syndrome, current guidelines recommend daily laboratory testing in the first week of hospitalization and 2-3 times/week for the following 3 weeks. The aims of this study were to determine the proportion of abnormal results of the blood tests done during the first week of nutritional rehabilitation in adolescents with AN, the proportion of test having led to supplementation and the cost of all these tests. METHOD: A retrospective chart review of admissions for eating disorders between May 2014 and May 2015 in a tertiary Pediatric University Hospital center was performed. Patients were included if they were younger than 18 years, admitted for protocol-based refeeding and met criteria for AN (DSM 5). RESULTS: Among the 99 hospitalizations included in the study, the mean age was 14.6 years (± 1.7), with a female predominance (97%). The mean admission BMI was 15.3 ± 2 kg/m2 (Z-score - 2.6 ± 1.4). The mean length of hospitalization was 40.3 days ± 21.8. Of the 1289 laboratory tests performed, only 1.5% revealed abnormal values and 0.85% led to supplementation. No critical value was identified. The total cost for the tests performed was 148,926.80 CAD$, 1504$/admitted patient, instead of 3890$/admitted patient had we followed the recommendations. CONCLUSION: More precise criteria should be developed regarding the frequency of laboratory tests needed to monitor and prevent refeeding syndrome. At present, the recommendations could lead to unnecessary testing and expenses. LEVEL OF EVIDENCE: Level IV: Dramatic results in uncontrolled trials.

Renal injury in pediatric anorexia nervosa: a retrospective study.

PURPOSE: Although primarily a mental health disorder, anorexia nervosa (AN) has many physical consequences. Among them, the consequences on kidney function are often underestimated. We evaluated renal function in adolescent AN inpatients and investigated the correlation between the GFR and intrinsic patient characteristics. METHODS: A single-center retrospective study was conducted on 51 patients hospitalized for the restrictive type of AN in 2013. Data were divided into: (1) medical history of AN; (2) growth parameters and vital signs upon admission; and (3) blood tests. The glomerular filtration rate (GFR) was calculated using the Cockroft-Gault, MAYO Clinical Quadratic (MCQ), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), the Modification of Diet in Renal Disease (MDRD), and Schwartz equations. RESULTS: The calculated percentages of patients with a GFR below 90 mL/min/1.73 m2 according to the different equations were as follows: Cockroft-Gault, 45%; MDRD, 28%; CKD-EPI, 14%; MCQ, 12%, and Schwartz, 4%. There was a strong association between the body mass index (BMI) and the GFR according to all equations (p < 0.0001). The lowest heart rate was significantly associated with a reduced GFR according to the Cockroft-Gault equation (p = 0.03). The GFR values did not differ significantly after rehydration. CONCLUSION: Clinicians should evaluate AN patients for renal complications, especially when the BMI and heart rate are very low. Dehydration was not solely responsible for renal impairment. LEVEL OF EVIDENCE: Level III, single-center retrospective cohort study.

Anorexia nervosa in adolescents: evolution of weight history and impact of excess premorbid weight.

The purpose of our study is to establish if the proportion of patients diagnosed with anorexia nervosa that have a history of excess weight has increased over a 10-year period and to study how different premorbid weight groups vary in terms of clinical characteristics. We performed a single-center, retrospective cohort study of all new patients presenting with anorexia nervosa, restrictive and binge/purge subtypes, in 2004 and 2014 at the Adolescent Medicine Clinic of Sainte-Justine University Health Centre (n = 172). The prevalence of excess premorbid weight was similar in both cohorts (32% in 2004 versus 29.5% in 2014). The historically overweight subgroup had a lower heart rate at intake (64.77 versus 69.75, p = 0.03). Patients with excess premorbid weight lost an average of 1 kg more per month than their historically thinner counterparts (2.6 kg versus 1.6 kg/month, p = 0.0011). The total decrease in BMI was much greater in patients with a history of excess weight (7 BMI points versus 3.8, p = 0.0001).Conclusion: Since overweight and obese patients present with significant weight suppression values, our study stresses the importance of screening for AN in all patients rather than in only the noticeably underweight. What is Known: • More than one third of patients presenting with AN have a history of overweight or obesity, which is comparable to the general population. • A delay between AN onset and diagnosis has been described in overweight adolescents. What is New: • Historically overweight patients presenting with AN demonstrate increased speed of weight loss, greater drop in BMI, and lower heart rate at presentation. • For patients with a history of excess weight considered as having recovered from AN, the average BMI at discharge was within normal limits.

Transitioning from medical school to residency: Evaluation of an innovative immersion rotation for PGY-1 paediatric residents.

Transition from medical school to residency is stressful due to new responsibilities in patient care. OBJECTIVE: To evaluate a new immersion curriculum on the transition from medical school to paediatric residency and its implications for future use in paediatric education. METHODS: In July 2013, a month-rotation offering one-third of time for clinical rounds and two-thirds of time for formal courses was conducted for postgraduate year 1 residents beginning paediatric residency training. Surveys were administered to residents before and after this rotation about their self-confidence in several paediatrics topics and abilities. RESULTS: Eleven junior residents were enrolled (100% participation rate). Among this cohort, pre- and postintervention confidence surveys showed differences for neonatalogy (P<0.001), respiratory distress (P=0.01) and seizure management skills (P<0.001). Among abilities surveyed, significant differences were noted for medical emergencies (P<0.001) and drug prescriptions (P<0.002). The healthy childcare item was the only topic with decreased self-confidence levels. Overall, 45.5% of participants felt confident and ready to begin clinical rotations in the paediatric program following completion of the rotation. CONCLUSION: First year paediatric residents who participated in this new curriculum felt their confidence was enhanced in several areas of paediatrics. These findings supported our program committee members in their decision to pursue this rotation since 2013, and may be generalizable to other programs and institutions.

Can a two-hour lecture by a pharmacist improve the quality of prescriptions in a pediatric hospital? A retrospective cohort study.

BACKGROUND: A high rate of prescription errors exists in pediatric teaching hospitals, especially during initial training. OBJECTIVES: To determine the effectiveness of a two-hour lecture by a pharmacist on rates of prescription errors and quality of prescriptions. METHODS: A two-hour lecture led by a pharmacist was provided to 11 junior pediatric residents (PGY-1) as part of a one-month immersion program. A control group included 15 residents without the intervention. We reviewed charts to analyze the first 50 prescriptions of each resident. RESULTS: Data were collected from 1300 prescriptions involving 451 patients, 550 in the intervention group and 750 in the control group. The rate of prescription errors in the intervention group was 9.6% compared to 11.3% in the control group (p=0.32), affecting 106 patients. Statistically significant differences between both groups were prescriptions with unwritten doses (p=0.01) and errors involving overdosing (p=0.04). We identified many errors as well as issues surrounding quality of prescriptions. CONCLUSION: We found a 10.6% prescription error rate. This two-hour lecture seems insufficient to reduce prescription errors among junior pediatric residents. This study highlights the most frequent types of errors and prescription quality issues that should be targeted by future educational interventions.

Cannabinoid Hyperemesis Syndrome in a 17-Year-Old Adolescent.

Cannabis is the most widely used illicit drug in the world. In Canada, cannabis use has been decreasing among youth since 2008. However, it is still two times more prevalent than among adults. A distinct syndrome, characterized by recurrent vomiting associated with abdominal pain and compulsive bathing, has been increasingly recognized in chronic adult users. The cannabinoid hyperemesis syndrome (CHS) is still underdiagnosed among adults and even more among adolescents. The authors describe the case of a 17-year-old adolescent, who sought emergency care five times over a year for uncontrolled nausea, profuse vomiting, and weight loss. The patient's symptoms were ameliorated by repetitive hot showering and by avoiding cannabis use. Cannabinoid hyperemesis syndrome is a clinical diagnosis and should be consider in every case of cyclical vomiting. A review of the clinical aspects and the treatment is presented here.

External validation of scoring instruments for evaluating pediatric resuscitation.

INTRODUCTION: Although many methods have been proposed to assess clinical performance during resuscitation, robust and generalizable metrics are still lacking. Further research is necessary to develop validated clinical performance assessment tools and show an improvement in outcomes after training. We aimed to establish evidence for validity of a previously published scoring instrument--the Clinical Performance Tool (CPT)--designed to evaluate clinical performance during simulated pediatric resuscitations. METHODS: This was a prospective experimental trial performed in the simulation laboratory of a pediatric tertiary care facility, with a pretest/posttest design that assessed residents before and after pediatric advanced life support (PALS) certification. Thirteen postgraduate year 1 (PGY1) and 11 PGY3 pediatric residents completed 5 simulated pediatric resuscitation scenarios each during 2 consecutive sessions; between the 2 sessions, they completed a full PALS certification course. All sessions were video recorded. Sessions were scored by raters using the CPT; total scores were expressed as a percentage of maximum points possible for each scenario. Validity evidence was established and interpreted according to Messick's framework. Evidence regarding relations to other variables was assessed by calculating differences in scores between pre-PALS and post-PALS certification and PGY1 and PGY3 using a repeated-measures analysis of variance test. Internal structure evidence was established by assessing interrater reliability using intraclass correlation coefficients (ICCs) for each scenario, a G-study, and a variance component analysis of individual measurement facets (scenarios, raters, and occasions) and associated interactions. RESULTS: Overall scores for the entire study cohort improved by 10% after PALS training. Scores improved by 9.9% (95% confidence interval [CI], 4.5-15.4) for the pulseless nonshockable arrest (ICC, 0.85; 95% CI, 0.74-0.92), 14.6% (95% CI, 6.7-22.4) for the pulseless shockable arrest (ICC, 0.98; 95% CI, 0.96-0.99), 4.1% (95% CI, -4.5 to 12.8) for the dysrhythmias (ICC, 0.92; 95% CI, 0.87-0.96), 18.4% (95% CI, 9.7-27.1) for the respiratory scenario (ICC, 0.97; 95% CI, 0.95-0.98), and 5.3% (95% CI, -1.4 to 2.0) for the shock scenarios (ICC, 0.94; 95% CI, 0.90-0.97). There were no differences between PGY1 and PGY3 scores before or after the PALS course. Reliability of the instrument was acceptable as demonstrated by a mean ICC of 0.95 (95% CI, 0.94-0.96). The G-study coefficient was 0.94. Most variance could be attributed to the subject (57%). Interactions between subject and scenario and subject and occasion were 9.9% and 1.4%, respectively, and variance attributable to rater was minimal (0%). CONCLUSIONS: Pediatric residents improved scores on CPT after completion of a PALS course. Clinical Performance Tool scores are sensitive to the increase in skills and knowledge resulting from such a course but not to learners' levels. Validity evidence from scores for the CPT confirms implementation in new contexts and partially supports internal structure. More evidence is required to further support internal structure and especially to support relations with other variables and consequence evidence. Additional modifications should be made to the CPT before considering its use for high-stakes certification such as PALS.