A Life-Affirming Palliative Care Model for Severe and Enduring Anorexia Nervosa.

Some individuals with severe and enduring anorexia nervosa experience dramatically degraded quality of life in the face of refractory illness and compulsory treatment. We propose a palliative care (PC) model for this group of patients that aims to support their unique goals of care, improve social-professional function, reduce physical suffering, and honor the whole person. Far from representing a pre-hospice model, a PC model for those with severe and enduring anorexia nervosa instead provides an alternative to current practices in hopes of meaningfully improving quality of life and outcomes.

Regardless of inequities in care, terminal anorexia nervosa exists: a response to Sharpe et al.

We are pleased that the concept of terminal anorexia nervosa is being considered in serious discussion. Our previous presentations were not intended to assess eating disorders care broadly, but solely to bring attention to the importance of end-of-life care issues for patients with anorexia nervosa. Regardless of differences in ability to access or utilize health care resources, inescapably, individuals contending with end-stage malnutrition due to anorexia nervosa who refuse further nutrition will progressively decline, and some will die as a result.

Terminal anorexia nervosa: three cases and proposed clinical characteristics.

Background: Most individuals with eating disorders will either recover, settle into an unrecovered but self-defined acceptable quality of life, or continue to cycle from crisis to relative stability over time. However, a minority of those with severe and enduring eating disorders recognize after years of trying that recovery remains elusive, and further treatment seems both futile and harmful. No level of harm reduction proves achievable or adequately ameliorates their suffering.

Body Mass Index Requirements for Gender-Affirming Surgeries Are Not Empirically Based.

Body mass index (BMI) requirements for gender affirmation surgery (GAS) are ubiquitous and vary across providers. Requirement variation is not surprising given little data to suggest an association between BMI and GAS outcomes. Implementation of subjective BMI requirements limits access to GAS and negatively impacts patient health and safety.

A comparison of the metabolic complications and hospital course of severe anorexia nervosa by binge-purge and restricting subtypes.

This study examines adult patients with severe, life-threatening anorexia nervosa who were admitted to an inpatient, medical stabilization unit between October 1, 2008 and December 31, 2014. Specifically, the study compares anorexia nervosa, binge purge subtype (AN-BP) and anorexia nervosa, restricting subtype (AN-R) on admission measures, hospital course, and outcomes. Of the 232 patients, 46% (N = 108) had AN-BP.

Rare medical manifestations of severe restricting and purging: "Zebras," missed diagnoses, and best practices.

Objective: Medical problems that arise due to severe restricting and/or purging may be misdiagnosed or suboptimally treated, from outpatient clinics to top medical hospitals. A symptom may be presumed to be a psychological manifestation of the eating disorder and inappropriately dismissed for further medical evaluation. Alternatively, a detailed medical workup may be performed, overlooking a classic relationship between starvation and a physical finding, which delays referral to eating disorder care.

Liver dysfunction in patients with severe anorexia nervosa.

Objective: Evaluation of liver dysfunction in patients with severe anorexia nervosa (AN) has typically been limited to small case series. We report an investigation into the admission characteristics and clinical outcomes associated with liver dysfunction in a large cohort of adults hospitalized for medical stabilization of severe AN.

Methods: We retrospectively evaluated electronic medical records to quantify the cumulative incidence of elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT).

Medical outcomes for adults hospitalized with severe anorexia nervosa: An analysis by age group.

Objective: Relatively little has been written about the outcomes of medical stabilization, analyzed specifically across the age spectrum, in adults with severe anorexia nervosa (AN).

Method: We retrospectively evaluated clinical parameters relevant to acuity of illness and outcomes of early refeeding in 142 adults with severe AN, admitted for definitive inpatient medical stabilization from October 1, 2008 to December 31, 2012. Patients were categorized into three age groups: 17 to 29, 30 to 40, and 41+ years.

Prevalence and management of oropharyngeal dysphagia in patients with severe anorexia nervosa: A large retrospective review.

Objective: Oropharyngeal dysphagia (OPD) refers to difficulty swallowing food or a liquid bolus from the oral and pharyngeal cavities into the esophagus and increases the risk of possibly life-threatening pneumonia. Little has been reported on OPD in adults with anorexia nervosa (AN). This study includes a description of OPD in severe AN and discusses potentially effective clinical management.

Predictors of hypophosphatemia during refeeding of patients with severe anorexia nervosa.

Objective: Hypophosphatemia of refeeding is one of the most dangerous complications seen during the treatment of patients with anorexia nervosa. Although easily detectable and treatable, hypophosphatemia is under-recognized as a complication of refeeding. Specific risk factors for the development of hypophosphatemia are likely to exist among patients with severe anorexia nervosa.

Motivated to survive: high cooperativeness in severe anorexia nervosa.

This study assessed the personality of severely ill patients with anorexia nervosa, restricting (AN-R) and binge-purge subtypes (AN-BP), during hospitalization for medical stabilization. Participants (N = 37) completed the Temperament and Character Inventory, Revised. Personality domains were similar between AN-R and AN-BP with the exception of cooperativeness.

Low prealbumin is a significant predictor of medical complications in severe anorexia nervosa.

Objective: Prealbumin levels have been proven to correlate with hospital length of stay, wound healing, infection rates, and mortality in adults hospitalized for medical or surgical purposes, or those who have chronic illnesses. Little is known about the utility of prealbumin evaluation in adults with severe anorexia nervosa (AN).

Method: We retrospectively evaluated prealbumin levels, along with numerous other clinical parameters relevant to illness acuity and early refeeding outcomes, in 132 adults with AN admitted for definitive inpatient medical stabilization from October 1, 2008 to December 31, 2012.

Hematological abnormalities in severe anorexia nervosa.

Little is known about the prevalence of hematologic abnormalities in adults with severe anorexia nervosa. We report the first major analysis of hematologic dysfunction in such patients. We retrospectively analyzed the charts of 53 men and women with severe anorexia nervosa, admitted between October 2008 and December 2010 for medical stabilization to our center, which has a national referral base.

Dysphagia in severe anorexia nervosa and potential therapeutic intervention: a case series.

Objectives: In severe anorexia nervosa, there are a litany of medical complications that affect virtually every body system, and severe weakness is a typical characteristic. To our knowledge, aspiration risk, dysphagia recognition, and dysphagia management and intervention have not been well described in the literature in regard to severe anorexia nervosa. The purpose of this case series is to increase awareness among clinicians of possible oropharyngeal dysphagia symptoms that may present in patients with severe anorexia nervosa.

Ophthalmic changes in severe anorexia nervosa: a case series.

Objective: We describe the diagnosis and management of lagophthalmos, or failure of eyelid closure, in five patients with severe anorexia nervosa (AN) who complained of dry, irritated eyes and photophobia.

Method: Five patients with these findings are described retrospectively.

Results: Examination revealed lagopthalmos in the setting of ptosis and enophthalmos, with multiple other starvation-mediated medical complications.

Exercise electrocardiography extinguishes persistent junctional rhythm in a patient with severe anorexia nervosa.

Among psychiatric conditions, anorexia nervosa carries the highest mortality, in part due to the propensity for rhythm disturbances among patients with advanced disease. Patients with anorexia nervosa are prone to both bradycardia and tachyarrhythmias, though mortality has not been associated with the former. To date, only one case of junctional rhythm in the setting of anorexia nervosa has been previously described, which was unremitting and required prolonged hospitalization.

ACUTE center for eating disorders.

Background: While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs.

Methods: We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder.

Dysphagia in severe anorexia nervosa: a case report.

Objective: The purpose of this case report is to increase awareness among clinicians that oropharyngeal dysphagia occurs in patients with severe anorexia nervosa, placing them at risk for aspiration and impeding nutritional rehabilitation.

Method: We describe a patient with severe anorexia nervosa who manifested symptoms of dysphagia, with resultant aspiration pneumonia, at the time of her admission for medical stabilization.

Results: The speech pathology team administered dysphagia therapy, using neuromuscular electrical stimulation (NMES) in conjunction with swallowing therapy.

Severe anorexia nervosa: outcomes from a medical stabilization unit.

Objective: We report data from the medical stabilization and refeeding of patients with severe anorexia nervosa admitted over a 15-month period.

Method: Through chart review and computerized data collection, we evaluated demographic and clinical data from 25 consecutive patients admitted to our medical stabilization unit from October 2008 to January 2010.

Results: In this adult-patient population with a median body mass index (BMI) of 13.

Tampon use in patients with anorexia nervosa can cause persistent vaginal bleeding: a case series.

Objective: To describe the phenomenon of persistent vaginal bleeding in two patients with severe anorexia nervosa.

Method: We report two cases of young women with severe anorexia nervosa reporting vaginal bleeding that persisted for months despite trials of topical and systemic conjugated estrogen therapy.

Result: A speculum exam by a gynecologist ultimately revealed the source of the bleeding to be tampon-induced vaginal ulcers.