Predictors of outcome at 1 year in adolescents with DSM-5 restrictive eating disorders: report of the national eating disorders quality improvement collaborative

PURPOSE

The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year.

METHODS

Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed.

RESULTS

At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration.

CONCLUSIONS

The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.

Optimizing bone health in children and adolescents

The pediatrician plays a major role in helping optimize bone health in children and adolescents. This clinical report reviews normal bone acquisition in infants, children, and adolescents and discusses factors affecting bone health in this age group. Previous recommended daily allowances for calcium and vitamin D are updated, and clinical guidance is provided regarding weight-bearing activities and recommendations for calcium and vitamin D intake and supplementation. Routine calcium supplementation is not recommended for healthy children and adolescents, but increased dietary intake to meet daily requirements is encouraged. The American Academy of Pediatrics endorses the higher recommended dietary allowances for vitamin D advised by the Institute of Medicine and supports testing for vitamin D deficiency in children and adolescents with conditions associated with increased bone fragility. Universal screening for vitamin D deficiency is not routinely recommended in healthy children or in children with dark skin or obesity because there is insufficient evidence of the cost-benefit of such a practice in reducing fracture risk. The preferred test to assess bone health is dual-energy x-ray absorptiometry, but caution is advised when interpreting results in children and adolescents who may not yet have achieved peak bone mass. For analyses, z scores should be used instead of T scores, and corrections should be made for size. Office-based strategies for the pediatrician to optimize bone health are provided. This clinical report has been endorsed by American Bone Health.

Refeeding hypophosphatemia in hospitalized adolescents with anorexia nervosa: a position statement of the Society for Adolescent Health and Medicine

Refeeding hypophosphatemia in hospitalized adolescents with anorexia nervosa is correlated with degree of malnutrition. Therefore, when initiating nutritional rehabilitation, clinicians should have a heightened awareness of the possibility of refeeding hypophosphatemia in severely malnourished patients (<70% median body mass index).

Higher caloric intake in hospitalized adolescents with anorexia nervosa is associated with reduced length of stay and no increased rate of refeeding syndrome

PURPOSE

To determine the effect of higher caloric intake on weight gain, length of stay (LOS), and incidence of hypophosphatemia, hypomagnesemia, and hypokalemia in adolescents hospitalized with anorexia nervosa.

METHODS

Electronic medical records of all subjects 10-21 years of age with anorexia nervosa, first admitted to a tertiary children's hospital from Jan 2007 to Dec 2011, were retrospectively reviewed. Demographic factors, anthropometric measures, incidence of hypophosphatemia (≤3.0 mg/dL), hypomagnesemia (≤1.7 mg/dL), and hypokalemia (≤3.5 mEq/L), and daily change in percent median body mass index (BMI) (%mBMI) from baseline were recorded. Subjects started on higher-calorie diets (≥1,400 kcal/d) were compared with those started on lower-calorie diets (<1,400 kcal/d).

RESULTS

A total of 310 subjects met eligibility criteria (age, 16.1 ± 2.3 years; 88.4% female, 78.5 ± 8.3 %mBMI), including 88 in the lower-calorie group (1,163 ± 107 kcal/d; range, 720-1,320 kcal/d) and 222 in the higher-calorie group (1,557 ± 265 kcal/d; range, 1,400-2,800 kcal/d). Neither group had initial weight loss. The %mBMI increased significantly (p < .001) from baseline by day 1 in the higher-calorie group and day 2 in the lower-calorie group. Compared with the lower-calorie group, the higher-calorie group had reduced LOS (13.0 ± 7.3 days versus 16.6 ± 9.0 days; p < .0001), but the groups did not differ in rate of change in %mBMI (p = .50) or rates of hypophosphatemia (p = .49), hypomagnesemia (p = 1.0), or hypokalemia (p = .35). Hypophosphatemia was associated with %mBMI on admission (p = .004) but not caloric intake (p = .14).

CONCLUSIONS

A higher caloric diet on admission is associated with reduced LOS, but not increased rate of weight gain or rates of hypophosphatemia, hypomagnesemia, or hypokalemia. Refeeding hypophosphatemia depends on the degree of malnutrition but not prescribed caloric intake, within the range studied.

A self-defense program reduces the incidence of sexual assault in Kenyan adolescent girls

PURPOSE

To determine the effect of a standardized 6-week self-defense program on the incidence of sexual assault in adolescent high school girls in an urban slum in Nairobi, Kenya.

METHODS

Population-based survey of 522 high school girls in the Korogocho-Kariobangi locations in Nairobi, Kenya, at baseline and 10 months later. Subjects were assigned by school attended to either a "No Means No Worldwide" self-defense course (eight schools; N = 402) or to a life-skills class (two schools; N = 120). Both the intervention and the life-skills classes were taught in the schools by trained instructors. Participants were administered the same survey at baseline and follow-up.

RESULTS

A total of 522 girls (mean age, 16.7 ± 1.5 years; range, 14-21 years) completed surveys at baseline, and 489 at 10-month follow-up. At baseline, 24.5% reported sexual assault in the prior year, with the majority (90%) reporting assault by someone known to them (boyfriend, 52%; relative, 17%; neighbor, 15%; teacher or pastor, 6%). In the self-defense intervention group, the incidence of sexual assault decreased from 24.6% at baseline to 9.2% at follow-up (p < .001), in contrast to the control group, in which the incidence remained unchanged (24.2% at baseline and 23.1% at follow-up; p = .10). Over half the girls in the intervention group reported having used the self-defense skills to avert sexual assault in the year after the training. Rates of disclosure increased in the intervention group, but not in controls.

CONCLUSIONS

A standardized 6-week self-defense program is effective in reducing the incidence of sexual assault in slum-dwelling high school girls in Nairobi, Kenya.

Underestimation of weight status in Californian adolescents

BACKGROUND

Overweight and obese adolescents commonly underestimate their weight status, considering themselves to be at a healthy weight or underweight. These adolescents are more likely to be male, older, and Latino, black, or Native American. Associations with acculturation have not been previously assessed. The goal of this study was to identify the prevalence of underestimation of weight status in Californian adolescents and to identify factors associated with this underestimation, in particular examining relationships with race/ethnicity and acculturation.

METHODS

Secondary data analysis of the 2005 Adolescent California Health Interview Survey.

RESULTS

A total of 36.6% of overweight and obese Californian adolescents underestimated their weight status. Adolescents not born in the United States had increased odds of underestimating their weight status compared to those born in the United States [adjusted odds ratio (aOR)=1.94, 95% confidence interval (CI) 1.08, 3.49; p=0.03]. No significant associations with race/ethnicity were found. An age-sex interaction was observed with older adolescent males having increased odds compared to younger females.

CONCLUSIONS

Identification of individuals at increased odds of underestimating their weight status may be important in developing and targeting appropriate counseling and interventions to ameliorate long-term health risks of excess weight.

Language spoken at home and parental birthplace moderate the association of race/ethnicity and distorted weight perception

Distorted weight perception (DWP), specifically overestimating weight status, is common in adolescents and may lead to eating disorders. The authors examined the role of acculturation proxies as effect modifiers of the relationship between race/ethnicity and DWP in a diverse adolescent population. Analysis of the 2005 California Health Interview Survey showed that of 2955 adolescents with underweight or healthy weight status, 10.6% reported DWP. Latino adolescents had increased odds of DWP compared with white adolescents (adjusted odds ratio [aOR] = 3.02; 95% confidence interval [CI] = 2.00, 4.57). Latinos who spoke English and other language(s) at home (aOR = 3.38; 95% CI = 2.11, 5.41) and Latino (aOR = 5.00; 95% CI = 2.34, 10.72) and Asian (aOR = 3.10, 95% CI = 1.15, 8.35) adolescents who spoke no English at home had increased odds of DWP compared with white, English-only speakers. Latino adolescents had increased odds (aOR = 3.98, 95% CI = 2.45, 6.47) of DWP if neither parent was US born. Assessing acculturation proxies may help identify adolescents at risk of DWP.

Expected body weight in adolescents: comparison between weight-for-stature and BMI methods

OBJECTIVE

To test the hypothesis that the weight-for-stature (WFS) and BMI methods are not equivalent in determining expected body weight (EBW) in adolescents with eating disorders and to determine the sensitivity, specificity, and positive predictive value of each method to detect those <75% EBW. We hypothesized that differences in EBW would be greatest at the extremes of height.

METHODS

EBW was determined for 12 047 individual adolescents aged 12 to 19 years by the WFS and BMI methods by utilizing the same National Center for Health Statistics data sets. Absolute difference between the 2 methods for each individual was calculated and plotted against height by using a generalized additive model. The number of individuals whose weights were <75% EBW was determined by each method.

RESULTS

For girls, EBW was 3.52 ± 3.13% higher when using the WFS method compared with the BMI method. For boys, EBW(WFS) was 3.45 ± 2.72% higher than EBW(BMI). Among adolescent girls, 65% had EBW(WFS) higher than EBW(BMI). By using the EBW(WFS) method as the gold standard, specificity of the EBW(BMI) method to detect those <75% EBW was 0.999, but sensitivity was only 0.329. Absolute differences in EBW were most pronounced at the extremes of height.

CONCLUSIONS

The WFS and BMI methods are not equivalent in determining EBW in adolescents and are not interchangeable. EBW(WFS) was ~3.5% higher than EBW(BMI). In adolescents with eating disorders, use of the BMI method will underestimate the degree of malnutrition compared with the WFS method. Which method better predicts meaningful clinical outcomes remains to be determined.

Ovarian torsion in a patient with müllerian agenesis: increased risk?

BACKGROUND

Patients with müllerian agenesis may be at an increased risk of ovarian torsion due to the absence of the utero-ovarian ligament and the fact that the ovary is not tethered to a fixed and relatively non-mobile structure, the uterus.

CASE

We report a case of a 14-year-old female with abdominal pain who had a physical examination suggestive of müllerian agenesis. Imaging was non-diagnostic and demonstrated an abdominal mass. Emergent surgery revealed ovarian torsion.

SUMMARY AND CONCLUSION

We present this case of ovarian torsion and müllerian agenesis, in order to highlight the association and to review potential risk factors.

Pediatric residents' knowledge, use, and comfort with expedited partner therapy for STIs

OBJECTIVE

We examined California pediatric residents' knowledge, practices, and comfort of providing expedited partner therapy (EPT) for sexually transmitted infections, by postgraduate year of training and presence of an adolescent medicine fellowship. We hypothesized that few residents are aware of EPT, and fewer are comfortable providing it; knowledge, practices, and comfort increase during residency; and presence of an adolescent medicine fellowship increases knowledge, practices, and comfort.

METHODS

Online anonymous questionnaires were completed by pediatric residents from 14 California programs.

RESULTS

Two hundred eighty-nine pediatric residents (41% response; mean age, 29.4 ± 2.7 years; 78% female) responded. Twenty-two percent reported being moderately or very familiar with EPT. Most correctly identified several EPT methods. Incorrectly identified as EPT included patient (55%), health department (42%), and provider (37%) referrals. Only 8% were aware of California's legal status regarding EPT. Sixty-nine percent knew that California law allows EPT for chlamydia and gonorrhea, but 38% incorrectly stated that EPT can be used to treat trichomoniasis. Fifty-two percent reported ever providing EPT, but 30% of them were uncomfortable doing so. Postgraduate year 1 residents were significantly more likely to report lack of experience as a barrier to prescribing EPT. Residents in programs with the presence of an adolescent medicine fellowship had significantly higher global knowledge scores and were more likely to practice EPT with fewer concerns.

CONCLUSIONS

California pediatric residents have knowledge gaps and discomfort providing EPT, and the presence of adolescent medicine fellowship is associated with increased EPT knowledge, use, and comfort among residents. Our findings demonstrate a need to improve EPT education in pediatric residencies.

Hypomagnesemia in adolescents with eating disorders hospitalized for medical instability

BACKGROUND

Hypomagnesemia in patients with eating disorders is poorly characterized, particularly among adolescents.

METHODS

To determine the prevalence of hypomagnesemia (Mg ≤ 1.7 mg/dL) and clinical characteristics of adolescents hospitalized with a DSM-IV-diagnosed eating disorder who developed hypomagnesemia, a retrospective chart review was conducted on all adolescents aged 10-21 years with an eating disorder were hospitalized at a tertiary care children's hospital from 2007 to 2010. Patients were refed orally with standard nutrition and high-energy liquid supplements. Serum magnesium and phosphorus were obtained on admission, every 24-48 hours for the first week, and thereafter as clinically indicated. Clinical characteristics of patients with hypomagnesemia were compared with those of individuals with normal magnesium levels and those with hypophosphatemia.

RESULTS

Eighty-six of 541 eligible participants (15.9%) developed hypomagnesemia. Forty (47%) with hypomagnesemia admitted to purging in the year before admission, with 88% purging during the prior month. Compared with those with normal serum magnesium levels, patients with hypomagnesemia were older (P = .0001), ill longer (P = .001), more likely to be purging (P = .04), and more likely to have an alkaline urine (P = .01). They did not differ in eating disorder diagnosis, BMI, or other electrolyte disturbances. Hypomagnesemia developed 4.9 ± 5.5 days after refeeding was initiated, significantly later than the onset of hypophosphatemia, 0.95 ± 2.6 days (P < .001).

CONCLUSIONS

Hypomagnesemia is prevalent in adolescents hospitalized for an eating disorder and is associated with purging and alkaline urine. Hypomagnesemia develops later in the course of refeeding than hypophosphatemia. Magnesium levels should continue to be monitored after the more immediate risk of hypophosphatemia has passed, especially in those with alkaline urine.

An eleven site national quality improvement evaluation of adolescent medicine-based eating disorder programs: predictors of weight outcomes at one year and risk adjustment analyses

PURPOSE

This quality improvement project collected and analyzed short-term weight gain data for patients with restrictive eating disorders (EDs) treated in outpatient adolescent medicine-based ED programs nationally.

METHODS

Data on presentation and treatment of low-weight ED patients aged 9-21 years presenting in 2006 were retrospectively collected from 11 independent ED programs at intake and at 1-year follow-up. Low-weight was defined as < 90% median body weight (MBW) which is specific to age. Treatment components at each program were analyzed. Risk adjustment was performed for weight gain at 1 year for each site, accounting for clinical variables identified as significant in bivariate analyses.

RESULTS

The sites contained 6-51 patients per site (total N = 267); the mean age was 14.1-17.1 years; duration of illness before intake was 5.7-18.6 months; % MBW at intake was 77.5-83.0; and % MBW at follow-up was 88.8-93.8. In general, 40%-63% of low weight ED subjects reached ≥90% MBW at 1-year follow-up. At intake, patients with higher % MBW (p = .0002) and shorter duration of illness (p = .01) were more likely to be ≥90% MBW at follow-up. Risk-adjusted odds ratios controlled for % MBW and duration of illness were .8 (.5, 1.4)-1.3 (.3, 3.8), with no significant differences among sites.

CONCLUSION

A total of 11 ED programs successfully compared quality improvement data. Shorter duration of illness before intake and higher % MBW predicted improved weight outcomes at 1 year. After adjusting for risk factors, program outcomes did not differ significantly. All adolescent medicine-based ED programs were effective in assisting patients to gain weight.

A placebo-controlled pilot study of adjunctive olanzapine for adolescents with anorexia nervosa

OBJECTIVE

The objective of this study was to explore whether the addition of olanzapine versus placebo increases weight gain and improves psychological symptoms in adolescents with anorexia nervosa-restricting type who are participating in a comprehensive eating disorders treatment program.

METHODS

Twenty underweight females participated in this 10-week, double-blind, placebo-controlled pilot study of olanzapine. The primary efficacy measure was change in percentage of median body weight measured at baseline and weeks 5 and 10. Secondary efficacy measures included clinician-rated and self-reported measures of psychological functioning measured at 2-week intervals and eating disorder symptoms measured at baseline and weeks 5 and 10 as well as laboratory assessments (including indirect calorimetry), which were also performed at baseline and weeks 5 and 10. A mixed models approach to repeated measures analysis of variance was utilized to detect any treatment-by-time interaction.

RESULTS

Fifteen of 20 enrolled females (median age, 17.1 years; range, 12.3-21.8 years; mean body mass index, 16.3) completed this 10-week pilot study. Change in % median body weight did not differ between the treatment groups at midpoint or end of study. Both groups gained weight at a similar rate and had similar improvements in eating attitudes and behaviors, psychological functioning, and resting energy expenditure. A trend of increasing fasting glucose and insulin levels was found only in the olanzapine group at week 10.

CONCLUSIONS

These preliminary findings do not support a role for adjunctive olanzapine for underweight adolescent females with anorexia nervosa-restricting type who are receiving standard care in an eating disorder treatment program (clinical trials.gov; no. NCT00592930).

Psychopharmacology of eating disorders in children and adolescents

Eating disorders are serious psychiatric illnesses that often present during adolescence and young adulthood. They are associated with medical as well as psychological disturbances, and pediatricians play an important role in their identification, diagnosis, and management. There has been a paucity of treatment research that specifically focuses on children and adolescents with eating disorders. This article reviews the scientific evidence for the use of psychotropic medication in the treatment of children and adolescents with eating disorders.

Osteoporosis in anorexia nervosa

Anorexia nervosa is a condition associated with reduced bone mass and increased bone fragility, for which there is no known effective treatment. Anorexia nervosa usually has its onset during adolescence, the critical time when peak bone mass is accrued. Low bone mass is caused by reduced bone formation, as well as accelerated bone resorption. The etiology is multifactorial and includes poor nutrition, low bodyweight, sex hormone deficiency and hypercortisolism. Weight gain and resumption of menses is accompanied by some improvement in bone mass, but may not restore it to normal levels. Oral estrogen-replacement therapy is not effective in increasing bone mass in this disorder. The bisphosphonates, used in conjunction with nutritional rehabilitation and weight gain, have shown promise, but concerns about safety have limited their use. The aim of this article is to highlight recent recommendations regarding the assessment of fracture risk in children and adolescents, summarize the evidence for low bone mass and increased fracture risk in anorexia nervosa, and discuss approaches to the management of low bone mass in this disorder.

An introduction to eating disorders: clinical presentation, epidemiology, and prognosis

The spectrum of eating disorders varies widely, ranging from mildly abnormal eating habits to life-threatening chronic disease. Given the many different cultural food norms and individual preferences, along with the fact that dieting behavior is extremely common, it can be challenging to differentiate unusual eating behaviors from clinically significant eating disorders. In this article, the authors provide an introduction to eating disorders including anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified, focusing on the clinical presentation, epidemiology, and prognosis.

Metabolic assessment of menstruating and nonmenstruating normal weight adolescents

OBJECTIVE

Resumption of menses (ROM) is a key indicator of recovery in AN, but patients may remain amenorrheic despite weight restoration. The objective of this study is to better understand the mechanism of amenorrhea in patients with eating disorders.

METHOD

A retrospective chart review was conducted of 382 normal weight adolescents with a history of anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified, who had been referred for indirect calorimetry tests. Resting energy expenditure (REE) was compared between amenorrheic (n = 60) and regularly menstruating females (n = 121).

RESULTS

Participants with amenorrhea had a mean REE of 1,103 kcal/24 h (79% predicted), whereas participants who were menstruating regularly had a mean REE of 1,217 kcal/24 h (85% predicted; p = 0.001). The amenorrheic group was found to be at a lower mean body weight (53.7 +/- 5.6 kg vs. 57.5 +/- 7.4 kg; p < or = 0.001), at a lower percent ideal body weight (98.5 +/- 8.3% vs. 102.8 +/- 10.2%; p = 0.005), and at a lower BMI (20.5 +/- 1.7 vs. 21.5 +/- 2.2; p = 0.002).

DISCUSSION

This study highlights that amenorrheic participants with a history of eating disorders who are at normal body weight are hypometabolic, suggesting an adaptive response to dietary restriction.

Treatment goal weight in adolescents with anorexia nervosa: use of BMI percentiles

OBJECTIVE

There is a lack of consensus as to how to determine treatment goal weight in the growing adolescent with anorexia nervosa (AN). Resumption of menses (ROM) is an indicator of biological health and weight at ROM can be used as a treatment goal weight. This study determined the BMI percentile for age at which ROM occurs.

METHOD

A secondary analysis of a prospective cohort study examining 56 adolescent females with AN, aged 12-19 years, followed every 3 months until ROM. BMI percentiles for age and gender at ROM were determined using the nutrition module of Epi Info 2002.

RESULTS

At 1-year follow-up, 36 participants (64.3%) resumed menses and 20 (35.7%) remained amenorrheic. Mean BMI percentile at ROM was 27.1 (95% CI = 20.0-34.2). Fifty percent of participants who resumed menses, did so at a BMI percentile between the 14th and 39th percentile.

CONCLUSION

A BMI percentile range of 14th-39th percentile can be used to assign a treatment goal weight, with adjustments for prior weight, stage of pubertal development, and anticipated growth.

Eating disorders in adolescence: what is the role of hormone replacement therapy?

PURPOSE OF REVIEW

To review the diagnostic criteria and clinical presentation of eating disorders in adolescence, to outline an approach to treatment, and examine evidence for prescribing hormone replacement therapy to increase bone mineral density in anorexia nervosa.

RECENT FINDINGS

Eating disorders are prevalent in adolescents and can present with amenorrhea and menstrual disturbances. Reduced bone mineral density leading to osteoporosis and increased fracture risk is a frequent, severe, and potentially irreversible complication of anorexia nervosa. The degree of bone mineral density reduction depends on the duration of amenorrhea and degree of malnutrition. Limited evidence supports the use of hormone replacement therapy to increase bone mineral density in adolescents with anorexia nervosa.

SUMMARY

In adolescents with amenorrhea or menstrual disturbances, the gynecologist should consider the possibility of an eating disorder. The diagnosis can be made on history and physical examination. If an eating disorder is suspected, the patient should be referred for evaluation and treatment. Support for the use of hormone replacement therapy to increase bone mineral density in adolescents with anorexia nervosa is limited, and its routine use should be discouraged. Weight restoration, calcium and vitamin D supplementation and the resumption of spontaneous menses is the mainstay of treatment.

Concentrations of metals in blood and feathers of nestling ospreys (Pandion haliaetus) in Chesapeake and Delaware Bays

In 2000, 2001, and 2002, blood and feather samples were collected from 40-45-day-old nestling ospreys (Pandion haliaetus) from Chesapeake Bay and Delaware Bay and River. Concentrations of 18 metals, metalloids, and other elements were determined in these samples by inductively coupled plasma-mass spectroscopy, and Hg concentrations were measured by cold vapor atomic absorption spectroscopy. When compared to concurrent reference areas (South, West, and Rhode Rivers), mean As and Hg concentrations in blood were greater (p < 0.05) in two of three Chesapeake Bay regions of concern (Baltimore Harbor [As: 1.18 vs. 0.548 microg/g dw], Anacostia River [Hg: 0.305 vs. 0.178 microg/g dw], and Elizabeth River [As: 0.876 vs. 0.663 microg/g dw; Hg: 0.260 vs. 0.180 microg/g dw]). Lead was detected more frequently in blood of nestlings from the highly industrialized Elizabeth River compared to the rural reference area. When compared to the concurrent reference area, mean Al, Ba, Hg, Mn, and Pb concentrations in feathers were substantially greater (p < 0.05) in one or more Chesapeake regions of concern (Anacostia River [Al: 206 vs. 62.1 microg/g dw; Ba: 3.31 vs. 0.823 microg/g dw; Mn: 65.4 vs. 22.9 microg/g dw] and Elizabeth River [Al: 165 vs. 63.5 microg/g dw; Hg: 1.24 vs. 0.599 microg/g dw; Pb 1.47 vs. 0.543 microg/g dw]). When compared to the coastal Inland Bays reference area, feathers of nestlings from northern Delaware Bay and River had greater concentrations (p < 0.05) of Ba (1.90 vs. 0.660 microg/g dw), Fe (258 vs. 109 microg/g dw), Mn (18.5 vs. 4.66 microg/g dw), Mo (0.130 vs. 0.040 microg/g dw), Pb (1.96 vs. 0.624 microg/g dw), and V (0.671 vs. 0.325 microg/g dw), presumably due to extensive metal-working and petroleum refinery activities. Concentrations of Hg in nestling feathers from Delaware were frequently greater than in the Chesapeake. The present findings and those of related reproductive studies suggest that concentrations of several heavy metals (e.g., Cd, Hg, Pb) in nestling blood and feathers from Chesapeake and Delaware Bays were below toxicity thresholds and do not seem to be affecting chick survival during the nestling period.

Retrospective ecotoxicological data and current information needs for terrestrial vertebrates residing in coastal habitat of the United States

The Contaminant Exposure and Effects-Terrestrial Vertebrates (CEE-TV) database was developed to conduct simple searches for ecotoxicological information, examine exposure trends, and identify significant data gaps. The CEE-TV database contains 16,696 data records on free-ranging amphibians, reptiles, birds, and mammals residing in estuarine and coastal habitats of the Atlantic, Gulf, and Pacific coasts, Alaska, Hawaii, and the Great Lakes. Information in the database was derived from over 1800 source documents, representing 483 unique species (about 252,000 individuals), with sample collection dates spanning from 1884 to 2003. The majority of the records contain exposure data (generally contaminant concentrations) on a limited number (n = 209) of chlorinated and brominated compounds, cholinesterase-inhibiting pesticides, economic poisons, metals, and petroleum hydrocarbons, whereas only 9.3% of the records contain biomarker or bioindicator effects data. Temporal examination of exposure data provides evidence of declining concentrations of certain organochlorine pesticides in some avian species (e.g., ospreys, Pandion haliaetus), and an apparent increase in the detection and possibly the incidence of avian die-offs related to cholinesterase-inhibiting pesticides. To identify spatial data gaps, 11,360 database records with specific sampling locations were combined with the boundaries of coastal watersheds, and National Wildlife Refuge and National Park units. Terrestrial vertebrate ecotoxicological data were lacking in 41.9% of 464 coastal watersheds in the continental United States. Recent (1990-2003) terrestrial vertebrate contaminant exposure or effects data were available for only about half of the National Wildlife Refuge and National Park units in the geographic area encompassed by the database. When these data gaps were overlaid on watersheds exhibiting serious water quality problems and/or high vulnerability to pollution, 72 coastal watersheds, and 76 National Wildlife Refuge and 59 National Park units in the continental United States were found to lack recent terrestrial vertebrate ecotoxicology data. Delineation of data gaps in watersheds of concern can help prioritize monitoring in areas with impaired water quality and emphasize the need for comprehensive monitoring to gain a more complete understanding of coastal ecosystem health.

Alendronate for the treatment of osteopenia in anorexia nervosa: a randomized, double-blind, placebo-controlled trial

Osteopenia is a serious medical complication of anorexia nervosa, with no known effective treatment. We conducted a double-blinded, randomized trial comparing alendronate (10 mg daily) with placebo in 32 adolescents with anorexia nervosa (mean age, 16.9 +/- 1.9 yr). All subjects received 1200 mg elemental calcium and 400 IU vitamin D daily and received the same multidisciplinary treatment for their eating disorder. Bone mineral densities (BMDs) of the lumbar spine and femoral neck were measured by dual energy x-ray absorptiometry at baseline and after 1 yr of treatment. Twenty-nine subjects completed the study. Femoral neck and lumbar spine BMDs increased 4.4 +/- 6.4% and 3.5 +/- 4.6% in the alendronate group compared with increases of 2.3 +/- 6.9% and 2.2 + 6.1% in the control group (P = 0.41, femoral neck; P = 0.53, lumbar spine). From baseline to follow-up, BMD increased significantly at the femoral neck (P = 0.02) and lumbar spine (P = 0.02) in those receiving alendronate, but did not increase in those assigned placebo (P = 0.22, femoral neck; P = 0.18, lumbar spine). At follow-up, body weight was the most important determinant of BMD. BMD was significantly higher in subjects who were weight-restored compared with those who remained at low weight (P = 0.002, femoral neck; P = 0.04, lumbar spine). After controlling for body weight, treatment group assignment still had an independent effect at the femoral neck. We conclude that in adolescents with anorexia nervosa, weight restoration is the most important determinant of BMD, but treatment with alendronate did increase the BMD of the lumbar spine and femoral neck within the group receiving alendronate, but not compared with placebo in the primary analysis. Until additional studies have demonstrated efficacy and long-term safety, the use of alendronate in this population should be confined to controlled clinical trials.