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Franchetti G, Cestonaro C, Giordano R, Callegari E, Giraudo C, Viel G, Cecchetto G. Severe starvation and restraint in a 47-year-old woman: Clinical, autopsy and histopathological evidence of abuse and neglect. Forensic Sci Int 2024; 355:111941. [PMID: 38290228 DOI: 10.1016/j.forsciint.2024.111941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/14/2024] [Indexed: 02/01/2024]
Abstract
The recognition of abuse and/or neglect still represents a challenge for both clinicians and forensic pathologists. Whereas abusive behaviors have been largely described among pediatric and elderly populations, adults' abuse and neglect is less frequently encountered, and therefore investigated. We report a case of a middle-aged woman without any known organic or psychiatric disorders who died of a multiple organ failure (MOF) due to extreme cachexia and bed-resting syndrome. The integration of all clinical, autopsy and histopathological data highlighted a picture of severe malnutrition, restraint, and widespread traumatic injuries related to abuse and neglect. We believe that the case here presented could be useful for both clinicians and forensic pathologists as it underlines once again the importance of collecting and integrating all medical evidence (both in the ante- and post-mortem settings) for reconstructing the most probable pathophysiology of disorders and injuries, comparing that reconstruction with the allegations of the caregivers, and thus identifying any potential abuse and/or neglect behaviors.
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Affiliation(s)
- Giorgia Franchetti
- Unit of Legal Medicine and Toxicology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Falloppio 50, 35100 Padova, Italy.
| | - Clara Cestonaro
- Unit of Legal Medicine and Toxicology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Falloppio 50, 35100 Padova, Italy
| | - Renzo Giordano
- Unit of Legal Medicine and Toxicology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Falloppio 50, 35100 Padova, Italy
| | - Enrica Callegari
- Unit of Legal Medicine and Toxicology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Falloppio 50, 35100 Padova, Italy
| | - Chiara Giraudo
- Unit of Advanced Clinical and Translational Imaging, Department of Medicine - DIMED, Via Giustiniani 2, 35121 Padova, Italy
| | - Guido Viel
- Unit of Legal Medicine and Toxicology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Falloppio 50, 35100 Padova, Italy
| | - Giovanni Cecchetto
- Unit of Legal Medicine and Toxicology, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Falloppio 50, 35100 Padova, Italy
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2
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Obegi JH. Death by hunger strike: suicide or not? PSYCHIATRY, PSYCHOLOGY, AND LAW : AN INTERDISCIPLINARY JOURNAL OF THE AUSTRALIAN AND NEW ZEALAND ASSOCIATION OF PSYCHIATRY, PSYCHOLOGY AND LAW 2023; 31:121-131. [PMID: 38455271 PMCID: PMC10916891 DOI: 10.1080/13218719.2023.2175069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 01/11/2023] [Indexed: 03/09/2024]
Abstract
Conventional thinking holds that most inmates who hunger strike do not desire to die. Rather, they want prison officials to concede to their demands. In this paper, I examine whether death by hunger strike can be classified as suicide. After reviewing definitions of suicide and suicidal intent, I conclude that some deaths by hunger strike can be readily classified as suicides. I further propose that conditional intention is a useful way to understand the complex motivations of hunger strikers. I close by discussing the implications of conditional intention for the assessment of suicidal intent among hunger strikers and for the duty of mental health providers to prevent suicide.
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Affiliation(s)
- Joseph H. Obegi
- California Department of Corrections and Rehabilitation, California Correctional Health Care Services, Elk Grove, CA, USA
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3
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Zegers RHC, Ciesielska M, Grzybowski A. Ophthalmology research in the Warsaw Jewish ghetto-hunger disease and the story of Szymon Fajgenblat, MD. Acta Ophthalmol 2023; 101:236-241. [PMID: 35934882 DOI: 10.1111/aos.15231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE During World War II, scientific studies were conducted in the Jewish ghetto of Warsaw (Poland). This research, focusing on hunger-induced disease, was embedded in circumstances of omnipresent hunger and starvation. Ophthalmologist Szymon Fajgenblat (1900-1944) was one of the involved physicians and wrote a manuscript about ophthalmological changes during starvation. The background and the findings of his research are discussed in this article. METHODS Literature and archival research. RESULTS The Warsaw ghetto existed from 1941 to 1943 until it was destroyed, just like most of its inhabitants. Before destruction took place, the Nazis tried to kill the residents-almost half a million Jews-by means of starvation. Led by dermatologist Israel Milejkowski, a group of Jewish physicians decided to study the physical effects of hunger on human beings. Twenty-eight physicians would participate in the Hunger Disease Studies, including Fajgenblat. He linked cataracts to serious undernourishment and observed scleral thinning as another sign in hunger disease; the latter likely responsible for the low intraocular pressure found in the study population. Surprisingly, no complaints of night blindness or ophthalmological findings, characteristic of vitamin A deficiency, were observed in the study population. CONCLUSION The Hunger Disease Studies are a unique written medical and historical monument of the Jewish physicians of the Warsaw ghetto. Ophthalmologist Szymon Fajgenblat was one of them and left behind an ophthalmological study as his legacy.
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Affiliation(s)
| | - Maria Ciesielska
- Medical Review Auschwitz Project, Wydawnictwo Medycyna Praktyczna, Kraków, Poland
| | - Andrzej Grzybowski
- Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland.,Institute for Research in Ophthalmology, Foundation for Development of Ophthalmology, Poznan, Poland
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4
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Garland J, Irvine R. A Guide to the Postmortem Investigation of Starvation in Adults. Am J Forensic Med Pathol 2022; 43:205-214. [PMID: 35588207 DOI: 10.1097/paf.0000000000000763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Starvation is a rare cause of death in developed countries and is a complex multifaceted pathological process. To complicate the forensic investigation of starvation further, many medical conditions independent of starvation may cause wasting. This article provides one of the first comprehensive guides to the postmortem investigation of starvation in adults, with reference tables on organ-specific macroscopic and microscopic features, as well as features for excluding alternative causes of wasting. The eclectic literature on this complex topic is summarized in an accessible and easily referenced format, including mechanisms of death and ancillary postmortem investigations.
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Affiliation(s)
- Jack Garland
- From the Forensic and Analytical Science Service, NSW Health Pathology, New South Wales, Lidcombe, Australia
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5
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Mack RA, Stanton CE. Responding to "Terminal anorexia nervosa: three cases and proposed clinical characteristics". J Eat Disord 2022; 10:87. [PMID: 35752866 PMCID: PMC9233818 DOI: 10.1186/s40337-022-00612-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/10/2022] [Indexed: 11/23/2022] Open
Abstract
The treatment of eating disorders raises many ethical debates given the pervasiveness with which this illness impacts individuals, especially as the length of time with the illness increases. A recent case study supported the appropriateness of pursuing medical aid in dying for individuals with eating disorders who wish to end their fight with their disorder. This correspondence raises concerns related to this controversial proposal as the current authors dispute that the use of medical aid in dying for individuals with eating disorders is ethically judicious or appropriate. Additionally, this correspondence highlights additional treatment implications that should be considered when trying to provide individuals with eating disorders with the best evidence-based care possible, with the goal of promoting steps toward recovery.
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Affiliation(s)
- Rebekah A Mack
- The Johns Hopkins Hospital, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
| | - Caroline E Stanton
- The Medical University of South Carolina, 151 Rutledge Ave, Charleston, SC, 29425, USA
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6
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Bozzetti F. Survival of the starving cancer patient a food for thought for oncologists. Eur J Surg Oncol 2022; 48:2119-2126. [DOI: 10.1016/j.ejso.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/18/2022] [Accepted: 05/31/2022] [Indexed: 11/16/2022] Open
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Gaudiani JL, Bogetz A, Yager J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. J Eat Disord 2022; 10:23. [PMID: 35168671 PMCID: PMC8845309 DOI: 10.1186/s40337-022-00548-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/01/2022] [Indexed: 12/15/2022] Open
Abstract
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. In this subgroup, many of those with anorexia nervosa will experience the medical consequences of malnutrition as their future cause of death. Whereas anyone who wishes to keep striving for recovery despite exhaustion and depletion should wholeheartedly be supported in doing so, some patients simply cannot continue to fight. They recognize that death from anorexia nervosa, while perhaps not welcome, will be inevitable. Unfortunately, these patients and their carers often receive minimal support from eating disorders health professionals who are conflicted about terminal care, and who are hampered and limited by the paucity of literature on end-of-life care for those with anorexia nervosa. CASE PRESENTATION Three case studies elucidate this condition. One patient was so passionate about this topic that she asked to be a posthumous co-author of this paper. CONCLUSIONS Consistent with literature on managing terminal illness, this article proposes clinical characteristics of patients who may be considered to have a terminal eating disorder: diagnosis of anorexia nervosa, older age (e.g. age over 30), previous participation in high quality care, and clear and consistent determination by a patient who possesses decision-making capacity that additional treatment would be futile, knowing their actions will result in death. By proposing the clinical characteristics of terminal anorexia nervosa, we hope to educate, inspire compassion, and help providers properly assess these patients and provide appropriate care. We hope that this proposal stimulates further expert consensus definitions and clinical guidelines for management of this population. In our view, these patients deserve the same attendant care and rights as all other patients with terminal illness, up to and including medical aid in dying in jurisdictions where such care is legal.
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Affiliation(s)
| | - Alyssa Bogetz
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joel Yager
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
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Kelly P. Starvation and Its Effects on the Gut. Adv Nutr 2021; 12:897-903. [PMID: 33271592 PMCID: PMC8166558 DOI: 10.1093/advances/nmaa135] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/09/2020] [Accepted: 09/21/2020] [Indexed: 12/20/2022] Open
Abstract
There is growing awareness that intestinal dysfunction determines the clinical outcomes of situations as diverse as undernourished children in urban tropical slums and undernourished surgical patients in intensive care units. As experimental starvation in humans has only rarely been studied, and largely not using current biomedical research tools, we must draw inference from disparate clinical and experimental observations as to the derangements present in the starved gut. There is good evidence of intestinal atrophy and achlorhydria in starvation and severe undernutrition. Historical reports from concentration camps and conflict settings consistently reported a noncontagious phenomenon called "hunger diarrhea," but in settings where starved individuals are isolated from others (prisoners on hunger strike, anorexia nervosa) diarrhea is not a feature. Changes in intestinal permeability and absorption have been infrequently studied in experimental starvation; available data suggest that short-term starvation reduces sugar absorption but not permeability. Severe acute malnutrition in children is associated with severe changes in the intestinal mucosa. Experimental animal models may help explain some observations in humans. Starved rats develop a hypersecretory state and intestinal barrier defects. Starved pigs demonstrate prolongation of rotavirus diarrhea and reproduce some of the absorptive and barrier defects observed in malnourished children. However, there remains much to be learned about the effects of starvation on the gut. Given the high prevalence of undernutrition in hospitals and disadvantaged communities, the lack of attention to the interaction between undernutrition and gastrointestinal damage is surprising and needs to be corrected. Current sophisticated cellular and molecular techniques now provide the opportunity to create fresh understanding of gastrointestinal changes in pure undernutrition, using volunteer studies and samples from anorexia nervosa.
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Affiliation(s)
- Paul Kelly
- Blizard Institute, Barts and The London School of Medicine, London, United Kingdom; and Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
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Lodebo BT, Shah A, Kopple JD. Is it Important to Prevent and Treat Protein-Energy Wasting in Chronic Kidney Disease and Chronic Dialysis Patients? J Ren Nutr 2018; 28:369-379. [DOI: 10.1053/j.jrn.2018.04.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/30/2018] [Accepted: 04/05/2018] [Indexed: 01/05/2023] Open
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Lederman Z. Prisoners' competence to die: hunger strike and cognitive competence. THEORETICAL MEDICINE AND BIOETHICS 2018; 39:321-334. [PMID: 29948503 DOI: 10.1007/s11017-018-9439-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Several bioethicists have recently advocated the force-feeding of prisoners, based on the assumption that prisoners have reduced or no autonomy. This assumed lack of autonomy follows from a decrease in cognitive competence, which, in turn, supposedly derives from imprisonment and/or being on hunger strike. In brief, causal links are made between imprisonment or voluntary total fasting (VTF) and mental disorders and between mental disorders and lack of cognitive competence. I engage the bioethicists that support force-feeding by severing both of these causal links. Specifically, I refute the claims that VTF automatically and necessarily causes mental disorders such as depression, and that these mental disorders necessarily or commonly entail cognitive impairment. Instead, I critically review more nuanced approaches to assessing mental competence in hunger strikes, urging that a diagnosis of incompetence be made on a case-by-case basis-a position that is widely shared by the medical community.
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Affiliation(s)
- Zohar Lederman
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Assuta Samson Hospital, Ashdod, Israel.
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11
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Gordon D, Drescher M, Shiber S. Security Hunger-Strike Prisoners in the Emergency Department: Physiological and Laboratory Findings. J Emerg Med 2018; 55:185-191. [PMID: 29858143 DOI: 10.1016/j.jemermed.2018.04.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 03/15/2018] [Accepted: 04/20/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Medical treatment of hunger-strike patients, especially those in incarceration facilities, may pose clinical and treatment challenges for the treating physicians. OBJECTIVE The aim of our study is to describe the epidemiology and clinical and laboratory characteristics of hunger-strike prisoners presenting to the emergency department (ED) and to describe etiologies of hospitalization and complications among this group. METHOD We retrospectively examined clinical and laboratory manifestations of 50 hunger-strike prisoners who were referred for evaluation to the ED after a longstanding fast. RESULTS After a mean of 38 (28-44) days of a hunger strike, the most common complaints were chest pain and abdominal pain (14/60 [23.3%], 13/60 [21.6%], respectively). Mean weight loss percentage was 18.5%, and most patients were bradycardic (25/40 [62.5%]), and some hypothermic (16/50, [32%]). We describe several laboratory disturbances observed in these patients; leukopenia was the most common hematologic manifestation (31/50 [62%]), and a prolonged international normalized ratio was observed in 12/29 (41.3%) patients. We hospitalized 12% of the patients; the most common hospitalization cause was bradycardia (3/6 [50%]). CONCLUSIONS Our study found that the most common clinical symptom was chest pain, which has not been previously reported among hunger strikers. We observed a substantial number of laboratory disturbances due to muscle wasting and protein loss and due to presumed vitamin and micronutrient deficiencies. We suggest monitoring electrocardiograms for heart rate, blood count, chemistry, coagulation tests, and vitamin levels.
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Affiliation(s)
| | - Michael Drescher
- Department of Emergency Medicine, Rabin Medical Centre, Beilinson Campus, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shachaf Shiber
- Department of Emergency Medicine, Rabin Medical Centre, Beilinson Campus, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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12
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Toulson Davisson Correia MI. Addressing the Hidden Burden of Malnutrition for Hospitalized Patients. J Acad Nutr Diet 2017; 118:37-39. [PMID: 28416433 DOI: 10.1016/j.jand.2017.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/06/2017] [Indexed: 12/16/2022]
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13
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Baković M, Vreča P, Mayer D. Case of Fatal Starvation: Can Stable Isotope Analysis Serve to Support Morphological Diagnosis and Approximate the Length of Starvation? J Forensic Sci 2017; 62:258-264. [PMID: 27861910 DOI: 10.1111/1556-4029.13244] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 01/12/2016] [Accepted: 04/03/2016] [Indexed: 11/28/2022]
Abstract
The diagnosis of death as a result of starvation is established on anthropological measurements, visual appearance of the deceased on external and internal examination, microscopic analysis, laboratory testing, and exclusion of other causes of death. Herein, we present our findings on a case of 95-year-old man who died of starvation. After the diagnosis of starvation was established by traditional forensic medicine methods, we have conducted retrospective segmental analysis of stable carbon (δ13 C) and nitrogen (δ15 N) isotope ratios in hair sample. This method reveals periods of starvation through decrease in δ13 C and increase in δ15 N along the strand of hair. Our analysis revealed the decrease of 0.6 ‰ in δ13 C during the last 10-12 weeks prior to death, similar as reported in other investigations. Also, a decrease of 0.7 ‰ in δ15 N during the last 8-10 weeks prior to death was determined that was different than observed in previous studies.
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Affiliation(s)
- Marija Baković
- Institute of Forensic Medicine and Criminalistics, School of Medicine, University of Zagreb, Šalata 11, Zagreb, 10 000, Croatia
| | - Polona Vreča
- Department of Environmental Sciences, Jožef Stefan Institute, Jamova 39, Ljubljana, 1000, Slovenia
| | - Davor Mayer
- Institute of Forensic Medicine and Criminalistics, School of Medicine, University of Zagreb, Šalata 11, Zagreb, 10 000, Croatia
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Dauby N, Libois A, Van Broeck J, Delmée M, Vandenberg O, Martiny D. Fatal community-acquired ribotype 002 Clostridium difficile bacteremia. Anaerobe 2016; 44:1-2. [PMID: 28043925 DOI: 10.1016/j.anaerobe.2016.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/17/2016] [Accepted: 12/28/2016] [Indexed: 02/08/2023]
Abstract
Extra-colonic infections, and especially bacteremia, are infrequent manifestations of Clostridium difficile infection. C. difficile bacteremia is generally health-care associated and polymicrobial. We report the case of a patient on hunger strike that presented a C. difficile colitis and mono-microbial bacteremia on its admission to the hospital. Multilocus variable number tandem repeat analysis of stool and blood isolates indicated clonality. The strain was characterized as a ribotype 002, an emerging ribotype previously associated with high fatality rate. The patient received treatment by intra-venous amoxicillin-clavulanate and oral vancomycin but eventually died on the seventh day of admission with concomitant pneumonia and pulmonary embolism.
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Affiliation(s)
- Nicolas Dauby
- Department of Infectious Diseases, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium.
| | - Agnès Libois
- Department of Infectious Diseases, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Johan Van Broeck
- National Reference Center for Clostridium Difficile, Brussels, Belgium
| | - Michel Delmée
- National Reference Center for Clostridium Difficile, Brussels, Belgium; IREC, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Olivier Vandenberg
- Center for Environmental Health and Occupational Health, School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium; Department of Microbiology, LHUB - ULB, Pôle Hospitalier Universitaire de Bruxelles (PHUB), Brussels, Belgium
| | - Delphine Martiny
- Department of Microbiology, LHUB - ULB, Pôle Hospitalier Universitaire de Bruxelles (PHUB), Brussels, Belgium; Faculty of Medicine and Pharmacy, Université de Mons, Mons, Belgium
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15
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16
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Casaer MP, Ziegler TR. Nutritional support in critical illness and recovery. Lancet Diabetes Endocrinol 2015; 3:734-45. [PMID: 26071886 DOI: 10.1016/s2213-8587(15)00222-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 01/10/2023]
Abstract
An adequate nutritional status is crucial for optimum function of cells and organs, and for wound healing. Options for artificial nutrition have greatly expanded in the past few decades, but have concomitantly shown limitations and potential side-effects. Few rigorous randomised controlled trials (RCTs) have investigated enteral or parenteral nutritional support, and evidence-based clinical guidance is largely restricted to the first week of critical illness. In the early stages of critical illness, whether artificial feeding is better than no feeding intervention has been given little attention in existing RCTs. Expected beneficial effects of various forms of early feeding interventions on rates of morbidity or mortality have generally not been supported by results of recent high-quality RCTs. Thus, whether nutritional interventions early in an intensive care unit (ICU) stay improve outcomes remains unclear. Trials assessing feeding interventions that continue after the first week of critical illness and into the post-ICU and post-hospital settings are clearly needed. Although acute morbidity and mortality will remain important safety parameters in such trials, primary outcomes should perhaps, in view of the adjunctive nature of nutritional intervention in critical illness, be focused on physical function and assessed months or even years after patients are discharged from the ICU. This Series paper is based on results of high-quality RCTs and provides new perspectives on nutritional support during critical illness and recovery.
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Affiliation(s)
- Michael P Casaer
- Intensive Care Department and Laboratory of Intensive Care Medicine, Leuven University Hospitals, Leuven, Belgium.
| | - Thomas R Ziegler
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids and Center for Clinical and Molecular Nutrition, Emory University School of Medicine, Atlanta, GA, USA
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17
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Cuculic D, Sosa I, Petaros A. Decubitus ulcers and ligature marks as evidence in a homicide case. Forensic Sci Int 2015; 254:e13-7. [PMID: 26169914 DOI: 10.1016/j.forsciint.2015.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 04/24/2015] [Accepted: 06/21/2015] [Indexed: 11/18/2022]
Abstract
When abuse, maltreatment and neglect are suspected, a proper physical examination is essential. This is even more important at autopsy, when there is no possibility to gain information from the alleged victim and where the forensic pathologist has to link the evidenced signs or sequalae of abuse with the possible manner and cause of death. This case report presents the results and conclusions of the medico-legal autopsy of a 30-year-old woman found dead in her fiancé's home. The conditions and material evidence found on scene aroused doubts on the cause and manner of death. Dermatological signs found on the corpse (abrasions, contusions and decubitus ulcers) suggested a history of domestic abuse and neglect that was further confirmed by a detailed macroscopic and microscopic examination of the body. An insight into the woman's medical history further implied the possibility of long-term domestic violence. The forensic pathologist reported bronchopneumonia as the main cause of death, provoked by the combined effect of malnourishment, deliberated immobilization and neglected decubitus ulcers. This case is uncommon as it presents the homicide of a young woman caused by a prolonged abusive behaviour associated with complete neglect of her aggravating health conditions and provoked injuries.
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Affiliation(s)
- Drazen Cuculic
- Department of Forensic Medicine and Criminalistics, Rijeka University School of Medicine, Braće Branchetta 20, 51 000 Rijeka, Croatia
| | - Ivan Sosa
- Department of Forensic Medicine and Criminalistics, Rijeka University School of Medicine, Braće Branchetta 20, 51 000 Rijeka, Croatia
| | - Anja Petaros
- Department of Forensic Medicine and Criminalistics, Rijeka University School of Medicine, Braće Branchetta 20, 51 000 Rijeka, Croatia.
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18
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Malnick S, Abdul-Hai A, Abdullah A, Gharaba Y, Brand A, Basevitz A, Alin P, Binder Y, Raz O, Melzer E, Ziv-Sokolowski N, Somin M. Bloody diarrhoea in a hunger striker: starvation colitis. Lancet 2015; 385:1696. [PMID: 25943822 DOI: 10.1016/s0140-6736(15)60309-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Stephen Malnick
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel.
| | - Ali Abdul-Hai
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel
| | - Ali Abdullah
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel
| | - Yazid Gharaba
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel
| | - Avital Brand
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel
| | - Alon Basevitz
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel
| | - Pavel Alin
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel
| | - Yuval Binder
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel; Institute of Gastroenterology and Liver Diseases, Kaplan Medical Center, Rehovot, Israel
| | - Ofer Raz
- Institute of Gastroenterology and Liver Diseases, Kaplan Medical Center, Rehovot, Israel
| | - Ehud Melzer
- Institute of Gastroenterology and Liver Diseases, Kaplan Medical Center, Rehovot, Israel
| | | | - Marina Somin
- Department of Internal Medicine C, Kaplan Medical Center, Rehovot, Israel
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Abstract
The death of a person who is incarcerated often raises public concern, family inquiries, and media attention, and such deaths require special handling. The careful investigation of deaths of individuals held in the custody of the corrections system is necessary not only to discover any evidence of abuse, but moreover to ensure that the custodians are cleared of any false allegations of mistreatment. The same logic applies to use-of-force cases resulting in inmate injury but not fatality, in which inmate and correctional officers’ accounts of the events may be incongruous. The forensic pathologist is indispensible in both situations. The purpose of this article is to consider all aspects of the inmate's uniquely vulnerable situation relevant to the forensic pathologist, to review the various types of disease, injury and death occurring in the incarcerated and their relative prevalence, to present a 4.5-year retrospective review of inmate death investigations, and to describe best practices to be utilized in the medicolegal investigation of deaths of incarcerated individuals.
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Affiliation(s)
- Laura D. Knight
- Deputy Chief Medical Examiner at the Onondaga County Medical Examiner's Office in the Wallie Howard Jr. Center for Forensic Sciences, Pathology at State University of New York Upstate Medical University, and a Part-time Instructor in the Forensic and National Securities Sciences Institute at Syracuse University, Syracuse, NY
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Eichelberger M, Joray ML, Perrig M, Bodmer M, Stanga Z. Management of patients during hunger strike and refeeding phase. Nutrition 2014; 30:1372-8. [PMID: 25280415 DOI: 10.1016/j.nut.2014.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 03/28/2014] [Accepted: 04/02/2014] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- M Eichelberger
- Department of General Internal Medicine, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - M L Joray
- Department of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - M Perrig
- Department of General Internal Medicine, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - M Bodmer
- Department of General Internal Medicine, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Z Stanga
- Department of General Internal Medicine, Bern University Hospital, and University of Bern, Bern, Switzerland; Department of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital, and University of Bern, Bern, Switzerland.
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Webster BR, Scott I, Traba J, Han K, Sack MN. Regulation of autophagy and mitophagy by nutrient availability and acetylation. Biochim Biophys Acta Mol Cell Biol Lipids 2014; 1841:525-34. [PMID: 24525425 DOI: 10.1016/j.bbalip.2014.02.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 01/10/2014] [Accepted: 02/04/2014] [Indexed: 12/15/2022]
Abstract
Normal cellular function is dependent on a number of highly regulated homeostatic mechanisms, which act in concert to maintain conditions suitable for life. During periods of nutritional deficit, cells initiate a number of recycling programs which break down complex intracellular structures, thus allowing them to utilize the energy stored within. These recycling systems, broadly named "autophagy", enable the cell to maintain the flow of nutritional substrates until they can be replenished from external sources. Recent research has shown that a number of regulatory components of the autophagy program are controlled by lysine acetylation. Lysine acetylation is a reversible post-translational modification that can alter the activity of enzymes in a number of cellular compartments. Strikingly, the main substrate for this modification is a product of cellular energy metabolism: acetyl-CoA. This suggests a direct and intricate link between fuel metabolites and the systems which regulate nutritional homeostasis. In this review, we examine how acetylation regulates the systems that control cellular autophagy, and how global protein acetylation status may act as a trigger for recycling of cellular components in a nutrient-dependent fashion. In particular, we focus on how acetylation may control the degradation and turnover of mitochondria, the major source of fuel-derived acetyl-CoA.
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Affiliation(s)
| | - Iain Scott
- Center for Molecular Medicine, NHLBI, NIH, Bethesda, MD, USA
| | - Javier Traba
- Center for Molecular Medicine, NHLBI, NIH, Bethesda, MD, USA
| | - Kim Han
- Center for Molecular Medicine, NHLBI, NIH, Bethesda, MD, USA
| | - Michael N Sack
- Center for Molecular Medicine, NHLBI, NIH, Bethesda, MD, USA.
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Abstract
Starvation due to neglect is a form of fatal child abuse. Although a thorough autopsy examination for organic causes of malnutrition is warranted, the detection or exclusion of such a disease is not determinative for the manner of death. When neglect results in these deaths, it is irrelevant for the manner determination whether the malnutrition is caused by untreated disease or by inadequate feeding. The physical appearance of the child should be documented photographically at autopsy. Autopsy measurements, vitreous analysis, radiology, scene and medical history investigations, and histologic examinations are important components of the death investigation. Secondary infections are common immediate causes of death with malnutrition, however, they should not be listed as the underlying cause of death. The proximate cause of death is malnutrition/starvation. If neglect is involved with the malnutrition, these deaths are appropriately certified as homicides.
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Affiliation(s)
- James R. Gill
- Deputy Chief Medical Examiner for Bronx County of the New York City Office of Chief Medical Examiner Department of Forensic Medicine at New York University School of Medicine, New York, New York
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Speakman JR, Westerterp KR. A mathematical model of weight loss under total starvation: evidence against the thrifty-gene hypothesis. Dis Model Mech 2012; 6:236-51. [PMID: 22864023 PMCID: PMC3529354 DOI: 10.1242/dmm.010009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The thrifty-gene hypothesis (TGH) posits that the modern genetic predisposition to obesity stems from a historical past where famine selected for genes that promote efficient fat deposition. It has been previously argued that such a scenario is unfeasible because under such strong selection any gene favouring fat deposition would rapidly move to fixation. Hence, we should all be predisposed to obesity: which we are not. The genetic architecture of obesity that has been revealed by genome-wide association studies (GWAS), however, calls into question such an argument. Obesity is caused by mutations in many hundreds (maybe thousands) of genes, each with a very minor, independent and additive impact. Selection on such genes would probably be very weak because the individual advantages they would confer would be very small. Hence, the genetic architecture of the epidemic may indeed be compatible with, and hence support, the TGH. To evaluate whether this is correct, it is necessary to know the likely effects of the identified GWAS alleles on survival during starvation. This would allow definition of their advantage in famine conditions, and hence the likely selection pressure for such alleles to have spread over the time course of human evolution. We constructed a mathematical model of weight loss under total starvation using the established principles of energy balance. Using the model, we found that fatter individuals would indeed survive longer and, at a given body weight, females would survive longer than males, when totally starved. An allele causing deposition of an extra 80 g of fat would result in an extension of life under total starvation by about 1.1-1.6% in an individual with 10 kg of fat and by 0.25-0.27% in an individual carrying 32 kg of fat. A mutation causing a per allele effect of 0.25% would become completely fixed in a population with an effective size of 5 million individuals in 6000 selection events. Because there have probably been about 24,000 famine events since the evolution of hominins 4 million years ago, there has been ample time even for genes with only very minor impacts on adiposity to move to fixation. The observed polymorphic variation in the genes causing the predisposition to obesity is incompatible with the TGH, unless all these single nucleotide polymorphisms (SNPs) arose in the last 900,000 years, a requirement we know is incorrect. The TGH is further weakened by the observation of no link between the effect size of these SNPs and their prevalence, which would be anticipated under the TGH model of selection if all the SNPs had arisen in the last 900,000 years.
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Affiliation(s)
- John R Speakman
- Institute of Genetics and Developmental Biology, Key State Laboratory of Molecular Development, Chinese Academy of Sciences, Beijing, China.
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Dubois F, Sudre E, Porte A, Bédry R, Gromb S. Évolution et surveillance des patients grévistes de la faim : expérience d’une unité hospitalière sécurisée interrégionale. Rev Med Interne 2011; 32:669-77. [DOI: 10.1016/j.revmed.2011.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 05/01/2011] [Accepted: 05/17/2011] [Indexed: 10/18/2022]
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Alempijevic D, Pavlekic S, Jecmenica D, Nedeljkov A, Jankovic M. Ethical and legal consideration of prisoner's hunger strike in Serbia. J Forensic Sci 2011; 56:547-50. [PMID: 21265842 DOI: 10.1111/j.1556-4029.2010.01669.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hunger strike of prisoners and detainees remains a major human rights and ethical issue for medical professionals. We are reporting on a case of a 48-year-old male sentenced prisoner, intravenous heroin user, who went on a hunger strike and died 15 days later. Throughout the fasting period, the prisoner, who was capable of decision making, refused any medical examination. Autopsy findings were not supporting prolonged starvation, while toxicology revealed benzodiazepines and opiates in blood and urine. Cause of death was given as "heroin intoxication" in keeping with detection of 6-MAM. Legal and ethical issues pertinent to medical examination and treatment of prisoners on hunger strike are explored in accordance with legislation and professional ethical standards in Serbia. A recommendation for the best autopsy practice in deaths following hunger strike has been made.
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Affiliation(s)
- Djordje Alempijevic
- Institute of Forensic Medicine, Faculty of Medicine, University of Belgrade, 31a Deligradska Street, Belgrade 11000, Serbia.
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Fayeulle S, Renou F, Protais E, Hédouin V, Wartel G, Yvin JL. [Management of the hunger strike in prison]. Presse Med 2010; 39:e217-22. [PMID: 20471780 DOI: 10.1016/j.lpm.2010.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Revised: 12/21/2009] [Accepted: 01/12/2010] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Entering prison can feed pre-existent behavior of demands or generate them. Several means of expression are then used. Hunger strike is an average privileged act. It belongs to prison culture. OBJECTIVE Estimate how practitioners working in prison take care of the hunger strikers. METHODOLOGY The study, realised in 2008, was led with all the Units of Consultations and Ambulatory Care in France. It is a declarative investigation where a medical testimony by unit was asked. RESULTS From 174 "maisons d'arrêt" and establishments for punishment in France, 95 answers were obtained. This situation was already seen by 98,8% of the doctors. The motives for hunger strike were mainly judicial for "maisons d'arrêt" (70,1%) and prison motives for detention centers (68,7%). Mainly, doctors opted for a neutral attitude (63% of the cases). The hunger strikes were mostly brief (less than a week in 85% of the cases). Only 5,5% of the doctors proposed written information concerning the risks incurred during a fast. A doctor in 4 approximately (23%) was already witness to complications due to fasting. The fact that a patient may refuse care makes the medical approach difficult. Faced with such a situation, 45% of the doctors privileged their duty of care, 28% respected the patient's wishes, and 27% did not pronounce. From a therapeutic point of view, the place of treatment using vitamins was rarely recognized (32,7%). DISCUSSION Hunger strike is rarely severe, but it is rather frequent in prison so that every doctor working there will be confronted with it. The refeeding syndrome seems often ignored. The coverage of hunger strike is governed by the law, but ethical questions stay in the appreciation of every doctor.
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Affiliation(s)
- Stéphanie Fayeulle
- Service de médecine interne, maladies infectieuses, UCSA, centre hospitalier régional Félix-Guyon, 97400 Saint-Denis, Réunion.
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Oriot D, Lassaunière JM. Physiopathologie et sémiologie de l’arrêt de nutrition et d’hydratation. MÉDECINE PALLIATIVE : SOINS DE SUPPORT - ACCOMPAGNEMENT - ÉTHIQUE 2008. [DOI: 10.1016/j.medpal.2008.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Unlu E, Cakir B, Asil T. MRI findings of Wernicke encephalopathy revisited due to hunger strike. Eur J Radiol 2006; 57:43-53. [PMID: 16085381 DOI: 10.1016/j.ejrad.2005.07.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2005] [Revised: 07/04/2005] [Accepted: 07/08/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to determine the characteristic magnetic resonance imaging (MRI) findings among a group of patients who presented with Wernicke encephalopathy (WE) due to the neurological complications of a long-term hunger strike (HS). METHODS MRI studies also including the fluid-attenuated inversion recovery (FLAIR) sequence and diffusion-weighted imaging (DWI) of six male patients with WE aged from 25 to 38 years (mean age 31 years) were evaluated. RESULTS In all subjects, T2-weighted sequences, FLAIR and DWI revealed a signal hyperintensity within the posteromedial thalami and surrounding the third ventricle. In particular, on coronal images, the hyperintense areas around the third ventricle showed a suggestive "double wing" configuration. We observed an increased signal on proton-density and T2-weighted images in the mamillary bodies of three patients. Four patients demonstrated additional hyperintensities within the periaqueductal region and/or the tectal plate. At least one lesion area in five of six patients demonstrated contrast enhancement. CONCLUSION The consistent imaging findings of our study suggest that MRI is a reliable means of diagnosing WE. Acute WE is sometimes underdiagnosed, yet early diagnosis and treatment of WE is crucial in order to avoid persistent brain damage. MRI, including postcontrast T1-weighted imaging, DWI beneath standardized T2-weighted imaging, and FLAIR sequences may prove to be a valuable adjunct to clinical diagnosis and to provide additional information in acute and/or subacute WE.
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Affiliation(s)
- Ercument Unlu
- Department of Radiology, Trakya University School of Medicine, Mimar Sinan m, Muammer Aksoy c, Edirne, Turkey.
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