Consequences of Anorexia of Aging in Hospital Settings: An Updated Review

The anorexia of aging is a widespread problem amongst older people, particularly in the hospital setting with up to 60% affected. Despite its high prevalence anorexia often goes undiagnosed in hospital, due to a lack of standardized assessment and evidence-based management, but also lack of knowledge regarding consequences. This review summarizes current evidence for anorexia of aging specific to the hospital setting, giving an overview of correlates of appetite in hospital and consequences of anorexia. It highlights an overall scarcity of research on this important clinical problem for hospitalized cohorts. The few studies point to the importance of anorexia of aging in major health burdens for older people, namely malnutrition, sarcopenia and reduced physical performance, as well as higher mortality. Further research is needed to assess temporal sequence in pathways of causality and to develop effective interventions to combat anorexia.

What do patients and oncologists think about the evaluation and management of cancer-related anorexia-cachexia? The Quasar_SEOM study

INTRODUCTION

Cancer patients often suffer from malnutrition and early detection and raising awareness of nutritional issues is crucial in this population.

METHODS

The Spanish Oncology Society (SEOM) conducted the Quasar_SEOM study to investigate the current impact of the Anorexia-Cachexia Syndrome (ACS). The study employed questionnaires and the Delphi method to gather input from both cancer patients and oncologists on key issues related to early detection and treatment of ACS. A total of 134 patients and 34 medical oncologists were surveyed about their experiences with ACS. The Delphi methodology was used to evaluate oncologists' perspectives of ACS management, ultimately leading to a consensus on the most critical issues.

RESULTS

Despite widespread acknowledgement of malnutrition in cancer as a significant issue by 94% of oncologists, the study revealed deficiencies in knowledge and protocol implementation. A mere 65% of physicians reported being trained to identify and treat these patients, with 53% failing to address ACS in a timely manner, 30% not monitoring weight, and 59% not adhering to any clinical guidelines. The lack of experience was identified as the primary hindrance to the use of orexigens in 18% of cases. Furthermore, patients reported concerns and a perception of inadequate attention to malnutrition-related issues from their physicians.

CONCLUSION

The results of this study point to a gap in the care of this syndrome and a need to improve education and follow-up of cancer patients with anorexia-cachexia.

Anorexia of aging: An international assessment of healthcare providers' knowledge and practice gaps

BACKGROUND

Anorexia of aging is a common geriatric syndrome that includes loss of appetite and/or reduced food intake, with associated undernutrition, unintended weight loss, sarcopenia, functional decline, loss of independence and other adverse health outcomes. Anorexia of aging can have multiple and severe consequences and is often overlooked by healthcare professionals (HCPs). Even more concerningly, clinicians commonly accept anorexia of aging as an inevitable part of 'normal' aging. The aim of this assessment was to identify current gaps in professional knowledge and practice in identifying and managing older persons with anorexia. Results may guide educational programmes to fill the gaps identified and therefore improve patient outcomes.

METHODS

This international assessment was conducted using a mixed-methods approach, including focus group interviews with subject matter experts and an electronic survey of practicing HCPs. The assessment was led by the Society on Sarcopenia, Cachexia and Wasting Disorders (SCWD) and was supported by in-country collaborating organizations.

RESULTS

A quantitative survey of 26 multiple-choice questions was completed by physicians, dietitians and other HCPs (n = 1545). Most HCPs (56.8%) recognize a consistent definition of anorexia of aging as a loss of appetite and/or low food intake. Cognitive changes/dementia (91%) and dysphagia (87%) are seen as the biggest risk factors. Most respondents were confident to give nutritional (62%) and physical activity (59.4%) recommendations and engaged caregivers such as family members in supporting older adults with anorexia (80.6%). Most clinicians assessed appetite at each visit (66.7%), although weight is not measured at every visit (41.5%). Apart from the Mini-Nutritional Assessment Short Form (39%), other tools to screen for appetite loss are not frequently used or no tools are used at all (29.4%). A high number of respondents (38.7%) believe that anorexia is a normal part of aging. Results show that treatment is focused on swallowing disorders (78%), dentition issues (76%) and increasing oral intake (fortified foods [75%] and oral nutritional supplements [74%]). Nevertheless, the lack of high-quality evidence is perceived as a barrier to optimal treatment (49.2%).

CONCLUSIONS

Findings from this international assessment highlight the challenges in the care of older adults with or at risk for anorexia of aging. Identifying professional practice gaps between individual HCPs and team-based gaps can provide a basis for healthcare education that is addressed at root causes, targeted to specific audiences and developed to improve individual and team practices that contribute to improving patient outcomes.

Should Loss of Appetite Be Palliated in Patients with Advanced Cancer?

Loss of appetite is common among patients with advanced cancer. However, it remains controversial how, when, and if to palliate this symptom. Here, we provide an update on recent as well as past literature to address the question of whether loss of appetite should be palliated in patients with advanced cancer. In our opinion—and as discussed here—we believe that this symptom should be palliated, although perhaps not always with pharmacologic interventions.

Using real patients in e-learning: case-based online training in child and adolescent psychiatry

Objectives: In undergraduate medical education and in the subject of child and adolescent psychiatry, examining young patients face-to-face is a key element of teaching. With the abrupt shutdown of face-to-face teaching caused by the SARS-CoV-2 pandemic, a case-based online training program integrating audio and video of real patients was developed. Methods: The blended learning platform CaseTrain guides medical students in their final year through real child-psychiatric patient cases, such as anorexia, autism, or attention deficit disorder, through presentation of video and audio of real patients and parents. The teaching format complements lectures on child psychiatric topics, comprising asynchronous elements (self-study using the digital material) as well as synchronous elements (web-conferences with a specialist). Learning objectives for students were set to develop knowledge of the spectra of psychiatric disorders that affect children and to recognize approaches how to assess and manage common psychiatric problems of childhood and adolescence. Results: The feedback from medical students through oral and written evaluation was positive. They appreciated getting to know 'real-world patients' in times of such a pandemic, to learn explorative techniques from role models, and to be in close contact with the supervising specialist. In consequence of critical feedback on the length of some video sequences, these training units will undergo revision. Conclusions: Case-based online training may continue to be a useful option in a post-pandemic future as integral part of medical education, complementing face-to-face lectures and training in (child) psychiatry.

Anorexia of Aging Associated with Nutrients Intake in Brazilian Elderly

This study evaluated the association between anorexia of aging and nutrients intake. It was a cross-sectional study with 130 individuals aged 60 years or older, undergoing outpatient care in the city of Campinas, São Paulo. Anorexia of Aging (AA) was assessed using the Simplified Nutrition Appetite Questionnaire (SNAQ), and food consumption was evaluated using the 24-hour recall (24HR). The prevalence of AA was 27.7%, in which 66.7% were women and 38.9% were older than 80 years. Elderly with AA presented lower intake of calories (1172.6 kcal vs 1477.9 kcal; p = 0.003), carbohydrates (158.5 g vs 194.1 g; p = 0.015), proteins (49.9 g vs 68.5 g; p = 0.004) and lipids (34.6 g vs 46.1 g; p = 0.006). They also had lower intake of fibers (12.6 g vs 19.4 g; p < 0.001), iron (6.4 mg vs 8.9 mg; p < 0.001) and zinc (6.0 mg vs 8.5 mg; p = 0.004). Our results show that intake of most nutrients is significantly lower in AA elderly, except carbohydrates, which may point to worse-quality diets. The diagnosis of AA, as well as the evaluation of elderly food intake, are essential to prevent undernutrition, vulnerabilities, and increased morbidity and mortality.

Assessing pathophysiology of cancer anorexia

PURPOSE OF REVIEW

Cancer anorexia is a negative prognostic factor and is broadly defined as the loss of the interest in food. However, multiple clinical domains contribute to the phenotype of cancer anorexia. The characterization of the clinical and molecular pathophysiology of cancer anorexia may enhance the efficacy of preventive and therapeutic strategies.

RECENT FINDINGS

Clinical trials showed that cancer anorexia should be considered as an umbrella encompassing different signs and symptoms contributing to appetite disruption in cancer patients. Loss of appetite, early satiety, changes in taste and smell are determinants of cancer anorexia, whose presence should be assessed in cancer patients. Interestingly, neuronal correlates of cancer anorexia-related symptoms have been revealed by brain imaging techniques.

SUMMARY

The pathophysiology of cancer anorexia is complex and involves different domains influencing eating behavior. Limiting the assessment of cancer anorexia to questions investigating changes in appetite may impede correct identification of the targets to address.

[Anorexia in prepubescent adolescents]

Anorexia in young prepubescent patients is often linked to clinical signs occurring in early childhood. While therapies offer somatic, dietetic or medication-based treatments, the psychotherapeutic approach gives children and their families the opportunity to talk.

Differences in Symptom Burden Among Cancer Patients With Different Stages of Cachexia

CONTEXT

Cancer patients with cachexia may suffer from significant burden of symptoms and it can severely impair patients' quality of life. However, only few studies have targeted the symptom burden in cancer cachexia patients, and whether the symptom burden differed in different cachexia stages is still unclear.

OBJECTIVES

The aims of this study were to evaluate the symptom burden in cancer cachexia patients and to compare the severity and occurrence rates of symptoms among cancer patients with non-cachexia, pre-cachexia, cachexia, and refractory cachexia.

METHODS

Advanced cancer patients (n = 306) were included in this cross-sectional study. Patients were divided into four groups, based on the cachexia stages of the international consensus. The M.D. Anderson Symptom Inventory added with eight more cachexia-specific symptoms were evaluated in our patients. Differences in symptom severity and occurrence rates among the four groups were compared using one-way ANOVA or Kruskal-Wallis test analyses.

RESULTS

Lack of appetite, disturbed sleep, fatigue, lack of energy, and distress were the symptoms with highest occurrence rates and severity scores in all four groups and were exacerbated by the severity of cachexia stages. After confounders were adjusted for, significant differences were seen in symptoms of pain, fatigue, disturbed sleep, remembering problems, lack of appetite, dry mouth, vomiting, numbness, feeling dizzy, early satiety, lack of energy, tastes/smell changes, and diarrhea.

CONCLUSION

This study identified higher symptom burden in cancer patients with cachexia and it increased with the stages of cachexia, which emphasized the importance of screening in multiple co-occurring symptoms for cachexia patients.

The use of serum beta-hydroxybutyrate to determine whether nursery pigs selected on the basis of clinical signs are anorexic

The process of weaning pigs alters intestinal structures and influences piglet behavior, which can result in anorexia. When housed in large groups, affected pigs can be difficult to identify at an early stage. The clinical signs of anorexia include loss in body condition (thinness) and repetitive oral behavior (chomping). The objective of this study was to determine if pigs identified at 4 to 7 days post-weaning on the basis of clinical signs were anorexic based on elevated serum beta-hydroxybutyrate (BHB) levels (ketosis). A total of 240 pigs from 8 farms (30 pigs per farm) were selected based on observation of their abnormal oral behavior (Chomp; n = 10), poor body condition, (Thin; n = 10), or healthy appearance (Control; n = 10). Standard laboratory testing and a ketone handheld meter were used to measure BHB levels and were compared using non-parametric receiver operating characteristic analyses. Most pigs selected based on clinical signs were not anorexic as confirmed by their normal BHB levels.

[Anorexia with sinus bradycardia: a case report]

As anorexia patients always go to the psychiatric clinic, little is concerned about the occurrence of sinus bradycardia in these patients for cardiologists and psychiatrists. The aim of this paper is to discuss the relationship between anorexia and sinus bradycardia, and the feature analysis, differential diagnosis and therapeutic principles of this type of sinus bradycardia. We report a case of sinus bradycardia in an anorexia patient with the clinical manifestations, laboratory exams, auxiliary exams, therapeutic methods, and her prognosis, who was admitted to Peking University Third Hospital recently. The patient was a 19-year-old female, who had the manifestation of anorexia. She lost obvious weight in a short time (about 15 kg in 6 months), and her body mass index was 14.8 kg/m(2). The patient felt apparent palpitation, chest depression and short breath, without dizziness, amaurosis or unconsciousness. Vitals on presentation were notable for hypotension, and bradycardia. The initial exam was significant for emaciation, but without lethargy or lower extremity edema. The electrocardiogram showed sinus bradycardia with her heart rate being 32 beats per minute. The laboratory work -up revealed her normal blood routine, electrolytes and liver function. But in her thyroid function test, the free thyroid (FT) hormones 3 was 0.91 ng/L (2.3-4.2 ng/L),and FT4 was 8.2 ng/L (8.9-18.0 ng/L), which were all lower; yet the thyroid stimulating hormone (TSH) was normal 1.48 IU/mL (0.55-4.78 IU/mL). Ultrasound revealed her normal thyroid. Anorexia is an eating disorder characterized by extremely low body weight, fear of gaining weight or distorted perception of body image, and amenorrhea. Anorexia patients who lose weight apparently in short time enhance the excitability of the parasympathetic nerve, and inhibit the sympathetic nerve which lead to the appearance of sinus bradycardia, and functional abnormalities of multiple systems such as hypothyroidism. But this kind of sinus bradycardia and hypothyroidism have good prognosis. And asymptomatic sinus bradycardia with reversible causes, because of the great prognosis, they do not need special treatment. Multiple medical and psychiatric disciplines were consulted, and then, family care, nutritional support and psychiatric therapy were given, and she did not need thyroid hormone replacement therapy. The patient's overall clinical status improved gradually during her hospital stay and her heart rate was recovered to 55 beats per minute.

Correlation between the international consensus definition of the Cancer Anorexia-Cachexia Syndrome (CACS) and patient-centered outcomes in advanced non-small cell lung cancer

CONTEXT

The cancer anorexia-cachexia syndrome (CACS) is common in patients with advanced solid tumors and is associated with adverse outcomes including poor quality of life (QOL), impaired functioning, and shortened survival.

OBJECTIVES

To apply the recently posed weight-based international consensus CACS definition to a population of patients with advanced non-small cell lung cancer (NSCLC) and explore its impact on patient-reported outcomes.

METHODS

Ninety-nine patients participated in up to four study visits over a six-month period. Longitudinal assessments included measures of physical function, QOL, and other clinical variables such as weight and survival.

RESULTS

Patients meeting the consensus CACS criteria at Visit 1 had a significantly shorter median survival (239.5 vs. 446 days; hazard ratio, 2.06, P < 0.05). Physical function was worse in the CACS group (mean Karnofsky Performance Status score 68 vs. 77, Eastern Cooperative Oncology Group Performance Status score 1.8 vs. 1.3, P < 0.05 for both), as was QOL (Functional Assessment of Cancer Therapy-General [FACT-G] Lung Cancer subscale of 17.2 vs. 19.9, Anorexia/Cachexia subscale of 31.4 vs. 37.9, P < 0.05 for both). Differences in the FACT-G and the Functional Assessment of Chronic Illness Therapy-Fatigue subscale approached but did not reach statistical significance. Longitudinally, all measures of physical function and QOL worsened regardless of CACS status, but the rate of decline was more rapid in the CACS group.

CONCLUSION

The weight-based component of the recently proposed international consensus CACS definition is useful in identifying patients with advanced NSCLC who are likely to have significantly inferior survival and who will develop more precipitous declines in physical function and QOL. This definition may be useful for clinical screening purposes and identify patients with high palliative care needs.

An innovative solid oral nutritional supplement to fight weight loss and anorexia: open, randomised controlled trial of efficacy in institutionalised, malnourished older adults

BACKGROUND AND OBJECTIVE

To evaluate the impact of a solid nutritional supplement on the weight gain of institutionalised older adults>70 years with protein-energy malnutrition. The innovation of these high-protein and high-energy cookies was the texture adapted to edentulous patients (Protibis®, Solidages, France).

DESIGN

An open, multicentre, randomised controlled trial.

SETTING

Seven nursing homes.

PARTICIPANTS

One hundred and seventy-five malnourished older adults, aged 86±8 years.

INTERVENTION

All participants received the standard institutional diet. In addition, Intervention group participants received eight cookies daily (11.5 g protein; 244 kcal) for 6 weeks (w0-w6).

MEASUREMENTS

Five visits (w-4, w0, w6, w10 and w18).

MAIN OUTCOME

Percentage of weight gain from w0 to w6 (body mass in kg).

SECONDARY OUTCOMES

Appetite, rated using a numerical scale (0: no appetite to 10: extremely good appetite); current episodes of pressure ulcers and diarrhea.

RESULTS

Average weight increased in Intervention group (n=88) compared with Control group (n=87) without cookies supplementation (+1.6 versus -0.7%, P=0.038). Weight gain persisted 1 month (+3.0 versus -0.2%, P=0.025) and 3 months after the end of cookies consumption (+3.9 versus -0.9%, P=0.003), with diarrhea reduction (P=0.027). There was a synergistic effect with liquid/creamy dietary supplements. Subgroup analysis confirmed the positive impact of cookies supplementation alone on weight increase (P=0.024), appetite increase (P=0.009) and pressure ulcers reduction (P=0.031).

CONCLUSION

The trial suggested that, to fight against anorexia, the stimulation of touch (finger food; chewing, even on edentulous gums) and hearing (intra-oral sounds) could be valuable alternatives to sight, smell and taste alterations.

Current and future care of patients with the cancer anorexia-cachexia syndrome

Many important advances have occurred in the field of cancer cachexia over the past decade, including progress in understanding the mechanisms of the cancer anorexia-cachexia syndrome (CACS) and the development of promising pharmacologic and supportive care interventions. However, no approved agents for cancer cachexia currently exist, emphasizing the unmet need for an effective pharmacologic therapy. This article reviews the key elements of CACS assessment in daily practice, the contribution of nutritional impact symptoms (NIS), the evidence for current pharmacologic options, and promising anticachexia agents in perclinical and clinical trials. It also proposes a model for multimodality therapy and highlights issues pertinent to CACS in patients with pancreatic, gastric, and esophageal cancer.

Prevalence of eating disorders amongst dancers: a systemic review and meta-analysis

Eating disorders in dancers are thought to be common, but the exact rates remain to be clarified. The aim of this study is to systematically compile and analyse the rates of eating disorders in dancers. A literature search, appraisal and meta-analysis were conducted. Thirty-three relevant studies were published between 1966 and 2013 with sufficient data for extraction. Primary data were extracted as raw numbers or confidence intervals. Risk ratios and 95% confidence intervals were calculated for controlled studies. The overall prevalence of eating disorders was 12.0% (16.4% for ballet dancers), 2.0% (4% for ballet dancers) for anorexia, 4.4% (2% for ballet dancers) for bulimia and 9.5% (14.9% for ballet dancers) for eating disorders not otherwise specified (EDNOS). The dancer group had higher mean scores on the EAT-26 and the Eating Disorder Inventory subscales. Dancers, in general, had a higher risk of suffering from eating disorders in general, anorexia nervosa and EDNOS, but no higher risk of suffering from bulimia nervosa. The study concluded that as dancers had a three times higher risk of suffering from eating disorders, particularly anorexia nervosa and EDNOS, specifically designed services for this population should be considered.

Evaluation of the psychometric characteristics of the Spanish version of the Anorectic Behaviour Observation Scale

AIMS

The Anorectic Behaviour Observation Scale (ABOS) was designed to obtain information from relatives about behaviours and attitudes of patients with eating disorders (ED). The aim of this study was to validate the ABOS into Spanish.

METHODS

We evaluated the psychometric characteristics of the Spanish version of the ABOS in a clinical ED sample (239 caregivers of 143 ED patients). Instrument reliability (internal consistency), validity (construct, convergent and discriminant, known groups), responsiveness and goodness-of-fit were measured.

RESULTS

Data from the Spanish population revealed a three-factor structure similar to that of the original ABOS, although the composition of subscales differed somewhat from the original. An ABOS cut-point of 21 was identified. The Cronbach's alpha coefficient for the total ABOS score was 0.81. Correlations with other instruments demonstrated convergent and divergent validity. Among caregivers, the total ABOS score and Factor scores significantly discriminated between anxiety, depression and health-related quality of life, while among ED patients they discriminated between diagnosis, severity and level of ED symptoms - evidence of known-groups validity.

CONCLUSION

These findings suggest that the ABOS can be reliably and validly used in Spain in a number of different clinical contexts, by researchers and clinicians alike.

[Constitutional syndrome: clinical entity or a mixed bag]

Fatigue, anorexia and involuntary weight loss have been included under the term constitutional syndrome. These manifestations accompany many diseases in which the diagnosis is made by specific symptoms and signs. However, these events are generally the main reason for consultation and the patient does not report other specific data. This forces us to rigorously investigate the possible causes of the disorder. Usually, three manifestations coexist: asthenia, anorexia and weight loss, but sometimes the patient has only one or two of them. The causes of constitutional symptoms are varied and can be divided into three groups: psychiatric diseases, neoplasms and non-neoplastic diseases. The etiological identification is usually done with a simple protocol, which rules out malignancy; the rest of the cases of uncertain etiology are subject to evolution. The constitutional syndrome correlates well with good prognosis or medical functional processes. Although no clinical guidelines have been developed, score scales may help for the etiological assessment. Given the myriad of different causes of the constitutional syndrome, the treatment of this illness depends primarily on the etiology.

Cancer anorexia - cachexia syndrome

Cancer anorexia-cachexia syndrome (CACS) is a devastating and debilitating aspect at any stage of malignancy. It presents primarily as anorexia, weight loss and muscle wasting secondary to inadequate oral intake and metabolic changes. This syndrome is highly prevalent among cancer patients, has a large impact on morbidity and mortality, and impinges on patient quality of life. The pathogenic mechanisms of CACS are multifactorial. It is suggested to be the result of tumor-host interactions and cytokines have a siginificant role. Diagnosis of cancer cachexia is complex and multifaceted and requires meticulous clinical examination of the patient. The challenge for clinicians is to know how best to manage the symptoms of weight loss and anorexia for optimal patient outcome. This article outlines the diagnosis of cancer cachexia, reviews its impact on patient quality of life and survival, and updates the reader on potential therapies that may suppress it.

Heterotopic pancreas of the gallbladder associated with chronic cholecystitis and high levels of amylasuria

CONTEXT

Heterotopic pancreas of the gallbladder is an extremely rare entity, especially when pancreatic tissue appears histologically with an exclusively exocrine structure.

CASE REPORT

We report the case of a 35-year-old man who presented with symptoms of acalculous gallbladder disease with high levels of amylasuria. Immunohistochemical analysis of the surgical specimen of the cholecystectomy revealed pancreatic tissue at the gallbladder wall.

CONCLUSIONS

Heterotopic pancreatic tissue is a rare pathological finding in the gallbladder. It requires consideration and sensitization in the differential diagnosis of acalculous gallbladder disease, which can explain hyperamylasuria in cases of unknown origin.

[Neural pathophysiology of cancer anorexia]

INTRODUCTION

Approximately two thirds of cancer patients at advanced stages of the disease suffer from anorexia. Defined as the loss of the desire to eat, anorexia lower the energy intake which further exacerbates a progressive deterioration of the patient nutritional status. Malnutrition has a large impact on morbidity and mortality affecting the quality of life. Cancer anorexia etiology is multifactorial including complex interactions among the tumor, host metabolism and antineoplastic treatment. New related theories include peripheral and brain mechanisms affecting hypothalamic pathways; inducing behavioral and metabolic failure of responses to energy balance. The aim of this review is to describe actual concepts involved in the pathogenesis of cancer anorexia with special interest in brain mechanisms.

CONCLUSIONS

Anorexia and reduced food intake are important issues in the management of cancer patients, more knowledge about pathogenic mechanism is needed to improve therapeutic options, prognosis and quality of life in cancer patients.

How should DSM-V classify eating disorder not otherwise specified (EDNOS) presentations in women with lifetime anorexia or bulimia nervosa?

OBJECTIVE

Anorexia nervosa (AN) and bulimia nervosa (BN) are marked by longitudinal symptom fluctuations. DSM-IV-TR does not address how to classify eating disorder (ED) presentations in individuals who no longer meet full criteria for these disorders. To consider this issue, we examined subthreshold presentations in women with initial diagnoses of AN and BN.

METHOD

A total of 246 women with AN or BN were followed for a median of 9 years; weekly symptom data were collected at frequent intervals using the Longitudinal Interval Follow-up Evaluation of Eating Disorders (LIFE-EAT-II). Outcomes were ED presentations that were subthreshold for 3 months, including those narrowly missing full criteria for AN or BN, along with binge eating disorder (BED) and purging disorder.

RESULTS

During follow-up, most women (77.6%) experienced a subthreshold presentation. Subthreshold presentation was related to intake diagnosis (Wald chi2=8.065, df=2, p=0.018). Individuals with AN most often developed subthreshold presentations resembling AN; those with BN were more likely to develop subthreshold BN. Purging disorder was experienced by half of those with BN and one-quarter of those with AN binge/purge type (ANBP); BED occurred in 20% with BN. Transition from AN or BN to most subthreshold types was associated with improved psychosocial functioning (p<0.001).

CONCLUSIONS

Subthreshold presentations in women with lifetime AN and BN were common, resembled the initial diagnosis, and were associated with modest improvements in psychosocial functioning. For most with lifetime AN and BN, subthreshold presentations seem to represent part of the course of illness and to fit within the original AN or BN diagnosis.

Anorexia, bulimia, and the female athlete triad: evaluation and management

The female athlete triad is an increasingly prevalent condition involving disordered eating, amenorrhea, and osteoporosis. An athlete can suffer from all 3 components of the triad, or just 1 or 2 of the individual conditions. The main element underlying all the aspects of the triad is an adaptation to a negative caloric balance. Screening for these disorders should be an important component of an athlete's care. Prevention and treatment should involve a team approach, including a physician, a nutritionist, and a mental health provider.

[Maybe the way to beauty is compulsion?]

In article was presented characteristic features of mental disorders from spectrum obsessive compulsive disorder, dysmorphic disorder and spectrum impulse control disorders. Dysmorphophobia is a psychiatric disorder characterized by imagined aesthetic defect in physical appearance in spite of visual changes. This paper is a review of the up-to-date knowledge on prevalence, diagnostic criteria and clinical picture of body dysmorphic disorder. The authors underline the connections between this disorder and other disorders, classified by some authors, as a part of the obsessive compulsive disorder spectrum. The problem with distinguishing the psychotic feature of body dysmorphic disorder is presented in this paper.

Validation of a simplified anorexia questionnaire

CONTEXT

Anorexia is a common symptom in cancer and is usually assessed by multiple questions and multidimensional questionnaires. A simplified questionnaire would be less burdensome to patients and abbreviate the process.

OBJECTIVES

We compared the reliability at one point in time, sensitivity to change over time, and prognostic accuracy of a two-item questionnaire with the Functional Assessment of Anorexia and Cachexia Therapy shortened 12-question version (A/CS-12).

METHODS

Individuals with cancer, who were cognitively intact and verbally agreed to participate, completed a two-item questionnaire and A/CS-12 in random order and again seven days later. We compared the direction of response to the summated two-item questionnaire to the validated A/CS-12 score at a single point in time, then intra-patient changes over a seven-day period of time. Scores of both questionnaires were divided into poor, moderate and good appetite and compared to survival using Kaplan-Meyer curves. Bootstrapping was used to construct confidence intervals for estimated probability agreement. Survival analysis also used hazard ratios from a Cox Proportional Hazards model.

RESULTS

One hundred seventeen individuals from a single institution participated, who were either admitted to an inpatient palliative unit or seen in an outpatient/palliative medicine unit. Median age was 58.8 (range 10.7-87.1 years). Agreement at one point in time was 0.64 (95% confidence interval [CI] 0.63 - 0.66). Agreement over time was 0.53 (CI 0.41 - 0.64). The A/CS-12 predicted survival based on scores on Days 1 and 7 (P<0.001), (P=0.003) (HR 0.97 day 1, HR 0.95 day 7), whereas the simplified questionnaire failed to predict survival.

CONCLUSIONS

A simplified questionnaire has moderate correlation with the A/CS-12 at one point in time but loses sensitivity over time, and lacks the ability to predict survival. A change in the questionnaire may improve reliability. Changing question 2 of the simplified questionnaire to a neutral form (better, same or worse appetite) may improve sensitivity and prognostic capability.

Serum ghrelin in infants with protein-energy malnutrition

BACKGROUND

Ghrelin is an appetite and weight physiologic controller. The question is whether there is a relation between ghrelin and protein-energy malnutrition (PEM). Our aim was to assess serum ghrelin in these patients and its relation to different patient variables.

METHODS

A cross-sectional study was conducted on 30 PEM infants (12 marasmic=Ia, 10 kwashiorkor=Ib and 8 marasmic kwashiorkor=Ic) and 15 age and sex matched controls (II). Plasma ghrelin was measured in all subjects using radioimmunoassay with thorough medical history and clinical assessment.

RESULTS

The mean serum ghrelin levels were significantly higher among the 3 patient subgroups than controls with no significant inter-subgroup differences. The presence of intestinal parasitic infestations or edema, type of milk feeding and gender had no significant effects on serum ghrelin levels.

CONCLUSION

Serum ghrelin is elevated in PEM as an adapting consequence of the malnutrition rather than a primary event. Although this elevation may not be helpful to correct the growth failure because of deficient nutrients, it may prove to have a role in the catch up phenomenon after the recovery. Further research should be directed toward therapeutic trials of ghrelin in the recovery phase.

Cytokines and their relationship to the symptoms and outcome of cancer

Tumours contain immune cells and a network of pro- and anti-inflammatory cytokines, which collaborate in the development and progression of cancer. Cytokine profiles might prove to be prognostic. The systemic effects of pro-inflammatory cytokines are associated with fatigue, depression and cognitive impairment, and can affect quality of life before, during and after treatment. In people with advanced cancer, pro-inflammatory cytokines are additionally associated with anorexia and cachexia, pain, toxicity of treatment and resistance to treatment. However, physical activity might modify cytokine levels and decrease fatigue in patients with cancer, and might also improve their prognosis.

Use of a single-item screening tool to detect clinically significant fatigue, pain, distress, and anorexia in ambulatory cancer practice

Fatigue, pain, distress, and anorexia are four commonly encountered symptoms in cancer. To evaluate the usefulness of a single-item screening for these symptoms, 597 ambulatory outpatients with solid tumors were administered a self-report screening instrument within the first 12 weeks of chemotherapy. Patients rated the severity of each symptom on a 0-10 scale, at its worst over the past three days, with higher ratings associated with higher symptom levels. From this sample, 148 patients also completed a more comprehensive assessment of these symptoms. Two criteria were used to determine optimal cut-off scores on the screening items: 1) the sensitivity and specificity of each screening item to predict clinical cases using receiver-operating characteristics analysis and 2) the proportion of patients at each screening score who reported that some relief of the target symptom would significantly improve their life. Optimal cut-off scores ranged from 4 to 6 depending on the target symptom (area under the curve range=0.68-0.88). Use of single-item screening instruments for fatigue, pain, distress, and anorexia may assist routine clinical assessment in ambulatory oncology practice. In turn, such assessments may improve identification of those at risk of morbidity and decreased quality of life due to excess symptom burden.

Assessment of appetite and weight loss syndromes in nursing home residents

This article presents an appropriate definition of the construct of appetite and outlines an evidence based approach to appetite assessment and weight loss prevention in the nursing home. The Simplified Nutritional Appetite Questionnaire, a recently developed and validated appetite assessment tool that predicts weight loss in older and young nursing home residents and community dwelling adults is discussed.

Office management of weight loss in older persons

Weight loss in older persons is associated with a variety of deleterious effects, including hip fracture, pressure ulcers, decreasing immune function, decreased functional status, and death. There are 4 major causes of weight loss: anorexia, sarcopenia, cachexia, and dehydration. Many of the reasons for the development of these conditions are treatable. For example, depression is the most common cause of weight loss in the elderly. Early screening for anorexia can be undertaken in the physician's office utilizing the Simplified Nutritional Assessment Questionnaire. An algorithmic approach to the office management of weight loss is provided.

Virchow's node, jaundice, and weight loss--lymphoma mimicking gastrointestinal malignancy

BACKGROUND

A 46-year-old white male with a history of well-controlled paranoid schizophrenia presented with painless jaundice, progressive anorexia, weight loss, and dyspnea of 3 months' duration. His only medication at presentation was the antipsychotic olanzapine, taken orally.

INVESTIGATIONS

Physical examination and laboratory tests, including a complete blood cell count, electrolyte, lactate dehydrogenase and haptoglobin levels, liver function tests, and a Coombs' test; CT scan of the chest and abdomen; invasive investigations, including thoracentesis and pleural fluid analysis, bone-marrow biopsy, and left supraclavicular lymph-node biopsy.

DIAGNOSIS

Diffuse large B-cell lymphoma.

MANAGEMENT

Large-volume thoracentesis. Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone chemotherapy followed by dexamethasone, cytarabine, and cisplatin chemotherapy, and autologous stem-cell transplantation.

Magersucht

Die Magersucht unterscheidet sich deutlich von anderen psychogenen Ess-Störungen: Seit mehr als dreihundert Jahren bekannt, tritt sie mit konstanter Häufigkeit auf und gehört zu den gefährlichsten Erkrankungen der betroffenen Altersstufe: Dreiviertel der Patientinnen gesunden oder bessern sich langfristig, ein Viertel hat einen chronischen Verlauf, häufig mit somatischen Komplikationen und tödlichem Ausgang. Wegen des sich oft über viele Jahre erstreckenden Gesundungsprozesses und der erheblichen Chronifizierungs- und Komplikationsrate sollte zu Beginn jeder Behandlung ein individueller Gesamtbehandlungsplan stehen, um den Therapieverlauf langfristig zu strukturieren. In Abhängigkeit von Schwere, Phase und Komorbidität sind stationäre oder ambulante Therapien indiziert. Bei kurzem Krankheitsverlauf, hinreichendem Gewicht (BMI > 15 kg/m2), guter Motivation und fehlenden Komplikationen ist eine ambulanter Psychotherapieversuch gerechtfertigt. Entsprechend der multifaktoriellen Ätiologie der Anorexia nervosa ist die stationäre Psychotherapie multimodal. Die Gewichtszunahme ist ein wichtiges erstes Therapieziel und Voraussetzung für eine konfliktzentrierte, ambulant fortzusetzende Psychotherapie. Die ambivalente Psychotherapiemotivation und die Notwendigkeit zur Symptomorientierung erfordern sowohl stationär als auch ambulant technische Modifikationen der Psychotherapie und feste Rahmenbedingungen.

The psychobiology and diagnostic significance of amenorrhea in patients with anorexia nervosa

Amenorrhea is a diagnostic criterion for anorexia nervosa (AN), although menstrual cycles have been found to persist in some women with all the other features of AN. This study sought to determine factors that are associated with amenorrhea in 39 women with current primary spectrum AN. The use of exercise to control weight (odds ratio (OR) = 3.5; 95% confidence interval (CI) = 1.3-9.9; P = .02), low novelty seeking scores (OR = 0.7; 95% CI = 0.58-0.94; P = .02), and low systolic blood pressure (OR = 0.9; 95% CI = 0.84-0.99; P = .046) were predictors of amenorrhea independent of body mass index.

Female athlete triad

Although eating disorders have received much attention over the last few years in athletics, its prevalence was not always well appreciated. Over the years, professional organizations began to pay close attention to the effects of eating disorders, and with this heightened awareness, professionals as well as the general public began to recognize eating disorders as a major problem in our society. In the early 1990s, the American College of Sports Medicine (ACSM) convened the Task Force on Women's Issues in Seattle, Washington . During this conference, members of the ACSM discussed issues related to females and athletics with specific attention to eating disorders, amenorrhea, and osteoporosis. They collectively called these pathologies the Female Athlete Triad (Triad) and hence coined the phrase in 1993. Since the publication, much time and effort has been devoted towards research and understanding of the Triad. In trying to understand this complicated problem, one must grasp the concept that the three pathologies are interrelated and difficult to explain without the influence of any of the other components.

Nighttime eating: a descriptive study

OBJECTIVE

The definition of night eating syndrome (NES) is inconsistent across various studies and literatures. The goal of the current descriptive study was to collect data on participants who were selected using broad criteria for nighttime eating. Researchers have cogently argued for consideration of wide ranges including "subsyndromal" cases before reifying diagnostic constructs prematurely.

METHOD

One-hundred six participants with broadly defined nighttime eating problems were recruited through newspaper advertisements and were interviewed over the phone. The following instruments were administered: the Night Eating Questionnaire, the Night Eating Syndrome History and Inventory, the Eating Disorder Questionnaire, the Structured Clinical Interview for DSM-IV diagnoses and a Sleep Disorder Questionnaire.

RESULTS

Thirty-one (29.2%) participants met the original criteria described by Stunkard et al. (Am J Med 1955;19:78) and only 14 (13.2%) participants met all of the most recent proposed criteria for NES (Birketvedt et al., JAMA 1999;282:657). The overlap between binge eating disorder (BED) and nighttime eating problems was modest in our sample with only 9 participants meeting current BED criteria. One half of our sample was obese. Regular nocturnal eating was reported by 57.5% of the participants. Dieting was not a frequent precursor or antecedent of nocturnal eating. However, self-reported current parasomnias were quite frequent in our sample.

CONCLUSION

Our descriptive study confirms some of the observations made by other researchers. Nevertheless, nighttime eating is still an evolving concept that requires close collaboration between eating and sleep researchers.

The importance of symptom assessment in the surgical treatment of gastroesophageal reflux disease and Barrett's esophagus

The "art" and science of symptom assessment in the evaluation of patients with gastroesophageal reflux disease has been under emphasized. In fact, it is critical to judgements regarding surgical versus non-surgical therapy and is much more difficult than meets the eye. Many symptoms thought to be secondary to gastroesophageal reflux are not, and some, such as asthma cough and chest pain, which are commonly thought secondary to other causes, are indeed symptoms of reflux. Diagnostic studies are helpful but far from perfect, ultimately requiring the clinician's expert judgement as the key factor in determining a successful outcome. The following outlines both an approach to the assessment of symptoms and when possible, clinical studies shedding light on their cause and interpretation.

Medical use of cannabis in the Netherlands

The authors investigated the indications for cannabis prescription in the Netherlands and assessed its efficacy and side effects. A majority (64.1%) of patients reported a good or excellent effect on their symptoms. Of these patients, approximately 44% used cannabis for >/=5 months. Indications were neurologic disorders, pain, musculoskeletal disorders, and cancer anorexia/cachexia. Inhaled cannabis was perceived as more effective than oral administration. Reported side effects were generally mild.

Anorexia/cachexia-related quality of life for children with cancer

BACKGROUND

Anorexia is a common symptom in patients with cancer, which can lead to poor tolerance of treatment and can contribute to cachexia in extreme cases. Children with advanced-stage cancer are especially vulnerable to malnutrition resulting from anorexia and cachexia. Currently, there are no instruments that measure common concerns specifically associated with anorexia and cachexia in children with cancer. The purpose of the current article was to test the psychometric properties of a newly developed pediatric Functional Assessment of Anorexia and Cachexia Therapy (peds-FAACT) for children with cancer.

METHODS

Ninety-six patients (ages 7-17 yrs) receiving cancer treatment and their parents were asked to complete the 12-item peds-FAACT. The authors implemented both classical test theory and item response theory to evaluate the agreement between parents and patients, internal consistency and unidimensionality of the scale, and stability of items across subgroups.

RESULTS

As a result, a patient-reported six-item scale was recommended as the core measure for all pediatric patients with cancer and four additional peripheral items were recommended for adolescent patients.

CONCLUSIONS

The peds-FAACT demonstrated good psychometric properties, differentiated patients with different functional performance status, and was determined to be a useful tool for future clinical trials.