Variation in care for inpatients with avoidant restrictive food intake disorder leads to development of a novel inpatient clinical pathway to standardize care.

INTRODUCTION: There is limited evidence to guide management of patients with avoidant restrictive food intake disorder (ARFID) admitted for medical stabilization. We describe variations in inpatient care which led to the development of a multidisciplinary inpatient clinical pathway (ICP) to provide standardized management and examine differences after the ICP was implemented. METHODS: A retrospective review of patients with ARFID admitted to Adolescent Medicine, Gastroenterology, and General Pediatrics at a single academic center was conducted. We compare hospital utilization and use of consulting services during the pre-ICP (2015-2017) and post-ICP (2018-2020) periods. RESULTS: 110 patients were admitted with ARFID (n = 57 pre- vs. n = 53 post-ICP). Most presented with moderate/severe malnutrition (63% pre vs. 81% post; p = 0.11) and co-morbid anxiety and/or depression (74% pre vs. 92% post; p = 0.01). There was some variation in use of enteral tube feeding by service in both periods (p = 0.76 and p = 0.38, respectively), although overall use was consistent between periods (46% pre vs. 58% post; p = 0.18). Pre-ICP, use of the restrictive eating disorder protocol differed across services (p < 0.001), with only AM using it. Overall, utilization of the restrictive eating disorder protocol decreased from 16% pre-ICP to 2% post-ICP (p = 0.02). There was variation by service in psychiatry/psychology (range 82-100% by service; p = 0.09) and social work consultations (range 17-71% by service; p = 0.001) during the pre-ICP period, though variation was reduced in the post-ICP period (p = 0.99 and p = 0.05, respectively). Implementation of the ICP led to improvements in these consultative services, with all patients in the post-ICP period receiving psychiatry/psychology consultation (p = 0.05) and an increase in social work consults from 44 to 64% (p = 0.03). Nutrition consults were consistently utilized in both periods (98% pre vs. 100% post; p = 0.33). CONCLUSION: The ICP was developed to standardize inpatient medical stabilization for patients with ARFID. In this single center study, implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: there were improvements in the use of consulting services and a reduction in the use of the restrictive eating disorder protocol. The ICP demonstrates the potential to further standardize and improve care over time.

There is limited evidence to guide management of children and adolescents with Avoidant Restrictive Food Intake Disorder (ARFID) admitted for medical stabilization. The study describes the variation in inpatient care for ARFID, which led to the development of a multidisciplinary standardized inpatient clinical pathway (ICP). The ICP centers the experience of the patient and family with an emphasis on biopsychosocial support. Implementation of the ICP increased standardized care for inpatients with ARFID with variation in care reduced: There were improvements in the use of psychiatry/psychology and social work consulting services and a reduction in the use of the restrictive eating disorder protocol. Future research is needed to better understand the impact of the inpatient clinical pathway to improve care over time.

Psychogenic Nonepileptic Seizures Associated with an Eating Disorder and PTSD Are Responsive to Cognitive Processing Therapy.

Objective: Eating disorders (EDs) are often associated with prior histories of trauma, subsequent PTSD and related psychiatric comorbidities. There is a paucity of information about their relationship to somatic symptom disorders, specifically psychogenic nonepileptic seizures (PNES), a type of functional neurological symptom disorder or conversion disorder. Methods: We report a case of a 39-year-old bisexual female with bulimia nervosa (BN), PTSD, recurrent major depressive disorder (MDD), cannabis use disorder, and PNES who responded to integrated trauma-focused treatment during residential ED treatment using cognitive processing therapy (CPT). Symptoms of ED, PTSD, major depression, and state-trait anxiety were measured using validated assessment instruments. Results: During the course of CPT treatment, the patient's total scores on the PTSD Symptom Checklist for DSM-5 (PCL-5) went from 59 to 26, which is below the diagnostic threshold for PTSD. In addition, she demonstrated improvements in the Eating Disorder Examination Questionnaire (EDE-Q) Global Severity score, the Eating Disorder Inventory (EDI-2) total score, the Patient Health Questionnaire (PHQ-9) total score, the Spielberger State and Trait Anxiety Inventory scores, and the Eating Disorder Quality of Life (EDQOL) total score. Furthermore, her PNES also abated, and she remained seizure free for ∼1 year following discharge with the exception of one short seizure, per report of the patient. Conclusion: The use of CPT as part of an integrated trauma-informed treatment approach during residential ED treatment was successful in a woman with PNES, BN, PTSD, MDD, and cannabis use disorder.

Hallux Sesamoid Injury Characteristics in Young Athletes Presented to the Sports Medicine Clinic.

OBJECTIVE: To investigate clinical diagnoses, sports participation, and return to sport timeline associated with hallux sesamoid injuries with sex comparisons. DESIGN: Descriptive epidemiology study. SETTING: Sports medicine clinics at a tertiary-level pediatric medical center. PATIENTS: Six hundred eighty-three young athletes (546 women and 137 men). INDEPENDENT VARIABLES: Sex (women vs men). MAIN OUTCOME MEASURES: Clinical diagnoses, participating sports, and injury timeline. RESULTS: The most common diagnosis was sesamoiditis (62.6%). The top 3 primary sports were dance (34.6%), running (13.7%), and soccer (11.7%). When stratified by sex, dance (40.1%), running (13.6%), and soccer (10.7%) were the top primary sports for women while running (19.4%), soccer (18.5%), and basketball (11.3%) were the leading diagnoses for male athletes. The mean time between injury occurrence and first clinic visit was 135.5 ± 229.3 days. The mean time between the first clinic visit and return to sport was 104.3 ± 128.2 days. Comparison by sex showed that women had a longer mean time than men (women: 111.5 ± 132.5 days, men: 67.2 ± 96.3 days, P = 0.001). The mean time from injury occurrence to return to sport was 235.2 ± 281.0 days. Women showed a longer mean timeline for return to sport compared with men (women: 245.2 ± 288.2 days, men: 179.3 ± 231.9 days, P = 0.014). CONCLUSION: Sesamoiditis was the most common diagnosis, and dance, running, and soccer were top 3 sports. The most salient finding was that women taking almost twice as long to return the sport or activity compared with men, which likely stems from delay of reporting symptom onset to clinics.

Career Transitions for the Young Dancer: Considering Psychological Implications, Challenges with Athletic Identity, and Need for Available Resources.

AIMS: Young dancers are likely to revolve their entire identity around dance, and there is the potential risk for disruption to their identity and psychological upset upon change of status or loss of dance following high school. The objective of our study was to systematically review the current literature examining psychological implications, athletic identity, and career transitions for young dancers. METHODS: A systematic review was performed covering the last 30 years of dance-related literature (1987-2017) through PubMed and EBSCOhost. To be included, the following criteria had to be met: 1) dancers' ages were between 14-22 years, 2) dancers' training experience was documented and its duration was at least 5 years, and 3) information regarding career transition including available resources, athletic identity, or psychological impact was stated. All statements, documentation, and information related to dancer career transition and choice, including psychological impact, athletic identity, and available resources, were extracted. Quality assessment and level of evidence plans were set a priori. RESULTS: Four publications were found as a result of the systematic review; however, no study met all three of our inclusion criteria. CONCLUSIONS: No formal research exists that focuses on career transition for young dancers. More studies are needed that focus on the psychological and physical implications of career decisions for dancers in order to guide healthy decisions when transitioning out of high school into a career path.

Body Satisfaction, Performance Perception, and Weight Loss Behavior in Young Female Dancers.

OBJECTIVE: To understand the impact of body satisfaction and performance perception on intentional weight loss behavior and body mass index (BMI) in young female dancers. METHODS: Young female dancers who visited an injury prevention center were provided a questionnaire including three questions designed to elicit their body satisfaction, perception of weight toward performance, and any intentional weight loss behavior. Binary responses (yes/no) were compared between the three questions using chi-square analysis. Also, a binary logistic regression was performed to find an indicator for intentional weight loss behaviors. Finally, BMI was compared among subgroups. RESULTS: Data from 43 young female dancers, aged 12-23 yrs, were analyzed. Dancers who were not happy with their weight were more likely to engage with intentional weight loss activity than dancers who were happy with their weight (p=0.002). Those who did not believe that their athletic activities were influenced by their weight were less likely engage with intentional weight loss and more likely to be happy with their weight than dancers who believed that athletic activities were influenced by their weight (p=0.049 and 0.015, respectively). Binary logistic regression indicated female dancers who were not happy with their body weight had nearly 9 times greater odds of intentional weight loss activity (p=0.029). There were no BMI differences among the three subgroups. CONCLUSION: Intentional weight loss behavior is heavily influenced by body satisfaction in young female dancers regardless of their current BMI.