Development of significant disordered eating in an adolescent following gastric bypass surgery.

The development of eating pathology is a concern following bariatric surgery, even in the absence of any pre-surgical psychopathology. No consistent risk factors have emerged in the literature to identify those at greatest risk. However, post-surgical guidelines encourage eating behaviors that would be considered disordered in other contexts. We present a case of an adolescent developing bulimia nervosa following gastric bypass surgery and the escalation of her symptoms from diligently following recommended food behaviors to a full-syndrome clinical eating disorder. We discuss the differences between appropriate post-surgical eating behaviors and disordered eating behaviors. We provide recommendations for clinicians to screen for eating pathology and referrals to an interprofessional treatment team to address eating disordered behaviors and cognitions.

Pulmonary nocardiosis in an adolescent patient with Crohn's disease treated with infliximab: a serious complication of TNF-alpha blockers.

Nocardiosis is a serious complication of tumor necrosis factor (TNF) alpha blockers. With the increasing use of biologics for inflammatory bowel disease, it is to be anticipated that opportunistic infections such as nocardia will be more frequently encountered in children. We present the case of a 16 year old male with Crohn's disease who developed pulmonary nocardiosis during the course of his treatment with infliximab. This case illustrates the diagnostic and therapeutic challenges faced in patients with inflammatory bowel disease infected with opportunistic organisms. Pediatric health care providers need to be aware so that early diagnosis and treatment can be provided thereby preventing disseminated disease and having favorable outcomes. Although TNF blocker therapy must be discontinued in the presence of such infections, biologic therapy may be reintroduced after successful treatment with trimethoprim-sulfamethoxazole to control underlying symptoms of inflammatory bowel disease.

Occurrence of vitamin D deficiency in pediatric patients at high risk in West Virginia.

OBJECTIVES: Vitamin D deficiency is prevalent and is increasingly associated with the development of medical conditions both related and unrelated to bone metabolism. The purpose of this study was to examine vitamin D deficiency in patients of a pediatrics subspecialty practice. METHODS: The study consisted of a retrospective chart review of patients aged 2 to 18 years who were referred to the West Virginia University Physicians of Charleston pediatrics subspecialty group with a diagnosis of obesity, chronic kidney disease, diabetes, hypertension, or cystic fibrosis. All of the patients had 25-hydroxyvitamin D levels measured from 2007-2009. Seventy-six patients met inclusion criteria. RESULTS: A total of 23.7% of patients were vitamin D deficient (≤ 20 ng/mL). Children with vitamin D deficiency were older and had higher rates of obesity than those with nondeficient vitamin D levels. The comorbidities of cystic fibrosis, diabetes, hypertension, and chronic kidney disease did not associate with vitamin D deficiency. CONCLUSIONS: Vitamin D deficiency is common in children in West Virginia and is associated with increasing age and obesity. Vitamin D screening and supplementation should be considered in all children with chronic illness, particularly those who are overweight.

Rhabdomyolysis in an adolescent with nonpurging bulimia nervosa.

A 14-year-old girl with a history of nonpurging bulimia nervosa (BN) was presented with muscular pain and weakness after several days of fasting and vigorous exercise. On hospital admission, the serum creatine kinase was 3,277 U/L and serum potassium was 2.5 mmol/L. The creatine kinase level reached a peak of 4,588 U/L before declining after intravenous hydration and correction of electrolytes. Renal function remained normal throughout hospitalization. Rhabdomyolysis has not been previously reported as a complication of BN in an adolescent or in nonpurging BN. Practitioners who treat patients with eating disorders, including BN, should be aware of rhabdomyolysis as a potential complication, because delay in treatment can lead to acute renal failure.

Exercise intolerance in obese children--is it asthma?

This is a pilot study designed to examine the frequency of asthma in obese children who have exertional dyspnea. Obese children who complained of breathlessness with exercise and who denied asthma were invited to enroll. If there was evidence of airflow limitation on spirometry, nebulized albuterol was administered and spirometry was repeated. If there was no significant improvement or if the baseline spirometry was normal, exercise testing was performed. A total of 20 patients (ages from 8 to 16 years) with BMI from 22 to 61 were enrolled. Of the 19 who completed the study, 9 (47.3%) met criteria for asthma. Recognizing and treating asthma may lead to improved exercise tolerance and improved weight status in these obese individuals.

Obtaining a history of sexual victimization from adolescent females seeking routine health care.

OBJECTIVE: To evaluate the clinical practice of direct physician inquiry of adolescent females during routine history taking and medical examination, with regard to their experience of childhood sexual abuse and/or assault. METHOD: During a one-year period, a female physician directly questioned 146 consecutive female patients, aged 12-22, who were being seen for routine medical histories and physical examinations, as to whether they had ever been sexually victimized. Patients who disclosed histories of sexual victimization were immediately counseled and provided with appropriate on-site mental health referrals. Follow-up of these referrals was conducted to determine if patients complied with referrals to seek mental health services. RESULTS: For 141 of the 146 patients, the physician was unaware of a history of sexual victimization. Of these 141 patients, thirty-two (23%) cases were identified using this clinical strategy. Almost all (93%) of these young women accepted referrals for on-site psychotherapy, and 81% kept their initial appointments for psychotherapy. CONCLUSIONS: The routine medical history and physical examination may be an appropriate setting for health care providers to accurately and comfortably elicit a history of sexual victimization from adolescent females, and provide appropriate referrals for mental health counseling.

Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents.

OBJECTIVES: To compare the effects of a low-carbohydrate (LC) diet with those of a low-fat (LF) diet on weight loss and serum lipids in overweight adolescents. DESIGN: A randomized, controlled 12-week trial. SETTING: Atherosclerosis prevention referral center. METHODS: Random, nonblinded assignment of participants referred for weight management. The study group (LC) (n = 16) was instructed to consume <20 g of carbohydrate per day for 2 weeks, then <40 g/day for 10 weeks, and to eat LC foods according to hunger. The control group (LF) (n = 14) was instructed to consume <30% of energy from fat. Diet composition and weight were monitored and recorded every 2 weeks. Serum lipid profiles were obtained at the start of the study and after 12 weeks. RESULTS: The LC group lost more weight (mean, 9.9 +/- 9.3 kg vs 4.1 +/- 4.9 kg, P <.05) and had improvement in non-HDL cholesterol levels (P <.05). There was improvement in LDL cholesterol levels (P <.05) in the LF group but not in the LC group. There were no adverse effects on the lipid profiles of participants in either group. CONCLUSIONS: The LC diet appears to be an effective method for short-term weight loss in overweight adolescents and does not harm the lipid profile.