Medical and Psychiatric Features of Patients Hospitalized for Severe Restrictive Eating Disorders: Analysis of 545 Consecutive Patients with Severe Anorexia Nervosa or Avoidant/Restrictive Food Intake Disorder.

BACKGROUND: People with severe eating and feeding disorders regularly require hospitalization due to complications inherent to their disease, though formal training regarding this care is limited. METHODS: This retrospective study included 545 patients with severe anorexia nervosa (AN) or avoidant restrictive food intake disorder hospitalized in a medical stabilization unit between 2018 and 2021. Biometrics were obtained throughout hospitalization. Nutrition was increased until patients were gaining 0.2 kg/day. RESULTS: Average admission body mass index was 13 kg/m2 with diagnoses of 46% AN-R (restricting), 39% AN-BP (binge-purge), and 15% avoidant restrictive food intake disorder. Average daily Kcals by discharge were 3343 for females and 3962 for males; 26% required nasogastric feeding. Hypoglycemia was common until day 7, correlated with elevated liver function tests and low prealbumin. Liver function tests were abnormal in 31% of patients. Refeeding hypophosphatemia developed in 26% of patients starting day 2 and was associated with lower body mass index. Hypokalemia appeared on admission among 39%, twice as common in patients diagnosed with AN-BP. Initial electrocardiograms were abnormal in 50% of patients, usually sinus bradycardia. Average QTc was normal, but only 14% prolonged. Bone density testing revealed 70% osteoporosis. History of suicide attempts were present in 19%, while 76% and 50% presented with anxiety and depressive disorders, respectively. CONCLUSIONS: Given the inextricability of medical complications from severe eating and feeding disorders, familiarity among consult-liaison psychiatrists with the prevalence of frequently observed abnormal findings can inform consultation, prevent adverse events, prevent unnecessary intervention, and facilitate weight restoration and medical stabilization.

Commentary on "Fatal cardiac air embolism after CT-guided percutaneous needle lung biopsy: medical complication or medical malpractice?"

To differentiate between medical malpractice and expected, but rare, medical complication in a medicolegal autopsy context is often difficult. Such an assessment requires knowledge about the clinical practice associated with the procedure at hand, and that findings of the autopsy, including medical relevant information such as patient chart, radiological imaging, and statements from witnesses about the medical procedure itself, provides evidence that substantiate either conclusion. In a case report published in the journal such an assessment is discussed by presenting findings and circumstances surrounding the death of a patient during a percutaneous needle lung biopsy procedure. The authors conclude that the death was not due to medical malpractice. However, in this commentary it is highlighted that the reasoning behind the conclusion needs to be further substantiated.

Neurogenic pulmonary edema and Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage.

PURPOSE: Neurogenic pulmonary edema (NPE) combined with Takotsubo cardiomyopathy (TCM) is a rare condition associated with aneurysmal subarachnoid hemorrhage (aSAH). Although several mechanisms have been proposed, the pathophysiology and management strategies are not yet fully established. We aimed to determine the radiological and clinical outcomes of patients with NPE and with TCM after aSAH to propose management strategies. METHODS: We analyzed the data of 564 patients with aSAH recorded at a single medical center from February 2015 to July 2022. This study retrospectively investigated the incidence and demographics of SAH combined with both NPE and TCM and the clinical outcomes of the patients. Correlating factors, independently associated with NPE-TCM, were also investigated. RESULTS: During the 7 years, 11 (2.0%) of 564 patients had NPE complicated with TCM after aSAH. Seven of 11 (63.6%) patients had poor-grade SAH (Hunt-Hess Grade 4 to 5). Three of 11 patients had a posterior circulation in the NPE-TCM group. The most prevalent treatment option was endovascular coil embolization, except for one case of clip. Long-term outcomes were favorable in 6 of 11 patients, and there was one case of mortality. Age, troponin I level, and alveolar-arterial oxygen gradient were correlating factors of NPE-TCM. CONCLUSION: Although NPE-TCM represents a rare complication associated with aSAH, achieving active resolution of underlying neurological causes through early and appropriate treatment may contribute to a favorable prognosis. Considering the limited incidence of SAH complicated with NPE-TCM, a multi-center study may be needed.

Care of Older People in Surgery for general surgery: a single centre experience.

BACKGROUND: Older patients undergoing emergency surgery experience higher mortality and morbidity. 'Care of Older People in Surgery' (COPS) is a comprehensive geriatric care model developed for acute surgical units (ASU) to improve clinical outcomes in older general surgical patients. This study aimed to evaluate the impact of COPS on clinical and health service outcomes in an Australian hospital. METHODS: The before-and-after study was conducted in the ASU, at Nepean Hospital. Data from patients ≥75 years admitted for >24 h into the ASU during the intervention period between April 2017 and March 2018 were compared to patients admitted in the previous year (April 2016 to March 2017) prior to the COPS intervention (n = 212). Health service outcomes measured include the average stay length, medical emergency team response, unplanned intensive care unit admission and 28-day readmission rates. RESULTS: The COPS group (n = 214) suffered significantly fewer medical complications, including less acute kidney injuries, arrhythmias and urinary tract infections compared to the pre-intervention cohort (n = 212). Medical emergency team activation was significantly reduced after COPS model implementation and the average length of stay decreased. However, the incidence of postoperative delirium and acute coronary syndrome were higher in COPS cohort. CONCLUSION: Our study demonstrated that comprehensive geriatric assessment and care delivered through a shared model of care in older general surgical patients improved clinical outcome and patient safety measures.

Acute medical stabilisation of adults with anorexia nervosa: experience of a defined interdisciplinary model of care.

BACKGROUND: Patients with anorexia nervosa (AN) are vulnerable to physiological decompensation and often require inpatient management by an eating disorders unit. AIMS: Patients admitted to an Australian tertiary medical centre for medical stabilisation of AN were assessed as part of quality assurance. Analysis included: (i) medical complications during acute inpatient stabilisation; (ii) predictors of refeeding syndrome; (iii) predictors governing length of stay (LOS); and (iv) outcomes pre- and post-implementation of multidisciplinary treatment guidelines. METHODS: A retrosepctive analysis of 95 consecutive admissions (60 individual patients) between November 2011 and August 2017 was performed. RESULTS: Patients had a median LOS of 9.6 days (interquartile range 5.8-19.7) and a mean weight gain of 1.4 kg (standard deviation 2.9). Medical complications included the following: hypoglycaemia (11.6%) and refeeding electrolyte derangement (26.3%). Advancing age (odds ratio (OR) 1.06 per year, P = 0.019), nasogastric tube requirement (OR 3.4, P = 0.014) and Code Grey(s) (security calls) (OR 7.1, P = 0.010) were associated with refeeding electrolyte derangement. Parameters associated with increased LOS included the following: lower body mass index (P = 0.029), Code Grey(s) (P = 0.029) and tachycardia (P = 0.013). Following multivariate analysis, the post-guidelines implementation group required less intravenous fluid and electrolyte replacement, though had lower rates of refeeding electrolyte derangement (OR 0.33 (0.11-0.99)). CONCLUSION: Patients with moderate to severe AN are at risk of dangerous medical complications, and older patients may have heightened predisposition to refeeding electrolyte derangement. Early identification of medically high-risk patients is imperative to implement timely, life-saving interventions.

Complications of Spine Surgery in Elderly Japanese Patients: Implications for Future of World Population Aging.

OBJECTIVE: To analyze the relationship between age and perioperative complications of spine surgery in a Japanese cohort with the longest average life expectancy in the world. METHODS: Patients with spinal stenosis who underwent standard spine surgery without instrumented fusion were divided into 4 groups: adults (20-64 years), the young-old (65-74), the middle old (75-84), and the oldest-old (≥85). Data on medical complications, surgical complications, and deaths within 30 days of index surgery were compared across the groups. Risk factors for complications were identified through multivariate analysis. RESULTS: A total of 584 patients underwent 673 operations: 35% were performed on adult patients, 33% on the young-old, 27% on the middle old, and 5% on the oldest-old. The rates of total or [major] medical complications significantly increased with age (8% [0.8%], 11% [0.9%], 27% [3.9%], 45% [9.1%], respectively; p<0.001 [p=0.003]), whereas those of surgical complications did not differ (11%, 8.1%, 14%, 9.1%, respectively; p=0.25). Independent risk factors for medical complications were an age of 75 years or older (75-84: odds ratio [OR], 5.1; ≥85: OR, 6.2) and American Society of Anesthesiologists (ASA) physical status classification III (OR, 5.4). Two patients older than 85 years died from medical complications. CONCLUSION: The complications of spine surgery increased in the middle and oldest-old patients because of medical complications; however, most were minor and treatable. Major complications were associated with preoperative medical comorbidities and their severities; therefore, most elderly patients with low ASA physical status classification (≤II) may benefit from spine surgery.

Risk Factors and Functional Impact of Medical Complications in Stroke.

OBJECTIVE: To determine the incidence and risk factors for medical complications in Korean patients suffering from stroke and the impact of such complications on post-stroke functional outcomes. METHODS: We assessed patients enrolled in a prospective cohort study. All recruited patients had suffered a first acute stroke episode and been admitted to nine university hospitals in Korea between August 2012 and June 2015. We analyzed patient and stroke characteristics, comorbidities, prevalence of post-stroke medical complications, and functional outcomes at time of discharge and 3, 6, and 12 months after stroke onset. RESULTS: Of 10,625 patients with acute stroke, 2,210 (20.8%) presented with medical complications including bladder dysfunction, bowel dysfunction, sleep disturbance, pneumonia, and urinary tract infection. In particular, complications occurred more frequently in older patients and in patients with hemorrhagic strokes, more co-morbidities, severe initial motor impairment, or poor swallowing function. In-hospital medical complications were significantly correlated with poor functional outcomes at all time points. CONCLUSION: Post-stroke medical complications affect functional recovery. The majority of complications are preventable and treatable; therefore, the functional outcomes of patients with stroke can be improved by providing timely, appropriate care. Special care should be provided to elderly patients with comorbid risk factors.

Survival Rate of Limb Replantation in Different Age Groups.

Revascularization of damaged limbs/digits is technically feasible, but indications for surgical replantation remain controversial. The authors analyzed the survival rate of upper limb amputations and the associated factors in different age groups. They grouped 371 limb/digit amputees (average age, 44 years; range, 2-85 years) treated in their hospital during the past 10 years into three groups based on age (young, ≤ 15 years, n = 12; adult, 16-64 years, n = 302; elderly, ≥ 65 years, n = 57) and analyzed their injury type (extent of injury and stump status), operation method, presence of medical complications (Charlson comorbidity index), and survival rate. There were 168 replantations, and the overall replantation survival rate was 93%. The Charlson comorbidity index of the replantation patients was 0 in 124 cases; 1 in 32; 2 in 9; and 3 in 3, but it did not show any significant difference in survival rate after replantation. Eight elderly patients (14%) did not opt for replantation. Younger patients tended to undergo replantation, but they had lower success rates due to their severe injury status. The results of this study show that the survival rate of replantation in elderly patients is equal to that in adults. Stump evaluation is important for survival, but the presence of medical complications is not associated with the overall survival rate.

A novel index for quantifying the risk of early complications for patients undergoing cervical spine surgeries.

OBJECTIVE It is becoming increasingly necessary for surgeons to provide evidence supporting cost-effectiveness of surgical treatment for cervical spine pathology. Anticipating surgical risk is critical in accurately evaluating the risk/benefit balance of such treatment. Determining the risk and cost-effectiveness of surgery, complications, revision procedures, and mortality rates are the most significant limitations. The purpose of this study was to determine independent risk factors for medical complications (MCs), surgical complications (SCs), revisions, and mortality rates following surgery for patients with cervical spine pathology. The most relevant risk factors were used to structure an index that will help quantify risk and anticipate failure for such procedures. METHODS The authors of this study performed a retrospective review of the National Inpatient Sample (NIS) database for patients treated surgically for cervical spine pathology between 2001 and 2010. Multivariate models were performed to calculate the odds ratio (OR) of the independent risk factors that led to MCs and repeated for SCs, revisions, and mortality. The models controlled for age (< and > 65 years old), sex, race, revision status (except for revision analysis), surgical approach, number of levels fused/re-fused (2-3, 4-8, ≥ 9), and osteotomy utilization. ORs were weighted based on their predictive category: 2 times for revision surgery predictors and 4 times for mortality predictors. Fifty points were distributed among the predictors based on their cumulative OR to establish a risk index. RESULTS Discharges for 362,989 patients with cervical spine pathology were identified. The mean age was 52.65 years, and 49.47% of patients were women. Independent risk factors included medical comorbidities, surgical parameters, and demographic factors. Medical comorbidities included the following: pulmonary circulation disorder, coagulopathy, metastatic cancer, renal failure, congestive heart failure, alcohol abuse, neurological disorder, nonmetastatic cancer, liver disease, rheumatoid arthritis/collagen vascular diseases, and chronic blood loss/anemia. Surgical parameters included posterior approach to fusion/re-fusion, ≥ 9 levels fused/re-fused, corpectomy, 4-8 levels fused/re-fused, and osteotomy; demographic variables included age ≥ 65 years. These factors increased the risk of at least 1 of MC, SC, revision, or mortality (risk of death). A total of 50 points were distributed among the factors based on the cumulative risk ratio of every factor in proportion to the total risk ratios. CONCLUSIONS This study proposed an index to quantify the potential risk of morbidity and mortality prior to surgical intervention for patients with cervical spine pathology. This index may be useful for surgeons in patient counseling efforts as well as for health insurance companies and future socioeconomics studies in assessing surgical risks and benefits for patients undergoing surgical treatment of the cervical spine.

Risk Factors and Functional Impact of Medical Complications in Stroke

OBJECTIVE: To determine the incidence and risk factors for medical complications in Korean patients suffering from stroke and the impact of such complications on post-stroke functional outcomes. METHODS: We assessed patients enrolled in a prospective cohort study. All recruited patients had suffered a first acute stroke episode and been admitted to nine university hospitals in Korea between August 2012 and June 2015. We analyzed patient and stroke characteristics, comorbidities, prevalence of post-stroke medical complications, and functional outcomes at time of discharge and 3, 6, and 12 months after stroke onset. RESULTS: Of 10,625 patients with acute stroke, 2,210 (20.8%) presented with medical complications including bladder dysfunction, bowel dysfunction, sleep disturbance, pneumonia, and urinary tract infection. In particular, complications occurred more frequently in older patients and in patients with hemorrhagic strokes, more co-morbidities, severe initial motor impairment, or poor swallowing function. In-hospital medical complications were significantly correlated with poor functional outcomes at all time points. CONCLUSION: Post-stroke medical complications affect functional recovery. The majority of complications are preventable and treatable; therefore, the functional outcomes of patients with stroke can be improved by providing timely, appropriate care. Special care should be provided to elderly patients with comorbid risk factors.

Case-Control Study of Patients at Risk of Medical Complications after Elective Craniotomy.

OBJECTIVE: Medical complications severely impair recovery of neurosurgical patients after craniotomy. The purpose of this study was to identify patients at risk of peri- and postoperative medical complications. Therefore, we present a large population of patients with different medical complications after elective craniotomy. METHODS: We retrospectively screened all patients who had been consecutively treated at our department between June 2009 and June 2014. Patients with any postoperative thromboembolic complication or pulmonary or systemic infection were compared with a control group without any medical complication. Peri- and postoperative complications were statistically analyzed with regard to their association with age, sex, comorbidity, indication for craniotomy, duration of surgery, surgical position, type of anesthesia, and previous craniotomy by means of logistic regression models. RESULTS: Of 1800 patients screened, 133 patients (67 women and 66 men aged between 14 and 85 years) had developed medical complications (overall morbidity, 7.4%). We found statistically significant correlations between thromboembolic events and meningioma, previous craniotomy, duration of surgery, and hypertension (P = 0.002, P = 0.032, P < 0.001, and P < 0.001, respectively). Severe infection was associated with age, duration of surgery, and craniopharyngioma and pituitary adenoma (P = 0.012, P = 0.004, and P = 0.029, respectively). Prolonged stay in the intensive care unit was associated with increased duration of surgery and hypertension (P = 0.002 and P < 0.001). CONCLUSIONS: In this study, we identified predictors that help characterize patients at risk of medical complications after elective neurosurgical procedures. These correlations should be taken into account when advising patients on craniotomy.

Medical complications experienced by first-time ischemic stroke patients during inpatient, tertiary level stroke rehabilitation.

[Purpose] The aim of this study was to assess the medical complications in first-time ischemic stroke patients, to identify the factors related to occurrence of complications. [Subjects and Methods] First-time ischemic stroke patients (n=81) admitted to a tertiary level inpatient rehabilitation center during a 5 year period were included in the study. The attending physiatrist noted the presence of specific medical complications and complications that required transfer to the acute care facility from patient records. The Oxfordshire Community Stroke Project classification was used to define the clinical subtypes of the ischemic stroke patients. The Charlson comorbidity index was used to evaluate co-morbid conditions. Functional disability was assessed using the Functional Independence Measure at admission and discharge. [Results] We found that 88.9% of the patients had at least one complication. The five most common complications were urinary tract infection (48.1%), shoulder pain (37.0%), insomnia (37.0%), depression (32.1%), and musculoskeletal pain other than shoulder pain (32.1%) and 11.1% of patients were transferred to acute care facility during rehabilitation period. Functional Independence Measure scores both at admission and discharge were significantly lower in patients with at least one complication than in patients with no complications. [Conclusion] Medical complications are common among patients undergoing stroke rehabilitation. Close interdisciplinary collaboration between physiatrists and other medical specialities is necessary for optimal management.

Rare medical manifestations of severe restricting and purging: "Zebras," missed diagnoses, and best practices.

OBJECTIVE: Medical problems that arise due to severe restricting and/or purging may be misdiagnosed or suboptimally treated, from outpatient clinics to top medical hospitals. A symptom may be presumed to be a psychological manifestation of the eating disorder and inappropriately dismissed for further medical evaluation. Alternatively, a detailed medical workup may be performed, overlooking a classic relationship between starvation and a physical finding, which delays referral to eating disorder care. This review article focuses on rare medical issues (also called "zebras" in medical training), diagnoses that may be missed in patients with eating disorders, and best practices for management, organized by organ system. METHOD: A PubMed search was performed, using search terms "eating disorder," "anorexia nervosa," and "bulimia nervosa" in combination with different words for each organ system and known medical manifestations of severe eating disorders, with high quality and relevant studies from the past 20 years cited. DISCUSSION: Adults with eating disorders may present with extreme organ dysfunction and atypical signs and symptoms of typical medical problems. Timely diagnosis, risk awareness, appropriate treatment, and avoidance of harm are all vital. With judicious management and nutritional rehabilitation, most of these complications will significantly improve or resolve. ©

Acute cholecystitis in elderly patients after hip fracture: Incidence and epidemiology.

AIM: Acute cholecystitis is a medical complication that can develop in the postoperative period after hip surgery. However, few studies have examined this complication in elderly patients. Our aim was therefore to evaluate the incidence and clinical manifestations of acute cholecystitis after hip fracture in elderly patients. METHODS: Medical records and radiological studies of patients aged older than 65 years who underwent hip surgery for femoral neck or intertrochanteric fractures at a single hospital from April 2003 to March 2013 were reviewed retrospectively. We analyzed the type of cholecystitis (acalculous or calculous), clinical manifestations, fracture type (neck or trochanteric fracture), age, sex, body mass index, type of surgery, time to surgery, time from surgery to onset of acute cholecystitis and the timing of ambulation in acute cholecystitis cases. RESULTS: There were nine confirmed acute cholecystitis cases among 1211 hip fractures; thus, the incidence of acute cholecystitis within 2 months after hip fracture surgery was 0.74%. CONCLUSIONS: The incidence of acute cholecystitis was higher than we expected, and this condition can lead to more serious problems if overlooked. Acute cholecystitis as a medical complication after hip fracture was underestimated in previous studies. Furthermore, acute cholecystitis should be considered as a complication of hip fracture, not hip surgery, in the elderly. The present study does not imply that hip fracture causes acute cholecystitis, although elderly hip fracture patients are in an extremely debilitated state and are prone to developing acute cholecystitis.

Medical findings in women with anorexia nervosa in a korean population.

OBJECTIVE: Eating disorders are a common clinical problem among young women in Asian countries. The aim of this study is to determine the medical effects of anorexia nervosa (AN) in the Korean population. METHODS: We comprehensively investigated medical complications including haemodynamic, haematologic, endocrine, and bone density abnormalities in 67 Korean women with AN, together with 194 healthy Korean women of comparable age with a cross-sectional design. RESULTS: In AN, 36.9% were anaemic, 50.8% were leukopenic, 35.5% were hypoproteinemic, 7.9% were hypokalemic, 9.5% had increased alanine aminotransferase, 6.3% were hyperbilirubinemia, 14.5% were hypercholesterolemia, 14.8% had decreased triiodothyronine. Osteopenia at any one site was identified in 43.3% and an additional 13.4% had osteoporosis. The lowest-ever body mass index was the main determinant of bone mineral density. CONCLUSION: Our data in Korean patients with AN show high frequencies of laboratory abnormalities for medical complications. This study emphasizes the importance of recognizing AN as a medical risk in young Korean women.

Medical Findings in Women with Anorexia Nervosa in a Korean Population

OBJECTIVE: Eating disorders are a common clinical problem among young women in Asian countries. The aim of this study is to determine the medical effects of anorexia nervosa (AN) in the Korean population. METHODS: We comprehensively investigated medical complications including haemodynamic, haematologic, endocrine, and bone density abnormalities in 67 Korean women with AN, together with 194 healthy Korean women of comparable age with a cross-sectional design. RESULTS: In AN, 36.9% were anaemic, 50.8% were leukopenic, 35.5% were hypoproteinemic, 7.9% were hypokalemic, 9.5% had increased alanine aminotransferase, 6.3% were hyperbilirubinemia, 14.5% were hypercholesterolemia, 14.8% had decreased triiodothyronine. Osteopenia at any one site was identified in 43.3% and an additional 13.4% had osteoporosis. The lowest-ever body mass index was the main determinant of bone mineral density. CONCLUSION: Our data in Korean patients with AN show high frequencies of laboratory abnormalities for medical complications. This study emphasizes the importance of recognizing AN as a medical risk in young Korean women.

Medical Findings in Korean Women with Bulimia Nervosa / 신경정신의학

OBJECTIVES: Medical complications are common and often serious in patients with eating disorders, however, little is known about complications in patients with bulimia nervosa. METHODS: We conducted a retrospectively investigation of clinical characteristics and hematologic, biochemical, hormonal, and bone density evaluations in 90 Korean women with bulimia nervosa together with 100 healthy Korean women of comparable ages. RESULTS: In patients with bulimia nervosa, 20% were anemic, 3.3% were hypokalemic, 14.4% had increased alanine aminotransferase, 24.4% were lower in serum protein, 8.8% were hypercholesterolemia, and 77.8% were hyperamylasemia. Osteopenia at any one site was identified in 26.7% of patients and the lowest-ever body mass index was the main determinant of bone mineral density in patients with bulimia nervosa. CONCLUSION: In this study, many features of medical findings reported in anorexia nervosa were found in bulimia nervosa, however, the findings in bulimia nervosa were milder form than in anorexia nervosa. Management of any physical abnormalities in bulimia nervosa should focus on correction of the eating disorder.

Alcohol Abuse Related Medical Complications and Treatment

Alcohol abuse is related to a wide variety of medical complications including liver diseases, pancreatitis, cardiovascular diseases, immunological abnormalities, malignant neoplasms, endocrine disturbances, and kidney problems. The liver is the organ most severely affected by alcoholism. Alcoholic liver disease (ALD) remains a major cause of morbidity and mortality in Korea. The mainstay of therapy for alcohol-related medical problems is cessation of drinking. This article summarizes alcohol-related medical complications and treatment with focus on alcoholic liver injury.