Underweight Patient Research Articles

Ethical concerns in caring for persons with anorexia nervosa: content analysis of a series of documentations from ethics consultations

BackgroundCaring for patients with anorexia nervosa (AN) is associated with high levels of moral distress among healthcare professionals. The main moral conflict has been posited to be between applying coercion to prevent serious complications such as premature death and accepting treatment refusals. However, empirical evidence on this topic is scarce.MethodsWe identified all 19 documentations of ethics consultations (ECs) in the context of AN from one clinical ethics support service in Switzerland. These documentations were coded with a sequential deductive-inductive approach and the code system was interpreted in a case-based manner. Here, we present findings on patient characteristics and ethical concerns.FindingsThe ECs typically concerned an intensely pretreated, extremely underweight AN patient endangering herself by refusing the proposed treatment. In addition to the justifiability of coercion, frequent ethical concerns were whether further coerced treatment aimed at weight gain would be ineffective or even harmful, evidencing uncertainty about beneficence and non-maleficence and a conflict between these principles. Discussed options included harm reduction (e.g. psychotherapy without weight gain requirements) and palliation (e.g. initiating end-of-life care), the appropriateness of which were ethical concerns in themselves. Overall, nine different types of conflicts between or uncertainties regarding ethical principles were identified with a median of eight per case.ConclusionsEthical concerns in caring for persons with AN are diverse and complex. To deal with uncertainty about and conflict between respect for autonomy, beneficence and non-maleficence, healthcare professionals consider non-curative approaches. However, currently, uncertainty around general justifiability, eligibility criteria, and concrete protocols hinders their adoption.

Evaluation and implementation of optimized antimicrobial dosing strategies in obese and underweight patients.

We aimed to develop and implement dosing recommendations for antimicrobials in obese and underweight patients within an academic hospital, and assess their impact on antibiotic prescribing. A multi-step approach project was performed. First, obese and underweight patient prevalence and antimicrobial prescription frequency was determined in a point prevalence study. Second and third, a literature review and e-survey provided dosing evidence. Fourth, a consensus meeting was organized to formulate dosing recommendations. Fifth, these were implemented in our clinical validation service as six clinical rules continuously screening patients' records for potentially inappropriate prescriptions (PIPs). Uptake was evaluated by documenting the number of advices and acceptance rate. Last, an interrupted time series analysis (ITS) compared pre- and post-implementation periods to measure the impact of the intervention on residual PIPs/day. A residual PIP was defined as a PIP which persisted up to 48h. First, 41% of 15.896 hospitalized patients received antimicrobials over 20days; of which 12% were obese and 9% underweight. Antibiotics were predominantly prescribed according to standard dosing regimens, adjusted to renal function. Next, six dosing recommendations, derived from literature, survey, and consensus, were implemented. In the fifth step, during an 18-week period, 219 advices were given, with 86% acceptance rate. Last, in the ITS analysis, at preintervention, a median of 75% residual PIPs/day existed, reduced to 0% postintervention. Use of clinical rules resulted in a significant immediate 84% relative reduction in residual PIPs (95% CI 0.55-0.94). After conducting a literature review, e-survey, and seeking consensus from a panel of experts, dosing recommendations for antimicrobial treatment in both obese and underweight patients were developed. These recommendations have been successfully implemented into clinical practice, addressing the specific needs of these patient populations.

The obesity paradox exists for perioperative complications and mortality following lower extremity arterial bypass surgery

ObjectiveThe obesity paradox refers to a phenomenon by which obese individuals experience lower risk of mortality and even protective associations from chronic disease sequelae when compared with the non-obese and underweight population. Prior literature has demonstrated an obesity paradox after cardiac and other surgical procedures. However, the relationship between body mass index (BMI) and perioperative complications for patients undergoing major open lower extremity arterial revascularization is unclear. MethodsWe queried the Vascular Quality Initiative for individuals receiving unilateral infrainguinal bypass between 2003 and 2020. We used multivariable logistic regression to assess the relationship of BMI categories (underweight [<18.5 kg/m2], non-obese [18.5-24.9 kg/m2], overweight [25-29.9 kg/m2], Class 1 obesity [30-34.9 kg/m2], Class 2 obesity [35-39.9 kg/m2], and Class 3 obesity [>40 kg/m2]) with 30-day mortality, surgical site infection, and adverse cardiovascular events. We adjusted the models for key patient demographics, comorbidities, and technical and perioperative characteristics. ResultsFrom 2003 to 2020, 60,588 arterial bypass procedures met inclusion criteria for analysis. Upon multivariable logistic regression with the non-obese category as the reference group, odds of 30-day mortality were significantly decreased among the overweight (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.53-0.78), Class 1 obese (OR, 0.65; 95% CI, 0.52-0.81), Class 2 obese (OR, 0.66; 95% CI, 0.48-0.90), and Class 3 obese (OR, 0.61; 95% CI, 0.39-0.97) patient categories. Conversely, odds of 30-day mortality were increased in the underweight patient group (OR, 1.58; 95% CI, 1.16-2.13). Furthermore, a BMI-dependent positive association was present, with odds of surgical site infections with patients in Class 3 obesity having the highest odds (OR, 2.10; 95% CI, 1.60-2.76). Finally, among the adverse cardiovascular event outcomes assessed, only myocardial infarction (MI) demonstrated decreased odds among overweight (OR, 0.82; 95% CI, 0.71-0.96), Class 1 obese (OR, 0.78; 95% CI, 0.65-0.93), and Class 2 obese (OR, 0.66; 95% CI, 0.51-0.86) patient populations. Odds of MI among the underweight and Class 3 obesity groups were not significant. ConclusionsThe obesity paradox is evident in patients undergoing lower extremity bypass procedures, particularly with odds of 30-day mortality and MI. Our findings suggest that having higher BMI (overweight and Class 1-3 obesity) is not associated with increased mortality and should not be interpreted as a contraindication for lower extremity arterial bypass surgery. However, these patients should be under vigilant surveillance for surgical site infections. Finally, patients that are underweight have a significantly increased odds of 30-day mortality and may be more suitable candidates for endovascular therapy.

The effect of female body mass index on cumulative live birth rate in women undergoing in vitro fertilization according to age.

The aim of this study was to explore the impact of female body mass index (BMI) on cumulative live birth rates (CLBR) in patients treated with in vitro fertilization (IVF) and embryo transfer. A total of 2377 patients who visited the Reproductive Medical Center, Luoyang Maternal and Child Health Hospital from January 2015 to December 2021. The patients underwent the first IVF cycles. According to female BMI, patients were divided into 3 groups, group A: BMI ≤ 18.5 kg/m2 (underweight), group B: BMI: 18.5 to 24.0 kg/m2 (normal), group C: BMI ≥ 24.0 kg/m2 (overweight/obesity). Patient basic parameters and clinical outcomes were compared among these 3 groups. Multivariate logistic regression analysis was used to explore the impact of BMI on CLBR. In all treatment cycles, patients' basic parameters were significantly different among 3 BMI groups. Age of underweight patient was younger than patients in the other 2 groups (28.45 ± 5.32 vs 29.89 ± 5.00 vs 30.74 ± 5.40; P = .000). In addition, number of oocytes retrieved was also significantly higher in group A (11.25 ± 5.97 vs 11.07 ± 5.49 vs 10.52 ± 5.02; P = .000). CLBR in these 3 groups were 66.40%, 65.98%, and 59.14%, respectively. In logistic analysis, overweight/obesity was associated with CLBR in young patients (aOR = 0.822, 95% CI: 0.817-0.957, P = .000). However, in the cycles of older patients, the effect of overweight/obesity on the CLBR was not significant (aOR = 0.986, 95% CI: 0.903-1.027, P > .05). Overweight/obesity is a predictor for CLBR in younger patients (<35 years old), but not in advanced age patients undergoing their first IVF/intracytoplasmic sperm injection treatment cycles.

“A ghost doesn’t need insulin,” Cotard’s delusion leading to diabetic ketoacidosis and a body-mass index of 15: a case presentation

BackgroundCotard’s Syndrome (CS) is a rare clinical entity where patients can report nihilistic, delusional beliefs that they are already dead. Curiously, while weight loss, dehydration, and metabolic derangements have been described as discussed above, a review of the literature revealed neither a single case of a severely underweight patient nor a serious metabolic complication such as Diabetic Ketoacidosis. Further, a search on PubMed revealed no articles discussing the co-occurrence of Cotard’s Delusion and eating disorders or comorbid metabolic illnesses such as diabetes mellitus. In order to better examine the association between Cotard’s Delusion and comorbid eating disorders and metabolic illness, we will present and discuss a case where Cotard’s delusion led to a severe metabolic outcome of DKA and a BMI of 15.Case presentationMr. B is a 19 year old transgender man admitted to the hospital due to diabetic ketoacidosis secondary to Type 1 Diabetes Mellitus. Mr. B had a history of Obsessive–Compulsive Disorder, Major Depressive Disorder, and Post-Traumatic Stress Disorder. The primary pediatric team discovered that Mr. B had not been using his insulin appropriately and was severely underweight, and they believed this could be due to his underlying mental illness. The psychiatric consultation/liaison service found that Mr. B was suffering from Cotard’s delusion leading him to be noncompliant with his insulin due to a belief that he was already dead. Cotard’s delusion had in this case led to a severe metabolic outcome of DKA and a BMI of 15.ConclusionsThis case provides clinical insight into the interactions of eating disorders and Cotard’s delusion as well as the potential medical complications when Cotard’s delusion is co-morbid with medical conditions such as Diabetes Mellitus. We recommend that clinicians routinely screen patients for Cotard’s delusion and assess whether the presence of which could exacerbate any underlying medical illness. This includes clinicians taking special care in assessing patient’s caloric and fluid intake as well as their adherence to medications both psychiatric and medical. Further research could be conducted to explore the potential overlap of Cotard’s delusion and eating disorder phenomenology.

Anesthetic management with remimazolam for laryngectomy in a severely underweight patient with facioscapulohumeral muscular dystrophy.

Anesthetic management with remimazolam for laryngectomy in a severely underweight patient with facioscapulohumeral muscular dystrophy.

Higher Heart Rate is Independently Associated with Abnormal Body Mass Index in a J Shape Pattern.

High heart rate is independently associated with higher cardiovascular mortality and usually occurs in sedentary persons. Inactivity can also lead to obesity. The purpose of this study was to evaluate the associations between body mass index as an independent marker of high heart rate. Data generated from screening echocardiography, for the prevention of sudden death at the Anthony Bates Foundation, was used. Data from 1,340 subjects, with documented heart rate (HR) and body mass index, between the ages 19-79 years with a mean age of 32 years, was used. We correlated the presence of a high heart rate (HR) > 90 beats per minute (BPM)) with different body mass index (BMI) categories. High heart rate was significantly associated with higher BMI categories and underweight subjects in adults suggesting a J shape association. A total of 22.7% of participants with a HR of more than 90 bpm had BMI > 40 kg/m2, vs 19.0% of patients with BMI of 35-40 kg/m2 vs 13.5% of subjects with BMI of 30-35 kg/m2 vs 12.2% of subjects with BMI of 25-30 kg/m2 - 29.9 kg/m2, vs in 10.3% of subjects with BMI between 18.5-25 kg/m2 , P< 0.01) Furthermore, increased HR was also more prevalent in underweight patient. (17.4% in subjects with BMI < 18.5 kg/m2 }. High heart rate is strongly associated with obesity and underweight suggesting that maintaining a normal weight is associated with most positive effect on the cardiovascular system.

Paradoxical Associations Exist Between BMI Category and Perioperative Complications Following Lower Extremity Arterial Bypass

Paradoxical Associations Exist Between BMI Category and Perioperative Complications Following Lower Extremity Arterial Bypass

Hubungan Underweight dengan Pertumbuhan Maksila

Maxillary growth can be assessed from linear measurements, which is the length of the maxilla. The process of growth and development of the maxilla is influenced by several factors, one of which is nutrition. Inadequate nutritional status can interfere with maxillary growth and development. To determine whether there is a relationship between underweight and maxillary growth. Samples were lateral cephalograms and patient data from the Department of Orthodontics, Faculty of Dentistry, The University of North Sumatra who met the inclusion and exclusion criteria. The total sample was 100, consisting of 50 underweight patients and 50 normal-weight patients. The Data was obtained from examination of the Body Mass Index, measurement with the ratio of body weight and height squared then adjusted to the BMI criteria according to the Indonesian Ministry of Health in 2010, then the maxillary length was measured on the cephalogram based on the Anthanasiou method using the CorelDraw application. Data were statistically analyzed using the independent t-test to see if there was a relationship based on maxillary growth (p &lt;0.05). The results of this research stated that mean maxillary length in the normal-weight patient group was 115,824 ± 5.56 mm higher than the underweight patient group of 101.875 ± 4.45 mm. There was a difference in maxillary length between the normal-weight patient group and the underweight patient group (p &lt;0.05). The conclusion from this research that there is a relationship between underweight and maxillary growth.

S2230 Atypical Endoscopic Appearance of Duodenal Mucosa in Whipple’s Disease: An Incidental Finding in an African American Patient

Introduction: Whipple’s disease (WD) is an extremely rare disorder of European white males with an annual incidence reported as less than one case per million. It is a chronic infectious multisystem disorder caused by the bacterium Tropheryma whipplei. Esophagogastroduodenoscopy (EGD) is the gold standard for diagnosis which typically reveals alternating yellow shaggy and eroded erythematous small bowel mucosa. We report a biopsy-proven case of WD in an African American male with atypical endoscopic appearance of the duodenum revealing diffusely dispersed prominent white spots, swollen folds and mucosal nodularity. Case Description/Methods: A 45-year-old male presented with a 6-month history of watery diarrhea, anorexia, unintentional weight loss and exertional dyspnea. He had a history of seizures, recurrent pleural effusion of unknown etiology, vitamin D deficiency and iron deficiency anemia. Physical exam was remarkable for an underweight patient with pale conjunctivae, mild diffuse abdominal tenderness and decreased right sided breath sounds. Vital signs were stable. Patient was in no acute distress. Labs include Hb 10 mg/dL, albumin 2.1 g/dL, vitamin D 13.6 ng/mL, zinc 44 mcg/dL, ESR 45 mm and CRP 107 mg/dL. Stool was negative for ova/parasite, bacterial culture, C.difficile and AFB. Workup for celiac disease and neuroendocrine tumors also reported negative. CT imaging revealed gastric antral wall thickening, abdominal/pelvic ascites and right pleural effusion. Given these non-specific findings, malignancy workup was warranted. EGD revealed an unusual gross appearance of the second portion of duodenum with diffusely dispersed prominent white spots, swollen folds and mucosal nodularity (Fig. 1-a). Biopsy was consistent with WD (Fig. 1-b,c). Colonic and pleural biopsies were negative for malignancy. The patient showed significant clinical response to induction therapy with ceftriaxone followed by maintenance phase with TMP-SMX. Follow up is scheduled to assess endoscopic response to antibiotic therapy. Discussion: WD is a challenging diagnosis due to a constellation of symptoms that mimic other disorders. Whitish discoloration with mucosal nodularity is a rare but more specific endoscopic finding for WD, as reported in our case. Biopsy is required to confirm the diagnosis. This case is reported to draw gastroenterologists’ attention towards atypical endoscopic findings of WD. Early recognition of this debilitating and potentially fatal illness is the key before commencement of prolonged antibiotic therapy.Figure 1.: A. CT Chest with Pneumomediastinum B. Upper Endoscopy With Erythematous Posterior Oropharynx and an Extrinsic, Longitudinal Bulge in the Proximal Esophagus C. Intraoperative Photograph During Thoracotomy.

Case Report: Cerebral venous thrombosis revealing celiac disease

Celiac disease (CD) is an autoimmune enteropathy resulting from intolerance of an individual genetically predisposed to gluten. It has a large clinical polymorphism ranging from a classic digestive clinical presentation due to the malabsorption syndrome to extra-intestinal symptoms. Among the hematologic abnormalities, venous thromboembolic disease (VTE) has been reported, and they are most often located in the abdomen or lower limbs, but the cerebral localization was exceptionally described. We report a case of CD revealed by cerebral thrombophlebitis. A 44-year-old patient with no medical history and no drug intake, presented with hemiplegia followed by a status epilepticus in a context of apyrexia, initially hospitalized in intensive care. Magnetic imaging resonance displayed a cerebral venous thrombosis of the sigmoid sinus requiring anticoagulant treatment, then transferred to our department for the etiological investigation. On questioning, the patient reported chronic diarrhea and weight loss with no other associated symptoms. The examination revealed an underweight patient with pale conjunctiva, improvement of her deficit symptoms, and no other abnormalities. Laboratory tests noted biological signs of malabsorption. The thrombophilia assessment revealed a protein C deficiency with a slight increase in anticardiolipin antibodies and anti-Beta 2 glycoprotein 1 antibodies. Immunological tests noted positives anti-transglutaminase and IgA anti-endomysium antibodies. Duodenal biopsy demonstrated villous atrophy. After ruling out the other causes of VTE, the diagnosis of cerebral venous thrombosis secondary to CD was retained. Early diagnosis and treatment of CD improves the quality-of-life for patients and may spare them various long-term or even fatal complications.

Insulinoma presenting with postprandial hypoglycemia and a low body mass index: A case report

BACKGROUNDInsulinomas are the most common type of functioning endocrine neoplasms of the pancreas presenting hypoglycemic symptoms. Patients characteristically develop symptoms while fasting, but some patients have reported symptoms only in the postprandial state. Repeated and prolonged hypoglycemic episodes can reduce the awareness of adrenergic symptoms, and patients may have amnesia, which delays diagnosis.CASE SUMMARYWe describe a case of a 24-year-old underweight patient who showed hypoglycemic symptoms for almost 6 years. Although patients with insulinoma characteristically develop symptoms while fasting, this young man had hypoglycemic symptoms up to one hour postprandially, especially after high-sugar meals and after physical activity. The fasting tests and imaging methods performed at local hospitals were evaluated as negative for abnormal results. However, brown adipose tissue exhibited increased metabolic activity, and some muscle groups had histological changes as indicated by positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography. Glycogen deficiency was also histologically confirmed. The patient’s symptoms progressed over the years and occurred more frequently, i.e., several times a month, and the patient had reduced awareness of adrenergic symptoms. The follow-up fasting test was positive, and the imaging results showed a tumor in the head of the pancreas. The patient underwent laparotomy with enucleation of the insulinoma.CONCLUSIONWeight gain and fasting hypoglycemia are not necessarily characteristics of insulinoma. In prolonged cases, adrenergic symptoms can be suppressed.

Effect of Body Mass Index on the Disease Activity of Patients With Rheumatoid Arthritis in a Gender-Specific Manner and the Association of Respective Serum C-Reactive Protein Levels With the Body's Inflammatory Status.

BackgroundCurrent literature evaluating the effect of high body mass index (BMI) on the disease activity of patients with rheumatoid arthritis (RA) is mixed as some studies have shown a positive, linear relationship between BMI and disease activity while others have demonstrated an inverse correlation. Through this study, we have expanded the effect of BMI on disease activity in patients with RA. We have further expanded on whether BMI influences the disease activity depending on the gender being studied. Finally, we have studied whether there is a correlation between high BMI values and rising C-reactive protein (CRP) levels.MethodologyThis cross-sectional study was conducted at the Outpatient Clinical Department of Buffalo Rheumatology. The study was ethically approved by the Catholic Health Institutional Review Board. A total number of 451 patients’ clinical data was selected based on inclusion/exclusion criteria. The patients were divided into different BMI categories based on the guidelines of national obesity education initiative of the national heart, lung, and blood Institute. The following clinical parameters were studied: BMI, serum CRP level, and disease activity through routine assessment of patient index data questionnaire 3 (RAPID3). The minimum sample size (n = 358) was calculated via the world health organization sample size calculator. All data were entered and analyzed through Statistical Package for the Social Sciences (SPSS), version 16.0 (IBM Corp., Armonk, NY).ResultsOur study sample included 98 males and 353 females (22% and 78%, respectively). Collective data for both the genders showed significantly increased disease activity in RA patients with high BMI values (p = 0.04). When the data sets were categorized according to the two genders, it was noted that the aforementioned results remain significant for the females only (p = 0.02 for females and p = 0.57 for males). At all BMI values, mean RAPID3 scoring remained significantly higher for females as opposed to their male counterparts (p = 0.006). Mean serum CRP levels increased linearly with increasing BMI (p < 0.001); however, for the underweight patient population, mean CRP levels were the highest as compared to normal weight, overweight, moderately obese, and severely obese patients.ConclusionWe conclude that the association between the BMI and the severity of disease remains elusive. High BMI values increase the risk of a pro-inflammatory state of the body due to higher serum CRP levels. Estimating the clinically significant benefit of this theory would require a large-scale clinical trial that would highlight the role of losing weight in improving the patients’ quality of life, pain control, and mortality.

Being Underweight Is Associated with Worse Surgical Outcomes of Total Knee Arthroplasty Compared to Normal Body Mass Index in Elderly Patients.

PurposeBeing underweight has never been studied in relation to the radiologic and clinical outcomes of total knee arthroplasty (TKA) in elderly patients. The aim of this study was to determine the effect of being underweight on TKA radiological and clinical outcomes and to investigate whether being underweight influences postoperative complications compared to normal body mass index (BMI) in elderly patients.Patients and MethodsA total of 118 female patients aged 65 years or older with BMI < 25 kg/m2 who underwent primary TKA were divided into two groups based on BMI: group A: 18.5 kg/m2 < BMI < 25 kg/m2; group B: BMI < 18.5 kg/m2. The radiologic and clinical outcomes were evaluated at follow-up of 6, 12, and 24 months after surgery such as the hip-knee-ankle angle, the American Knee Society (AKS) score, Western Ontario and McMaster University score (WOMAC), and patellofemoral (PF) scale. Moreover, postoperative complications during follow-up were investigated.ResultsPreoperative clinical scores did not differ significantly between the two groups. Postoperative WOMAC pain (1.8 ± 1.9 versus 3.4 ± 2.6, p = 0.02), WOMAC function (12.4 ± 8.1 versus 16.5 ± 8.5, p = 0.012) and PF scales (26.1 ± 3.6 versus 23.7 ± 4.1, p = 0.002) were worse in the underweight group at 12 and 24 months after surgery. The frequency of postoperative complications did not differ significantly between groups. In multivariate linear regression analysis, underweight patient group was significantly associated with worse postoperative WOMAC and PF scores (p = 0.002, 0.005).ConclusionAlthough postoperative complications of TKA did not differ between groups, underweight patients had worse clinical outcomes of TKA compared to patients with normal BMI in elderly patients. Therefore, care should be taken when performing TKA in elderly underweight patients.

Body Mass Index And Survival Rate in Nasopharyngeal Cancer Patient: An Evidence-based Case Report

Introduction: Nasopharyngeal cancer is the most common type of head and neck cancer with prevalence of 6.2/100000 population. Recently, study of prognostic factors for nasopharyngeal cancer still becomes one of research focuses. Several studies have tried to find the relationship between nutritional status (body mass index/BMI) and nasopharyngeal cancer patients’ survival rate, but the results are still inconsistent. Objective: To find the relationship between nutritional status represented by BMI and nasopharyngeal cancer patients’ survival rate.Methods: Electronic literature searches were performed in Cochrane®, Scopus®, and Pubmed®. Mesh term and title/abstracts were screened based on inclusion and exclusion criteria before relevant journals were reviewed.Results: Two articles were selected based on the eligibility criteria and relevancy to the clinical question. In the study of Huang et al., the subject was nasopharyngeal cancer patient stage III and IV was included as subject of the study. In the study of Lin et al., nasopharyngeal cancer patient with metastases was also included. Patient with higher BMI has better survival rate than underweight BMI category.Conclusion: Increasing BMI in underweight cancer patient simproves nasopharyngeal cancer patient’ survival rate.

Overweight and obesity are associated with cardiac adverse structure remodeling in Chinese elderly with hypertension

There is limited information on the association of overweight and obesity with cardiac remodeling in elderly population. Therefore, we investigated whether overweight and obesity are associated with cardiac geometric structures and function in Chinese elderly. A total of 1183 hospitalized patients (aged 65–99 years) with primary hypertension were collected retrospectively in a cross-sectional study, and divided into underweight, normal weight, overweight and obesity patient groups according to their body mass index (BMI). Cardiac echocardiographic parameters were compared between the groups. BMI was 17.2 ± 1.2, 21.4 ± 1.2, 25.1 ± 1.2, 30.2 ± 2.6 kg/m2 in underweight, normal weight, overweight and obesity groups respectively. Aortic and left atrial diameter, interventricular septal and left ventricular (LV) posterior wall thickness, LV end-diastolic and end-systolic diameter, and indexed LV mass, and prevalence of E/A reversal were higher, while LV ejection fraction and fractional shortening were lower in elderly with overweight or obesity, as compared with whose with underweight or normal weight separately (All P < 0.05). However, multivariable regression analysis showed that overweight and obesity are independently related to increased LV wall thickness, end-diastolic diameter and mass (All P < 0.05). In conclusions, this study demonstrates that overweight and obesity are associated with increased LV wall thickness, end-diastolic diameter and mass in Asian elderly.

INTESTINAL FAILURE IN SYSTEMIC SCLEROSIS: A STRATEGY ATTEMPT FOR INTESTINAL REHABILITATION

Objective Aim of our group was to define etiopathogenesis of severe malnutrition in an highly compromised severely underweight patient, and to define the most high-benefit/low-risk nutritional intervention. Research Methods & Procedures A 62-years-old women affected by systemic sclerosis (SS) was admitted because of asthenia, dyspnea and weight loss: -38% of her usual body weight (BW) in 6 years, -23% BW in the last 6 months; current BW was 31kg (Body Mass Index 12.1kg/m2). Nutritional assessment at admission excluded the hypothesis of both anorexia nervosa and dysphagia. After prompt thiamin and multivitaminic/multimineral supplementation, we started night-time enteral nutrition support (EN) through naso-gastric tube (SNG) with semi-elemental mixture. Neither BW nor prealbumin improved despite rich oral intakes, as documented by the dietitian's monitoring, plus EN support. Risks from parenteral nutrition (PN), mainly infective ones, were too high with respect to the patient. We then decided to stop oral nutrition and to give the patient total enteral nutrition (TEN) with semi-elemental mixture in slow, continuous administration. Results Fourteen days after the beginning of TEN, prealbumin increased from 10 to 21 mg/dL. Refeeding Syndrome was adequately prevented. The patient well tolerated slow, continuous TEN and felt subjective clinical improvement. Conclusions SS can provoke motility disorders associated with inflammation, leading to intestinal failure and, consequently, to severe malnutrition. Nutritional assessment and follow-up after SS diagnosis could positively influence this evolution. Anyway, when intestinal failure is already present, an attempt to intestinal rehabilitation is demanded, especially when risks from PN are too high for the patient.

Predictive performance of a new pharmacokinetic model for propofol in underweight patients during target-controlled infusion.

In a previous study, the modified Marsh and Schnider models respectively showed negatively- and positively-biased predictions in underweight patients. To overcome this drawback, we developed a new pharmacokinetic propofol model-the Choi model-for use in underweight patients. In the present study, we evaluated the predictive performance of the Choi model. Twenty underweight patients undergoing elective surgery received propofol via TCI using the Choi model. The target effect-site concentrations (Ces) of propofol were 2.5, 3, 3.5, 4, 4.5, and 2μg/mL. Arterial blood samples were obtained at least 10minutes after achieving pseudo-steady-state. Predicted propofol concentrations with the modified Marsh, Schnider, and Eleveld pharmacokinetic models were obtained by simulation (Asan pump, version 2.1.3; Bionet Co. Ltd., Seoul, Korea). The predictive performance of each model was assessed by calculation of four parameters: inaccuracy, divergence, bias, and wobble. A total of 119 plasma samples were used to determine the predictive performance of the Choi model. Our evaluation showed that the pooled median (95% CI) bias and inaccuracy were 4.0 (-4.2 to 12.2) and 23.9 (17.6-30.3), respectively. The pooled biases and inaccuracies of the modified Marsh, Schnider, and Eleveld models were clinically acceptable. However, the modified Marsh and Eleveld models consistently produced negatively biased predictions in underweight patients. In particular, the Schnider model showed greater inaccuracy at a target Ce≥3µg/mL. The new propofol pharmacokinetic model (the Choi model) developed for underweight patient showed adequate performance for clinical use.

Three Cases of Canine Dermatomyositis-Like Disease

Background: Dermatomyositis is an idiopathic, inflammatory/immunemediated disease of the skin, muscles and bloodvessels of hereditary nature and unclear pathogenesis. This familial disease has been described in certain breeds, especially collies and Shetland sheep dogs and is of rare occurrence in mongrel dogs. To describe and discuss three clinical cases of dermatomyositis-like disease and provide a brief review of the literature.Cases: Three young mongrel dogs are included in this report. Case 1: Mandarino, a 4-year-old mongrel dog, having a history of skin lesions for at least a year. Showed an underweight patient, skin ulcers, crusts, alopecia, peri-ocular scarring causing severe lagophthalmia and a corneal ulcer. Muscle atrophy was most notable in the head and legs; the dog haddifficulty and pain walking. Treatment was initialised with cephalexin 30 mg/kg BID, pentoxifylline 25 mg/kg BID, and prednisone 2.2 mg/kg SID. The patient was presented after two weeks for follow up; the anaemia and skin condition had improved, the weight had increased by 2 kg, dysphagia and locomotor abnormalities were not present. Case 2: Milagros,a mongrel female dog approximately two years of age, rescued from a shelter. Physical examination showed facial alopecia, erythema and scarring of the periocular skin, crusting and scaling in alopecic areas, pinnae tip necrosis and crusting, ear alopecia, tail tip necrosis and crusting. Also present were distal limb alopecia, crusting and ulcers in areas of trauma in the hock and carpal surfaces; some nails presented onychorhexis and onychoschizia. The patient has been treated for12 months with a good clinical outcome, with pentoxifylline, azathioprine 2.2 mg/kg EOD alternating with prednisone 1 mg/kg EOD. Case 3: Chuchito, an 11-month-old male mongrel rescued dog had been previously hospitalised due to his skin condition. Physical examination showed depigmented and alopecic areas in the nasal planum, perioral and periocular areas, and inflammation of the palpebral tissues. Necrosis of the distal pinnae, alopecia and scales were evident, along with sloughing of scales and ulcers. Skin lesions were also present in the distal limbs, and alopecia, erythema and some crusting and scales in the carpal, tarsal and digital areas. Onychodystrophy was present in several digits. This study describes the physical examination and the clinical pathological findings, including skin scrapings, fungal cultures, and skin biopsies, in three dogs with dermatomyositis-like disease, as well as the clinical outcomes after slightly different treatment protocols were used. The biopsy results of two dogs showed ischaemic dermatopathy.Discussion: The most common initial signs of the disease are erythema, desquamation and alopecia in the facial area, ears, distal limbs and pinnae in young puppies aged between two and six months of age, followed by pigmentary changes. Muscular lesions are uncommon; when present, they represent the most severe form of this disease. Dysphagia is a common sign and mega-oesophagus may be present. Patients with muscular disease can manifest difficulty walking, with a stiff high gait. The immune mediated pathogenesis of dermatomyositis can relate to triggering factors in some dogs, such as drugs, infections, paraneoplasms, or toxins. Other potential inducing stressors include oestrus, whelping and excessive solar exposure. Dermatomyositis-like or familiar dermatomyositis is diagnosed using clinical findings, histopathologyof skin and muscle, and muscle physiology studies. Electromyography, breed predisposition and genetic background can be helpful in some cases. The clinical findings and response to the treatment of all three cases were compatible with dermatomyositis-like disease in mongrel dogs.Keywords: dermatomyositis, dermatopathy, vascular disease, inflammatory myopathies, mongrel dog.

Abstract No. 502 Increased rate of pneumothorax in underweight patient after CT-guided lung biopsy

Identify the influence of body mass index on rates of clinically significant pneumothorax after CT-guided lung nodule biopsy requiring additional management. Retrospective analysis of 98 CT-guided lung nodule biopsies was performed to evaluate for development of clinically significant pneumothorax requiring chest tube placement. The procedures were performed by two experienced interventional radiologists using standardized, outpatient protocol for CT-guided lung biopsy. The patients were categorized by body mass index (BMI) as follows = overweight. Statistical analysis was performed using Chi-square analysis, Fisher’s Exact test and linear regression analysis to determine significance. Based on the standard BMI scale, 75% of underweight patients suffered a pneumothorax requiring chest tube placement. Four out of 34 normal-weight patients and 4 out of 40 overweight patients experienced a pneumothorax. None of the twenty obese patients developed a pneumothorax. Significance was determined at a level <.05. The chi-square value was 21.011, df = 3 with a p-value of 0.0001407. The Fisher’s exact test was used to compare underweight patients to the remainder of the patient population. This also demonstrated a high-level of significance with the two-tailed p values = 0.0028. Underweight patients are at a higher risk of developing a clinically significant pneumothorax after CT-guided lung biopsy. This may be due to technical factors such as a lack of the stabilizing effect of the body habitus in heavier patients. Underweight patients may have more severe confounding disease processes such as COPD. Patient’s capacity to control respiration may also be altered in these populations adding to the complexity of the procedure and increasing the complication rate. Significant care and peri-procedural caution must be exercised in the under-weight patient. Perhaps use of pleural closure devices should be considered in high-risk patients.