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Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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Bulimia Help Method

Endorsed by University Professors, Eating Disorders Specialists, Doctors and former bulimics, the Bulimia Help Method is a proven & trusted approach to lifelong recovery from bulimia. The Bulimia Help Method home treatment program gives you the insight, skills and tools needed to break free from bulimia and to make peace with food and your body. You are guided step-by-step along the way so you always know what to expect and what to do next. A powerful audio program will help to reprogram your old eating habits at a sub-conscious level, speed up your recovery and help you feel more calm and grounded.

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Pathogenesis of Anorexia

The pathogenesis of anorexia is multifactorial and related to disturbances of the central physiological mechanisms controlling food intake. The precise neurochemical mechanisms are still matter of debate however, by understanding how energy intake is physiologically controlled, insights might be obtained. the hypothalamus transduces these inputs into neuronal responses and, via second-order neuronal signalling pathways, into behavioural responses. Intuitively, anorexia may be secondary to defective signals arising from the periphery, due to an error in the transduction process, or to a disturbance in the activity of second-order neuronal signalling pathways.

Cytokines and Anorexia General

Several proinflammatory cytokines, including interleukin-1 (IL-1), IL-2, IL-6, IL-8, tumour necrosis factor-a (TNF-a) and interferon-y (IFN-Y), reduce food intake after peripheral or central administration in laboratory animals 3, 4 . Some cytokines suppress feeding synergistically 3, 4 . The anorectic effects of cytokines are pathophysi-ologically relevant because acute antagonism of particular cytokines and or their receptors often attenuates anorexia in various diseases or models of disease 5 . Furthermore, several immune challenges reduce food intake less in mice that are genetically deficient in a particular cytokine or cytokine receptor than in control animals (see below). Failure to establish a role for a particular cytokine in disease-related anorexia with genetic knock-out (KO) mice 5 is presumably due to the redundant and overlapping actions of cytokines, which allow for developmental compensation. Interestingly, the feeding-suppressive effect of proinflammatory cytokines...

Central Neural Mediation of Cytokine Induced Anorexia

The major hypothalamic detection site for blood-derived signals. Yet, severing the ARC from PVN or its connections with the PVN only slightly attenuated peripheral IL-1p-induced anorexia 35 , indicating that the ARC is involved but not necessary for peripheral IL-1p-induced anorexia. Several lines of evidence 20 implicate activation of hindbrain to forebrain aminergic neurons in the feeding suppression and hypermetabolic effects of circulating IL-1 p. IL-1p-induced anorexia may in part be mediated through prostaglandin E2-dependent activation of serotoninergic neurons originating in the raphe nuclei and projecting to the hypothalamus 36 . In line with this idea, systemic administration of a serotonin (5-HT2c) receptor antagonist and microinjection of the 5-HT1A autoreceptor agonist 8-hydroxy-2-(di-n-propylamino)tetraline (8-OH-DPAT) directly into the raphe nucleus both markedly attenuated the feeding-suppressive effect of peripherally injected IL-1-p 3 . Interestingly, anorexia...

Ghrelin and Anorexia Nervosa

Anorexia nervosa is a psychiatric disorder characterised by patient-induced and maintained weight loss that leads to progressive malnutrition and specific pathophysiological signs (disturbance of body image and fear of obesity). Based on the presence or not of bulimic symptoms, anorexia nervosa appears in two specific subtypes, restricting and binge-eating purging 70 . Complications in many organ systems can occur, including cardiovascular, gastrointestinal, haematological, renal, skeletal, endocrine and metabolic systems. These alterations are not only related to the state of malnutrition, but also to the behaviour of these patients to control their weight. The endocrine disturbances include hypothalamic amenorrhoea, hyperactivity of the hypothalamus-pituitary-adrenal (HPA) axis, low T3 syndrome and alterations in the activity of the GH IGF-1 axis 71-73 . Exaggerated GH secretion coupled with reduced IGF-1 levels are common findings in anorexia nervosa as well as in other catabolic...

Leptin and Anorexia in Ageing

Ageing appears to be associated with leptin resistance. It has been found that the relatively hyper-leptinaemic state of ageing animals blunts the sensitivity of the hypothalamic energy regulatory system, thus decreasing appetite even during episodes of negative energy balance. It has been found that age-associated decreased levels of orexigenic signalling through AgRP and NPY neurons in the arcuate nucleus of the hypothalamus are accompanied by increased levels of anorexi-genic signalling through POMC CART neurons. This pattern of neuropeptide gene expression may contribute to the loss of appetite and anorexia associated with ageing 56 .

Leptin and Cancer Anorexia Cachexia

The persistence of anorexia and the onset of cachexia in cancer patients, therefore, implies a failure of this adaptive feeding response 86 . Leptin, a member of the gp 130 family of cytokines, induces a strong T helper-1 lymphocyte response and is regarded as a proin-flammatory inducer 87 . Several data suggested a role of leptin in inflammatory diseases. Proinflammatory cytokines up-regulate leptin expression in white adipose tissue and increase plasma leptin levels in hamsters and mice 88 . However, in many common diseases associated with cachexia, such as chronic obstructive pulmonary disease and chronic inflammatory bowel disease, there is an inflammatory status caused by high proinflammatory cytokine levels, whereby leptin concentrations are decreased related to body fat mass. In patients with advanced non-small-cell lung cancer, serum leptin levels were lower than in controls and lower still in those who were cachectic who also showed an increase of...

Cancer Cachexia and Anorexia

The most common problems are cancer cachexia and anorexia, particularly when the tumor is already in a progressive stage. In a large study, DeWrys and co-workers reported that more than 50 of patients suffered from weight loss (21). About 15 lost more than 10 of their weight during the course of the disease. Signs of cancer cachexia are anemia, anorexia, lack of energy, and increasing weight loss. The latter is caused by a decrease in body fat and muscle mass (56-58). There is no clear correlation between the extent of malnutrition, the tumor's size,

Proinflammatory Cytokines and Anorexia

Another cause of CACS which, due to its particular aspects and appearance, may be considered specific for the syndrome is decreased food intake. Malnutrition may be considered a hallmark of cancer cachexia and it is associated with anorexia - that is, loss of appetite and or decreased food intake. Nutrition is a complex function resulting from the contribution of peripheral and central nervous afferents in the ventral hypothalamus. Stimulation of the medial hypothalamic nucleus inhibits feeding, while stimulation of the lateral nucleus promotes food intake. Among peripheral afferents, oral stimulation by pleasant tastes elicits eating, whereas gastric distension inhibits it. There is evidence that while the proinflammatory cytokines IL-1, IL-6, and TNF-a are involved in cancer-related anorexia and decreased food intake (see below), they are probably not the only mediators of CACS. Since multiple factors are involved in the control of food intake, it is possible that there are also...

Cytokines in Cancer Anorexia

Cytokines play a key role in the activation of the immune system and the inflammatory response typical of the catabolic state 39-41 . Different experimental approaches have demonstrated that cytokines are able to induce weight loss. They initiate a cascade of events that ultimately leads to a state of wasting, malnourishment, and eventually death. A number of pro-inflammatory cytokines, including IL-1, TNF-a, and interferon (IFN)-y, have been isolated in tumours, as shown in Fig. 4 7 . These cytokines together with IL-6, leukaemia inhibitory factor (LIF), and ciliary neurotrophic factor (CNTF) are also implicated in the aetiology of cancer anorexia-cachexia syndrome 6,7 . A variety of tumours and peri-tumour cells release these cytokines into the circulation 42 . Elevated serum concentrations of IL-1, IL-6, and TNF- a occur in cancer patients and the concentrations of these cytokines correlate with tumour progression 4, 42, 43 . Furthermore, peripherally circulating cytokines...

Neuropeptides and Cancer Anorexia

Food intake in tumour-bearing rats (TB-R) and control groups before and after tumour resection and sham operation, respectively. In the TB-R group, food intake decreased with the onset of anorexia. When rats were defined as anorectic, tumours were resected, while their controls underwent sham operation. Food intake continued to be measured until it normalised in TB-R, at which time rats in both groups were killed to harvest their brains. (From 59 ) Fig. 7. Food intake in tumour-bearing rats (TB-R) and control groups before and after tumour resection and sham operation, respectively. In the TB-R group, food intake decreased with the onset of anorexia. When rats were defined as anorectic, tumours were resected, while their controls underwent sham operation. Food intake continued to be measured until it normalised in TB-R, at which time rats in both groups were killed to harvest their brains. (From 59 ) ferent neuropeptides in cancer anorexia-cachexia syndrome, our knowledge...

Mechanisms of Cancer Related Anorexia Cachexia

The anorexia cachexia syndrome is one of the most common causes of death among patients with cancer and is present in 80 at death 1 . The term 'cachexia' derives from the Greek kakos, which means 'bad', and hexis, meaning 'condition'. The characteristic clinical picture of anorexia, tissue wasting, loss of body weight accompanied by a decrease in muscle mass and adipose tissue, and poor performance status that often precedes death has been named cancer-related anorexia cachexia (CAC) 2-5 . Since the 1980s, the previous concepts explaining CAC were replaced by a more complex insight, which stresses the interaction between metabolically active molecules produced by the tumour itself and the host immune response. One of the main features of the cachectic syndrome is anorexia, which may be so significant that spontaneous nutrition is totally inhibited. The pathogenesis of anorexia is most certainly multi-factorial but not yet well understood. It seems to be attributable, in part, to...

Treatment of Symptoms and Constipation as Causes for Secondary Anorexia Cachexia

In patients with advanced, progressive, incurable disease, the causes of anorexia, decreased oral intake and loss of weight are complex. Besides the primary (paraneoplastic) catabolic processes, a number of important causes for loss of appetite or weight may occur, such as severe symptoms (i.e. pain, shortness of breath, depression), syndromes (i.e. constipation, mucositis, bowel obstruction) or prolonged bed rest 12 . Poor assessment of interfering symptoms (see Chp. 9.11) by not acknowledging risk factors for symptom expression and insufficient symptom management (i.e. pain, depression, social distress), or negligence of the syndromes constipation 13 or sedation 14 can lead to sub-standard management.

Role of Brain Serotonin in Disease Associated Anorexia

Considering disease-associated anorexia as a pathological and persistent form of satiety, it is intuitive to speculate that the pathogenesis of anorexia could be related to a derangement of the physiological mechanism mediating satiety. As a consequence, much scientific effort has been devoted to clarify the involvement of hypothalam-ic appetite-suppressing circuits in the onset of anorexia. Many studies have been conducted in animal models of cancer anorexia, but it is reasonable to translate the results obtained to other diseases. Therefore, it appears that disease-associated anorexia is related to the inability of the hypothalamus to respond appropriately to consistent peripheral signals, primarily due to the hyperacti-vation of the melanocortin system. This derangement could be triggered by cytokines. The mechanisms by which cytokines negatively influence energy intake are currently under investigation. As proposed by Inui, cytokines may play a pivotal role in long-term inhibition...

Antiserotonergic Therapies Targeting Anorexia and Cachexia

Disease-associated anorexia might be therapeuti-cally approached by interfering with the neuro-chemical events downstream of cytokine activation. Serotonergic hypothalamic neurotransmission represents a suitable example, and it is therefore tempting to speculate that by interfering with hypothalamic serotonin release, food intake might be improved. Hypothalamic serotonin synthesis strictly depends on the brain availability of its precursor, the amino acid tryptophan 10 . An increase of plasma and brain tryptophan levels, leading to increased brain serotonergic activity, has been demonstrated in different diseases and linked to the presence of anorexia and reduced food intake. Tryptophan crosses the blood-brain barrier via a specific transport mechanism shared with the other neutral amino acids, including the branched-chain amino acids (BCAA). Thus, by artificially increasing the plasma levels of the competing amino acids, a reduction of tryptophan brain entry could be achieved,...

Role of Brain Monoamines in Disease Associated Anorexia Cachexia

More data support a role for hypothalamic neurotransmission as an effective therapeutic target in the treatment of anorexia. Using in vivo microdial-ysis, Blaha et al. showed that intrahypothalamic serotonin concentrations are increased in anorec-tic tumour-bearing rats 22 . In the same study, they also showed a more complex derangement of hypothalamic monoaminergic neurotransmission, since dopamine levels were also found to be depressed 22 . This evidence may give the neurochemical explanation for the results obtained in anorectic cancer patients, whose food intake has been restored and quality of life improved by the administration of dopamine (L-DOPA) at a dosage ranging from 375 750 mg day 23, 24 . Although not obtained in prospective randomised clinical trials, these data are very intriguing and further support the 'monoaminergic' approach to the treatment of anorexia. The nitric oxide system and the production of eicosanoids might be of importance for the pathogenesis of...

The Impetus Behind Studying and Treating the Cancer Anorexia Weight Loss Syndrome

Experienced oncologists acknowledge that the cancer anorexia weight loss syndrome predicts a shorter survival for patients with advanced, incurable disease. Several powerful, well-conducted studies have borne out this clinical impression. DeWys et al. focused on weight loss in a multi-institutional, retrospective review of 3047 cancer patients and observed that loss of more than 5 of premorbid weight predicted an early demise 1 . This prognostic effect occurred independently of tumour stage, tumour histology and patient performance status. Weight loss was also associated with a trend towards lower chemotherapy response rates. Anorexia carries this same prognostic effect. Chang recently reviewed the predictive capability of various cancer symptoms and found that, similar to weight loss, anorexia, or loss of appetite, also predicts an early demise for the cancer patient 2 . Thus, the impetus for studying the cancer anorexia weight loss syndrome rests in part in the hope that effective...

Brief Overview of Mechanisms To Explain the Cancer Anorexia Weight Loss Syndrome

Recent strategies for treating the cancer anorexia weight loss syndrome have relied heavily on an improved understanding of mechanisms of disease. How does cancer cause weight loss, debility and anorexia A variety of different mediators have been described. Todorov et al. have discovered a 24-kilodalton proteoglycan derived from the MAC16 tumour line 9 and have labelled this mediator proteolysis-inducing factor (PIF). Although only a few studies have focused on PIF, antibodies to this substance appear to prevent weight loss in tumour-bearing animal models. Clinical data suggest that PIF is specific to cancer-associated wasting, as it is not found in cancer patients without weight loss nor in patients who are losing weight as a result of other diseases. To our knowledge, no clinical studies that have specifically focused on PIF inhibition have been reported thus far. In addition to this mediator, other mediators that appear to play an active role in cancer-associated anorexia weight...

Eating Disorders

Although the name of this diagnostic class focuses on the fact that the disorders in this section are characterized by abnormal eating behavior (refusal to maintain adequate body weight in the case of anorexia nervosa and discrete episodes of uncontrolled eating of excessively large amounts of food in the case of bulimia nervosa), of near equal importance is the individual's pathological overemphasis on body image. A third category, which is being actively researched but has not been officially added to the DSM-IV-TR, is binge-eating disorder (included in the appendix of Criteria Sets and Axes Provided for Further Study). Like bulimia nervosa, individuals with binge-eating disorder have frequent episodes of binge-eating. However, unlike bulimia nervosa, these individuals do not do anything significant to counteract the effects of their binge-eating (i.e., they do not purge, use laxatives or diet pills, or excessively exercise). All three disorders are described in Chapter 38.

Anorexia Nervosa

Anorexia nervosa (AN) is characterised by a deliberate reduction of food intake in order to achieve an 'ideal' body weight and due to constant fear of getting fat. People affected by this disorder are constantly concerned with their body weight they try to reduce their body size and do not consider their weight loss as abnormal. AN patients have an altered way of experiencing their own body they 'feel they are fat,' even though they are underweight, and believe that some parts of their body are 'too fat,' even if they are objectively underweight. Table 1 lists the main criteria for the diagnosis of AN. Table 1. Diagnostic criteria for anorexia nervosa (DSM-IV)

Infantile Anorexia

In this condition, the infant refuses to eat adequate amounts of food for at least 1 month, leading to significant growth deficiency. The onset of the food refusal under 3 years of age is most commonly during the transition to spoon- and self-feeding. Furthermore, the infant does not communicate hunger signals, lacks interest in food, but shows strong interest in exploration and or interaction with the caregiver. Infants with this infantile anorexia are usually referred for a psychiatric evaluation due to food refusal and growth failure. The infants' food refusal usually becomes of concern between 6 months and 3 years, most commonly between 9 and 18 months of age, during the transition to spoon- and self-feeding.

Cancer Anorexia

Cancer anorexia is defined as the loss of the desire to eat, and several factors are involved in its pathogenesis. Anorexia and reduced food intake are physiological responses prompted by the growing tumour, and persistent anorexia compromises host defences, which ultimately delays recovery. Anorexia contributes to the development of malnutrition and cachexia, since it reduces the oral intake of calories, thus promoting skeletal-muscle wasting 13 . In the methylcholanthrene-induced sarcoma (MCA)-bearing Fischer rat, anorexia develops with progression of tumour growth, so that a characteristic feeding pattern is observed with the onset of anorexia (Fig. 1,11).A decrease in food intake occurs, first via a decrease in meal number associated with a simultaneous partial compensatory increase in meal size that lasts for approximately 24-48 h. Thereafter, meal size also decreases, and anorexia becomes apparent and profound 30-33 , leading ultimately to the rats' demise 32 . The decrease in...

Anorexia and Bulimia

Eating disorders that make you underweight cause health problems as severe as those caused by overweight. Anorexia, or self-starvation, is rampant on college campuses. Estimates suggest that one in five college women, and one in 20 college men restrict their intake of Calories so severely that they are essentially starving themselves to death. Others allow themselves to eat, sometimes very large amounts of food (called binge eating), but prevent the nutrients from being turned into fat by purging themselves, often by vomiting. Binge eating followed by purging is called bulimia. Anorexia has serious long-term health consequences. Anorexia can starve heart muscles to the point that it develops altered rhythms. Blood flow is reduced and blood pressure drops so much that the little nourishment that is present cannot get to the cells. The lack of fat that accompanies anorexia can also lead to the cessation of menstruation, amenorrhea. Amenorrhea occurs when Health problems resulting from...

Obsessive Compulsive Disorder

OCD is a chronic and often disabling disorder that affects 2-3 of the US population. OCD has been labeled a 'hidden epidemic' and is ranked 20th in the Global Burden of Disease studies among all diseases as a cause of disability-adjusted life years lost in developed countries. OCD is often associated with substantial quality of life impairment especially in individuals with more severe symptoms. The disease usually begins in adolescence or early adulthood with 31 of first episodes occurring at 10-15 years of age and 75 by the age of 30. The essential features of OCD are recurrent obsessions or compulsions that are severe enough to be time consuming (i.e., take more than 1 h per day) and or cause significant levels of distress or interference with normal daily activities. OCD can have comorbidity with major depression and social phobia, as well as other mental disorders such as eating disorders and schizophrenia.9

Proinflammatory Cytokines

Solid tumours 15 , this cytokine has been implicated as the initiating signal for a variety of cellular and metabolic events seen in critically ill patients. TNF-a may circulate predominantly as a complex with its soluble receptors, making detection of the bioactive ligand more difficult. Increased levels of these soluble TNF-a receptors are seen in response to diverse inflammatory stimuli including sepsis, cancer and AIDS 16 . Nevertheless, elevated TNF-a levels are detected in many disease states including bacterial infections, cancer, sepsis and AIDS 17 . TNF-a is a metabolic hormone acting both in a paracrine fashion, and, in some istances, as an endocrine hormone 18 . Systemically, TNF-a has been suggested to act in the brain to cause anorexia and subsequent body weight loss 19 . The metabolic effects of TNF-a seem to promote redistribution of body protein and lipid stores. The result is a net loss of peripheral tissue protein with a concomitant increase in hepatic uptake 20 ....

Other thoracic malignancies

A Phase I study has been underway at the M.D. Anderson Cancer Center for patients with advanced unresectable gastric, gastroesophageal, or esophageal cancer (48). Patients must not have had previous treatment, and eligibility criteria regarding a baseline hema-tologic and liver function tests are standard. Previous treatment with irinotecan or topotecan (Hycamtin) or prior radiotherapy were exclusion criteria. The treatment plan consisted of a Phase I dose-escalation study beginning at 30 mg m2 and extending to a dose of 70 mg m2. A weekly dose of irinotecan was modified according to blood counts. Radiotherapy treatment consisted of 45-50 Gy in 1.8 Gy fractions for a total of 2528 fractions delivered over 5 wk. The irinotecan was administered 1 h prior to administration of radiation therapy on d 1 of each week of radiotherapy. In 18 patients enrolled between January and November of 1998, there were 12 patients evaluable for toxicities and response. There was a male predominance of 16...

General Symptom Data on Children at the End of Life

A retrospective chart review examined the signs and symptoms occurring at the end of life in 28 children dying from cancer in Japan. All children experienced anorexia, 82.1 had dyspnea, and 75 had pain. Other symptoms included fatigue (71.4 ), nausea vomiting (57.1 ), constipation (46.4 ), and diarrhea (21.4 ) (4). This symptom profile parallels that of the North American reviews of the symptoms of dying children (2,5,6).

General Symptom Data in the Context of Life Limiting Illness

The pattern of symptoms based on the self-report of US children aged 10-18 years treated for cancer was studied (7). This study included children across the spectrum of illness and included newly diagnosed patients, those receiving a bone marrow transplant, and those receiving palliative care. It showed that children with cancer are very symptomatic and are often highly distressed by their symptoms. A prevalence rate greater than 35 was noted for the symptoms of pain, drowsiness, nausea, cough, anorexia, lack of energy, and psychological upset. Inpatients reported being more symptomatic than their outpatient cohort, as evidenced by comparing their mean number of symptoms of 12.7 4.9 and 6.5 5.7, respectively. Recent administration of chemotherapy is associated with significant symptomatology in children with cancer (7). Children with solid tumors were more symptomatic than children with other malignancies. Pain, nausea, and anorexia were clustered as highly distressing symptoms (7)....

Diagnosis Symptoms and Clinical Signs

Mon symptoms and physical findings result from anemia, thrombocytopenia, and neutropenia, and include pallor and fatigue, anorexia, petechiae, purpura, bleeding, and infection. Occurrence of initial hyperleukocy-tosis (white blood cell count> 100,000 l) did not vary significantly in the different age groups. Initial involvement of the central nervous system (CNS) is seen less often in adolescents ( 10 ) and in children aged 213 years ( 8 ) than in infants ( 17 ) with AML (data not available for young adults, who rarely get diagnostic lumbar puncture). Infiltration of the skin, especially in monocytic leukemias, is also most frequent ( 20 ) in young children (< 2 years) and rarely seen in older children and adolescents. Likewise, leukemic infiltrations of the periosteum and bone occur more often in young children than in adolescents.

Chronic Obstructive Pulmonary Disease

In COPD patients, the prevalence of anorexia is particularly high, since most patients suffer from breathlessness, which affects food intake. Recent data indicate that 67 of chronic lung disease patients experience anorexia during the last year of life. This figure is not much different from the prevalence of 76 found among lung cancer patients 12 . More striking, however, are data showing that although COPD patients have physical and psychosocial needs at least as severe as those of lung cancer patients, their symptoms, including anorexia, receive much less attention from health care professionals 12 .

Second Order Neuronal Signalling

The hypothalamic arcuate nucleus, where peripheral signals mainly converge, projects to other hypothalamic areas, thus interacting with a number of neuronal populations 20 . Many pathways serving as second-order neuronal signalling pathways, including those of orexins A and B, have been described but their involvement in the pathogenesis of anorexia has so far received little attention, although it cannot be excluded. In a recent study, Li et al. showed that a loss of renal function in Wistar rats reduced hypothalamic orexin A, a prophagic mediator 33 , which in turn may have contributed to the development of anorexia in these animals. Evidence exists suggesting that disease-associated metabolic changes, and particularly alterations of protein turnover, impact on the neu-rochemistry in localised brain areas 34 . However, they also appear to have a role in sustaining and corroborating anorexia, while its onset seems to be secondary to the inability of the hypothalamus to recognise and...

Role of Hypothalamic Neuroimmune Interactions

Recent data suggested that hypothalamic sero-tonergic neurotransmission may be critical in linking cytokines and the melanocortin system. Fenfluramine is a serotonin agonist once widely prescribed in the treatment of obesity. It has been recently shown that fenfluramine raises hypothalamic serotonin levels, which in turn activate POMC CART neurons in the arcuate nucleus, therefore inducing anorexia and reduced food intake 54 . It is also well-documented that cytokines, and particularly IL-1, stimulate the release of hypothalamic serotonin 55 . Thus, it could be speculated that during disease cytokines increase hypothalamic serotonergic activity, which in turn contributes to persistent activation of POMC CART neurons, leading to the onset of anorexia and reduced food intake. Supporting the role of serotonin in the pathogenesis of anorexia, we demonstrated that in anorectic tumour-bearing animals hypothalamic serotonin levels are increased when compared with the levels in control rats...

Signs and Symptoms of the Arteritic Form of AION j Note

The average age at the onset of anterior ischemic optic neuropathy in patients with temporal arteritis (AAION) is about 75 years. Arteritis can also present with branch retinal vessel occlusions, choroidal infarctions, or retinal ischemia, as indicated by the presence of numerous cottonwool spots. Ischemic pareses of the extraocular muscles may be present, and ischemia of the scalp, sufficient to cause patchy areas of hair loss, have been known to appear. Even myocardial infarctions, hemispheric strokes, and cranial nerve palsies can be caused by severe forms of arteritic disease. Temporal arteritis (also called giant cell arteritis, cranial arteritis, or Horton's cephalgia a now-obsolete term ) has the following typical signs and symptoms headache, jaw claudication, scalp pain when combing or brushing the hair, malaise, fatigue, low-grade fever, anorexia, migratory myalgias, weight loss, and thickened, cord-like enlargements of the superficial, subcutaneous arteries of the scalp (...

Social Causes of Weight Loss

Hospitalised AIDS patients, who take in only 70 of resting energy expenditure (REE) needs and 65 of protein needs, excluding the extra needs resulting from the hypermetabolism associated with fever, acute infections, and physical activity. Dietetic deficits in protein and calorie consumption interfere with the natural course of the main disease, emphasising subjective symptoms such as sickness, asthenia, anorexia, emesis, and constipation, which in turn interfere with feeding. A close relationship exists between susceptibility to infectious diseases and nutritional status regular nutrition and general good health make individuals more resistant to infections. Similarly, anergy to cutaneous tests (PPD, candidin, DNCB, etc.) is closely related to body-weight insufficiency and hypoalbuminaemia. The pre-surgical correction of denutrition reduces the incidence of post-surgical infectious complications, favouring the healing of the wounds and a quicker return to health 18-20 .

Frontotemporal Lobar Dementias

A selective degeneration of the frontal and temporal lobes is the distinctive feature of a group of dementias estimated to comprise 15 to 20 of all dementia cases. Frontotemporal lobar dementias (FTLD) are not common, but their incidence is increasing as more cases are recognized. Individuals from early to late midlife are affected, and the clinical course averages from 5 to 15 years. Most diseases are sporadic, but familial examples with autosomal dominant inheritance also have been identified. The clinical presentation varies greatly among the diseases but all share neuropsychiatric symptoms, cognitive decline, and neurologic disorders. Neuropsy-chiatric symptoms in various combinations are usually in the foreground of the clinical picture, including behavioral and personality changes, emotional lability, depression, anxiety, restlessness, agitation, social disinhibition, and lack of initiative, planning, organizing (executive functions), insight, and judgment. Adding to the...

Description Of Empirical Research

Additional adaptations of DBT have recently been developed and evaluated for a range of populations and diagnostic groups, including eating disorders (Palmer et al., 2003 Safer, Telch, & Agras, 2001 Telch, Agras, & Linehan, 2000 Telch, Agras, & Linehan, 2001 Wisniewski & Kelly, 2003) incarcerated men (McCann, Ball, Ghanizadeh, Gallietta, & Froelich, 2002), suicidal adolescents (Miller, 1999 Miller, Wyman, Huppert, Glassman, & Rathus, 2000 Rathus & Miller, 2002), female juvenile offenders (Trupin, Stewart, Beach, & Boesky, 2002), and older adults with depression (Lynch, Morse, Mendelson, & Robins, 2003) preliminary data are encouraging. Although apparently disparate groups, each can be conceptualized according to the combined capability deficit and motivational model that underlies DBT. For example, Telch and colleagues view binge eating behavior as dysfunctional emotion regulation behavior that develops from inadequate emotion regulation skills and is...

Glucose Metabolism Changes in CACS

In cancer patients, glucose intake is severely compromised by the presence of symptoms such as nausea, vomiting and anorexia. The reduced glucose intake induces the activation of gluconeo-genesis from lactate, muscle amino acids and free fatty acids, finally leading to depletion of fat and protein stores. The cycle converting lactate to pyruvate and glucose is named the Cory cycle. The Cory cycle activity is increased from 20 (value observed in healthy subjects) to 50 in cancer patients with CACS.

Consequences of Altered Glucose Metabolism Oxidative Stress

An inadequate detoxification due to altered glucose metabolism in addition to symptoms such as anorexia cachexia, nausea, and vomiting, that prevent a normal nutrition and thereby a normal supply of nutrients such as glucose, proteins and vitamins, leading to accumulation of ROS 53 . In a series of our recently published studies

Changes in Intermediary Metabolism During the Acute Phase Response

Low-density lipoproteins, decreased lipoprotein lipase activity, increased de novo triglyceride synthesis and esterification, increased release of free fatty acid from the periphery, and a futile cycle of fatty acids between the liver and adipose tissue beds. These changes, which are promoted by a variety of cytokines, maintain serum lipid concentrations despite the presence of anorexia 4 .

Cytokine Regulation of the Acute Phase Response

The realisation that the response to illness and injury is an endogenous, not exogenous, process was a milestone in the understanding of cachexia. Our understanding that cytokines regulate the acute-phase response and cachexia resulted from several observations. For example, studies of hypertriglyceridaemia in experimental infections suggested indirect, or endogenous, control the degree of hypertriglyceridaemia was not necessarily correlated with infectious or tumour burden, and metabolic effects of infection could be reproduced with dead organisms or even with supernatants of macrophage cultures stimulated in vitro. The responsible protein was sought, isolated, and named cachectin, and its sequence was found to be identical to that reported for tumour necrosis factor (TNF) 5 . These studies concluded that this molecule was the mediator of cachexia. At approximately the same time, other investigators demonstrated that proteolysis in animals occurred after infusion of a...

Cytokines in Chronic Inflammation

With the tremendous increase in scientific knowledge about cytokines and their immune functions, it has also become clear that cytokines have systemic and local effects that are only partly related to their coordinating functions in the immune system. Thus, proinflammatory cytokines are the major endogenous mediators of anorexia and cachexia during chronic diseases. They have substantial hypermetabolic effects, which are at the core of the organism's fever reaction, and, last but not least, they are implicated in the metabolic disturbances and several other comorbidities of obesity, in particular by contributing to insulin resistance. This chapter summarises current knowledge of these effects it describes studies including different levels of scientific analysis, from the molecular through cellular to the systemic and behavioural levels, which reveal interesting features of the role of cytokines in these phenomena.

Early Childhood Developmental Social and Family History

A history of trauma is significant in evaluating for trauma sequelae including dissociative phenomena, hyperarousal, depression, eating disorders, substance use disorders, psychiatric disorders (especially posttrau-matic stress disorder), domestic violence, and commercial sex work. Specific questions about posttrau-matic stress disorder include those about dissociation, intrusive thoughts, flashbacks, nightmares, easy startle, hypervigilance, insomnia, and a sense of a foreshortened future.

First Line Agents NonSelective Serotonin Reuptake Inhibitors

Bupropion must be given in divided doses at least 4 hours apart (usually three times a day), and no single dose may be greater than 150 mg the extended-action form (Wellbutrin SR) may be given twice a day, and the Wellbutrin extended-release version is given once daily. Bupropion is contraindicated in patients with seizure disorder, even if only by history, or in patients with a history or current diagnosis of anorexia or bulimia. Significant

Physiological Control of Ghrelin Secretion

In agreement with the major influence of nutrition on ghrelin secretion, circulating ghrelin levels are inversely related to body mass index (BMI), i.e. increased in anorexia and cachexia while reduced in obesity and overfeeding, a notable exception being patients with Prader-Willi syndrome (PWS) 3, 32, 33 . In particular, ghrelin hypersecretion has been suggested to be responsible for the hyperphagia and weight excess commonly present in this syndrome 32,33 . In both anorexia and obesity, ghrelin secretion is normalised by recovery of ideal body weight 18,34,35 . These changes are opposite to those of leptin, suggesting that both ghrelin and leptin are hormones signalling the metabolic balance and managing the neuroendocrine and metabolic response to starvation 3,35,36 .

Medical Complications Of Alcoholism Gastrointestinal Tract and Pancreas

Alcohol decreases gastric emptying and increases gastric secretion. As a result, the mucosal barrier of the gastrium is disrupted, allowing hydrogen ions to seep into the mucosa, which release histamine and may cause bleeding. Acute gastritis is characterized by vomiting (with or without hematemesis), anorexia, and epigastric pain. It remains unclear whether chronic alcohol abuse increases the risk of ulcer disease.

Identifying key symptoms

Sometimes more than one symptom may be important. For instance, patients may present with a complex mixture of symptoms which the treatment should palliate. In this situation a combination score or an algorithm maybe considered. In a trial assessing the value of mitoxantrone and prednisone in twenty-seven patients with hormonally resistant prostate cancer, Moore etal. 40 pre-defined a palliative response as a decrease in analgesic score by > 50 per cent or a decrease in 'present pain intensity' by > 2 points without an increase in analgesic score. In this phase II study nine patients were considered 'palliated' using this trial-specific definition, compared with only one who showed a traditional partial response. In an MRC Lung Cancer Working Party trial 41 comparing oral chemotherapy versus standard intravenous chemotherapy in patients with small cell lung cancer, QL was considered to be a primary outcome. In order to be considered 'equivalent' the oral treatment was required 'to...

Main Proposed Brain Mechanisms in Wasting and Cachexia

Wasting and cachexia that can affect brain function directly or indirectly. It is accepted that, in many cases, the magnitude of anorexia does not have a relationship with the severity of wasting and cachexia and degree of malnutrition. Here, metabolic abnormalities and prevalence of cata-bolic pathway activation play a pivotal role. In addition, although the brain monitors the status of peripheral energy stores and fuel availability, it is unknown how the fine modulation of anabolic and catabolic processes and energy homeosta-sis balance interact on a moment-to-moment basis with the profile mentioned below.

Cytokines General Comments

Multiple classes of cytokines have been proposed to participate in the induction and development of wasting and cachexia including via brain mechanisms. These comprise IL-1, IL-6 subfamily members including CNTF and leukaemia inhibitory factor, IFN-y, TNF-a and BDNF, which in many cases also induce anorexia 9,11,14, 28 . Studies have shown that intratumoral administration of IL-1 receptor antagonist significantly

Neurophysiology Responses

The behavioural mode of action of cytokines has been found to be consistent with the neurophysio-logical pattern induced by a cytokine 11, 27 . For instance, IL-1p activates specifically and reversibly the glucosensitive neurons in the ventromedial hypothalamic nucleus or VMN (a site involved in the integrative control of meal termination). This would predict changes of meal size and meal duration as those induced by IL-1p. Based on the data of IL-1p-induced inhibition of the inward calcium channel current (and hence calcium permeability), a model has been proposed that would be consistent with an IL-1p long-lasting VMN neuronal activity modulation that may be associated with the long-term anorexia induced by the cytokine. A decrease of calcium influx in VMN glucose-sensitive neurons may inhibit the defined calcium-dependent potassium conductance in these neurons, leading to maintenance of intracellular potassium, depolarisation and increase in neuronal activity.

Cytokine Model in Brain Responses

Model-dependent differences, e.g. in tumour-bearing mice with prostanoid-related anorexia, cytokine alterations seemed secondary to anorexia and not the driver of the process 34 . Data also support that cytokines are relevant to cancer anorexia and cachexia in mice bearing experimentally induced brain tumours. Negri et al. 19 used athymic mice bearing human tumour cells that enable direct identification of the origin of the cytokines from the host or tumour. Anorexia quickly developed in mice bearing human A431 epidermoid carcinoma or human OVCAR 3 ovarian carcinoma in the brain 19 . Anorexia was independent from tumour mass in the lateral cerebral ventricle. Brains exhibited significant up-regulation of IL-1a, IL-1 p and leukaemia inhibitory factor (A431), and IL-6, TNF-a, and leukaemia inhibitory factor (OVCAR 3). This indicates that different cytokines were up-regulated depending on the tumour cell type 19 .

Cytokine Peptide Interactions

Modulation of the neuroendocrine system by cytokines is robust and has been discussed previously in multiple elegant papers. Cytokine-neuropeptide interactions can also be antagonistic. IL-1p blocks neuropeptide Y-induced feeding and neuropeptide Y blocks IL-1p-induced anorexia IL-1p stimulates vasopressin release and vasopressin inhibits IL-lp-induced fever. In cancer models, a CNS dysregulation of neuropeptide Y mechanisms associated with an enhanced IL-1 activity and serotonin concentrations has been proposed 8,9,22 . Other endogenous cytokine-peptide interactions relevant to wasting, cachexia and the cachexia-anorexia syndrome include reciprocal cytokine-leptin (a member of the long-chain helical cytokine family)-neuropeptide Y-corti-cotropin-releasing hormone-glucocorticoid interactions, and perhaps also among cytokines and other CNS neuropeptide regulators involved in the control of energy balance including cocaine- and amphetamine-regulated transcript, melanin-concentrating...

Transducing Mechanisms and Functional Antagonism

And is indirect since IL-1 receptors are not G-pro-tein coupled. Receptors coupled to GaO that respond to feeding-stimulatory signals include receptors for galanin, endogenous opioids, and neuropeptide Y. Thus, IL-1p-induced modulation of GaO protein may be involved in IL-1p-induced brain activities and anorexia including antagonism of neuropeptide Y action. The consequence of this cytokine mode of action is broad. G-protein-coupled receptors that have been associated with energy balance regulation by the brain include receptors for cate-cholamines, serotonin, histamine, neuropeptide Y, hypocretins orexins, melanin-concentrating hormone, agouti-related protein, a-melanocyte stimulating hormone, IL-8 and other chemokines intercrines, cholecystokinin, opioids, glucagon and others. Cytokines have the ability to modulate mechanisms associated with all of these endogenous substances, and therefore, the potential of cytokine-induced modulation of G-proteins - the interface between...

Ten Aspects To Consider for Future Research into Brain Mechanisms Involved in Wasting and Cachexia

Links and feedbacks exist among neurological, psychological and psychiatric manifestations of diseases accompanied by wasting and cachexia. Symptoms or signs such as anxiety, depression, cognitive impairment, fatigue and asthenia, and anorexia can exacerbate wasting and cachexia due to deleterious positive feedback cycles. This increases the frequency of complications, decreases the quality of life and activities of daily living and performance, and has an impact on overall morbidity and mortality. What are the main mechanistic interactions and magnitude of the individual contributions responsible for symptomatology interface

Opioid Peptides Cannabinoids and Cocaine and Amphetamine Regulated Transcript

The intracerebroventricular injection of CART is followed by reduction in food intake 45, 46 , even in co-administration with NPY 46 , coupled with a decrease in plasma insulin and leptin and an increase in lipid oxidation 47 . However, other experimental models showed that chronic CART over-expression in ARC neurons determines significant weight gain and reduction in thyrotropin levels in rats 48 , and the anx anx mice, characterised by anorexia, low body weight, abnormal movement, hyperactivity and early death, present lower hypothalamic CART levels 49 . These disparate data suggest the existence of some central and peripheral resistance mechanisms to CART that need further elucidation.

Diabetic Neuropathy and Digestive System Dysfunction

Thesias over the limbs and trunk with spontaneous resolution usually occurring within a year. In 1974, Ellenberg reported on six patients with diabetic neuropathy who complained of profound weight loss and severe neuropathic pain. These patients were all males, chiefly in the sixth decade of life, had bilateral symmetrical peripheral neuropathy, severe emotional disturbance, anorexia, impotence, mild diabetes, simultaneous onset of neuropathy and diabetes, the absence of other specific diabetic complications, and a uniformly spontaneous recovery in about 1 year. Neurologic examination revealed severe muscle wasting and atrophy in all patients. Motor nerve conduction velocity studies and electromyographic studies corroborated the presence of neuropathy in all cases. Biopsies of muscle and nerve showed neu-rogenic atrophy in muscle and marked involvement of the nerves, with decrease of axon fibres. Ellenberg coined the term 'diabetic neuropathic

Thyroid Disorders Thyrotoxicosis

Anorexia occasional, usually younger patient with mild disease, weight gain may occur when caloric intake exceeds metabolic demand 18 . Anorexia, rather than hyperphagia, occurs in about one-third of elderly TS patients and contributes to the picture of apathetic TS 22 .

Ectopic ACTH Syndrome and Weight Loss

Most patients affected by ectopic ACTH syndrome have malignant tumours, half of them being small-cell lung carcinoma. The metabolic manifestations appear suddenly and progress rapidly while the typical Cushing's habitus is absent. Anorexia, weight loss, and anaemia are frequent and comprise the picture of neoplastic cachexia 30,31 .

Use in Prevention and Therapy

During increased physiologic stress, body requirements for BCAAs are greatly increased relative to other amino acids. Supplemental BCAAs are important in conserving body stores of protein in chronic illness, anorexia nervosa, very low-calorie diets, injury, surgery, burns, or infection.3 Anorexia. Appetite and food intake are increased when serotonin levels in the brain are low. By reducing brain uptake of tryptophan (the precursor of serotonin), BCAAs may increase appetite and food intake in disorders where appetite is lost (chronic infection, AIDS, cancer).

Hypothalamic Diseases and Weight Loss

Besides pituitary dysfunction, diseases of the hypothalamus can cause abnormal mental function and behavioural disorders, including hyper-phagia which leads to marked obesity or anorexia with weight loss 36 . Indeed, the hypothalamus is involved in the regulation of diverse functions and behaviours -in particular, social behaviours, sleep, sexuality, body temperature, and eating patterns. The abnormal eating pattern in subjects affected by hypothalamic lesions include exaggerated and uncontrolled food intake (binge eating, or bulimia) or profound anorexia with cachexia, as in Simmond's disease 37 . These are analogous to syndromes of hyperphagia produced in rats by destruction of the ventromedial nucleus or of connections to the paraventricular nucleus, while lateral hypothalamic damage causes profound anorexia 36 .

Effects On The Fetus And Neonate

Although maternal poliomyelitis in the first two trimesters can be associated with spontaneous abortion or stillbirth and can predispose to intrauterine growth retardation and premature delivery, poliovirus infection of the fetus was an infrequent occurrence in the prevaccine era (2-7). Maternal poliovirus infection was not linked to an increased incidence of congenital anomalies (8). Neonatal poliomyelitis was a complication of maternal infection, however. Cases presented from birth to 28 days of age, with most cases occurring between days 5 and 21. The incubation period of neonatal poliomyelitis was often shorter (< 11 days) than that observed with poliomyelitis acquired at a later age. Symptoms included anorexia and lethargy, and paralytic disease was frequent. Fever was variable, and diarrhea occasionally was present. Reports of neonatal Neonatal infections by the nonpoliovirus EVs can be asymptomatic, cause benign illness, or produce life-threatening, severe disease (33,34)....

Protein Energy Malnutrition

The main cause of protein-energy malnutrition in Crohn's disease patients is anorexia, probably resulting from postprandial abdominal pain, diarrhoea, dietary restriction, and the side effects of medications 5,6 . In addition, animal studies have shown that anorexia can result from increased levels of tumour necrosis factor (TNF)-a, interleukin (IL)-1, and other cytokines 7, 8 . These weight-loss-inducing cytokines increase the expression of leptin mRNA in adipose tissue as well as plasma levels of leptin, despite the decrease in food intake that normally suppresses leptin expression 1011 . Thus, leptin may also be involved in anorexia accompanying Crohn's disease. In contrast, Lanfranchi and Geerling showed that energy intake was not decreased, but tended to increase in patients with Crohn's disease in the stage of remission or low activity 13, 14 . These results suggest that the amount of dietary intake in patients with Crohn's disease depends on the activity of the disease.

Initial Evaluation Of The Patient With Substance Use Disorders

Ally begins crossing the blood-brain barrier within 15-20 seconds. Physical signs of acute opiate intoxication include euphoria and tranquility, sedation, slurred speech, problems with memory and attention, and miosis. Signs and symptoms of opioid withdrawal can be both objective (rhinorrhea and lacrimation, nausea and vomiting, diarrhea, piloerection, mydria-sis, yawning, and muscle spasms) and subjective (body aches, insomnia, craving, dysphoria, anxiety, hot and cold flashes, and anorexia). Heroin withdrawal usually begins within 4 to 8 hours after last use, whereas with methadone, with its longer elimination half-life, withdrawal may not begin until 24 to 48 hours after last use.

Nutritional Support

In case of hypona-traemia, water restriction should be imposed, and in case of ascites or oedema, sodium restriction is needed. Cirrhosis patients with encephalopathy require protein restriction and solutions enriched in branched-chain amino acids (BCAAs) 78 . Because BCAAs compete with tryptophan, which is the precursor of brain serotonin, across the blood-brain barrier, they block the increased hypothalam-ic activity of serotonin that strongly decreases appetite therefore, BCAAs may also serve to counteract anorexia and cachexia 79 .

Feeding Disorder of Infancy or Early Childhood Diagnosis

Feeding Disorder of Infancy or Early Childhood is defined in the DSM-IV-TR as a persistent failure to eat adequately with significant failure to gain weight or a significant loss of weight over a period of at least 1 month. However, this general definition of feeding disorder in DSM-IV-TR does not take into account the heterogeneity of feeding and growth problems in infants and its implication for treatment. Several authors have used various diagnostic methods and assigned different labels to address the heterogeneity of feeding problems associated with failure to thrive. Because of the diversity of feeding disorders associated with failure to thrive and the lack of a subclassification of feeding disorder as defined in DSM-IV-TR, this chapter focuses on a classification of feeding disorders proposed by Chatoor. Three developmental feeding disorders are described as (1) feeding disorder of state regulation, (2) feeding disorder of poor mother-infant reciprocity, and (3) feeding...

Client And Clinician Selection

In selecting clients, in general, the goal is to be as inclusive as possible, with a plan to monitor clients over time and evaluate whether the model appears helpful to them. As noted earlier, although most of the empirical studies on Seeking Safety were conducted on clients formally and currently diagnosed with both disorders, in clinical practice the range has been much broader. It has included clients with a history of trauma and or SUD, clients with serious and persistent mental illness, clients with just one or the other disorder, and clients with other disorders (e.g., eating disorders). An important consideration is clients' own preference. Given the powerlessness inherent in both PTSD and SUD, empowerment is key. It appears best to describe the

Regulation of Appetite in the Elderly

Regulation of appetite is a sophisticated process that involves feedback from peripheral sensory endings and the interaction of a variety of neurotransmitters in the central nervous system 1 . Numerous studies have shown that food intake declines over the human lifespan, with males having a greater decrease in food intake than females. A large part of the anorexia of aging seems to be related to the changes in gastrointestinal activity that occurs with aging 1 . Starvation (Anorexia of aging) The hormone leptin is released from adipose tissue 18 and exerts its effects by decreasing food intake and increasing the metabolic rate. Circulating leptin levels increase in older men and decrease in older women 19 . The increase in lep-tin levels in men is related to the decrease in testosterone that occurs with aging 1 , which, in turn, is associated with muscle loss 20 and an increase in body fat 21 . Testosterone replacement in older men leads to a decline in leptin levels 1 . The increase...

Major Depressive Disorder And Mood Disorders With Depressive Features Due To Hiv And Aids

Depressive illness is a major cause of distress in patients with HIV and AIDS, and has a severe impact on the quality of life and on medication adherence. Depression is a debilitating condition its symptoms include sadness, pessimism, anhedonia, guilt, and sui-cidality in addition to neurovegetative changes such as impaired sleep and appetite. These latter signs can often be confused with the primary illness, as HIV and AIDS often produce fatigue, anorexia, and wasting syndromes, making the diagnosis of depression challenging in this patient group. Additionally, somatic symptoms of depression may be confused with opportunistic infections, further complicating the differential diagnosis and increasing utilization of physicians' time and services.

Clinical Features Of Hivassociated Castlemans Disease

In general, MCD presents in the fourth or fifth decade of life but occurs earlier in people who are HIV positive. Patients often present with generalized malaise, night sweats, rigors, fever, anorexia, and weight loss. On examination, they have multiple lymphadenopa-thy, hepatosplenomegaly, ascites, edema, and effusions both pulmonary and pericardial. Laboratory investigations may reveal thrombocytopenia, anemia, hypoalbuminemia, and hypergammaglobulinemia. The systemic symptoms are attributed to IL-6 and can be severe enough to cause pancytopenia, organ failure, particularly respiratory and renal, as well as shock, requiring admission into intensive care units. HIV-infected patients with MCD have a greater preponderance for pulmonary complications. MCD is more likely to lead to neuropathic complications than does locally confined Castleman's disease. Patients can develop polyneuropathies, leptomeningeal and CNS infiltration, as well as myasthenia gravis.114 The polyneuropathy is a...

Posttraumatic Feeding Disorder

In addition to a thorough history about the onset of the infant's food refusal and the medical and developmental history, the observation of the infant and mother during feeding is critical for understanding this feeding disorder and differentiating it from infantile anorexia and from sensory food aversions. It is helpful to ask the mother to bring a variety of foods, including those that the infant refuses and those that he or she accepts. Infants with a posttraumatic feeding disorder characteristically appear engaged and comfortable with their mothers as long as the feared food is out of sight.

Cachexia Pathophysiology

Cachexia in the elderly cannot be completely explained by reduced food intake rather, several social and psychological factors, disease conditions, and medications can aggravate the physiological anorexia of aging and lead to weight loss 1 . Furthermore, a person eats less when he or she eats alone compared to when eating in a group. The pleasurable qualities of food are determined by taste, smell, and vision 1 , with olfaction being the most important determinant 1 . The decreased sense of smell and the changes in taste that occur with aging (taste threshold, difficulty in recognising taste mixtures, and increased perception of irritating tastes) contribute to anorexia 1 . Other factors that contribute to the development of cachexia are detailed in the following sections.

Nonsurgical Therapy 1781 Adjuvant therapy 17811 Interferon

Despite the evidence that adjuvant HDI is effective in patients with high-risk melanoma, the use of HDI is associated with significant toxicity, including anorexia and weight loss, neuro-psychiatric symptoms, myelo-suppression, and hepatotoxicity 92-94 . There are limited data on the use of this interferon regimen in patients under age 18 years. At the MD Anderson Cancer Center, 11 patients under aged 18 years have been treated with HDI, 1 patient was lost to follow-up after completion of the IV interferon (age 4 years), 6 completed the regimen with no problems (ages 916 years), and 4 had therapy discontinued early due to toxicity, 2 liver (age 6 and 11 years), 1 each neuro-cog-nitive (age 5 years) and pancreatic (age 2 years). At St. Jude Children's Hospital, 11 patients have been treated with HDI. It was well tolerated during induction, with only two grade 4 hematologic events and one grade 4 liver event (WL Furman, personal communication).

Tumour Necrosis Factor

Depend on the site of production 40 . This was demonstrated by intracerebral injection of TNF-a-secreting cells, which resulted in body weight loss and anorexia, while TNF-a-producing cells inoculated into peripheral tissue triggered cachexia, including weight loss, depletion of lipid and protein stores, and anaemia but without significant anorexia 39,40 .

Role of Ghrelin in Cachexia

The infusion of ghrelin stimulates eating and produces obesity in rats 79 , and a study in humans showed that ghrelin infusion led to short-term increase in hunger 80 . Maintenance of weight reduction after gastric bypass surgery was suggested to be due to markedly low levels of ghre-lin 76 . It has also been shown that ghrelin levels are elevated in cachectic patients with chronic heart failure or anorexia nervosa 78 . Several studies are currently underway to explore the effects of ghrelin and its agonists on cachexia.

Pathophysiology of Cachexia Mechanisms of Cachexia

Lack of protein-caloric nutrients due to famine, voluntary refusal, nervous anorexia, or poor diets, causes slimming. Infectious diseases, cancer, burns, traumas, or surgery induce hyperca-tabolism, which, by means of very similar metabolic responses (e.g. acute-phase response APR ) leads to self-cannibalism and to cachexia 35, 36 . Self-cannibalism is, in the short-term, the physiological strategy for coping with a pathogenic noxa. It can be advantageous because it immediately supplies amino acids to repair tissue damage and for the synthesis of acute-phase proteins in the liver 32,37 .

Symptoms and Complications

The incubation period is approx 6 weeks to 6 months. As the name suggests, the virus primarily affects the liver. Typical symptoms include malaise, anorexia, nausea, mild fever, and abdominal discomfort and may last from 2 days to 3 weeks before the insidious onset of jaundice. Joint pain and skin rashes may also occur as a result of immune complex formation. Infections in the newborn are usually asymptomatic.

Physiological Effects

The plateau stage of drug effects lasts 3-4 hours. The principal desired effect, according to most users, is a profound feeling of relatedness to the rest of the world. Most users experience this feeling as a powerful connection to those around them, as well as to the universe (Leister, Grob, Bravo, & Walsh, 1992). Although the desire for sex can increase, the ability to achieve arousal and orgasm is greatly diminished in both men and women (Buffum & Moser, 1986). MDMA has thus been termed a sensual, not a sexual, drug. The prescription drug sildenafil (Viagra) may be taken in order to counteract this effect, and may be sold along with MDMA (Weir, 2000) the successor medications involving sexual enhancement can be expected to be used in this manner. The array of physical effects and behaviors produced by MDMA is remarkably similar across mammalian species (Green et al., 1995) and includes mild psychomotor restlessness, bruxism, trismus, anorexia, diaphoresis, hot flashes,...

Pancreatic cancer 31 Background

Specifically, the pain is constant and radiates to the middle and upper back, and it is due to invasion of the celiac and mesenteric plexuses (31-33). Obstructive jaundice occurs in approx 50 of all patients and up to 90 of those having cancer in the head of the pancreas (34). However, obstructive jaundice may represent less advanced cancer because patients seek medical attention early. Nausea, anorexia, weight loss, and fatigue also occur frequently.

Endocrine Abnormalities and Cytokines

The clinical symptoms of anorexia, nausea, fever, asthenia, fatigue, lethargy, myalgia, sickness, diarrhoea, anaemia, leucocytopaenia, tachycardia, headache, neurovegetative disturbances, etc., can be attributed to the release of cytokines by macrophages and activated inflammatory cells. Lipid metabolism disturbances, anorexia, and weight loss together lead to cachexia and are caused by the combined action of TNF, IL-1, IL-6, and IFN-y, the production of each being stimulated by infections and cancer 82, 83 . We demonstrated 84 high levels of TNF-a in HIV patients who had lost more than 10 of their ideal weight (Table 3).

Futile Metabolic Cycles of Lipids

Correct amount of calories is given 87 . Many studies have shown, instead, that disturbances in lipid metabolism, anorexia, and weight loss, all of which lead to cachexia, are due to the combined action of TNF, IL-1, IL-6, and IFN-y 85, 86 , whose production is stimulated by infection and neoplasms 78,82 .

Mechanism of Action

MDMA is a dirty drug, affecting many neurotransmitter systems. It is primarily serotonergic, and its principal mechanism of action is as an indirect seroto-nergic agonist (Ames & Wirshing, 1993 Rattray, 1991 Sprague et al., 1998). The drug's effects, and side effects (an arbitrary distinction), including anorexia, psychomotor agitation, difficulty in achieving orgasm, and profound feelings of empathy, can be explained as a result of the flooding of the serotonin system (Beck & Rosenbaum, 1994). After ingestion, MDMA is taken up by the serotonin cells through active channels, effecting the release of serotonin stores. MDMA also blocks reuptake of serotonin, and this contributes to its length of action. Although it inhibits the synthesis of new serotonin, this does not contribute to the intoxication phase, but it may contribute to sustained feelings of depression reported by some users and to a diminished magnitude of subjective effects when the next dose is taken within a few...

Gallbladder and biliary system cancers 41 Background

Gallbladder cancers are often diagnosed incidentally or in late stages. The symptoms can include pain, vomiting, fatty food intolerance, anorexia, jaundice, and weight loss. Unlike gallbladder cancer, however, the most common symptom of bile duct cancer is painless jaundice, especially in patients having cancer involving the proximal bile duct. Nonspecific symptoms also can be manifested.

Amylin Analogs Pramlintide

Pramlintide is the first amylin analog commercially available and received FDA approval in March 2005 for therapy in both T1DM and T2DM. Pramlintide, studied as an adjunctive therapy to insulin, has been shown to improve postprandial and overall glycemic control in individuals with both T1DM and T2DM (improvements in HbA1C of 0.67 82 and HbA1C of 0.62 ,83 respectively) without increasing the incidence of hypoglycemia or weight gain. The glycemic improvements with pramlintide had no significant effects on lipid concentrations or blood pressure and showed no evidence of cardiac, hepatic, or renal toxicity. The most frequent adverse side effects associated with pramlintide therapy include transient mild to moderate nausea and anorexia. In its current formulation, pramlintide is administered via subcutaneous injection separately from insulin.

Medroxyprogesterone Acetate and Megestrol Acetate Clinical Experiences

Medroxyprogesterone Acetate In two clinical studies 22, 66 , we used MPA(1 g day, os) and a hypercaloric diet to correct anorexia and cachexia occurring in HIV-infected patients. In the first study 22 , MAP was administered to 74 AIDS patients. The control group of 96 The progestogenic synthesised derivative MA has been successfully used in the treatment of neoplas-tic cachexia, anorexia, and in AIDS patients 24,56, 81-83 , but the optimal dosage of the drug remains to be defined. Also, the mechanism of action of MA is many-sided and not yet completely understood. It is thought that the stimulation of appetite by progestogens takes place at the hypo-thalamic level 84-86 . A second effect of MA, which has been demonstrated in vitro, is the promotion of fibroblast transformation into adipocyte. Finally, evidence has emerged showing anti-TNF and anti-IL-1 action 83 . may be achieved with a dose of 320 mg day. We designed a controlled study to evaluate the safety and efficacy of MA at...

Radiolabeled Antibodies

Adverse events included fatigue (43 ), fever (30 ), nausea (25 ), infection (25 ), chills (15 ), vomiting (13 ), pruritis (13 ), anorexia (10 ), and hypotension (10 ). The hematologic nadir occurred on days 43, 46, and 34 for red cells, white cells, and platelets, and median recovery occurred at 74, 78, and 73 days, respectively. In this study, five patients developed myelodysplastic syndrome 1.2-7.5 years after treatment, but all had previously received alkylating agents.25 Two patients later developed bladder cancer, but both had previously received cyclophosphamide. An elevation of Thyroid stimulating humane (TSH) was noted in five patients, but was asymptomatic in all five.

CASE 4 Hypothalamic Amenorrhea Case Description

This 28-yr-old Asian-American female presented for the evaluation of secondary amenorrhea at age 24. Menarche began at 13 yr of age and was followed by several years of irregular periods. At age 16, her menses stopped and she remained amenorrheic until her presentation. She denied any significant change in lifestyle or activity. There was no antecedent weight loss or illness. She was not depressed and denied a history of eating disorders or anosmia. Her examination was significant for Tanner stage 4 breast development and Tanner stage 5 axillary and pubic hair development. Her vagina, however, was severely atrophic, suggesting long-term hypoestrogenism. There was no indication of other endocrine disorders.

Factors Other Than Cytokines

In addition to humoural factors, tumour-derived molecules have also been suggested as mediators of cancer cachexia. Firstly, cancer cells are capable of constitutively producing cytokines. These may act on cancer cells in an autocrine manner or on supporting tissues, such as fibroblasts and blood vessels, to produce an environment conducive to cancer growth 31 . While tumour-produced cytokines may have a more important role in the anorexia-cachexia syndrome, several compounds produced by the host 32 are likely to have an important role in mimicking the metabolic

Clinical Manifestations Of Dengue Infection

Dengue fever is characterized by sudden onset of fever, frontal headache, retro-orbital pain, general malaise, generalized myalgias and arthralgias, nausea, vomiting, and rash. One characteristic feature of dengue fever is the severity of body pain, which can be incapacitating and explains why the disease is sometimes called breakbone fever. Other nonspecific symptoms may be present, such as anorexia, mild conjunctival injection, diarrhea, pruritus, and changes in taste sensation. Leukopenia and thrombocytopenia are frequent, and liver enzymes may be mildly elevated. The febrile period lasts 5-7 days, but the patient may remain symptomatic for several more days. The disappearance of fever correlates with the disappearance of viremia. Convalescence may be marked by a period of lassitude. There have been reports of severe depression after the acute period of illness (4,5).

Alternative Models of Cachexia

Most of the studies that have identified cytokines as important determinants in cancer cachexia have employed rat tumours. These tumours tend to grow rapidly, have a strong anorectic component, and may require large tumour masses before cachexia is apparent. However, most human tumours grow slowly, can produce cachexia in the absence of anorexia 5 , and the tumour mass does not normally exceed 5 of the body weight. In human cachexia, there is also evidence for a circulatory factor capable of inducing protein degradation in skeletal muscle in patients with weight loss > 10 6 . MAC16 is a chemically induced, transplantable adenocarcinoma of the colon, that is passaged in inbred NMRI mice 7 .In male animals,weight loss occurs when the tumour mass comprises more than 0.3 of body weight and reaches 30 when the tumour represents just 3 of body weight 8 . Weight loss involves a decrease in both carcass fat and skeletal muscle mass and is directly proportional to the weight of the tumour....

Pharmacological treatments of OSA risk factors and morbidities

That particular psychotropic drugs such as the SSRI antidepressants fluoxetine (see also above), sertraline and fluvoxamine may be useful as weight-loss agents was initially suggested by the unexpected observation of weight loss in trials of these agents in patients treated for neuropsychiatry conditions 92 . Subsequently, randomized controlled trials were specifically designed to assess their efficacy as weight-loss agents in obesepatients without neuropsychiatry co-morbidities. Of these agents, fluoxetine has been the most studied, in obese subjects without attendant co-morbidities 93 , in obese subjects with diabetes 94, 95 and in obese subjects with eating disorders 96 . Short-term (8 weeks) studies in the first group showed an approximate weight loss of about 4 kg compared with placebo, though doubts have surfaced about sustained benefit in longer-term studies. Trials of fluoxetine as a weight-loss agent in obese type 2 diabetics have shown mixed results. Fluoxetine has shown to...

Pineal Gland and Cancer

The activity of pineal indoles on immune regulation suggests a major role for central nervous control of immune pathways 39-42 for example, melatonin has been reported to have anti-inflammatory effects 43, 44 . Indeed, pineal gland function may act on several levels in the pathways leading to cancer-associated anorexia-cachexia syndrome.

Cachexia and Melatonin

Among the possible mediators involved in the pathophysiology of cancer anorexia-cachexia, the increased production of tumour necrosis factor (TNF)-a has long been implicated 45 as one of the major cytokines inducing wasting syndrome and enhancing REE. Melatonin was demonstrated to be able, both in vitro and in animals, to inhibit the lipopolysaccharide-induced TNF production in an endotoxic shock model 46 . In a preliminary study 47 , we found evidence of feedback systems between the pineal release of melatonin and TNF secretion other studies on the clinical use of mela-tonin in the palliation of symptoms suggested a role for melatonin activity in the improvement of the clinical conditions of patients with advanced-stage cancer 48 .

Historical Context

Cancer is a leading cause of death in Americans, second only to heart disease. While breast cancer kills the most women, many gynecological cancers are part of the overall cancer statistic. Ovarian cancer, the so-called whispering disease because of its insidious nature, is detected in one in 70 predominantly perimenopausal and postmenopausal American women and often metastasizes undetected. Risk factors include family history of ovarian and breast cancer, high dietary fat, delayed menopause, and no or late childbearing. The use of oral contraceptives appears to decrease risk. Ovarian cancer often presents itself with a cluster of three persistent and severe symptoms a swollen abdomen, a bloated feeling, and urgent urination. Other symptoms associated with the disease include gas pains, anorexia, backache, and indigestion. Unfortunately most women seek medical advice when their ovarian cancer is in the advanced stage because the symptoms might be associated with other gynecological...

Nutrition in the Palliative Care Context

The goal of palliation is to alleviate the suffering of patients and their relatives that is caused by distressing symptoms and complications. Treatment is based on active assessments that take into account multidimensional (physical, psychological emotional, social, spiritual existential) aspects 6 . Palliative nutrition aims to primarily improve subjective well-being of patients and their relatives, rather than to improve weight or nutritional intake per se (for further discussion of this concept, see the chapter 'Palliative Management of Anorexia Cachexia and Associated Symptoms').

Symptom Assessment Close to the Patients Endof Life Multidimensional Issues

Eating-related symptoms may also carry a more multidimensional meaning, one that reflects the suffering. The concept of 'total anorexia' has not been defined, although attempts have been made to define 'total pain.' Likewise, a staging system for eating-related symptoms, in order to identify refractory eating-related symptoms, has not yet been developed.

The Meaning of Eating in Terminally Ill Patients Importance of Carers

Mc Clement et al. observed three patterns of family interactions with patients and health-care providers around the issue of nutritional care in the Palliative Care Unit setting 14 . The authors used a qualitative systematic approach with repeated interviews until saturation. The first pattern was 'fighting back.' Family interactions were driven by expectations to reverse anorexia and cachexia, which were perceived as the cause, not as a consequence of the terminal illness. Substantial conflict between family members and health-care providers was reported. The second pattern, 'letting nature take its course,' was characterised by desire-driven care. Nutrition was understood not to stave off the inevitable and so family members found other ways to care ('being there,' 'simply be'). They appreciated the opportunities to say goodbye and to express feelings. In the third pattern, 'waffling,' family members were ambivalent, shifting between fighting back and letting nature take its course....

Assessment Instruments for Eating Related Distress

Traditional instruments, such as the FAACT (Functional Assessment of Anorexia Cachexia Therapy) for anorexia cachexia, or widely used quality-of-life instruments, such as the EORTC-QlQ-c30, carry some items related to distress, but they were not specifically developed for the purpose of assessing distress. The FAACT 19 , as an example, asks at least three distress-related questions 'I am worried about my weight' (item 3), 'I am concerned how thin I look' (item 5), and 'my family or friends are pressuring me to eat' (item 8). In the general section of the FACT, there is a question regarding the impact of physical function on social contacts (item 3). In the EORTC-QlQ-c30, questions assessing interference with (physical) function (items 6, 7) or social contacts (items 26, 27) may depict issues related to cachexia and weakness, but not directly to eating. As a solitary symptom, only the impact of pain on daily life (item 19) is included in the EORTC-QLQ-C30, but there are no items...

Decreased Food Intake

Malnutrition may be considered one hallmark of cancer cachexia and it is associated with anorexia, that is, loss of appetite and or decreased food intake. Appetite is a complex function resulting from the contribution of peripheral and central nervous afferents in the ventral hypothalamus. Stimulation of the medial hypothalamic nucleus inhibits feeding, while stimulation of the lateral nucleus promotes food intake. Among peripheral afferents, oral stimulation by pleasant tastes elicits There is evidence that proinflammatory cytokines such as IL-1, IL-6 and TNF-a are involved in cancer-related anorexia and decreased food intake, but these cytokines do not seem to be the only mediators of CAC. Since multiple factors are involved in the control of food intake, it is possible that there are also many factors contributing to the tumour-associated anorexia. Indeed, anorexigenic compounds are either released by the tumour into the circulation or the tumour itself may induce metabolic changes...

Nonsteroidal Anti Inflammatory Drugs

Inhibiting PG production by the rate-limiting enzymes known as cyclo-oxygenases (COX). Because traditional NSAIDs inhibit both COX-1 and COX-2, these drugs induce adverse effects such as gastrointestinal injury up to ulceration, reduced appetite and consequent reduced body weight indeed, these drugs may be considered a potential cause of anorexia in patients with cancer.

Palliative Nutritional Endpoints and Decision Making

A careful multidimensional evaluation is the basis for treatment decisions for patients with advanced illness, such as cancer, suffering from anorexia, cachexia and related symptoms (see also Chp. 9.11 'Eating-related Distress of Patients with Advanced, Incurable Cancer and Their Partners'). In order to prioritise anorexia cachexia in the present (and often rapidly fluctuating) context, the patient should be assessed considering concurring physical (anorexia, fatigue, asthenia, body image, chronic nausea), psychological-emotional (anxiety, worthlessness, anhedonia), social (meal-ritual, express love through cooking) and spiritual-existential (bread of life) symptoms and distress. The subsequently developed comprehensive management approach involves team interactions and agreement with the patient and family about treatment goals and meaningful outcomes. The goals of the intervention may concentrate predominantly on changes in body image, focus on improvement of function, consist in...

Palliative Symptom and Syndrome Management

For palliative treatment of anorexia, the progestins are still the most effective drugs, but with limited effects on other nutritional endpoints. It remains to be discussed with the patient, whether the pure improvement of the sensation of appetite is a meaningful endpoint considering the side-effects and price. Corticosteroids are effective, but only for a few weeks, then side-effects gain importance. Prokinetics are helpful for chronic nausea in a subgroup of patients. Newer treatments have the Constipation often causes symptoms such as anorexia, early satiety or nausea before it is perceived as a symptom (feeling of incomplete evacuation, fullness of the bowel, etc.). It needs to be diagnosed as a syndrome (history, X-ray abdomen, rectal examination), not as a symptom.

The Diagnosis of Cancer Cachexia and its Implications

However, not all patients will conform to the stereotypical image of 'cachexia' for example, they may still be technically overweight despite having lost a substantial mass of lean tissue or they may be relatively weight-stable despite significant physiological change.