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Background: The question of where to hospitalize extremely malnourished patients with anorexia nervosa (AN) is a real dilemma. On one hand, psychiatrists have to deal with severe medical complications that are not within their competences and that justify hospitalization in an internal medicine ward. On the other hand, medical doctors have to face psychic decompensations that would justify admission to a psychiatric ward. In this context, we share our experience of management of severely malnourished AN adult patients in a transdisciplinary specialized eating disorders (ED) unit, referral center for AN associated with somatic severity. Method: First, we described the modalities of care proposed to patients with AN hospitalized in the medical unit. Intensive medical care, both somatic and psychiatric, are provided thanks to a transdisciplinary therapeutic program, where objectives are to: medically stabilize the patient, initiate progressive refeeding and start supportive psychotherapy before being transferred to a psychiatric ED unit. Secondly, we conducted a retrospective descriptive study that included all adult patients with AN admitted for the first time to the unit, between November 1997 and January 2014, for severe malnutrition and/or complications of the ED. Objective was to specify patients’ characteristics: demographic, nutritional status, history of ED, care pathway. Results: Among a cohort of 386 adult patients with AN (21 males and 365 females) admitted for the first time in the unit, mean age was 29.4 (±11.5) years, mean BMI was 12.7 (±2.2) kg/m2. Before being supported in the unit, 78.2% of patients had already been hospitalized in other hospitals. Mean length of stay was 35.2 days. Patients were clinically serious and unstable because of life-threatening somatic complications due to a low BMI. During hospital stay, a temporary transfer to medical intensive care unit was necessary for 25.6% of patients. Average patient weight gain was 0.777 kg per week and 81.9% of patients benefited from enteral nutrition. Conclusion: This specialized transdisciplinary unit where physician nutritionists and psychiatrists coordinate medical care together, allow a better understanding and management of extreme malnutrition associated with AN. Thanks to their expertise, care teams are less critical and less rejecting towards patients. Thus, therapeutic alliance could be optimized.

BACKGROUND: Citrulline (CIT), is not extracted by the splanchnic area, can stimulate muscle protein synthesis and could potentially find clinical applications in conditions involving low amino acid (AA) intake, such as in malnourished older subjects. OBJECTIVE: Our purpose was to research the effects of CIT supplementation on protein metabolism in particular on non-oxidative leucine disposal (NOLD, primary endpoint), and splanchnic extraction of amino acids in malnourished older patients. DESIGN: This prospective randomized multicenter study determined whole-body and liver protein synthesis, splanchnic protein metabolism and appendicular skeletal muscle mass (ASMM) in 24 malnourished older patients [80-92 years; 18 women and 6 men] in inpatient rehabilitation units. All received an oral dose of 10 g of CIT or an equimolar mixture of six non-essential amino acids (NEAAs), as isonitrogenous placebo, for 3 weeks. RESULTS: NOLD and albumin fractional synthesis rates were not different between the NEAA and CIT groups. Splanchnic extraction of dietary amino acid tended to decrease (p = 0.09) in the CIT group (45.2%) compared with the NEAA group (60.3%). Total differences in AA and NEAA area under the curves between fed-state and postabsorptive-state were significantly higher in the CIT than in the NEAA group. There were no significant differences for body mass index, fat mass (FM), lean mass (LM) or ASMM in the whole population except for a tendential decrease in FM for the citrulline group (p = 0.089). Compared with Day 1, lean mass and ASMM significantly increased (respectively p = 0.016 and p = 0.018) at Day 20 in CIT-treated women (mean respective increase of 1.7 kg and 1.1 kg), and fat mass significantly decreased (p = 0.001) at Day 20 in CIT-group women (mean decrease of 1.3 kg). CONCLUSIONS: Our results demonstrate that CIT supplementation has no effect on whole-body protein synthesis or liver protein synthesis in malnourished older subjects. However, CIT supplementation was associated with a higher systemic AA availability. In the subgroup of women, CIT supplementation increased LM and ASMM, and decreased FM.

Background The need to preserve operating room (OR) scheduling flexibility can challenge adherence to the 2-h pre-operative fasting period recommendation before elective surgery. Our primary objective was to assess the feasibility of a pre-operative carbohydrate (CHO) drink delivery strategy preserving OR scheduling flexibility. Methods During the 1st study phase, patients admitted for elective surgery fasted overnight (Control group); during the 2nd phase, patients fasted overnight and received a pre-operative CHO drink (CHO group). CHO delivery time was set to allow any patient to be ready for surgery 30 min ahead of the scheduled time and any patient with an operation scheduled in the afternoon to be ready at 13:00 hours; patients admitted the morning of an early morning operation would not be allowed to take a CHO drink. Results We included 194 patients in the Control group and 199 in the CHO group. In the CHO group, the morning CHO dose was delivered to 66.3% of the patients (95% CI 59.3–72.9%), with a median pre-operative fasting time period of 4 h 57 min. After excluding patients admitted the morning of an operation scheduled before 10:00 hours, the delivery rate was 77.2% (70.2–83.3%). Patients in the CHO group experienced significantly less pre-operative thirst (median 2 vs. 5 on a 0–10 scale, P < 0.0001) and hunger (0 vs. 2, P < 0.0001) than those in the Control group. Conclusion Although preservation of OR scheduling flexibility resulted in a longer fasting time than recommended, CHO drink can be made available to a large proportion of patients with significantly reduced perioperative discomfort.

L'infection par le VIH est une maladie aux facettes multiples. Cette infection virale chronique est, au moins a ces debuts, pauci symptomatique. Elle detruit pourtant progressivement le systeme immunitaire tout en provoquant des perturbations metaboliques aux consequences inattendues. Celles-ci vont constituer le lit de la denutrition chronique dont l'installation plus ou moins rapide dependra des conditions d'environnement du sujet infecte, jusqu'au moment ou les infections dites opportunistes, en raison de leur survenue avec l'immunodepression, vont elles-memes precipiter et rendre irreversible cette denutrition. Le controle par les anti-retroviraux de la multiplication du virus va totalement bouleverser les voies metaboliques precedemment mises a mal. Ces nouvelles perturbations vont laisser une trace visible sur la silhouette du sujet infecte alors que le developpement de l'atherosclerose semble etre promu par cette nouvelle situation metabolique. Ces differentes facettes doivent etre connues. L'extension de l'epidemie de sida a travers le monde conduira tous les praticiens quelques soit leur specialite a la rencontrer. La denutrition au premier plan des aspects nutritionnels du sida depuis 20 ans ne disparait pas. Elle reste une preoccupation majeure des pays depourvus de possibilite therapeutique et n'a pas disparu des pays occidentaux favorises. Les aspects metaboliques et nouveaux que la survie des malades fait apparaitre mettra en demeure bien des medecins de pouvoir repondre aux questions des malades.

ResumenEste trabajo era un estudio metabólico de la bulimia nerviosa necesario para diseñar una terapia cognitivoconductual (TCC) a corto plazo que comenzaba con una admisión breve en una sala psiquiátrica. El tratamiento produjo mejorías significativas en la conducta alimentaria, y los resultados se comparan con los de estudios publicados antes. Las comparaciones no indican que una admisión breve al comienzo de la terapia pueda aumentar su efectividad. Por otro lado, se encontró que el aumento en la ingesta normal de alimentos correlacionaba significativamente con la disminución en los atracones. Esto apoya la noción de que la ingesta apropiada de alimentos a la hora de las comidas debería ser una cuestión importante en la TCC para la bulimia nerviosa.

The relationship between birth weight and body composition at later stages in life was not studied previously in anorexia nervosa (AN). The aim of the following brief report is to present results concerning the relationship between birth weight and later body composition specifically in AN, and to check if the programming of body composition from birth weight is still detected in severely emaciated AN patients. One hundred and fifty-one female AN patients aged between 13 and 44 were recruited from 11 inpatient treatment facilities in France. Birth weight, body weight and height were obtained. Body composition was measured using bioelectrical impedance. Birth weight was significantly correlated to lifetime maximum body mass index (BMI; r=0.211, P=0.009) and significantly correlated to fat-free mass index (r=0.190, P=0.027) but not to fat mass index (FMI). This report confirms that even in AN when patients are severely emaciated and where fat-free mass (FFM) and fat mass (FM) are low, a link between birth weight and FFM and BMI can still be identified, independently from age. Further studies are needed on larger samples exploring other factors, such as gender, puberty and ethnicity.

Weight loss is reported by more than 20% of hepatitis C virus (HCV)-monoinfected patients treated with the peg-interferon (peg-IFN) and ribavirin combination. The aim of this study was to determine the incidence and risk factors of severe weight loss (> or =10%) in human immunodeficiency virus (HIV) / HCV-coinfected patients participating in a randomized, controlled 48-week trial comparing peg-IFN alpha 2b plus ribavirin with IFN alpha-2b plus ribavirin. Univariate and multivariate analyses were used to identify links with antiretroviral treatments, anti-HCV therapy and clinical and laboratory findings. One hundred eleven (28.9%) of 383 patients who received at least one dose of anti-HCV treatment subsequently had severe weight loss. Among patients who took at least 80% of the planned total dose, severe weight loss occurred in 74 patients (32.7%). In multivariate analysis, age >40 years [hazard ratio (HR), 1.59; 95% CI 1.09 to 2.31; P = 0.016], body mass index (BMI) >22 (HR, 1.72; 95% CI, 1.16 to 2.55; P = 0.0069), peg-IFN alpha-2b (HR, 1.82; 95% CI, 1.24 to 2.69; P = 0.0022) and female sex (HR, 1.60; 95% CI, 1.05 to 2.43; P = 0.027) were associated with severe weight loss. In contrast, patients taking non-nucleoside reverse transcriptase inhibitors (NNRTI)-containing antiretroviral regimens were less likely to lose weight (HR, 0.62; 95% CI, 0.39 to 0.96; P = 0.034). Lipodystrophy tended to occur more frequently in patients who had severe weight loss than in the other patients (26.1%vs 17.6%; P = 0.0682) and patients whose weight loss >5% persisted 24 weeks after the completion of anti-HCV therapy (n = 58 / 111) were more likely to be receiving stavudine-based antiretroviral therapy, suggesting that mitochondrial toxicity plays some role in weight loss. These findings show that severe weight loss is a frequent side effect of anti-HCV therapy in HIV / HCV-coinfected patients. The underlying mechanisms remain to be identified.

Undernutrition (wasting) is still frequent in patients infected with the human immunodeficiency virus (HIV), despite recent decreases in the prevalence of undernutrition in western countries (as opposed to developing countries) due to the use of highly active antiretroviral treatment. Undernutrition has been shown to have a negative prognostic effect independently of immunodeficiency and viral load. These guidelines are intended to give evidence-based recommendations for the use of enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) in HIV-infected patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. Nutritional therapy is indicated when significant weight loss (>5% in 3 months) or a significant loss of body cell mass (>5% in 3 months) has occurred, and should be considered when the body mass index (BMI) is

The majority of patients with advanced cancer develop malnutrition. This malnutrition has an important impact on quality of life, performance status and immune status. It can be responsible for increased morbidity, particularly infectious complications and thus mortality. In five to more than 20% of patients with cancer, death can be directly related to cachexia in the terminal phase (Inagaki et al, 1974; Bozzetti, 1995).

The purpose of this study was to estimate the prevalence of malnutrition in outpatients on long-term oxygen therapy or home mechanical ventilation, to determine the relationships between malnutrition and impairment/disability and smoking and also to identify relevant tools for routine nutritional assessment. In 744 patients (M:F 1.68, aged 65+/-15 yrs) with chronic obstructive pulmonary disease (COPD, 40%), restrictive disorders (27%), mixed respiratory failure (15%), neuromuscular diseases (13%) and bronchiectasis (5%), body mass index (BMI), fat-free mass (FFM), serum albumin, transthyretin, 6-min walking test, forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and blood gases were recorded. FFM was the most sensitive parameter for detecting malnutrition, being abnormal in 53.6% of patients, while BMI was

In 1999 the Council of Europe decided to collect information regarding Nutrition programmes in hospitals and for this purpose a network consisting of national experts from eight of the Partial Agreement member states was established. The aim was to review the current practice in Europe regarding hospital food provision, to highlight deficiencies and to issue guidelines to improve the nutritional care and support of hospitalized patients. Five major problems seemed to be common in this context: 1) lack of clearly defined responsibilities; 2) lack of sufficient education; 3) lack of influence of the patients; 4) lack of co-operation among all staff groups; and 5) lack of involvement from the hospital management. To solve the problems highlighted, a combined 'team-effort' is needed from national authorities and all staff involved in the nutritional care and support, including hospital managers.

The effects of malnutrition and refeeding on nutritional indices, pulmonary function, and diaphragmatic contractile properties were studied in severely malnourished patients with anorexia nervosa. Fifteen patients were evaluated upon hospital admission (Day 0) and on Days 7, 30, and 45 after starting feeding. Spirometry, lung volumes, and arterial blood gases were measured at each time interval, as were contractile properties of the diaphragm as assessed by transdiaphragmatic pressure generated during electrical phrenic nerve stimulation (Pdistim) and a maximal sniff maneuver (Pdisniff). Anthropomorphic and biochemical measurements were performed at each time interval. Patients were severely malnourished upon admission; mean body weight was 37.1 +/- 4.7 kg (63% ideal body weight). During nutritional support, body weight increased significantly to 42.9 +/- 4.6 kg on Day 45 (p0.01), as did muscle mass: 11.2 +/- 4.1 kg on Day 0, to 16.6 +/- 4.9 kg on Day 45 (p0.01). Vital capacity and FEV1 increased significantly by Day 30 (p0.05). Lung volumes were unchanged. Mean arterial blood gas values were also within the normal range at Day 0; PaO2, 92.6 +/- 2.4 mm Hg and PacO2, 41.0 +/- 1.5 mm Hg. Four patients, however, had an increased PacO2 (42 mm Hg) at Day 0, which returned to normal by Day 30. Diaphragmatic contractility was severely depressed initially; Pdistim, 15.9 +/- 1.4 cm H2O; Pdisniff, 65.4 +/- 5 cm H2O; but it significantly increased with nutritional support by Day 30 to 22.5 +/- 1.9 and 84.6 +/- 4.7 cm H2O, respectively. We conclude that diaphragmatic function is severely impaired in malnuorished patients free of other coexisting

After the introduction of cranial computed tomography (CT) it is now possible by an atraumatic procedure to evaluate the pathophysiological findings in children suffering from cerebral palsy (CP). The aim of this study is to describe the cranial CT findings in children with CP and relate these to CP-type, grade of handicap, aetiology, and presence of other functional cerebral defects. The CT-examination was performed in 83 children with spastic CP (44 boys and 39 girls). Fifty-seven children (67%) had pathological CT. There was no statistically significant difference between the frequencies of pathological CT findings in the groups with tetraplegia, diplegia, and paraplegia. The frequency of pathological CT findings was increasing with increasing severity of the motor handicap (p less than 0.05). There were significantly more children with pathological CT findings among CP children suffering from epilepsy, than among CP children without epilepsy (p less than 0.05). The CP children with the lowest IQ, had numerical more pathological CT findings but there was no significant difference among pathological CT findings in CP children with oligophrenia compared to the rest of the group. Infarction, its sequelae and hemiatrophy were much more frequent in patients with hemiplegia (p less than 0.001) compared to the other CP-types. The most frequent pathological CT finding was atrophy (44 cases among 56 pathological CT). Central atrophy with enlargement of the ventricular system or parts of this was found in 39 children.(ABSTRACT TRUNCATED AT 250 WORDS)

SUMMARY A case history of a boy born in breech presentation is reported together with the autopsy findings. In this case parturition had been uncomplicated. Throughout his seven months of life the boy had been marked by hypotonia of the lower extremities and of respiratory insufficiency. At autopsy a closed, almost transversal lesion of the cervical spinal cord was demonstrated, including progressive, degenerative processes and minor cortical injuries, all of which have probably developed simultaneously. The great value of a pathological-anatomical examination of the spinal cord is emphasized.

SUMMARY 1 Sixty children with febrile convulsions under the age of 3 were maintained on prophylactic phenobarbital in a dose of 3–4 mg/kg given in divided dosage twice daily. Double the ordinary dose was given for the first 2 days to achieve a therapeutic serum concentration within a few days. The serum concentration was checked before discharge from the hospital and at intervals of 1–3 months for 6 months. 2 Among 27 children with a serum concentration habitually at or over 16 mg/1, 1 had a brief febrile convulsion within 6 months (serum concentration not determined at the time of the convulsion). When the serum concentration was habitually or at the time of the convulsion at or under 15 mg/1, the incidence of recurrences was the same as in an untreated group, 21 % within 6 months. 3 It did not prove difficult to persuade the mothers to give the medication faithfully. There were few complications: hypersensitive rash in 1, emotional instability in 1 and acute intoxication in 2. If a few simple precautions are observed, prophylactic medication with phenobarbital is harmless and is effective in preventing recurrences. RESUME 1 Soixante enfants, âges sous 3 ans et ayant des convulsions febriles, ont ete maintenus a un traitement prophylactique, avec du phenobarbital a des doses de 3–4 mg/kg par jour. Pendant les 2 premiers jours, on a donne le double de la dose habituelle pour obtenir en quelques jours une concentration therapeutique dans le serum. Les concentrations seriques ont ete controlees apres l'admission a l'hopital et a des intervalles de un a trois mois pendant une periode de 6 mois. 2 Chez les sujets dont la concentration serique habituelle ou au moment des convulsions etait inferieure a 15 mg/1, les crises se sont reproduites avec un pourcentage identique a celui d'un groupe non-traite, c'est-a-dire 21 % au cours d'une periode d'observation de 6 mois. Par contre, chez 27 enfants qui avaient une concentration serique habituelle egale ou superieure a 16 mg/1, 1 seulement a presente une convulsion febrile de breve duree en 6 mois (au moment de la convulsion, on n'a pas determine la concentration serique). 3 Il s'est avere qu'il n'est pas difficile de persuader les meres de donner le traitement de facon adequate. II y a eu peu de complications: un rash hyper-sensitif dans 1 cas, une instabiliteemotive dans un cas et une intoxication aigue dans 2 cas. Si on prend quelques precautions simples, le traitement prophylactique par phenobarbital est sans danger et efficace pour prevenir la reapparition des crises.

SUMMARY 1 A well-controlled trial of prophylactic medication with diphenylhydantoin showed it to be ineffective in preventing febrile convulsions in children under 3 years of age. Twenty-three children were followed for 6 to 30 months. The serum concentration of diphenylhydantoin was determined every 2–3 months and was consistently above 10 μg/ml. The recurrence rate was slightly higher in them than to be expected in untreated children. Consideration was taken of the relation of age, sex and family history to the rate of recurrence. The serum concentration of the drug at the time of 5 febrile convulsions was in and above the therapeutic range in adults. 2 It is possible that diphenylhydantoin (

SUMMARY The clinical history and brain autopsy are presented of a girl who from the age of 2–3 years showed progressing neurological symptoms lasting 10 years with short periods of improvement. The clinical picture was one of mixed pyramidal and extrapyramidal signs, of speech difficulties, but well preserved mental abilities. At autopsy symmetrical lesions were found, involving the putamina and the caudate nuclei, also affecting the pons and medulla oblongata and spinal cord, being of younger age caudally in the central nervous system. The close resemblance of a case previously reported by us in 1956 is striking. Our two cases give no conclusive information with regard to the etiology and pathogenesis. Regarding classification, it is possible that we are dealing with a disorder representing a chronic form of infantile necrotizing encephalopathy comparable to a subacute form described by Richter. among others, and perhaps it is also comparable to an acute form described by Verhaart.

Eighty-three children with spastic cerebral palsy (CP) were examined with cranial CT. In 56 cases the CT findings were abnormal. The most frequent abnormality was atrophy, present in 44 patients. The frequency of pathologic CT increased with severity of the CP. Patients with CP of postnatal aetiology more often had abnormal CT than patients with other known causes. Pathologic CT findings were seen more often in patients with seizures than in patients without. Infarctions and hemiatrophy were much more frequent in patients with hemiplegia than in patients with other types of spastic CP. A special kind of central atrophy, called isolated atrophy around in the cella media, is described. This condition was seen in 20% of cases, most often in hemi- and paraplegic patients. Early infarctions in the border areas between the vascular territories of the internal carotid and the posterior cerebral artery may be the reason for this kind of atrophy.

Phenobarbital has been shown to offer effective prophylaxis against childhood febrile convulsions. However, a high percentage of children do not tolerate phenobarbital, mainly due to behavioral changes. Valproate, due to its low toxicity, appears to be an attractive alternative to phenobarbital treatment. Ninety children admitted with their first febrile convulsion were offered prophylactic treatment with either phenobarbital 3-5 mg/kg/day or valproate 20-30 mt/kg/day. Twenty-five children whose parents refused prophylactic treatment make up an untreated control group. Serum levels of the appropriate drug were measured at each follow-up visit. The three groups appear to be comparable. Twenty-one per cent of the phenobarbital treated children required discontinuation of the drug due to side effects. All the children tolerated valproate therapy. Twelve out of 25 untreated children suffered recurrences. Eight out of 33 children treated with phenobarbital suffered recurrences. Four out of 32 children on valproate therapy had recurrences. The difference between valproate treatment and no therapy at all is highly significant (p less than 0.001). Phenobarbital did not reduce the risk of recurrence. We now recommend prophylactic treatment with valproate to children with febrile seizures.

Temporal lobe epilepsy in particular has been considered a consequence of childhood febrile convulsions. Previous studies have dealt with populations of epileptic children. This retrospective, follow-up study concerns 362 children with a primary diagnosis of febrile convulsions. 4% developed epilepsy. When followed into early adulthood one half of those remitted. The incidence of temporal lobe epilepsy among the none-remitters did not differ from that of a random population of epileptics.

Among 2100 children with a diagnosis of cerebral palsy (CP) twenty carried the diagnosis: Previous CP, now normalized. Seventeen patients could be traced and were reevaluated. Cerebral palsy was diagnosed in these seventeen children (ten boys, seven girls) between the ages of three months and three years (average eleven months). They were found to be normal when reexamined between the ages of one year and five years (average two years two months). Two patients had tetraplegia, three diplegia, nine paraplegia ("paraplegia" were cases of diplegia with minimal affection of the upper limbs - now called "diplegia type I"), and one hemiplegia. One patient had atactic diplegia, and one was athetotic. The records of these seventeen patients were evaluated with respect to aetiology and symptomatology. Upon reexamination seven patients were found to be completely normal. Five patients had no motor symptoms but showed signs of specific neuropsychological difficulties. Two patients were intellectually retarded without motor symptoms. One showed signs of neuropathy, and one had fetal alcohol syndrome. Signs consistent with CP could be demonstrated in one patient only. This study shows that signs of CP may in rare cases disappear altogether.

113 cases of infantile spasms were diagnosed in the period 1 April 1970 to 31 March 1975 after Denmark changed her immunization programme. Previously whooping cough vaccine was given as the triple combination at 5, 6, and 15 months of age. From 1 April 1970 it was given as a monovalent vaccine at 5 and 9 weeks of age and at 10 months of age. A comparison with previous material of 86 cases of infantile spasms from 1957 to 1967 showed no change in the age at onset. Though there may be an occasional connection between immunization and infantile spasms, the most important factor is a time-coincidence between any immunization given at a certain age with the neurological disorders which are natural for that age.

Summary A case of idiopathic hypercalcemia of infancy with multiple anomalies of the arteries is described. This patient demonstrated a combination of supravalvular pulmonary artery stenosis, supravalvular aortic stenosis, hypoplasia of the aortic arch, coarctation of the aorta and multiple stenoses of the branches of the abdominal aorta. The pathogenesis of arterial hypertension in this syndrome is discussed.

On pneumoencephalograms (PEG) of children, assessed as normal, the Evans[See figure in the PDF file]ratio proved to be independent of age, while the septum caudate (S-C) distance showed a slight increase. In assessing the size of the lateral ventricles of children we, therefore, prefer using Evans' ratio.Our knowledge of normal ventricular size in infants under 1 year of age has proved insufficient.Whether the position of the head during the exposure influences the value of the septum caudate distance is discussed.

Anorexia and cachexia are serious complications frequently found in patients with cancer (Bozetti, 1995; Donnelly and Walsh, 1995). They are present in about 10% of patients at the time of diagnosis (Bozetti et al, 1989). Multiple factors are involved in their aetiology (Puccio and Nathanson, 1997). The resultant malnutrition is associated with a poorer response to anticancer treatment and an impaired quality of life (Holmes and Dickerson, 1987; Bozetti, 1995; De Conno et al, 1998). Many clinical trials have been undertaken to evaluate the efficacy of drugs thought to be appetite stimulants.