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Anorexia nervosa not only results in severe malnutrition but also carries a high risk of sudden death. Although fatal arrhythmias are the most common cause of sudden death, it is often unclear what exactly causes them. To the best of our knowledge, there have been no reports of cerebellar tonsillar herniations in patients with anorexia nervosa.A 17-year-old girl with anorexia nervosa and autism spectrum disorder was admitted to the pediatric ward for extreme weight loss. Since she refused to take oral nutrition or tube feeding, we started continuous intravenous fluids. Eight hours after admission, she suddenly went into cardiopulmonary arrest and died despite resuscitation. A postmortem autopsy revealed the unexpected findings of generalized severe cerebral edema and cerebellar tonsillar herniation.Intracranial hypertension may need to be considered when the condition of patients with anorexia nervosa suddenly worsens during refeeding periods. Postmortem autopsy and autopsy imaging are recommended to determine the exact cause of sudden death.Level IV: Evidence obtained from multiple time series analysis such as case studies. (NB: Dramatic results in uncontrolled trials might also be regarded as this type of evidence).

BACKGROUND Adolescent health promotion is important in preventing risk behaviors and improving mental health. Health promotion during adolescence has been shown to contribute to the prevention of late onset of the mental health disease. However, scalable interventions have not been established yet. OBJECTIVE This study was designed to test the efficacy of two adolescent health promotion interventions: a well-care visit (WCV) with a risk assessment interview and counseling and self-monitoring with a smartphone cognitive behavioral therapy (CBT) app. Our hypothesis was that participants who had received both WCV and the CBT app would have better outcomes than those who had received only WCV or those who had not received any intervention. We conducted a prospective multi-institutional randomized controlled trial. METHODS Participants were 217 adolescents aged 13-18 years. They were randomly divided into two intervention groups (WCV group and WCV with CBT app group) and a nonintervention group. WCV comprised a standardized physical examination along with a structured interview and counseling for youth risk assessment, which was designed with reference to the Guideline for Health Supervision of Adolescents of Bright Futures. A smartphone-based CBT program was developed based on the CBT approach. The CBT app comprised a 1-week psychoeducation component and a 1-week self-monitoring component. During the CBT program, participants created several self-monitoring sheets based on the CBT model with five window panels: event, thoughts, feelings, body response, and actions. The primary outcome was the change in scores for depressive symptoms. Secondary outcomes included changes in scores for self-esteem, quality of life, self-monitoring, and an adolescent health promotion scale. These outcomes were evaluated at baseline and at 1, 2, and 4 months after baseline. The exploratory outcome was the presence of suicidal ideation during the observation period. Intervention effects were estimated using mixed effect models. RESULTS In total, 94% (204/217) of the participants completed the 4-month evaluation. Both intervention groups showed a significant effect in the form of reduced scores for depressive symptoms at 1 month in high school students; however, these effects were not observed at 2 and 4 months. The intervention effect was significantly more predominant in those scoring above cutoff for depressive symptoms. There was significantly less suicidal ideation in the intervention groups. As for secondary outcomes, there was significant increase in health promotion scale scores at the 4-month follow-up among junior high school students in the WCV group. Moreover, the CBT app was significantly effective in terms of obtaining self-monitoring skills and reducing depressive symptoms. CONCLUSIONS Although adolescent health promotion interventions may have short-term benefits, the frequency of WCV and further revision of the CBT app should be considered to evaluate long-term effectiveness. CLINICALTRIAL University Hospital Medical Information Network Clinical Trials Registry UMIN 000036343; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000041246

The purpose of this study is to investigate the effects of a program containing a combination of social skills training (SST) and parenting training (PT) for the enrichment of social interaction skills and reduction of parenting stress for children with high-functioning autism spectrum disorder (HFASD) and their parents in Japan. Twenty-two patients with HFASD from second to fourth grade and their parents were assigned to a training group (TG) or treatment as usual (TAU) and compared. The children with HFASD and their parents who were assigned to the TG participated in the manualized program for over a period of five to six months. Subjects provided demographic and medical information and completed teacher and parent-rating scales for social competence (Social Responsiveness Scale-2: SRS-2) and parent-rating of parenting stress (Parental Stress Index: PSI) and mental health (General Health Questionnaire-28: GHQ-28). The participants exhibited some improvements pre-, middle-, and post-treatment, particularly regarding the GHQ, PSI and SRS-2, as reported by parents. However, the social skills improvement reported by teachers was not significant. At the three-month follow-up, parent-rated GHQ and PSI maintained improvement, and SRS-2 achieved the greatest improvement from the baseline rating. Although some findings indicate that a program combination of SST and PT might be useful for enhancing social skills and improving parental stress and mental health, some subscales did not show a sufficient effect. Future research should consider program contents and provide longitudinal follow-up data to test the durability of the treatment.

We developed and validated a childhood eating disorder outcome scale based on outcomes associated with body mass index standard deviation score (BMI-SDS). This prospective observational study included 131 children with eating disorders (aged 5–15 years). Participants’ outcomes scales were completed at the first visit and at 1, 3, 6, and 12 months. The scale evaluated 12 outcomes: body weight change (BW), eating attitude (EA), fear of being fat (FF), body image distortion (BD), menstruation (ME), perceived physical condition (PC), attending school (AS), disease recognition by school (RS), family function (FA), disease recognition by parent (RP), social adaptation (SA), and relationships with friends (RF). Responses to all items were on a four-point Likert scale. Exploratory factor analysis was used to determine the number of factors based on the 12 outcomes. The relation between outcome scale scores and BMI-SDS over the 12-month follow-up period was analyzed. Two types of factors were extracted: disease-specific factors (EA, FF, BD) and biopsychosocial factors (BW, PC, AS, FA, SA, RF). Three items (ME, RS, RP) were excluded because they showed no significant loading effect. There was a significant negative correlation between the outcome scale and BMI-SDS, and changes in outcome scale scores from baseline to 12 months were significantly associated with improvement in BMI-SDS. We developed a childhood eating disorder outcome scale characterized by disease-specific and biopsychosocial factors. Biopsychosocial management combined with a therapeutic approach for disease-specific symptoms may support body weight recovery for children with eating disorders.

Background: As the proportion of teens in the onset ages has increased, it has become important to detect eating disorder (ED) students early in school and clarify the way of support. Though epidemiological surveys of Yogo teachers have been conducted to inquire the number of ED students, none of these were based on DSM-5. Thus, we conducted a wide area survey in Japan for proposing a better framework of support for Yogo teachers in the early detection/support of ED students. Methods: A questionnaire survey organized by ED type (based on DSM-5) was administered to Yogo teachers working at elementary/junior high/senior high/special needs schools in four prefectures of Japan in 2015, and 1886 responses were obtained. Based on the results, the encounter rates (the proportions of Yogo teachers who had met ED students) were calculated, and factors affecting them were examined by logistic regression analysis. Results: The order of the encounter rates of the ED type was Anorexia Nervosa (AN)>Bulimia Nervosa (BN)>Avoidant/Restrictive Food Intake Disorder (ARFID)>Binge Eating Disorder (BED)>others. The factors significantly affecting the rates were location, school type, number of students, experience years, and AN knowledge for AN, school type, experience years, BN knowledge for BN, location, school type, experience years, BED knowledge for BED, location, experience years, ARFID knowledge for ARFID and school type, experience years, Others knowledge for Others. Conclusions: Since the encounter rate of AN was highest, providing support for AN would be effective. Moreover, a factor affecting the rate of all ED types was the ED knowledge. Senior high schools had the highest rates for AN, BN and BED, and special needs schools had the highest for others. These findings imply that for detecting/supporting ED students early, it is necessary to offer knowledge of the corresponding ED type to Yogo teachers at the corresponding school type.

Valproate sodium (VPA) is a commonly used antiepileptic drug. However, various side effects, including liver dysfunction, thrombocytopenia, anorexia, hyperammonemia, and pancreatitis have been reported in association with the administration of VPA. Recently, renal Fanconi syndrome associated with VPA treatment has occasionally been reported. However, the mechanisms and detailed characteristics of this adverse effect remain unknown. We herein report three cases of Fanconi syndrome associated with VPA treatment. All of these patients were severely disabled children, who had been previously treated with multiple antiepileptic drugs, and also required tube feeding. The possible risk factors of Fanconi syndrome in these three cases were similar to those previously reported in the literature. In addition, all three patients developed Fanconi syndrome after the onset of bacterial infections. Before developing Fanconi syndrome, hypouricemia was observed in all three and an increased urinary level of beta2 microglobulin (beta2MG) was also noted in one of the patients. None of these patients had hypophosphatemia. Two patients had an appropriate serum VPA level, while the other had an inappropriately high level. We therefore recommend that severely disabled children receiving multiple antiepileptic drugs and tube feeding be periodically checked for urinary beta2MG and uric acid, especially during the course of any infectious episodes.

Background The lowering of the age of onset and chronicity have been key problems related to eating disorders (EDs). As the proportion of teens in the estimated onset ages has increased, it has become important to detect students with EDs and to clarify how they can be supported. Though epidemiological surveys of Yogo teachers (school nurse/health science teachers) have been conducted to inquire about the number of such students, none of these were done according to ED type based on DSM-5. Thus, we conducted a wide area survey in Japan with the goal of proposing a better framework of support for Yogo teachers in their efforts to care for students with EDs. Methods A questionnaire survey organized by ED type (based on DSM-5) was administered to Yogo teachers working at elementary/junior high/senior high/special needs schools in four prefectures of Japan in 2015, and 1,886 responses were obtained. Based on the results, the encounter rates (the proportion of Yogo teachers who had encountered a student with an ED) were calculated, and factors that could affect the rates were examined by logistic regression analysis. Results The order of the encounter rates of the ED types was as follows: Anorexia Nervosa (AN) > Bulimia Nervosa (BN) > Avoidant/Restrictive Food Intake Disorder (ARFID) > Binge Eating Disorder (BED) > Others. The factors significantly affecting the rates were “location, school type, number of students, experience years, and AN knowledge” for AN, “school type, experience years, and BN knowledge” for BN, “school type, experience years, and BED knowledge” for BED, “location, experience years, and ARFID knowledge” for ARFID, and “school type, experience years, and Others knowledge” for Others. Conclusions Because the encounter rate of AN was the highest, providing support for AN would be the most effective. Moreover, one factor that affected the encounter rate of all ED types was ED knowledge. In addition to this, senior high schools had the highest encounter rates for AN, BN and BED, and special needs schools had the highest rates for Others. These findings imply that, in order to detect and support ED students at an early stage, it is necessary to offer knowledge of the most prevalent ED types to Yogo teachers at the corresponding school type.